How many inspection deficiencies does ELISEO have?

ELISEO has 50 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at ELISEO?

ELISEO has a three-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 ELISEO located?

ELISEO is located in TACOMA, WA. It is a Medicare and Medicaid certified skilled nursing facility.

ELISEO is a non profit - corporation facility and operates independently (not part of a chain).

ELISEO has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

What questions should families ask when visiting ELISEO?

Families visiting ELISEO should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ELISEO compare to other nursing homes?

ELISEO has a 4-star overall rating, placing it above average compared to other nursing homes in WA. Higher-rated facilities typically have better inspection results and staffing levels.

ELISEO

Name: ELISEO
Address: 1301 N HIGHLANDS PARKWAY, TACOMA, WA, 98406, US
Telephone: (253) 752-7112
Rating: 4.0

1301 N HIGHLANDS PARKWAY, TACOMA, WA 98406 · (253) 752-7112

Non profit - Corporation 187 Beds Independent Data: November 2025

Trust Grade

65/100

#64 of 190 in WA

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Last Inspection: May 2025

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

Overview

Families considering Eliseo nursing home in Tacoma, Washington, should note that it has a Trust Grade of C+, indicating it is slightly above average but not without concerns. It ranks #64 out of 190 facilities in Washington, placing it in the top half, and #10 of 21 in Pierce County, meaning there are better local options. Unfortunately, the facility's situation is worsening, as the number of issues increased from 18 in 2024 to 19 in 2025. Staffing is a relative strength, with a turnover rate of 39%, better than the state average, but it has concerning RN coverage, being lower than 82% of similar facilities. While there have been no fines, which is a positive sign, recent inspections revealed serious concerns, including a resident sustaining a neck fracture from a fall due to inadequate fall prevention measures and improper storage of medications and food, which could put residents at risk for health issues.

Trust Score: C+
In Washington: #64/190
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 39% turnover. Near Washington's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most Washington facilities.
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: 50 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 18 issues

2025: 19 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (39%)
9 points below Washington average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

Staff Turnover: 39%

Near Washington avg (46%)

Typical for the industry

The Ugly 50 deficiencies on record

1 actual harm

Jun 2025 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

Deficiency F0571 (Tag F0571)

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 residents of what the charge would be for services not covered under their Medicare Managed Care and/or private pay agreements for 1 of 1 resident (Resident 3) reviewed for billing practices. This failure put residents at risk of unknown service costs, frustration and lack of services. Findings included . Resident 3 was admitted to the facility on [DATE]. Resident 3's Health Center admission Packet, undated, showed the private pay charges for the daily room rates and showed that unless covered by a private insurance provider the resident would be charged for a list of services if they were prescribed or requested. The list of services did not include the charges for the services. On 06/18/2025 at 12:13 PM, Staff A, admission Assistant, said they reviewed the Health Center admission Packet with Resident 3. Staff A said the only charges they reviewed with residents admitting to the facility are the daily room and board charges for private pay residents and they gave residents a list of charges for the beauty salon. Staff A said they do not have the costs for medical supplies and/or therapy. Resident 3's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (ABN), dated 12/13/2025, showed Resident 3's insurance would no longer pay for the resident's stay as of 12/15/2024 and the resident would have to pay out of pocket beginning on 12/16/2024 for the care they had been receiving. The ABN showed the care they had received was physical therapy, occupational therapy, daily skilled nursing care and room and board. The ABN showed they estimated the costs at $687.00 per day and the resident was requesting the services continue. The ABN had no other charges listed. Resident 3's progress notes, dated 12/16/2024, showed the resident expressed they needed therapy since they were paying privately. Resident 3's therapy minutes report, dated 12/01/2024 through 12/31/2024, showed Resident 3 had no therapy minutes documented from 12/20/2024 through 12/27/2024. On 06/18/2025 at 1:33 PM, Staff H, Rehab Director, said they stopped Resident 3's therapy on 12/20/2025 because the resident's stay was no longer authorized by their insurance. On 06/18/2025 at 3:23 PM, Staff B, Social Service Director (SSD), said the facility utilized the ABN to notify residents of the charges they will incur when their insurance will no longer be paying for their stay. Staff B said the only charge listed on Resident 3's ABN was $687 per day. Staff B said that charge is the daily room and board charge. Staff B said they do not provide any information on the other charges residents may incur for the remainder of the stay. On 06/23/2025 at 11:35 AM, Collateral Contact (CC1), said they handled Resident 3's finances. CC1 said when Resident 3's insurance stopped paying for Resident 3's stay, the facility had Resident 3 sign an Advance Beneficiary Notice of Non-coverage (ABN) document that showed the resident would pay privately for the services they had been receiving. CC1 said Resident 3 and CC1 believed they would continue to receive all the services they had been receiving in the facility when the insurance was paying, to include room and board, physical therapy and occupational therapy. CC1 said the facility did not notify them of separate charges and/or provide them with the charges for services outside of the private pay daily rate that was listed on the ABN. On 06/26/2025 at 11:43 AM, Staff C, [NAME] Coordinator, said the facility did not provide a list of charges on admission except for the private daily room and board rates. Staff C said the charges for services and/or items were provided on the billing statement after the residents had incurred the cost. On 06/26/2025 at 12:19 PM, in a joint interview with Staff D, Administrator and Staff B, SSD, Staff B said they saw how the ABN could be confusing to residents and/or families regarding what services are covered for the estimated daily rate. Staff B said going forward they would be changing the form so there would be no confusion about what the estimated cost encompasses. Staff D said they had not been providing residents and/or families with charges for services except for the daily room and board rate prior to incurring the cost. WAC Reference 399-97-0300 (1)(e) .

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 ensure medical records were complete and accurate for 3 of 3 residents (Resident 1, 2 and 3). This failure placed residents at risk for incomplete and inaccurate medical records and unmet care needs. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE] with a diagnosis of a stroke. Resident 1's mental health provider notes, dated 06/17/2025, showed the resident was crying throughout the session, had thoughts of despair and was at moderate to high risk for suicide or self-injurious behaviors. Resident 1's progress notes, dated 06/18/2025 at 2:42 AM, showed the resident was on alert for suicidal ideation and was observed during Q [every] 15 minutes checks. Resident 1's physician orders, dated 06/17/2025 and discontinued on 06/19/2025, showed an order to ensure a 15-minute check form was completed. On 06/18/2025 at 12:54 PM Resident 1 was observed sitting in her wheelchair next to her bed. Observation from the hallway showed the resident's legs were visible and the resident's body and head were not visible due to the wall inside the room. Resident 1's room was observed during a continuous observation from 12:59 PM until 1:25 PM. During that time no staff members looked in the room and/or entered the resident's room. At 1:25 PM, Staff E, Certified Nursing Assistant (CNA), was observed entering the room. On 06/18/2025 at 1:27 PM, Staff E, CNA, said Resident 1 was on 15-minute checks and they were documenting they had checked on the resident on the 15-minute monitoring log that was hanging on a clipboard outside of the resident's room. The monitoring log was observed and there was no documentation for 12:45 PM, 1:00 PM, or 1:15 PM. When asked why there were no entries on the log for those times, Staff E said they had been on break, and that was the last time they had checked on the resident and they were just returning. On 06/26/2025, Resident 1's Q 15 Min Monitor [every 15-minute monitor] log, dated 06/18/2025, was reviewed. The log showed documentation every 15 minutes on 06/18/2025, including the times of 12:45 PM, 1:00 PM and 1:15 PM. On 06/26/2025 at 2:20 PM, Staff G, Resident Care Manager (RCM), said the expectation was for staff to only document the tasks they personally complete and Staff E should not have documented they completed observations on 06/18/2025 when they were not present. <RESIDENT 2> Resident 2 was admitted [DATE] with diagnoses of medically complex conditions. Review of the facility's fall investigation report, dated 06/04/2025, showed Resident 2 sustained a fall. The report showed the nursing post fall response was to begin monitoring every 15 minutes and a monitoring log was initiated. Resident 2's physician's orders, dated 06/05/2025 and ended 06/08/2025, showed an order for the nurse to ensure q [every] 15 minutes checks were completed. Resident 2's Q 15 Min Monitor log, dated 06/05/2025, showed documentation of every 15-minute checks from 12:00 AM through 6:00 AM. There was no documentation for the remainder of the day on the form. Resident 2's Medication Administration Record (MAR), dated 06/01/2025 through 06/30/2025, showed documentation the 15-minute checks were completed on 06/05/2025. On 06/26/2025 at 2:20 PM, Staff G, RCM, reviewed Resident 2's medical record and acknowledged the resident's log, dated 06/05/2025, was blank after 6:00 AM. Staff G said the checks should have been completed for the remainder of the day and the licensed nurse should not have documented on the MAR the 15-minute checks were completed. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE]. Review of the facility fall investigation report, dated 12/27/2024, showed Resident 3 sustained a fall. The investigation report showed the nursing post fall response was to begin monitoring every 15 minutes and a monitoring log was initiated. Review of Resident 3's Q 15 Min Monitor log showed documentation of 15 min checks after initiation on 12/27/2024 and on 12/28/2024. On 12/29/2024, the log showed monitoring every 15 minutes from 12:00 AM until 6:00 AM and again at 6:00 PM until the log was completed on 12/30/2024 at 10:00 AM. There was no documentation between 6:00 AM and 6:00 PM on 12/29/2024. On 06/26/2025 at 2:20 PM, Staff G, Resident Care Manager, said the facility used 15-minute checks for a variety of concerns including falls, suicidal thoughts and resident to resident altercations. Staff G said when a resident was placed on 15-minute checks a clipboard is placed outside of their room with a log to document the checks occurred. Staff G said everyone that completed the check documents on the log. Staff G said the licensed nurse documents on the MAR that the checks were completed for their shift. Staff G said the expectation is staff documented tasks they completed, and the licensed nurses reviewed the 15-minute documentation and signed off the MAR if the 15-minute checks were completed. Staff G said it was not acceptable to document the 15-minute checks were completed if they were not and/or to not complete the checks. Reference WAC 388-97-1720 (1)(a)(i-iv)(b) .

May 2025 15 deficiencies

CONCERN (D)

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

Deficiency F0559 (Tag F0559)

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 an opportunity for a resident to see the new location and meet new roommates for 1 of 1 Sample Resident (Resident 31) when reviewed for room changes. This failure placed residents at risk for psychosocial decline and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, prevents airflow to the lungs causing breathing issues), generalized muscle weakness and was able to make needs known. During an interview on 05/05/2025 at 2:26 PM, Resident 31 stated they had moved three times within the last few months. Resident 31 stated they were unhappy with the previous room move as they did not have a choice in the move and did not get to see the new room prior to moving. Review of the EHR showed Resident 31 had room moves on 02/18/2025, 02/27/2025 and 04/22/2025. Review of a progress note, dated 02/28/2025, showed Resident 31 voiced to staff the new room was too small and had concerns their personal belongings would not fit in the room. Resident 31 voiced concern their roommates' belongings were hung on Resident 31's portion of the shared wall. Staff documented social services staff were notified. During an interview on 05/08/2025 at 9:41 AM, Staff E, Social Services Director (SSD), stated Resident 31's 02/27/2025 move was an emergency move related to ongoing roommate issues. Staff E stated Resident 31 was not shown the room prior to the move but should have been. Staff E stated there should have been follow-up on Resident 31's concerns related to the room change. During an interview on 05/09/2025 at 8:22 AM, Staff A, Administrator, stated the expectation was residents were offered the opportunity to view the new room prior to moving. Staff A stated the lack of follow-up on Resident 31's concerns did not meet their expectation. Reference WAC 388-97-0580(1)(b)(i)(ii). .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

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 obtain a court-appointed guardianshipyes (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) and/or to obtain and periodically review a resident's advanced directive (AD, a legal document that establishes a medical decisionmaker if you are unable to make decisions for yourself) for 2 of 3 sampled residents (Residents 14 and 99) when reviewed for advanced directive. This failure placed residents at risk of not having an established decisionmaker, lack of ability to direct care, and a diminished quality of life. Findings included . Resident 14 Review of the electronic health record (EHR) showed Resident 14 initially admitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set (MDS, a required assessment tool), dated 03/21/2025, showed Resident 14 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), bipolar disorder, (episodes of mood swings ranging from depressive lows to manic highs) and psychotic disorder (a mental disorder characterized by a disconnection from reality). During an interview on 05/06/2025 at 1:44 PM, Resident 14 stated their spouse, and two children were their durable power of attorney (DPOA, a legal document that establishes a medical decisionmaker); however, they did not know if the facility had the legal paperwork or not. Review of Resident 14's EHR on 05/08/2025 at 3:33 PM showed in the Profile tab, two children were power of attorney (POA, a legal document that allows one person to grant another person the authority to act on their behalf) for Resident 14's financial reasons; however, it did not show that they were DPOA for healthcare. Review showed no documentation of an AD for healthcare. During an interview on 05/08/2025 at 10:38 AM Staff E, Social Services Director (SSD), stated Resident 14's EHR did not contain the DPOA for healthcare and they were unsure why. Staff E stated the AD should have been reviewed the prior quarter on 10/31/2024 or at the most recent care conference. Staff E stated they located a document titled, Physician's Statement Regarding Capacity/Competency that showed Resident 14 was treated/examined on 06/15/2016 and this document was signed by the physician on 07/13/2016 which showed Resident 14 no longer had the capacity to handle their own property, financial affairs and health care decision-making due to physical disability, mental illness, and dementia. Staff E stated they were unable to locate an AD/Guardianship in Resident 14's EHR and the lack of timely follow-up did not meet expectations. During an interview on 05/08/2025 at 11:53 AM Staff A, Administrator, stated residents' ADs were reviewed upon admission, during care conferences, upon request, and as needed. Staff A stated they should have moved forward with Resident 14's guardianship, especially if there was no DPOA for healthcare, and this did not meet expectations. Resident 99 Review of the EHR showed Resident 99 initially admitted to the facility on [DATE] with diagnoses that included high blood pressure and stroke (damage to the brain from interruption of its blood supply). The annual MDS dated [DATE] showed Resident 99 was able to make needs known. During an interview on 05/06/2025 at 1:04 PM Resident 99 stated they did not have an AD in place. Review of Resident 99's last two care conference reports dated 10/31/2024 and 02/18/2025 both showed the following questions answered: -AD/DPOA? = None -Surrogate decision maker hierarchy given to resident/family? = left blank -If guardian in place, was it up to date? = Not Applicable (N/A) -Resident cognizant to sign AD/DPOA? = N/A -If resident cognizant, offered assistance for completing AD/DPOA? = N/A Review of Resident 99's EHR on 05/06/2025 at 3:01 PM showed in the Profile tab, Resident 99 was their own responsible party/health care decision maker. Review showed no documentation of an AD for healthcare. On 05/08/2025 at 10:38 Staff E, SSD, stated they thought Resident 99 had a POA and it should have been scanned into the resident's EHR by now. Staff E stated they were not sure why Resident 99's care conference reports showed AD/DPOA was documented N/A. Staff E stated they were unable to locate an AD for healthcare in Resident 99's EHR and it needed to be followed up on. On 05/08/2025 at 11:53 AM, Staff A stated they were unable to explain why care conferences showed N/A documented for Resident 99's AD/DPOA. Staff A stated the AD should have been in Resident 99's EHR and/or documentation as to why it was not in place. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b) .

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 observation, interview, and record review, the facility failed to prevent the use of chemical restraints for 1 of 5 sampled residents (Resident 83) reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life. Findings included . Resident 83 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a condition resulting in symptoms such as memory loss, confusion, and difficulty with reasoning and planning) and depression. The quarterly minimum data set (MDS), an assessment tool, dated 03/07/2025, showed Resident 83 was confused and dependent on staff for care. Review of the electronic heath record (EHR) showed Resident 83 was taking Seroquel (an antipsychotic medication), dated 03/31/2024, Depakote (an antiseizure medication used for mood stabilization), and Mirtazapine (an antidepressant medication). Review of provider orders showed Resident 83 started on Depakote on 11/21/2024. Review of provider orders showed an increase in the Depakote dose on 01/24/2025. Review showed no dose reduction had been attempted for Seroquel since initiating Depakote. Observation on 05/06/2025 at 1:50 PM, showed Resident 83 was sitting in a wheelchair. Resident 83 was calm, confused, and conversive. Observation on 05/07/2025 at 1:36 PM, showed Resident 83 was with eyes closed. Observation on 05/07/2025 at 2:54 PM, showed Resident 83 was with eyes closed. Observation on 05/08/2025 at 9:07 AM, showed Resident 83 was with eyes closed. Resident 83 did not open their eyes when they were talked to, or their name was called. Observation on 05/08/2025 at 10:39 AM, showed Resident 83 was with eyes open and calm. Observation on 05/08/2025 at 12:53 PM, showed Resident 83 was with eyes open, calm, conversive, and pleasant. Review of progress note, dated 11/21/2024, showed the provider was updated on Resident 83 and evaluation was requested since Seroquel was not effective. Review of provider notes, dated 11/22/2024, showed the goal was to discontinue Seroquel given medication class risk. Review of the monthly psychoactive monitoring summary, dated 12/19/2025, showed Resident 83 was reviewed for a dose reduction of Seroquel. Review showed Seroquel was determined to be mostly ineffective. Review showed no dose reduction was recommended for that month. Rationale for no dose reduction was documented as continue current plan of care. Review of the monthly psychoactive monitoring summary, dated 01/30/2025, showed Resident 83 was reviewed for dose reduction of Seroquel. Review showed Seroquel was documented as mostly ineffective. Review showed changes were not recommended with a rationale as no change in Seroquel. During an interview on 05/08/2025 at 10:41 AM, Staff F, Certified Nursing Assistant (CNA), stated Resident 83 used to have behaviors every day during care. Staff F stated Resident 83 had not had behaviors for about a month. Staff F stated Resident 83 was redirectable with care when behaviors had occurred. During an interview on 05/08/2025 at 12:54 PM, Staff G, Registered Nurse (RN), stated Resident 83 was receiving Seroquel and Depakote for dementia with behaviors. Staff G stated Resident 83 had not had any behaviors that shift. During an interview on 05/08/2025 at 1:04 PM, Staff C, RN/Unit Manager, stated the last dose reduction attempted for Seroquel was February of 2024. Staff C stated no dose reduction was attempted after starting Depakote. During an interview on 05/09/2025 at 8:08 AM, Staff E, Social Service Director (SSD), stated the last dose reduction review for Seroquel was on 01/21/2025. Staff E stated a dose reduction was not attempted because the psychiatric nurse practitioner stated it was clinically contraindicated because Resident 83 was still having behaviors. During an interview on 05/09/2025 at 8:24 AM, Staff J, CNA, stated Resident 83 had not had any behaviors during their shift and had been asleep since the start of their shift. Staff J stated night shift reported Resident 83 had not had any behaviors all night and slept their entire shift. During an interview on 05/09/2025 at 8:26 AM, Staff K, Life Enrichment, stated Resident 83 had not had behaviors in activities. Staff K stated Resident 83 became sleepy at activities and staff had to often wake him up. Staff K stated Resident 83 attended activities one or two times a week but did not attend if they were sleepy. During an interview on 05/08/2025 at 2:13 PM, Staff H, Nurse Practitioner, stated a decrease in Seroquel had not been attempted since the start of Depakote. Staff H stated if Resident 83 had not had behaviors or had been sleepy the dose of Seroquel should have been decreased. Refer to F-658 Services Provided Meet Professional Standards- for additional information related to failing to accurately document behavior monitoring. Refer to F-744 Treatment/services For Dementia- for additional information related to failing to identify and implement person-centered, individualized interventions for dementia care. Reference WAC 388-97- 0620 (1)(a) .

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 identify and report an allegation of abuse for 1 of 1 sampled resident (Resident 31) when reviewed for abuse. This failure placed residents at risk for unidentified and repeated potential abuse, neglect and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, prevents airflow to the lungs causing breathing issues), generalized muscle weakness, and was able to make needs known. Review of the facility's policy titled, Abuse, Neglect and Exploitation dated October 2022, showed, As part of the resident abuse prevention, the staff will . identify the different types of abuse to include certain resident to resident altercations .immediately investigate . report all alleged violations of abuse within specified timeframes. During an interview on 05/05/2025 at 2:29 PM, Resident 31 stated they recently moved to their current room due to an altercation with their roommate. Resident 31 stated the roommate threw items at them and they had several shouting matches. Review of the facility's incident logs from February 2025 to May 2025 showed no allegation of abuse logged related to Resident 31. Review of a progress note dated 02/26/2025 at 3:08 PM, showed an alert charting note for roommate interaction. Review of a progress noted dated 02/27/2025 at 6:32 AM, showed and alert charting note: Resident and roommate got into a verbal altercation at 10:15 PM. Resident upset wants to keep light on in bedroom, roommate wants lights completely turned off. Resident and roommate shouting at one another. Resident was redirected, resident and roommate being monitored every 15 minutes for behaviors. During an interview on 05/08/2025 at 9:56 AM, Staff L, Unit Manager/Registered Nurse (UM/RN), stated an incident report should have been completed, and the allegation should have been reported to the state but was not. During an interview on 05/09/2025 at 8:29 AM, Staff B, Director of Nursing Services (DNS), stated when a disagreement rises to the level of verbal abuse the expectation was that an investigation was initiated, completed and a report made to the state. 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** . Based on interview and record review, the facility failed to provide and/or maintain documented care conferences in a timely manner for 2 of 3 sampled residents (Residents 72 and 77) when reviewed for care planning. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 72 Review of the electronic health record (EHR) showed Resident 72 admitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood) and high blood pressure and was able to make needs known. During an interview on 05/05/2025 at 2:29 PM Resident 72 stated they had not gone to a care conference meeting. Review of Resident 72's EHR on 05/08/2025 showed no documentation that a care conference had occurred. Resident 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] with diagnoses that included heart failure, arthritis (swelling of the joints), and depression. Resident 77 was able to make needs known. During an interview on 05/05/2025 at 1:17 PM Resident 77 stated they did not recall ever going to a care conference. Review of Resident 77's social services progress note dated 04/08/2025 showed the facility care conference was completed and was to be uploaded to the miscellaneous tab in the EHR. Review of Resident 77's EHR, miscellaneous tab, on 05/08/2025 showed no documentation a care conference had occurred on 04/08/2025. During an interview on 05/08/2025 at 11:19 AM, Staff E, Social Services Director (SSD), stated Resident 72 had not had a care conference yet and there should have been one conducted during the initial minimum data set (MDS, a required assessment tool) period and that did not happen and did not meet expectations. Staff E stated Resident 77's progress note dated 04/08/2025 showed Resident 77 had a care conference and the documentation was to be uploaded into the resident's EHR; however, there was no documentation to show the care conference occurred and this did not meet expectations. During an interview on 05/08/2025 at 12:13 PM, Staff A, Administrator, stated resident care conferences were to be held upon admission, quarterly, upon request, and as needed. Staff A stated Resident 72 should have had a scheduled care conference documented with the interdisciplinary team (IDT) and the resident and/or responsible party and the documentation placed in Resident 72's EHR; however, that did not happen. Staff A stated Resident 77 should have had evidence that a care conference occurred in Resident 77's EHR and this did not meet expectations. Reference WAC 388-97-1020 (2)(f), (4)(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** . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice by accurately documenting behavior monitoring for 1 of 3 residents (Resident 83) reviewed for dementia care. This failure placed residents/staff at risk of unmet care needs, unnecessary medications, and a diminished quality of life. Findings included . Resident 83 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a condition resulting in symptoms such as memory loss, confusion, and difficulty with reasoning and planning) and depression. The quarterly minimum data set (MDS), an assessment tool, dated 03/07/2025, showed Resident 83 was confused and dependent on staff for care. Observation on 05/06/2025 at 1:05 PM showed Resident 83 was awake, alert, and pleasantly confused. Observation on 05/07/2025 at 1:36 PM showed Resident 83 was with eyes closed in their wheelchair. Observation on 05/07/2025 at 2:54 PM showed Resident 83 was in bed with eyes closed. Observation on 05/08/2025 at 9:07 AM showed Resident 83 was in bed with eyes closed. Resident 83 did not respond when their name was called. Observation on 05/08/2025 at 10:39 AM showed Resident 83 was in bed, calm and awake. Observation on 05/08/2025 at 12:53 PM showed Resident 83 was in their wheelchair awake. Resident 83 was calm, conversive, and pleasant. Observation on 05/09/2025 at 8:18 AM showed Resident 83 was in bed sleeping. Review of a document titled Behavior Monitoring for May 2025 showed documentation by nursing staff that Resident 83 had continuous behaviors of agitation on 05/01/2025, 05/03/2025, 05/07/2025, and 05/08/2025 on day shift. Review showed Resident 83 had continuous behaviors of aggression on 05/01/2025 and 05/07/2025 on day shift. Review showed Resident 83 had continuous behaviors of agitation on 05/01/2025, 05/02/2025, 05/04/2025, 05/05/2025, 05/06/2025, 05/07/2025, and 05/08/2025 on night shift. Review showed Resident 83 had continuous behaviors of aggression on 05/01/2025, 05/04/2025, 05/05/2025, and 05/06/2025 on night shift. During an interview on 05/08/2025 at 10:41 AM, Staff F, Certified Nursing Assistant (CNA), stated Resident 83 had not had aggressive behaviors for about a month. Staff F stated on 05/07/2025 Resident 83 was asleep for the entire shift on day shift. During an interview on 05/08/2025 at 12:53 PM, Staff G, Registered Nurse (RN), stated they had not seen behaviors from Resident 83. Staff G stated Resident 83 was calm for their shift. During an interview on 05/09/2025 at 8:24 AM, Staff J, CNA, stated Resident 83 had been asleep since the start of their shift. Staff J stated night shift reported Resident 83 had no behaviors overnight and slept through their shift. During an interview on 05/09/2025 at 8:26 AM, Staff K, Life Enrichment, stated Resident 83 had not had behaviors in activities. Staff K stated Resident 83 would converse in group settings with no aggression or agitation. During an interview on 05/08/2025 at 2:13 PM, Staff B, Director of Nursing Services, stated it was their expectation behavior monitoring would be documented accurately. Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i) .

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

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 prompt services to maintain vision for 1 of 3 sampled residents (Resident 23) when reviewed for communication/sensory. This failure placed the resident at risk of unmet vision needs, inability to perform activities of daily living, inability to participate in leisure activities and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 23 readmitted to the facility on [DATE] with diagnoses that included diabetes (too much sugar in the blood) and depression. The quarterly minimum data set (MDS, a required assessment tool) dated 02/27/2025, showed Resident 23 had adequate vision with corrective lenses. During an interview on 05/05/2025 at 12:56 PM Resident 23 stated that they had gone to the eye doctor sometime in February of this year (2025) and received a prescription for new glasses; however, they had not received them, and staff were aware. Review of Resident 23's neuro-ophthalmology (brain and eye doctor) consultation report dated 02/03/2025 showed the provider recommended new glasses and included Resident 23's prescription for new glasses attached to the report. It showed, Okay to exchange right eye lens of current glasses. During an interview on 05/07/2025, Staff L, Unit Manager/Registered Nurse (UM/RN), stated they worked with the health information/medical records to determine if prescriptions for glasses would be filled by an outside office or by the inhouse optometrist (eye doctor). Staff L stated they had documented in a progress note on 05/05/2025 that showed the provider would review Resident 23's prescription and evaluate if the prescription could be added. Staff L stated Resident 23's prescription for new glasses on 02/03/2025 should have been followed up sooner. During an interview on 05/07/2025 at 1:46 PM, Staff M, Health Information Clerk, stated the timeline from obtaining a prescription for new glasses to getting the new glasses could take anywhere from two to three weeks. Staff M stated the in-house optometrist came to the facility once a month. Staff M stated they never received Resident 23's prescription for new glasses from nursing to be able to email it to the in-house optometrist. Staff M stated this did not meet expectations and should have been followed up sooner. During an interview on 05/07/2025 at 2:21 PM, Staff B, Director of Nursing Services, stated they were not aware that Resident 23's 02/03/2025 new glasses prescription had not been filled and should have been addressed sooner. Staff B stated there should have been proper communication between nursing and health information/medical records. Reference WAC 388-97-1060 (3)(a) .

CONCERN (D)

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 received the necessary services to maintain their level of functioning and/or prevent decline for 1 of 3 sampled residents (Resident 31) when reviewed positioning/mobility. This failure placed the residents at risk for decreased range of motion (ROM), increased pain, and diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 31 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, prevents airflow to the lungs causing breathing issues), generalized muscle weakness and was able to make needs known. Review of the care plan, revised on 02/11/2025, showed Resident 31 had an activities of daily living (ADL) self-care performance deficit related to impaired balance. Review of the admission minimum data set (MDS, an assessment tool), dated 02/17/2025, showed Resident 31 had impairment of lower extremities on both sides. Review of a document titled, Physical Therapy Treatment Encounter, dated 02/12/2025, showed Patient has no interest in therapy services due to preference to lay in bed, watch TV and read a book. Patient limits ROM beyond what he can do for himself thus no restorative program recommended. Based on today's treatment response, patient refused services. Review of a progress noted dated 02/19/2025 showed, during a social service check-in with the resident, Resident 31 stated they wanted to start a restorative therapy program. During an interview on 05/08/2025 at 11:30 AM, Staff E, Social Services Director, stated they were unable to locate documentation of follow up with nursing related to Resident 31's restorative therapy request. During an interview on 05/08/2025 at 10:03 AM, Staff L, Unit Manager/Registered Nurse (UM/RN), stated they were unaware of Resident 31's request to participate in restorative therapy. During an interview on 05/09/2025 at 8:33 AM, Staff B, Director of Nursing Services (DNS), stated a referral should have been made to the restorative nurse and an assessment completed within five days to see if Resident 31 was appropriate for a restorative therapy program. Staff B stated the lack of communication did not meet their expectations. Reference WAC 388-97-1060 (3)(d), (j)(ix) .

CONCERN (D)

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 observation, interview, and record review the facility failed to accurately assess and monitor pain for 2 of 4 residents (Residents 20 and 89) when reviewed for pain management. This failure placed the residents at risk for unidentified and unmanaged pain and a decreased quality of life. Findings included . Resident 20 Review of the electronic health record (EHR) showed Resident 20 was re-admitted to the facility on [DATE] with a diagnosis of chronic kidney disease with heart failure and was admitted to hospice (end of life care) services 01/16/2025. The resident was able to make needs known. During an interview and observation on 05/07/2025 at 9:23 AM, Resident 20 stated My chest and my kidneys hurt every day. It's getting worse. My belly hurts and my legs hurt all the time. I don't request pain medication unless I can't bear the pain because they are too busy. Review of the monthly pain management review dated 4/30/2025 showed a total of six as-needed (PRN) narcotic pain medications administered in the month of April. Review of the administration record for April 2025 showed Resident 20 received as needed narcotic pain medications a total of ten administrations. The resident also received as needed non-narcotic pain medications seven times in the month of April. Review of Resident 20's plan of care showed an intervention dated 12/01/2024 for staff to monitor and record pain characteristics to include severity, location, onset, and duration. Review of the EHR showed no documentation that Resident 20's pain was monitored. During an interview on 05/07/2025 at 9:03 AM, Staff C, Unit Manager/Registered Nurse (UM/RN), stated the facility used a pain management assessment every four hours and if Resident 20 had pain and received pain medications, it should be in their provider orders. Resident 20's pain monitor was discontinued 01/27/2025 and should not have been. During an interview on 05/07/2025 at 10:50 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that staff assessed residents with pain at least daily and documented it in the EHR. Resident 89 Resident 89 admitted to the facility on [DATE] with diagnoses that included spinal stenosis (a condition that puts pressure on the spinal cord or nerves), degenerative disc (changes in the bones of the back) with back pain and lower extremity pain, spondylosis (changes in the bones of the back), carpal tunnel syndrome (pressure in the nerves of the wrist), osteoarthritis (a form of arthritis) of the right knee, sciatica (pain in the nerve of the back and legs), and fibromyalgia (a chronic disorder characterized by pain, stiffness, and tenderness in the body). The minimum data set (MDS), an assessment tool, dated 05/01/2025, showed Resident 89 was able to make needs known. During an interview on 05/06/2025 at 10:20 AM, Resident 89 stated they had chronic pain and were waiting to talk to a doctor about it. Resident 89 stated they were on pain medications that were not effective enough overnight and had not been able to sleep the previous night. Review of the provider's orders, for May 2025, showed no order to monitor Resident 89's pain level. Review of the progress notes, dated May 2025, showed no documentation of Resident 89's pain level. During an interview on 05/08/2025 at 7:55 AM, Staff N, Unit Manager/Licensed Practical Nurse, stated a pain monitor was in place upon admission for seven days and a pain assessment was completed. Staff N stated Resident 89 was no longer on a pain monitor. During an interview on 05/07/2025 at 10:50 AM, Staff B, DNS, stated it was their expectation that staff assessed residents with pain at least daily and document it in the EHR. Reference WAC 388-97-1060 (1) .

CONCERN (D)

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

Deficiency F0744 (Tag F0744)

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 who experienced dementia-related behaviors received care and services to attain the highest practicable physical, mental, and psychosocial well-being when it did not identify and implement person-centered, individualized interventions for 1 of 3 sampled residents (Resident 83) when reviewed for dementia care. This failure placed residents at risk of unmet care needs, unnecessary medications, and a diminished quality of life. Findings included . Resident 83 admitted to the facility on [DATE] with diagnoses that included vascular dementia (a condition resulting in symptoms such as memory loss, confusion, and difficulty with reasoning and planning) and depression. The quarterly minimum data set (MDS), an assessment tool, dated 03/07/2025, showed Resident 83 was confused and dependent on staff for care. Review of the EHR showed Resident 83 was taking Seroquel (an antipsychotic medication) for a diagnosis of dementia with behaviors. Review showed Resident 83 was taking Depakote (a seizure medication used for mood stabilization) for vascular dementia and Namenda (a medication used to treat dementia) for dementia with behavioral disturbance. Review of the care plan, dated 03/18/2025, showed Resident 83 had a care plan for impaired cognitive function related to dementia. Review of the care plan showed the following interventions for dementia: administer medications as ordered, communicate with the resident/family/caregivers regarding residents capability and needs, engage the resident in simple, structured activities that avoid overly demanding tasks, the resident prefers (specify activities) [no activities where specified], keep the resident's routine consistent, provide the resident with a homelike environment, the resident requires approaches that maximize involvement in daily decision making and activity, and use task segmentation to support short term memory deficit. Review showed there were no resident specific interventions for dementia care and preferences were not documented. Review of a document titled Behavior Note dated 11/21/2024 at 11:47 AM showed Resident 83 became combative during care. Resident 83 agreed to care then punched at the staff caring for them. Review showed the staff tried to get Resident 83 into a safe position then stepped back to allow Resident 83 to calm down. During an interview on 05/08/2025 at 10:41 AM, Staff F, Certified Nursing Assistant (CNA), stated when Resident 83 had behaviors, staff would leave and reapproach Resident 83 at a different time. During an interview on 05/08/2025 at 1:04 PM, Staff C, Unit Manager, stated Resident 83 would become resistive to care and curse at staff. Staff C stated Resident 83 had behaviors almost continuously. Staff C stated Resident 83's behaviors would be triggered when care was being done by staff. During an interview on 05/08/2025 at 2:13 PM, Staff B, Director of Nursing Services (DNS), stated Resident 83 continued to have behaviors with aggression and agitation with multiple incidents. Staff B stated interventions such as distraction, offering fluids, and redirection had been attempted. Staff B stated their expectation was preferences and personalized needed be considered when care planning and treating dementia residents. Reference WAC 388-97-1040 (1)(a-c) .

CONCERN (E)

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 develop and/or implement comprehensive care plans for 5 of 23 sampled residents (Residents 104, 20, 72, 7 and 114) whose care plans were reviewed. Failure to develop/implement a comprehensive care plan related to activities, pain, edema (fluid build-up causing swelling), and personal hygiene placed the resident at risk for unmet needs and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 104 admitted to the facility on [DATE] with diagnoses that included dementia (a group of cognitive disorders with a decline in memory and thinking that interferes with daily life), diabetes (too much sugar in the blood) and high blood pressure. Resident 104 was rarely understood. Review of the Activity Preference section of the annual minimum data set (MDS, a required assessment tool) dated 03/24/2025 showed listening to music, having magazines, books or newspapers and doing favorite activities were documented as Very Important to Resident 104. Review of Resident 104's Life Enrichment Care Plan dated 03/24/2025 showed Focus enjoys outdoors, bingo, news, listening to music (just about anything), word puzzles, reading adventure, gambling, tv, and visiting with family and friends. Interventions showed, Invite and encourage to attend programs and offer leisure materials/supplies such as books and Daily Chronicles. Observations on 05/06/2025 at 9:38 AM and 1:53 PM showed Resident 104 sitting in a wheelchair in front of the nurses' station with their head down not engaged with staff or residents. Observation on 05/07/2025 at 8:49 AM, 10:22 AM and 12:24 PM showed Resident 104 sitting in a wheelchair in front of the nurses' station with their head down not engaging with staff or residents. During an interview on 05/06/2025 at 1:45 PM, Staff X, Life Enrichment Development Specialist, stated Resident 104 did not participate much since they moved from the dementia unit where there were more appropriate activities. During an interview on 05/07/2025 at 2:03 PM, Staff Y, Community Life Director, stated Resident 104 should have been offered sensory stimulation, music or the opportunity to attend entertainment events such as birthday parties or observations of holidays. Staff Y stated the lack of offering appropriate activities to Resident 104 did not meet their expectations. Resident 20 Review of the EHR showed Resident 20 was re-admitted to the facility on [DATE] with diagnoses of fibromyalgia (a long-term condition that involves widespread body pain), arthritis (joint pain) and colon cancer. The resident was able to make needs known. During an interview and observation on 05/07/2025 at 9:23 AM, Resident 20 stated My chest and my kidneys hurt every day, it's getting worse. My belly hurts and my legs hurt all the time. Review of Resident 20's plan of care showed a care plan dated 12/01/2024 for The resident has (Specify: acute/chronic) pain r/t Depression, Diabetic neuropathy with an intervention of Monitor/record pain characteristics (FREQ) and PRN. No pain monitor was found in the EHR. Resident 72 Review of the EHR showed Resident 72 admitted to the facility on [DATE] with diagnoses of back pain, sciatica (leg nerve pain) and arthritis. The resident was able to make needs known. During an interview on 05/05/2025 at 2:37 PM, Resident 72 stated they take pain medication, but it was not very effective, and they were in a lot of pain yesterday (05/04/2025) that made them cry. Review of the medication administration record for May 2025 showed Resident 72 received Tylenol as needed on 05/04/2025. Review of a pain assessment completed on 04/07/2025 showed Resident 72 complained of headache and buttock pain. Review of the EHR showed no care plan was initiated for Resident 72's pain. During an interview on 05/07/2025 at 9:03 AM, Staff C, Unit manager/Registered Nurse (UM/RN), stated residents with a history of complaints of pain should have a personalized plan of care in place to address pain, but Residents 20 and 72 did not. During an interview on 05/07/2025 at 10:50 AM, Staff B, DNS, stated it was their expectation the care plans be accurate and specific for each resident. Resident 7 Resident 7 admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a long term disease where the kidneys cannot filter the blood properly), dependence on renal dialysis (a treatment to remove extra fluid from the body), and localized edema. The minimum data set (MDS), an assessment tool, dated 04/21/2025, showed Resident 7 was able to make needs known. Observation on 05/05/2025 at 2:15 PM showed Resident 7 had moderate to severe swelling in their feet and ankles. During an interview on 05/08/2025 at 11:14 AM, Staff O, Licensed Practical Nurse stated Resident 7 usually had edema in their lower extremities. Review of the EHR showed no care plan was initiated for edema. During an interview on 05/08/2025 at 2:13 PM, Staff B, DNS stated their expectation was that care plans be completed accurately. Resident 114 Resident 114 admitted to the facility on [DATE] with diagnoses that included intracerebral hemorrhage (a sudden bleed in the brain), chronic kidney disease (a condition where the kidneys cannot filter blood properly), dementia, hemiplegia, and hemiparesis (paralysis and severe weakness on one side of the body) of the right side. The MDS, dated [DATE], showed Resident 114 was dependent on staff for all care. Observation on 05/06/2025 at 12:28 PM showed Resident 114 was not shaved. Observation showed Resident 114 had long, unclipped nails. Review of the care plan on 05/06/2025 showed no level of assistance needed or frequency for shaving. Review showed Resident 114's preference for shaving was not on the care plan. Review showed no level of assistance needed or frequency for nail care. During an interview on 05/08/2025 at 10:28 AM, Staff D, Certified Nursing Assistant (CNA), stated Resident 114 frequently refused care. Staff D stated Resident 114 was dependent on staff for shaving and nail care. Staff D stated Resident 114's family would often assist with shaving and nail care. During an interview on 05/08/2025 at 2:13 PM, Staff B, DNS, stated nail care and shaving should have been on the care plan. Staff B stated failure to care plan assistance needed and preference did not meet their expectations. Reference WAC 388-97- 1020(1), (2)(a)(b) .

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** Resident 7 Resident 7 admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a long-term disease where the kidneys cannot filter the blood properly), dependence on renal dialysis (a treatment to remove extra fluid from the body), and localized edema (swelling in specific areas in the body). The minimum data set (MDS), an assessment tool, dated 04/21/2025, showed Resident 7 was able to make needs known. Review of provider orders showed Resident 7 had an order to wear compression stockings every day for edema. Review showed compression stockings were ordered to be put on in the morning and removed at bedtime. Observation on 05/05/2025 at 2:15 PM showed Resident 7 with moderate edema to both feet. Resident 7 was sitting up in their wheelchair with feet on the floor. Resident 7 did not have compression socks on. Observation on 05/07/2025 at 9:25 AM showed Resident 7 did not have their compression socks on. Observation on 05/08/2025 at 1:36 PM showed Resident 7 was sitting up in their wheelchair with feet down on the floor. Moderate edema was noted in both feet. Mild edema was noted in both legs. Resident 7 had compression socks on that were slouched down under their calves on both legs. Review of nurses' notes dated 05/01/2025 through 05/08/2025 showed nursing staff documented no edema was present. Review of provider's notes dated 04/29/2025 and 04/30/2025 showed fluid status was managed by dialysis. There was no documentation for an assessment on edema. Review of EHR showed Resident 7 received dialysis every Tuesday, Thursday, and Saturday. Review showed Resident 7 was on a fluid restriction to manage fluid status. During an interview on 05/08/2025 at 1:36 PM, Staff R, Certified Nursing Assistant (CNA), stated Resident 7's feet looked swollen. During an interview on 05/08/2025 at 11:14 PM, Staff O, Licensed Practical Nurse (LPN), stated Resident 7 usually had mild to moderate edema. Staff O stated Resident 7 had orders for compression stockings to be placed on in the morning and removed at bedtime. Staff O stated any edema noted would be documented in the daily skilled nursing notes. During an interview on 05/08/2025 at 2:13 PM, Staff B, DNS, stated it was their expectation that an assessment for edema be completed every shift by a nurse and documented accurately. Staff B stated compression stocking should be applied as ordered. <Positioning> Resident 114 Resident 114 admitted to the facility on [DATE] with diagnoses that included intracerebral hemorrhage (a sudden bleed in the brain), chronic kidney disease, dementia, and hemiplegia and hemiparesis of the right side (weakness and paralysis of one side of the body). The MDS, dated [DATE], showed Resident 114 was dependent on staff for all care. Observation on 05/06/2025 at 9:24 AM showed Resident 114 in bed laying on their back. Observation on 05/06/2025 at 12:52 PM showed Resident 114 in bed, laying on their back. The head of the bed was elevated for lunch. Observation on 05/06/2025 at 1:26 PM showed Resident 114 in bed, laying on their back. The head of the bed was elevated. Observation on 05/06/2025 at 2:25 PM showed Resident 114 in bed, laying on their back. The head of the bed was down. Observation on 05/07/2025 at 8:37 AM, 12:34 PM, 1:33 PM, and 2:50 PM showed Resident 114 in bed, laying on their back. Review of the EHR showed Resident 114 was placed on hospice on 04/17/2025. Review showed Resident 114 was confused and unable to consistently voice their needs. During an interview on 05/08/2025 at 10:34 AM, Staff O, CNA, stated Resident 114 should be turned every two hours. During an interview on 05/08/2025 at 11:54 AM, Staff S, LPN, stated Resident 114 should be turned every two hours. During an interview on 05/08/2025 at 2:13 PM, Staff B, DNS, stated it was their expectation that dependent residents be turned every two hours or as per provider orders. Reference WAC 388-97- 1060 (1) Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for bowel management for 1 of 2 sampled residents (Resident 112) when reviewed for bowel management, for edema for 2 of 3 sampled residents (Residents 20 and 7) when reviewed for edema, and for positioning for 1 of 3 sampled residents (Resident 114) when reviewed for positioning. These failures placed residents at risk of medical complications and a diminished quality of life. Findings included . <Bowel Management> Resident 112 Review of the electronic health record (EHR) showed Resident 112 admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF, when the heart fails to pump enough blood). The resident was able to make needs known. Review of the provider orders showed Resident 112 had an order dated 02/07/2025 for Imodium to be given as needed for loose stools, and an order dated 04/14/2024 for banana flakes to be given as needed for loose stools. Review of the bowel monitor showed Resident 112 had reported loose stools on 04/23/2025, 04/29/2025, 05/02/2025 and 05/05/2025. Review of the administration records showed no as needed medications were provided on the dates Resident 112 reported loose stools. During an interview on 05/08/2025 at 9:34 AM, Staff C, Unit Manager/Registered Nurse (UM/RN), stated Resident 112 had loose stools on and off since admission and had as needed medications for it. Staff C stated they should have received the medications when they reported loose stools but did not. During an interview on 05/08/2025 at 9:54 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that residents who had orders for as needed medications for loose stools received them, and this did not happen for Resident 112 and should have. <Edema Management> Resident 20 Review of the EHR showed Resident 20 was re-admitted to the facility on [DATE] with diagnosis of CHF, respiratory failure and edema. The resident was able to make needs known. During an observation and interview on 05/05/2025 at 10:31 AM, Resident 20 stated they had pain and swelling in both feet. The resident sat in a wheelchair at the side of the bed, and both feet were swollen. Review of the care plan dated 12/04/2025 showed an edema management goal to assess daily for edema. Review of the EHR showed no documentation Resident 20's edema had been monitored daily. During an interview on 05/07/2025 at 9:53 AM, Staff C, UM/RN, stated residents who had a diagnosis of CHF should be monitored daily for edema and it should be documented in the EHR. During an interview on 05/07/2025 at 10:56 AM, Staff B, DNS, stated it was their expectation that residents with edema be monitored daily and documented in the skilled notes or progress notes and notify the provider of changes, but this did not happen for Resident 20 and should have.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

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 monitor residents' fluid intake and provide the amount of fluid per provider's orders for 2 of 2 sampled residents (Residents 7 and 381) when reviewed for nutrition/hydration. This failure placed residents at risk of fluid overload, avoidable pain, and a diminished quality of life. Findings included . Resident 7 Review of the electronic health record (EHR) showed Resident 7 readmitted to the facility on [DATE] with diagnoses of fracture of the spine, chronic kidney disease, and diabetes (too much sugar in the blood). Resident 7 was able to make needs known. Review of a provider's orders, dated 04/14/2025, showed Resident 7 had a 1200 cubic centimeter (cc) fluid restriction with 420 cc provided by nursing and 780 cc provided by dietary. Review showed a provider's order, dated 04/14/2025, for night nursing to total the fluids provided by nursing and dietary during the day. Observation on 05/06/2025 at 1:21 PM showed Resident 7 laid in bed with a lunch tray on their overbed table with a menu card showing the resident was on a one cup fluid restriction. Observation showed a full glass of water and a half glass of milk on Resident 7's tray. Observation on 05/07/2025 at 9:20 AM showed Resident 7 laid in bed with an empty paper cup, a plastic cup with water, and a plastic cup of water on the overbed table. Observation on 05/07/2025 at 10:28 AM showed Resident 7 laid in bed with an empty plastic cup, two paper cups with water, and a plastic cup of milk on the overbed table. During an interview on 05/08/2024 at 9:17 AM, Staff U, Certified Nursing Assistant (CNA), stated the CNAs were responsible for documenting how much fluid a resident received during meal services and a small cup was 120 cc. Staff U stated they knew which residents were on a fluid restriction by looking at the care directives. Staff U stated Resident 7 was not on a fluid restriction. Review of the EHR showed two care directive monitors, dated May 2025, for the CNA to document Resident 7's fluid intake; one for day and one for night. Review of 05/01/2025 to 05/07/2025 showed the following documented intake for both day and night: 05/01/2025 - Total 320 cc 05/02/2025 - Total 720 cc 05/03/2025 - Total 480 cc 05/04/2025 - Total 720 cc 05/05/2025 - Total 340 cc 05/06/2025 - Total 320 cc 05/07/2025 - Total 840 cc Review of the May 2025 medication administration record (MAR) showed Resident 7 was documented for both dietary and nursing fluid intake and had an area for nursing staff to total fluid intake on the night shift. Review from 05/01/2025 to 05/07/2025 showed the following amounts: 05/01/2025 - Dietary 960 cc, nursing 480 cc, and total intake for the day 920 cc 05/02/2025 - Dietary 300 cc, nursing 480 cc, and total intake for the day 1200 cc 05/03/2025 - Dietary 200 cc, nursing 360 cc, and total intake for the day 860 cc 05/04/2025 - Dietary 240 cc, nursing 340 cc, and total intake for the day 1080 cc 05/05/2025 - Dietary 360 cc, nursing 360 cc, and total intake for the day 1080 cc 05/06/2025 - Dietary 420 cc, nursing 1140 cc, and total intake for the day 1120 cc 05/07/2025 - Dietary 540 cc, nursing 560 cc, and total intake for the day 1120 cc [Seven of seven days were not totaled accurately.] During an interview on 05/08/2025 at 11:52 AM, Staff N, Unit Manager/Licensed Practical Nurse (UM/LPN), stated for a fluid restriction the nurse on the cart would monitor the amount provided with medications and the kitchen would provide the amount of liquid on the food tray card. Staff N stated the CNA should know what residents were on a fluid restriction by looking at the care directive and the signage at the head of the bed. Staff N stated the signage was not posted above Resident 7's bed. Observation, interview, and record review on 05/08/2025 at 12:33 PM showed Resident 7's meal tray had a cup of coffee, a cup of apple juice, and a cup of water. Review of the meal card showed to provide eight ounces water and six ounces juice and Resident 7 was on a one cup fluid restriction. Staff N, UM/LPN, stated the menu card indicated to provide one cup fluid restriction but Resident 7 received approximately 420 cc of liquid with lunch. Resident 381 Review of the EHR showed Resident 381 admitted to the facility on [DATE] with diagnoses of dementia and diabetes. Resident 381 was able to make needs known. Review of a provider's orders, dated 04/21/2025, showed Resident 7 had a 2000 cc fluid restriction with 600 cc provided by nursing and 1400 cc provided by dietary. Review showed a provider's order, dated 04/21/2025, for night nursing to total the fluids provided by nursing and dietary during the day. Observation on 05/082025 at 10:59 AM showed Resident 381 in bed with a full water pitcher on the overbed table. Review of the EHR showed two care directive monitors, dated May 2025, for the CNA to document Resident 381's fluid intake; one for day and one for night. Review of 05/01/2025 to 05/07/2025 showed the following documented intake for both day and night: 05/01/2025 - Total 2,520 cc 05/02/2025 - Total 940 cc 05/03/2025 - Total 980 cc 05/04/2025 - Total 960 cc 05/05/2025 - Total 1,560 cc 05/06/2025 - Total 2,760 cc 05/07/2025 - Total 960 cc Review of the May 2025 MAR showed Resident 7 was documented for both dietary and nursing fluid intake and had an area for nursing staff to total fluid intake on the night shift. Review from 05/01/2025 to 05/07/2025 showed the following amounts: 05/01/2025 - Dietary 240 cc, nursing 240 cc, and total intake for the day 120 cc 05/02/2025 - Dietary 360 cc, nursing 290 cc, and total intake for the day 2000 cc 05/03/2025 - Dietary 480 cc, nursing 240 cc, and total intake for the day 2000 cc 05/04/2025 - Dietary 1,250 cc, nursing 600 cc, and total intake for the day 2000 cc 05/05/2025 - Dietary 400 cc, nursing 400 cc, and total intake for the day 2000 cc 05/06/2025 - Dietary 400 cc, nursing 400 cc, and total intake for the day 2000 cc 05/07/2025 - Dietary 680 cc, nursing 370 cc, and total intake for the day 1170 cc [Seven of seven days were not totaled accurately.] During an interview on 05/08/2025 at 12:42 PM, Staff V, Registered Dietician, stated they compiled tray cards on the computer through reviewing provider's orders and interviewing the residents regarding their allergies and preferences. Staff V stated fluid restrictions were put at the bottom on the menu card, so kitchen staff were aware of how much fluid to provide. Staff V stated both Resident 7 and Resident 381's meal tickets instructed staff to provide more than the fluid restriction allowed. During an interview on 05/08/2025 at 2:09 PM, Staff B, Director of Nursing Services, stated Residents 7 and 381 were not provided with fluid restrictions per provider's orders and this did not meet their expectations. Reference WAC 388-97-1060 (3)(i) .

CONCERN (E)

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

Respiratory Care (Tag F0695)

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 oxygen tubing was dated and regularly changed for 3 of 3 sampled residents (Residents 7, 112 and 87) when reviewed for respiratory care. This failure placed residents at risk for unmet care needs, medical complications, and a diminished quality of life. Findings included . Review of a facility's policy titled, Oxygen Therapy, dated 1/2020 showed oxygen tubing, cannula or mask, humidification was to be changed weekly by nursing staff. An additional policy titled, Small Volume Nebulizer (SVN, a device used to deliver medication in the form of a fine mist, or aerosol, to the lungs through inhalation) and a Metered-Dose Inhaler, (MDI, a device that delivers a specific amount of medication to the lungs in a form of a short burst of aerosol medication via inhalation), treatment, dated 11/2023 showed the facility's clinical team members were responsible in the delivery of the intermittent aerosol therapy by SVN. The equipment was to be changed weekly, the SVN reservoir was to be rinsed, and the excess fluid shaken from the reservoir and allowed to air dry. Resident 7 Review of Resident 7's electronic health records (EHR) showed the resident admitted to the facility on [DATE] with multiple diagnoses to include congestive heart failure (CHF, a chronic condition that results from a weakened heart muscle making it unable to pump blood efficiently throughout the body), asthma (a chronic respiratory disease characterized by inflammation and narrowing of the airways in the lungs which may cause breathing difficulties, wheezing, coughing, and chest tightness), and pleural effusions (a condition that occurs when an abnormal buildup of fluid in the space between the lungs and the chest wall that may result in shortness of breath, coughing and chest pain). Observation on 05/06/2025 at 1:09 PM showed Resident 7's room had SVN equipment uncovered on top of their bedside table. The SVN tubing was undated, and the reservoir was observed to have approximately 2-3 milliliters (mls) of unknown clear liquid noted within the container. During an interview on 05/06/2025 at 1:10 PM, Resident 7 stated the nurses would administer the medication (SVN treatments) to them from time to time due to their shortness of breath. Review of the provider order, dated 05/02/2025, showed Resident 7 was prescribed Ipratropium-Albuterol solution to be inhaled orally via nebulizer (SVN) every 4 hours as needed for wheezing and shortness of breath. Review of Resident 7's medication administration record (MAR) for May 2025 showed the resident had been administered the Ipratropium-Albuterol inhaler on May 2, 2025, at 9:22 PM and May 4, 2025, at 5:01 AM and 9:23 PM. Resident 112 Review of Resident 112's electronic health records (EHR) showed the resident admitted to the facility on [DATE] with multiple diagnoses to include heart failure (a chronic condition that results from a weakened heart muscle making it unable to pump blood efficiently throughout the body), dyspnea (shortness of breath or difficulty breathing), and pulmonary hypertension (a condition characterized by high blood pressure in the pulmonary arteries, which carry blood from the heart to the lungs. It can be caused by various factors, including heart and lung diseases, and can lead to shortness of breath and other symptoms). During an interview and observation on 05/06/2025 at 12:37 PM, Resident 112 sat up next to their bed eating lunch, an oxygen mask and tubing was observed on the resident bed. The mask was clear and had elastic white straps attached, the mask's tubing was undated and was attached to an oxygen concentrator (a machine that delivers a higher concentration of oxygen who requires supplemental oxygen therapy due to low oxygen levels in their blood) set at 2.5 liter/minute. When asked about the oxygen mask observed on the bed, Resident 112 stated they had just removed the mask to eat their lunch, and they had that oxygen mask at a hospital they were previously at prior to being admitted to the facility. Review of Resident 112's provider order dated 02/07/2025 showed licensed nurses were to administer O2 (Oxygen) at 2-4 liters per minute nasal cannula and to maintain resident oxygen saturations greater than 92 %, every day and night shift for shortness of breath. In addition, staff were to change and label the resident's oxygen tubing and rinse and replace filter once weekly on Wednesday by night shift. During an interview on 05/06/2025 at 12:42 PM, when asked about the undated oxygen tubing and mask, Staff Q, Licensed Practical Nurse (LPN), stated they were an agency nurse and did not know the facility's policy for dating the tubing but stated they believed they were supposed to clean the mask with water and let it air dry. During an interview on 05/06/2025 at 12:44 PM, Staff P, Unit Coordinator/LPN (UC/LPN), stated their expectation would be for the mask to be changed and oxygen tubing dated weekly. During an interview on 05/06/2025 at 12:48 PM, Staff C, Unit Manager/Registered Nurse (UM/RN), stated their expectation would be for staff to date the tubing and changed the mask weekly. Resident 87 Review of Resident 87's EHR showed the resident admitted to the facility on [DATE] with multiple diagnoses to include heart failure and acute respiratory failure with hypoxia (a medical condition where the lungs are unable to adequately transfer oxygen into the bloodstream or remove carbon dioxide from the blood and results in low blood oxygen levels). Observation and interview on 05/05/2025 at 2:28 PM showed Resident 87 in their room and had an oxygen condenser set at 2 liters/minute with a small clear plastic humidifier attached, no date was observed on the oxygen tubing. Resident 87 stated the plastic water bottle (humidifier) would get changed routinely but was not sure how often. Review of Resident 87's EHR showed a provider's order for oxygen to be set at 2 liter/minute via nasal canula (plastic rubber tubing) and to keep the residents oxygen saturations greater than 92% or greater for comfort and shortness of breath; however, there was no order for the oxygen tubing or humidifier to be changed. During an interview on 05/06/2025 at 1:28 PM, Staff B, Director of Nursing Services (DNS), stated it was their expectation the tubing (oxygen) was changed by the staff weekly and there was an order in the resident's chart (EHR). Reference WAC 388-97-1060 (3)(j)(vi) .

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

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. Based on observation, interview, and record review, the facility failed to post the scheduled and actual hours worked for the nursing staffing hours daily for 4 of 4 observed days during the survey period (05/05/2025-05/08/2025) when reviewed for nurse staff posting. This failure prevented the residents, family members, and visitors from exercising their rights to know the scheduled and actual numbers of available nursing staff in the facility. Findings included . Observations of the daily posted nurse staffing information on 05/05/2025, 05/06/2025, 05/07/2025, and 05/08/2025 showed no scheduled or actual hours worked documented for each discipline on each shift. During an interview on 05/08/2025 at 12:45 PM, Staff T, Staffing Coordinator, stated they kept track of schedule and actual hours worked; however, they did not post them. Staff T stated once the nursing staffing hours were posted daily, they rarely got updated once posted for the day. During an interview on 05/08/2025 at 1:11 PM, Staff A, Administrator, stated the Staffing Coordinator was responsible for the daily nursing staffing postings. Staff A stated they were not aware that the daily postings did not include the scheduled and actual nursing hours worked and were not updated each shift. Staff A stated this did not meet expectations. No Associated WAC .

Mar 2025 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

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 promptly resolve grievances for 1 of 5 sample residents (Resident 1) reviewed for grievances and missing property. The failure to thoroughly investigate a grievance and either resolve the resident grievance timely or provide an explanation if the grievance could not be resolved placed residents at risk for frustration and a diminished quality of life. Findings included . Review of the facility Resident and Family Grievances policy and procedure, dated 01/2024, showed Staff E, Social Services Director was the designated Grievance Official. Grievances may be in the form of verbal complaint, or written complaint, to a staff member, Grievance Official, to an outside party, or during resident or family council meetings. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions on the grievance form. The Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum the date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Review of the facility Missing Property policy and procedure, dated 07/22/2022, showed the facility would replace residents' items if they were lost, broken, or misplaced due to negligence while in the possession of, or under the control of, facility staff. In order for these items to be replaced it must be documented in the resident's Personal Belongings Inventory list prior to being lost, broken, or misplaced. According to this policy the admitting nursing assistant would assist with filling out the Personal Belongings Inventory List. Review of the facility Personal Possessions Record/Care of Resident's Property policy and procedure dated 02/2008 showed the Personal Possessions Record was to be completed by nursing staff within eight hours of admission. After completion of the admission inventory, the form was to be dated and signed by the resident or responsible party, and facility employee. Review of the admission Checklist for Nursing Assistants, dated 11/20/2024, showed the Personal Possession Record was not Completed for Resident 1. Review of Resident 1's record showed a Glasses, Dentures, & Hearing Aids form, dated 11/20/2024, indicating Resident 1 did not have glasses. During an interview on 03/13/2025 at 11:49 AM, Staff D, Registered Nurse (RN), stated staff fill out a paper copy of the inventory list which was scanned and labeled Personal Belongings. Staff D stated, I don't see one for Resident 1. During an interview on 03/18/2025 at 5:04 PM, CC 2 stated at discharge it was noted that nobody filled out the inventory form at admission. Review of the December 2024 Grievance Log showed a 12/31/2025 entry for Resident 1 missing item which was referred to environmental services, and nursing 01/02/2025. According to the log, the grievance was resolved. Review of the Comment & Concern Form showed the Grievance type was identified as missing items; glasses brown and belt brown. Under description was documented, Missing Belt and Glasses. Other Grievances sent via email, awaiting response RE: Social worker and forms. Other Grievances filed as well regarding communication and appointments. The desired resolution was to be contacted regarding the concerns and to have the items returned. During an interview on 02/25/2025 at 2:56 PM Collateral Contact 1 (CC 1) stated they had multiple grievances which were not addressed at all. CC 1 stated Resident 1 had reported missing items; a khaki brown fabric twist belt with a metal clasp and turtle shell reddish colored glasses - cheaters from a pharmacy. They also had a grievance regarding Staff G's, Social Services Assistant, involvement in Resident 1's care. Review of a timeline of notes maintained by Resident 1's family members showed their eyeglasses went missing and was reported to (unnamed) staff on 12/05/2024. During an interview on 02/28/2025 at 11:08 AM, Staff E, Social Services Director, stated they received only one Grievance regarding Resident 1, it was the only one put in the box. Staff E stated the missing items were not found. Staff E stated Staff G called Resident 1, followed up and told them since they were not managing the items they would not be replacing them. Staff E was unable to provide the back side of the Grievance form with the documented investigation, actions taken, and/or resolution. Review of a 12/24/2025 Social Services Note written by Staff F, Social Services Assistant, documented Resident 1's daughter had questions regarding Skilled Nursing Care Advance Beneficiary Notice (SNF ABN) that was signed by the resident. Staff F explained the administrator was following up on SNF ABN and the information provided was all that Staff F had at that time. The conversation was concluded as it was no longer productive. Daughter would like to speak with administration. Staff F alerted proper departments. Review of an email communication to the facility on [DATE] showed a request from Resident 1's daughter to remove Staff F from Resident 1's care, with reasons listed and explained, mainly that Staff F had Resident 1 sign forms that they did not understand. Also regarding communication issues, and wanting a discussion with Staff A, Administrator. Review of an email communication to the facility on [DATE] asked Staff E, Following up again in hopes I can get an ETA (Estimated Time of Arrival) as to when these concerns will be addressed? Another email was sent 01/14/2025 to Staff E and Staff A commenting that they had still not heard from them regarding their concerns and asked them to respond to their emails, phone calls and grievance form. Review of an email communication dated 01/16/2025 showed Staff E wrote, We understand your concerns and want to assure you that during (Resident 1's) stay, they received the highest level of care, comfort, and respect from our team. As previously shared, we have provided all appropriate information regarding their stay and care. Beyond this, we have no additional information to offer regarding Resident 1's time at the facility. Review of email communication showed on 01/22/2025 another email was sent to the facility, with multiple questions, including, Why are the concerns about (their) missing items not being addressed? Why is the grievance form that the nurse asked me to fill out not being addressed? On 01/24/2025 Staff A wrote an email reply, Your concerns have been addressed by the care team. During an interview on 03/18/2025 at 12:22 PM Staff E stated the grievance follow up was documented on the grievance forms, not in the progress notes. Staff E stated they were not able to locate the back side of the grievance form. Staff E stated they addressed the issue regarding Staff F and forms and documented that action in the progress notes. During an interview on 03/18/2025 at 12:22 PM Staff A stated they responded to the grievances and questions posed, in a letter, and in multiple email communications. During an interview on 03/18/2025 at 1:09 PM Staff A stated they followed the missing items policy. REFERENCE: WAC 388-97-0460. .

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

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 interview, and record review the facility failed to ensure 1 of 3 sample residents (Resident 1) reviewed for Pressure Ulcers (PU - injury to the skin and underlying tissue due to prolonged pressure) received the necessary care and services, consistent with professional standards of practice, to prevent new ulcers from developing, identify and treat PUs. Failure to implement wound prevention, interventions, and to report on worsening conditions, placed residents at risk for deteriorating PU, increased discomfort, and a diminished quality of life. Findings included . Review of the 11/27/2024 admission Minimum Data Set (MDS - an assessment tool) showed Resident 1 was alert, oriented and was assessed to require substantial/maximal assistance with bed mobility, and had diagnoses including Peripheral vascular disease, and Diabetes Mellitus. Resident 1 was assessed at risk of developing pressure ulcers, and had no pressure ulcers, no venous ulcers, no arterial ulcers, no diabetic foot ulcers and no open lesions on the foot. Review of the Potential Skin Integrity Care Plan, initiated 11/21/2024, listed interventions to keep the feet clean and dry. The Resident prefered to wear cotton socks, slippers, podus boots etc. to protect the feet. Monitor/document location, size, and treatment of skin injury. Report abnormalities, signs/symptoms of infection, etc. to MD (Medical Doctor). Review of the December 2024 Treatment Administration Record (TAR) showed orders dated 11/20/2024 for nursing to check entirety of skin, update would rounds assessments for new or known skin issues per protocol, every Thursday. Staff documented performing the task on 12/26/2024. Review of physician orders showed a 12/13/2025 order to apply external lotion to the resident's bilateral arms and legs at bedtime for dry skin. Review of the December 2024 Medication Administration Record (MAR) showed staff documented application to both legs in the evenings of 12/13/2024 through 12/30/2024. Review of a timeline of notes maintained by Resident 1's family members showed on 12/15/2024 Resident 1 began reporting to staff that they had pain in the heels of both their feet and that no treatment was provided other than application of lotion. During an interview on 03/18/2025 at 4:00 PM, CC 2 stated Resident 1 had pain in their heel which they reported days before discharge. Review of a 12/28/2025 10:15 PM Alert Note showed Resident 1 reported left foot swelling and pain in their left heel for a few weeks. 1+ pitting edema (a mild degree of swelling) noted to left foot. RN (Registered Nurse) encouraged them to elevate legs and float heels when in bed. Review of a Care Plan Update Note, dated 12/31/2024, showed Resident 1 discharged from the facility at 12:00 PM - Noon. Review of the listing of active and inactive wounds in Resident 1's record, showed no heel wounds were identified. No open area to Resident 1's left heel was identified prior to discharge from the facility on 12/31/2025 to another nursing facility. During an interview on 03/18/2025 at 3:27 PM, CC 3 stated Resident 1 was admitted [DATE] with a pressure wound to their left heel that the facility did not disclose prior to admission. CC 3 stated that although the pressure ulcer had since healed, Resident 1 still complained of pain in their heel. Review of the receiving facility's Nursing admission Assessment, dated 12/31/2024 at 1:21 PM, showed Resident 1 was assessed with a Stage II (partial thickness shallow open ulcer) PU to their left heel measuring 1 centimeter (cm) x 1 cm x 0.1 cm deep. According to the assessment the wound bed was 100% slough tissue (yellow dead cell tissue). The surrounding area was red. Treatment orders were obtained and implemented to apply alginate to the wound and cover with a padded dressing. REFERENCE: WAC 388-97-1060 (3)(b). .

Oct 2024 1 deficiency 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 evaluate the effectiveness of fall prevention interventions, need for additional action, and/or attempt to mitigate envionmental modifications preferred by the resident that presented a risk to safety for 1 of 3 sampled residents (Resident 1) reviewed for accidents and hazards. Resident 1 experienced harm when they fell out of bed and sustained a neck fracture. This failure placed residents at risk for falls, injury and a diminished quality of life. Findings included . Review of the facility Fall Prevention Program policy and procedure dated 03/2023 showed the facility used a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. According to the policy, each resident's risk factors, and environmental hazards are evaluated when developing the resident's comprehensive plan of care. <Resident 1> Review of the 08/21/2024 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 1 was assessed as cognitively intact, with no behaviors, required substantial assistance with bed mobility, transfers, toileting, was frequently incontinent and a toileting program of scheduled toileting had not been attempted. According to this MDS, Resident 1 had two non-injury falls and two falls with injury since the last Quarter's MDS. Review of Resident 1's Fall Risk Assessment showed they were assessed at High Risk with a score of 20 on 08/26/2024, a High Risk with a score of 21 on 09/19/2024, and 10/01/2024. Review of the 12/01/2021 Fall Care Plan (CP) showed Resident 1 fell on [DATE], 06/21/2024, 08/13/2024, 08/25/2024, 08/26/2024, 09/19/2024 and 10/01/2024. Staff were directed to maintain a clear pathway, free of obstacles. Review of the 06/04/2024 Incident Report showed Resident 1 was found on their bedroom floor, on their left side, between the table and bed. One hour before the fall, Resident 1 was observed in bed sleeping. Resident 1 sustained skin tears and bruising to their arms. The Fall CP was revised on 06/05/2024 to place bed in a diagonal position to create space for the resident. Review of the 06/21/2024 3:00 AM Fall Investigation showed Resident 1 woke up, sat at the bedside and slipped off the bed landing in the sitting position. The resident sustained no injuries. During an interview on 10/21/2024 at 3:00 PM, Staff E, MDS Nurse, stated at that time Resident 1's bed was in room [ROOM NUMBER], diagonal to the door and accessible from either side of the bed. Review of the census showed Resident 1 changed rooms on 08/08/2024. During an interview on 10/25/2024 at 11:40 PM Staff G, Social Services, stated that they believed Nursing staff did a deviation of care (care that does not follow the standard) regarding the diagonal bed when Resident 1 moved from the 900 to the 800 hall. During an interview on 10/25/2024 at 11:33 AM, Staff F, Resident Care Manager (RCM), stated that when Resident 1 moved to the 800 Hall they told the staff how they wanted their bed and where to put their stuff. Staff F said the Resident was their own decision maker. Staff F stated they did not review risks and benefits and did not do a deviation of care. Staff F could not find that either had been completed and placed in the resident's record. Review of 08/13/2024 11:30 PM Fall Investigation showed Resident 1 attempted to self-transfer from the edge of the bed, slid and fell. Resident 1 was found on their left side. Resident 1 sustained skin tears and bruising to their arms. Review of the 08/26/2024 3:55 AM Fall Investigation showed Resident 1 was found on the floor next to their bed. The resident reported they were trying to get out of bed. Review of the undated Incident Summary showed Resident 1's fall risk score was 19 indicating they were at high risk for falls. The fall risk was related to diagnoses, medications, cognition, deconditioning, poor awareness of personal safety, and a strong desire to remain independent. Fall interventions in place included lock wheelchair at bedside when not in use, encourage resident to use call light when needing assistance, encourage to wait for staff when attempting to transfer. The resident was independent with bed mobility and reminded to turn every two hours. Review of the 10/01/2024 4:20 AM Fall Investigation showed Staff H, Licensed Practical Nurse (LPN), documented they responded to the alarm from Resident 1's room, I did not find the resident on the bed, but the wheelchair was besides the bed. I started looking for her in the bathroom, but she was not there. Then I looked on the other side of the bed and found her laying on her neck with all her weight, lower body up . Review of the 10/01/2024 5:12 AM Fall Note written by Staff H showed the resident was found in a cumbersome position, the bed was also restricting the space. Review of the undated Incident Summary showed the nurse and nursing assistant repositioned the resident to relieve pressure off their head and neck and ensure they could breathe. The nurse called 911 and the resident was transported and admitted to the hospital. During an interview on 10/25/2024 at 10:24 AM, Staff C, Assistant Director of Nursing, stated Resident 1 was found with their head down and feet up. The staff moved the resident so the resident could breathe and called 911. Staff C stated the bed was at an angle because that was how Resident 1 wanted it. During an interview on 10/21/2024 at 10:10 AM Resident 1's representative stated they felt the facility was negligent in Resident 1's safety as the resident was a high fall risk and the facility left the bed diagonal from the wall, with no fall mats, and Resident 1 fell in that area. Resident 1's representative stated the way the dresser was placed left only a triangle of floor space and would not have allowed Resident 1 to get out if they fell in there. Resident 1's representative stated they were told Resident 1 had rights and wanted the bed placed at a triangle from the wall, but it was an entrapment risk and should not have been allowed. On 10/21/2024 at 3:54 PM, Staff I, Certified Nursing Assistant (CNA), stated the bed was angled because that was what the resident preferred. Staff I explained the space between the dresser, the mattress and the wall, was a tiny bit of space, not much space. Staff I stated they suggested placing the bed against the wall, but was told it would be a restraint. On 10/21/2024 at 3:54 PM, Staff J, CNA, stated the resident wanted the bed angled to have more room. Staff J showed where the dresser was placed. When asked if the resident could get around the dresser from the side of the bed, Staff J stated no. A 10/03/2024 Social Services Note showed Staff G called Resident 1's family member to see if it was okay for staff to pack up some of Resident 1's belongings to create more space in the room and make things more accessible for resident when they returned from the hospital. Review of the undated Incident Summary showed upon return to the facility on [DATE] the resident was placed in a low bed with a mat to the left side of the bed. During an interview on 10/25/2024 at 11:33 AM, Staff F said when Resident 1 returned from the hospital the bed was placed against the wall with a floor mat for safety. When asked why the bed had not been placed against the wall sooner, Staff F said because Resident 1 did not want it that way. Review of hospital records showed Resident 1 was hospitalized from [DATE] to 10/04/2024, diagnosed with a Cervical (neck) Fracture, a Nondisplaced superior sternal body (breast bone) fracture, and left-sided rib fractures. REFERENCE: WAC 388-97-1060(3)(g). .

Jun 2024 15 deficiencies

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

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 physical restraints with the use of a mobility device for 1 of 3 sampled residents (Resident 78) when reviewed for physical restraints. This failure placed residents at risk for avoidable injury, psychological harm, and decreased quality of life. Findings included . Resident 78 was admitted to the facility on [DATE] with multiple diagnoses to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements and difficulty with coordination), asthma, and depression. Resident 78 was able to make needs known. Observation on 06/02/2024 at 11:15 AM showed Resident 78 using a tilt in space wheelchair (w/c) with a pressure alarm attached to it. Resident 78 was leaning to the front right. A staff member repositioned the resident and tilted the w/c back. Review of Resident 78's electronic health record showed no documentation of a restraint assessment or provider order for a restraint/tilt in space w/c. Review of initiated care plan, dated 03/03/2023, showed no care plan instructions about the tilt in space w/c or how to postition Resident 78. On 06/05/2024 Staff C, Registered Nurse/Unit Manager, produced a care plan, provider order and restraint assessment related to the use of the tilt in space w/c. The provider order and care plan included specific angles to tilt Resident 78's w/c. On 06/05/2024 at 2:22 PM, during an interview and observation of Resident 78, Staff C stated Resident 78 was not positioned appropriately and appeared uncomfortable. Staff C confirmed there were no markings on the w/c to identify the angle of tilt to meet the provider order and care plan. Reference WAC 388-97-0620(1) .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

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 accurately assess a pressure ulcer/skin condition for 1 of 3 sampled residents (Resident 7) reviewed for pressure injury. This failure placed the resident at risk for health complications and diminished quality of life. Findings included . Resident 7 was admitted to the facility on [DATE] with multiple diagnoses to include Alzheimer's disease (a brain disorder that destroys memory and thinking skills), adult failure to thrive, and abnormal weight loss. Resident 7 was not able to make needs known. Review of a quarterly Minimum Data Set (MDS), an assessment tool, dated 05/20/2024, showed Resident 7 had two unstageable pressure ulcers (injury to skin due to pressure) which were present on admission. During an interview on 06/05/2024 at 10:06 AM, Staff K, MDS Nurse, stated it was coded inaccurately as Resident 7's pressure ulcers developed after admission into the facility. During an interview on 06/05/2024 at 11:22 AM, Staff B, Director of Nursing Services, stated the expectation was to make sure the MDS assessment matched the resident's condition. Reference WAC 388-97-1000(1)(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** . Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 4 sampled residents (Residents 2, 88 & 28) reviewed for anticoagulant (blood thinner medication) use and/or indwelling urinary catheter (IUC, a tube inserted in the body to empty the bladder of urine) care. The facility failed to ensure Resident 28 and 88's provider's orders for IUC were in place and/or accurate, and Resident 2's anticoagulant monitoring for side effects were documented. These failures placed residents at risk of medical complications, unmet needs, and a poor quality of life. Findings included . Review of Lippincott's Manual of Nursing Practice, dated 2024, showed that for patients receiving anticoagulation therapy observe carefully for any possible signs of bleeding and report immediately so that anticoagulant dosage may be reviewed and altered, if necessary. Resident 2 Resident 2 admitted to the facility on [DATE] with a diagnosis of atrial fibrillation (a chronic heart condition with abnormal heartbeat). Review of the electronic health record (EHR) showed Resident 2 was receiving Eliquis (a medication that thins the blood) to prevent blood clots twice a day with a start date of 09/01/2020. Observation and interview on 06/02/2024 at 2:16 PM showed Resident 2 had some bruising on both their arms and stated they had some bruising on their legs. Review of Resident 2's care plan, dated 03/26/2020, showed an entry for alteration in cardiac status related to atrial fibrillation with an intervention to assess the resident for abnormal bleeding. Review of Resident 2's EHR showed no documentation related to monitoring for abnormal bleeding or bruising. During an interview on 06/04/2024 at 11:17 AM, Staff C, Registered Nurse/Unit Manager, stated Resident 2 should have had an order on the medication administration record (MAR) to monitor for adverse side effects of the anticoagulant medication but did not. During an interview on 06/04/2024 at 11:44 AM, Staff B, Director of Nursing Services, stated it was their expectation that Resident 2 had an order in the MAR for staff to monitor for adverse side effects of anticoagulant medications. Resident 88 Resident 88 admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements and difficulty with coordination), neuromuscular disfunction of the bladder (inability to control the bladder) and benign prostate hypertrophy (BPH, an enlarged prostate). During an interview and observation on 06/02/2024 at 10:58 AM, Resident 88 stated they had severe lower abdominal pain because of the catheter. The resident was grimacing and holding their groin. Review of the EHR showed an order dated 11/27/2023 for an IUC (Specify Size) for Retention -change monthly on 27th of Month, and an order dated 06/02/2024 for IUC Changed as Needed for BPH with urinary retention AND change on night shift on the 2nd of every month. Review of the care plan showed an entry dated 11/27/2023 for the IUC but did not specify the type or size to be used. During an interview on 06/04/2024 at 11:30 AM, Staff C, RN/UM, stated that Resident 88 should have had the size and type of IUC included in the orders and the care plan. Staff C stated the orders should have been clear on what day the IUC was to be changed. During an interview on 06/04/2024 at 11:41 AM, Staff B, DNS, stated Resident 88 should have had clear orders and a care plan which contained the type and size of IUC to be used. Resident 28 Resident 28 readmitted to the facility on [DATE] with a diagnosis of neurogenic bladder (lack of control to urinate), used an IUC, and was able to make needs known. Review of the June 2024 treatment administration record (TAR) showed Resident 28 had an order, dated 04/25/2024, for monthly IUC changes and as needed, 20 French (size of the IUC) on the 19th of every month. Documentation showed it was scheduled to be changed on 04/19/2024. An order dated 05/30/2024 showed to change the resident's IUC 22 French/30 cubic centimeters balloon (inflatable balloon at the end of the catheter to keep it in place) coude (a curved/bent tip at the end of the catheter) as needed for improper function. During an interview on 06/05/2024 at 12:09 PM Staff C stated that Resident 28 had two conflicting provider orders related to their IUC size and type and needed to be clarified by the provider. During an interview on 06/05/2024 at 12:25 PM, Staff B stated that Resident 28's provider orders related to their IUC did not meet expectations due to conflicting orders. Staff B stated that the expectation was that resident's with IUCs should have a clear and accurate provider order to include the type, size, and indication for use. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i) .

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 provide necessary treatment to heal pressure injuries for 1 of 3 sampled residents (Resident 7) reviewed for pressure injuries. This failure placed the resident at risk for worsening pressure injury, infection, and diminished quality of life. Findings included . Resident 7 admitted to the facility on [DATE] with multiple diagnoses to include Alzheimer's disease (brain disorder that destroys memory and thinking skills), adult failure to thrive, and abnormal weight loss. Resident 7 was unable to make needs known. Observation and interview on 06/05/2024 at 1:24 PM, during a dressing change, showed Resident 7 had a dressing on the right outer ankle area that was dated 05/31/2024. Staff L, Licensed Practical Nurse, stated the dressing was not changed on 06/03/2024 as ordered. Review of Resident 7's treatment administration record for June 2024 showed missing documentation for multiple orders on 06/03/2024 during day shift. During an interview on 06/05/2024 at 2:35 PM, Staff B, Director of Nursing Services, stated the expectation was for nurses to follow orders for dressing changes. Reference WAC 388-97-1060(3)(b) .

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 a fluid restriction for provided and monitored for 1 of 3 sampled residents (Resident 54) reviewed for nutrition. This failure placed the resident at risk of fluid overload, avoidable swelling, and a diminished quality of life. Findings included . Resident 54 admitted to the facility on [DATE] with diagnoses of pulmonary edema (water in the lungs) and kidney failure. Review of Resident 54's provider's orders showed a fluid restriction of 1500 milliliter (ml) with nursing to provide 600 ml and dietary 900 ml. Review of Resident 54's medication administration record (MAR) showed two sections to document the amount of fluid consumed. The first section showed for nursing and dietary to document the amount consumed from 6:00 AM with no end time. The second section showed for nursing and dietary to document the amount consumed from 6:00 PM to 6:00 AM. There was no location to total the daily amount consumed and no instructions on how much liquid to give per section. Review of the May 2024 MAR showed seven days where Resident 54 was provided more than 1500 ml of fluid. Review of the June 2024 MAR on 06/05/2024 showed three days where Resident 54 was provided more than 1500 ml of fluid. During an interview on 06/05/2024 at 10:57 AM, Staff C, Registered Nurse/Unit Manager, stated Resident 54 was on a 1500 ml fluid restriction and was receiving too much fluid. Staff C stated this did not meet their expectation. During an interview on 06/05/2024 at 1:30 PM, Staff B, Director of Nursing Services, stated Resident 54's fluid restriction documentation was confusing and there was no way to accurately monitor fluid intake. Staff B stated that the fluid restriction did not meet expectation. Reference WAC 388-97-1060 (3)(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 interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications (affecting the mind) were limited to 14 days for 1 of 5 sampled residents (Resident 6) when reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary psychotropic medication, avoidable medication side effects, and a diminished quality of life. Findings included . Resident 6 admitted to the facility on [DATE] with multiple diagnoses to include dementia (brain disorder that impairs memory and thinking skills), anxiety, and congestive heart failure. Resident 6 was unable to make needs known. Review of Resident 6's provider's orders showed an order for lorazepam (an antianxiety medication) every 2 hours PRN started on 05/04/2024 and without a stop date. Review of Resident 6's pharmacy recommendations dated 05/14/2024 showed a recommendation to stop lorazepam PRN after 14 days. Review of Resident 6's medication administration record showed that Resident 6 was administered lorazepam nine times in the month of May 2024 and one time in June 2024. During an interview on 06/05/2024 at 11:35 AM, Staff B, Director of Nursing Services, stated the expectation was for staff to follow pharmacy recommendations and Resident 6's lorazepam order did not meet this expectation. Reference WAC 388-97-1060(3)(k)(i) .

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 119 Resident 119 admitted to the facility on [DATE] with a diagnosis of dementia. Review of the EHR showed Resident 119 was receiving donepezil (used to treat Alzheimer's disease) daily for dementia, olanzapine (used to treat psychotic disorders) daily for dementia, with start dates of 02/25/2024; mirtazapine (used to treat depression) daily for sleep disturbance and risperidone daily for dementia with start dates of 2/24/2024. Review of Resident 119's EHR showed no documentation that the resident or their representative was provided education on the risks and benefits of the medications in writing or that consent was obtained prior to the use of the medications. During an interview on 06/05/2024 at 3:10 PM, Staff B stated it was their expectation that residents who received psychotropic medications or their representative received education on the risks and benefits of such medications and consent be obtained prior to administration. Reference WAC [PHONE NUMBER]300(3)(a), -0260, -1020(4) (a-b) Based on interview and record review the facility failed to have psychotropic (medications that affect a person's mental state) medication consents signed and in place prior to resident receiving medications for 3 of 5 sampled residents (Residents 40, 78 & 119) reviewed for psychotropic medication use. This failure placed the residents at risk for adverse side effects and diminished quality of life. Findings included . Review of the facility's document titled, The Process of Informed Consent, dated December 1998, showed to be fully informed, a nursing facility resident must receive appropriate and meaningful information relative to their health care decision-making. The procedure included language that residents could reasonably be expected to understand; Current medical condition or prognosis, Expected medical condition or prognosis, Suggested treatment or services, Anticipated results of proposed treatment, Recognized serious possible risks, complications and anticipated benefits involved in treatment and in the recognized possible alternative forms of treatment, including non-treatment. Resident 40 Resident 40 re-admitted to the facility on [DATE] with multiple diagnoses to include heart disease, dementia (a condition that impairs memory), anxiety and had a psychotic disorder. Review of Resident 40's quarterly Minimum Data Set (MDS), a required assessment tool, dated 03/01/2024, showed Resident 40 was able to make their needs known. Review of Resident 40's electronic health record (EHR) showed a current provider's order for risperidone (antipsychotic medication), dated 10/23/2023, to be administered by licensed nurses (LNs) three times a day to Resident 40. The provider had increased the risperidone medication from twice a day to three times a day; however, Resident 40's clinical documentation showed no consent was obtained from the resident's guardian for the increase. Resident 78 Resident 78 admitted to the facility on [DATE] with multiple diagnoses to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, and difficulty with balance and coordination), dementia, and depression. Review of quarterly MDS, dated [DATE], showed Resident 78 was able to make their needs known. Review of Resident 78's EHR showed a provider's order for citalopram (used in the treatment of depression), dated 03/20/2023, to be administered by LNs one time a day to Resident 78 for major depressive disorder. Review of Resident 78's EHR showed no consents were provided to the resident and/or residents representative upon admission for the medication citalopram. During an interview on 06/04/2024 at 12:20 PM, Staff C, Registered Nurse/Unit Manager, stated their expectations would be for the LNs to obtain the consents from either the resident or the resident's representative prior to administration of the psychotropic medication and document in the record. During an interview on 06/04/2024 at 1:30 PM, Staff B, Director of Nursing Services (DNS), stated the expectation for obtaining consents would be for the LNs to obtain the consents for the psychotropic medication first from either the resident's representative or the resident and document in the resident's medical records.

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** Resident 30 Resident 30 admitted to the facility on [DATE] with multiple diagnoses to include acute kidney failure (condition when the kidneys suddenly cannot filter waste from the blood) and edema (swelling). Resident 30 was able to make needs known. Observation and interview on 06/02/2024 at 11:45 AM showed Resident 30 sat in their wheelchair in their room with red non-skid socks on and stated their feet were swollen. Review of Resident 30's provider notes, signed on 05/20/2024, showed edema management to include to use TED hose stockings (compression stockings to reduce swelling in the legs), elevate legs when sitting for prolonged periods of time, and use of Lasix (medication that treats fluid retention) daily as needed for edema. Review of medication administration record showed no Lasix was administered for the month of May and June 2024. Review of Resident 30's EHR showed no care plan focus area that addressed the edema management and no documentation related to the resident's swelling of the feet. During an interview on 06/05/2024 at 11:30 AM, Staff B stated their expectation as that nursing staff would follow provider's orders. Resident 78 Resident 78 admitted to the facility on [DATE] with multiple diagnoses to include Parkinson's disease (brain disorder that causes unintended or uncontrollable movements and difficulty with coordination), asthma, and depression. Resident 78 was able to make needs known. Observation on 06/02/2024 at 11:15 AM showed Resident 78 used a tilt in space wheelchair (w/c). Resident 78 leaned to the front right, a staff member repositioned the resident, and tilted the w/c back. Multiple observations on 06/02/2024 through 06/05/2024 showed Resident 78 sat in the w/c and leaned towards the front and right side of the w/c. Review of Resident 78's care plan, initiated 03/03/2023, showed no instructions regarding positioning or sitting. Observation on 06/05/2024 at 1:23 PM showed Resident 78 was severely leaning toward the front right with their head on the right armrest and right hand was on the floor. During an interview 06/05/2024 at 2:22 PM, Staff C stated that Resident 78 was not positioned appropriately and appeared uncomfortable. During an interview on 06/05/2024 at 2:38 PM, Staff B stated the expectation was to have a clear care plan on resident's mobility and positioning. Reference WAC 388-91-1060(1) Resident 2 Resident 2 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a chronic lung disease) and CHF. During an interview on 06/02/2024 at 2:16 PM, Resident 2 stated that they had chest congestion and chest pain when they coughed. Observation showed the resident coughing up yellow mucus and was grimacing. The resident stated that the cough started on 06/01/2024. Observation and interview on 06/03/2024 at 11:51 AM showed Resident 2 coughing and grimacing and stated the staff had given them some cough medicine, but it did not help much. Review of the Resident 2's EHR showed an order for Mucinex cough syrup as needed every four hours with a start date of 08/12/2021 and an order for albuterol inhaler every four hours as needed for wheezing. Resident 2 had an order for oxygen with instructions to notify the provider if new cough or change in respiratory status. Review of the May 2024 medication administration record showed the resident did not receive any as needed cough medicine or albuterol inhalation for the month of May. Review of the June 2024 MAR showed the resident received two doses of cough medicine and one albuterol inhaler on 06/01/2024, and one dose of cough medicine on 06/02/2024. During an interview on 06/03/2024 at 11:52 AM, Staff F, Agency Licensed Nurse, stated they were aware of the resident's cough and had given the resident cough medicine but had not reported to the provider. Review of the progress notes showed no documentation that the provider was notified of new cough or change in respiratory status. A Social services note dated 06/03/2024 showed the resident reported being congested and not feeling well and that the nurse was aware. Observation and interview on 06/04/2024 at 10:48 AM showed Resident 2 laid in bed and was having difficulty breathing. The resident stated they still had a cough and it hurt to breath. Staff G, Unit Coordinator/Change Nurse, assessed the resident and stated that the resident should have been assessed to include testing for Covid-19 and the provider should have been notified of the respiratory symptoms. During an interview on 06/04/2024 at 11:22 AM, Staff C, Registered Nurse/Unit Manager, stated if a resident had new or worsening respiratory symptoms staff should have assessed the resident, notified the provider and placed the resident on alert. During an interview on 06/04/2024 at 11:49 AM, Staff B stated that floor staff should have alerted the provider as soon as possible when a change in respiratory status was identified for Resident 2. Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 5 of 25 sampled residents (Residents 107, 30, 42, 78, and 2) reviewed for quality of care. Failure to consistently monitor and document edema (swelling caused by too much fluid trapped in the body's tissues) for Resident 107 and 30, provide management of a surgical wound for Resident 42, ensure adequate positioning was provided for Resident 78, and notify the provider of an acute change in respiratory status for Resident 2 placed the residents at risk for worsening conditions, discomfort, and a decreased quality of life. Findings included . Resident 42 Resident 42 admitted to the facility on [DATE] with a diagnosis of fracture of left femur with subsequent placement of an intramedullary rod (a medal rod used to stabilize long bone fractures within the cavity of the bone). During an interview on 06/03/2024 at 10:08 AM, Resident 42's family member stated they believed the resident's surgical wound was not being properly managed at the facility and that Resident 42 had to be readmitted to the hospital for an infection to the surgical wound site. Review of Resident 42's electronic health record (EHR) showed that a surgical wound culture was obtained on 03/25/2024. Review of Resident 42's EHR showed that a call was placed to the lab by a licensed nurse (LN) on 03/29/2024 (four days after the culture was obtained) to check on the surgical wound culture; however, per the lab it was still being processed. Review of Resident 42's progress notes, dated 04/01/2024, showed the following: 6:46 AM - Resident 42's upper right hip incision showed inflamed, purulent (consisting of, containing, or discharging pus), and painful wound next to surgical site. Palpation (touching) by the LN revealed a possible cyst/abscess. The provider was contacted, assessed the resident, and informed the LN that antibiotics would be ordered. 5:24 PM - The on-call provider was notified of Resident 42's surgical wound cultures and an order for an antibiotic was obtained; however, the facility would need to contact the orthopedic surgeon prior to initiating the antibiotic orders. The antibiotic order for the right hip infection was placed on hold until the orthopedic doctor is called in the a.m. Review of Resident 42's progress notes, dated 04/02/2024, showed the following: 8:05 AM - A LN had called the orthopedic office and left a message with a scheduler regarding the resident's hip incision that had dehiscence (splitting or bursting open either partial or total separation of the wounds edges due to failure of proper wound healing), the wound culture results, and that the antibiotics had not yet been administered. 2:07 PM - LN was awaiting a call back from the orthopedics office. 5:17 PM - LN had documented the facility's provider ordered antibiotic that was on-hold to be administered. Review of Resident 42's progress notes, date 04/03/2024, showed that the resident was seen at the orthopedic office and new antibiotic orders were ordered along with a PICO drain (a wound care system that provides suction that draws out excess fluid from the wound to promote healing). During an interview on 06/04/2024 at 1:15 PM, Staff E, Registered Nurse/Unit manager, stated the culture results of Resident 42's surgical wound site should have been obtained within a timely manner and that there was a delay in getting the antibiotics started [greater than 9 days] while they waited on the orthopedics office to respond back to the facility. Staff E stated Resident 42 could have been sent to the emergency room to be seen quicker and treatment started sooner rather than waiting for the orthopedic providers office to respond. During an interview on 06/04/2024 at 1:35 PM, Staff B, Director of Nursing Services, stated that their expectation would be for the LNs to call the lab sooner to obtain the cultures results and if the orthopedic providers office was not responsive to the LNs calls then an option should have been to send the resident to the emergency room to be seen. Resident 107 Resident 107 re-admitted to the facility on [DATE] with a diagnosis to include congestive heart failure (CHF, a condition in which the hearts capacity to pump blood cannot keep up with the body's needs, that may result in buildup of fluid in the ankles, feet arms and other organs). Review of Resident 107's focus care plan, dated 05/19/2024, showed the resident had CHF. Multiple interventions directed the facility staff to assess daily for edema, to notify the provider for increased in edema, and weights to be monitored daily. During an interview on 06/03/2024 at 9:03 AM, Resident 107's family member stated that another family member had concerns that facility staff had not provided the necessary care and services for Resident 107's CHF, such as elevating Resident 107's legs and monitoring excess fluid accumulation. Review of Resident 107's incident investigation report dated 05/23/2024 showed documentation that Resident 107's family member had filed a complaint with the facility of neglect and the facility staff were not caring for the resident's needs related to CHF. Documentation within the incident report showed Resident 107 felt that their legs were swollen. During an interview on 06/05/2024 at 9:26 AM, Staff D, Registered Nurse/Minimum Data Set Nurse, stated they were the investigating staff who had reviewed the incident investigation and assessed Resident 107. Staff D stated they had noted the resident with +1 pitting edema (a measurement severity scale of fluid accumulation that showed an immediate rebound with a two millimeter (mm) pit or indentation in the resident's skin) to their lower extremities and that the resident's weight was up slightly. Staff D stated they had concluded the licensed nurse (LN) staff did not follow the focus care plan for the CHF and Resident 107's EHR clinical progress notes did not reflect any assessment of the resident's edema being documented. During an interview on 06/05/2024 at 11:20 AM, Staff B stated their expectation would be for LNs to ensure the focus care plan was followed and the LNs monitored and documented the resident's edema daily as part of their assessments.

CONCERN (E)

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

Accident Prevention (Tag F0689)

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 resident environments were free from accident hazards for 3 of 6 sampled residents (Residents 121, 68, and 4) when reviewed for accident hazards. The facility failure to secured medications (Resident 121), investigate falls and implement fall precautions (Resident 68), and ensure bedrails were firmly installed (Resident 4) placed residents at risk of avoidable injury, hospitalization, and a diminished quality of life. Findings included . <Unsecured Mediations> Observation on 06/02/2024 at 10:07 AM showed a refrigerator in the Narrows dining room with a lunch bag. Observation showed that the lunch bag contained a lidocaine patch (a topical medication to reduce pain). During an interview on 06/02/2024 at 10:42 AM, Staff A, Administrator, stated all medications should be locked in a medication cart or medication room and should not be accessible to residents. Staff A stated the lidocaine patch should not be left in the resident refrigerator. Observation on 06/04/2024 at 1:09 PM showed a lidocaine patch on Resident 121's bedside table unopened. During an interview on 06/04/2024 at 1:15 PM, Staff J, Licensed Practical Nurse, stated that Resident 121 was not assessed to be able to self-administer medications and should not have any medications at bedside. Staff J stated Resident 121 had a lidocaine patch at bedside and it should not have been there. During an interview on 06/05/2024 at 1:35 PM, Staff B, Director of Nursing Services, stated the facility ensured residents did not have access to medications by ensuring that they were secured inside medication carts or medication rooms. Staff B stated the lidocaine patch in the resident refrigerator and at Resident 121's bedside did not meet expectation. <Fall Investigation/Prevention> Resident 68 admitted to the facility on [DATE] and had diagnoses of heart failure, morbid obesity, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and psychotic order with hallucinations. Observation on 06/03/2024 at 9:13 AM showed Resident 68 had a transfer pole installed next to the bed and fall mats to either side of the bed. Review of the provider's orders showed Resident 68 had an order for a transfer pole with horizontal bar for transfers dated 11/03/2021. Review of assessments showed Resident 68 was assessed to be safe to use the transfer pole on 11/03/2021. Review of Resident 68's progress notes showed the following fall incidents: (1) 06/09/2023 - Resident 68 thought the window was open, decided to get up and close it, lost balance, and fell. (2) 06/21/2023 - Resident 68 did not remember why they got out of bed and fell. (3) 01/29/2024 - Resident 68 got out of bed to stretch and fell. (4) 02/27/2024 - Resident 68 got out of bed without assistance and fell. (5) 03/25/2024 - Resident 68 got out of bed without assistance and fell. Review of the care plan, initiated 07/13/2022, showed Resident 68 was at risk of falling due to confusion, deconditioning, balance problems, and psychoactive (affecting the brain) medication use and was unaware of their own safety needs. Review of the annual minimum data set assessment, dated 05/17/2024, showed Resident 68 required substantial/maximal assistance to transfer from sit to stand and from bed to wheelchair. Review of the fall investigations for the falls listed above showed the following conclusions: (1) 06/09/2023 - Resident 68 was closing the window and fell. This investigation did not show that Resident 68 was attempting to stand when they fell. (2) 06/21/2023 - Resident 68 was attempting to get out of bed due to impulsivity. (3) 01/29/2024 - Resident 68 had a trend of falls due to attempting to self-exit the bed. This investigation showed that Resident 68 was stretching in bed and not self-exiting the bed. (4) 02/27/2024 - Resident 68 was suspected to have self-exited bed and fell. (5) 03/25/2024 - Resident 68 got up and fell due to self-exiting. Review showed that none of these investigations considered the accident risk posed by the transfer pole. During an interview on 06/05/2024 at 11:33 AM, Staff C, Registered Nurse/Unit Manager, stated Resident 68 used the assistance of one person, the transfer pole, and a gait belt to transfer from the bed to the wheelchair. Staff C stated Resident 68 thought they could get up on their own and would attempt to self-transfer. Staff C stated that, due to behaviors, Resident 68 required two staff to be present when providing care and that the transfer pole provided the resident a level of independence. Staff C was unsure whether the transfer pole was considered as a cause for the previous falls when investigated. During an interview on 06/05/2024 at 2:44 PM, Staff B, Director of Nursing Services, stated Resident 68 should have been re-assessed for the safe use of the transfer pole after falls resulting from impulsively attempting to self-exit the bed. Staff B stated nursing staff assumed the transfer pole was safe because it was assessed by physical therapy in 2021, and physical therapy was not aware a new assessment should be completed as nursing did not inform physical therapy of Resident 68's falls. Staff B stated the communication between the nursing staff and physical therapy did not meet expectation. <Bed Rail> Review showed Resident 4 admitted to the facility on [DATE] with diagnoses of amputation, muscle wasting, dementia, and hemiplegia (inability to move) the left side. Observation on 06/02/2024 and 06/05/2024 showed Resident 4 had bedrails on both sides of the bed and the bedrails were able to move approximately an inch and a half back and forth. During an interview on 06/05/2024 at 11:33 AM, Staff C stated Resident 4's bedrails were loose and needed to be tightened. Staff C stated there was no regular system for inspecting bedrails and staff were expected to notice loose bedrails and notify maintenance. During an interview on 06/05/2024 at 1:37 PM, Staff B stated staff were to notice loose bedrails and notify maintenance. Staff B stated loose bedrails were a safety risk for entrapment and Resident 4's loose bedrails did not meet expectation. Reference WAC 388-97-1060 (3)(g) .

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

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 offer, educate, and obtain consent for influenza and/or pneumococcal vaccines for 5 of 5 residents (Residents 74, 90, 102, 108, and 120) when reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included . Review of the facility policy titled Vaccination for Residents dated 01/28/2022 showed that all residents would be offered vaccines that aided in preventing infectious diseases. Prior to receiving a vaccination, the resident or their representative would be provided information and education on the benefit and potential side effects of the vaccination and documented in the resident's medical record. Review of Resident 74's electronic health record (EHR) showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and provided education on the risks and benefits of the pneumococcal vaccination. Review of Resident 90's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and provided education on the risks and benefits of the influenza vaccination. Review of Resident 102's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and provided education on the risks and benefits of the pneumococcal vaccination. Review of Resident 108's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and provided education on the risks and benefits of the influenza vaccination. Review of Resident 120's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and provided education on the risks and benefits of the influenza vaccination. During an interview on 06/05/2024 at 11:49 AM, Staff H, Infection Preventionist/Registered Nurse, stated they did not have a consistent process in place for educating and obtaining consent for resident influenza and pneumococcal vaccines. During an interview on 06/05/2024 at 11:56 AM, Staff B, Director of Nursing Services, stated it was their expectation that staff would provide education on risks and benefits prior to offering and obtaining consent for influenza and pneumococcal vaccines for all residents. Reference WAC 388-97- 1340 (1), (2), (3) .

CONCERN (E)

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

Deficiency F0887 (Tag F0887)

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 offer, educate, and obtain consent for Covid-19 vaccinations for 5 of 5 residents (Residents 74, 90, 102, 108, and 120) when reviewed for immunizations. This failure denied residents the opportunity to make an informed decision regarding receiving Covid-19 vaccines and/or placed the residents at risk for complications, hospitalization, and a decreased quality of life. Findings included . Review of the facility policy titled Vaccination for Residents dated 01/28/2022 showed that all residents would be offered vaccines that aided in preventing infectious diseases. Prior to receiving a vaccination, the resident or their representative would be provided information and education on the benefit and potential side effects of the vaccination and this would be documented in the resident's medical record. Review of Resident 74's electronic health record (EHR) showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and/or provided education on the risks and benefits of the Covid-19 vaccine. Review of Resident 90's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and/or provided education on the risks and benefits of the Covid-19 vaccine. Review of Resident 102's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and/or provided education on the risks and benefits of the Covid-19 vaccine. Review of Resident 108's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and/or provided education on the risks and benefits of the Covid-19 vaccine. Review of Resident 120's EHR showed the resident admitted to the facility on [DATE]. No documentation was in the EHR that staff offered and/or provided education on the risks and benefits of the Covid-19 vaccine. During an interview on 06/05/2024 at 11:49 AM, Staff H, Infection Preventionist/Registered Nurse, stated they did not have a process in place for educating and obtaining consent for resident Covid-19 vaccines. During an interview on 06/05/2024 at 11:56 AM, Staff B, Director of Nursing Services, stated it was their expectation that staff would provide education on risks and benefits prior to offering and obtaining consent for all resident Covid-19 vaccines. No Reference WAC .

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to maintain kitchen equipment in safe working order for a griddle/oven combo unit and 1 of 4 freestanding refrigerators when reviewed for kitchen. These failures places residents at risk of eating contaminated food, avoidable foodborne illness, fire injury, smoke inhalation, and a diminished quality of life. Findings included . Observation on 06/02/2024 at 9:35 AM showed a freestanding refrigerator with a tray of sandwiches inside. Observation showed standing water on the bottom of the refrigerator and droplets of condensation gathered on the ceiling. A metal container was on a crossbar inside the refrigerator and had approximately two inches of water and a small screwdriver and screws inside. Observation on 06/02/2024 at 9:48 AM showed a griddle/oven combo unit with a grease trap which stuck out approximately one and a half inches. Below the grease trap there was dried grease on the side of the unit and on the ground underneath. Observation on 06/04/2024 at 11:21 AM showed the freestanding refrigerator continued with water on the floor and droplets on the ceiling, contained a rack of resident foods, and the container with water, screwdriver, and screws was on the crossbar. During an interview on 06/04/2024 at 11:21 AM, Staff P, Senior Food and Nutrition Services Director, stated the freestanding refrigerator was not in working order and should not be used to store resident foods. Observation on 06/04/2024 at 11:45 AM showed the griddle/oven combo unit had brown grease actively leaking down the side of the unit. Observation showed an area below the grease trap which had accumulated grease which leaked down. During an interview on 06/04/2024 at 1:57 PM, Staff A, Administrator, stated there were no work orders open for the kitchen. During an interview on 06/04/2024 at 1:59 PM, Staff M, Maintenance Director, stated they were made aware of the broken freestanding refrigerator and griddle/oven combo unit on 06/04/2024. During an interview on 06/05/2024 at 12:04 PM, Staff P stated that they had put in a work order for the freestanding refrigerator but thought it had been fixed. Staff P stated the refrigerator should not be used until it was repaired. During an interview on 06/05/2024 at 12:19 PM, Staff A stated staff should inform them if there were needed repairs to kitchen equipment. Refence WAC 388-97-2100 .

CONCERN (E)

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

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to inspect bedrails as part of a regular maintenance program. This failure placed residents at risk of falling, entrapment, avoidable injury, and a diminished quality of life. Findings included . During an interview on 06/05/2024 at 11:33 AM, Staff C, Registered Nurse/Unit Manager, stated there was no regular system for inspecting bedrails and staff were expected to notice loose bedrails and notify maintenance. During an interview on 06/05/2024 at 1:37 PM, Staff B, Director of Nursing Services, stated staff were to notice loose bedrails and notify maintenance. During an interview on 06/05/2024 at 2:40 PM, Staff M, Maintenance Director, stated there was no system for regular inspection of bedrails. Staff M stated staff would inform maintenance that bedrails needed tightening as they were discovered. During an interview on 06/05/2024 at 3:05 PM, Staff A, Administrator, stated that inspection of bedrails should be part of a regular preventative maintenance schedule. SEE F689 Reference WAC 388-97-2100 .

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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. Based on observation, interview, and record review, the facility failed to ensure proper labeling of insulins in 1 of 4 medication carts (700-hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective medications, and a diminished quality of life. Findings included . Observation on 06/05/2024 at 9:22 AM showed two multi-dose insulin pens with no open date or expiration date in the 700-hall medication cart. During an interview on 06/05/2024 at 9:35 AM, Staff N, Licensed Practical Nurse, stated insulin pens should be dated when opened and there were two undated pens in the 700-hall medication cart. During an interview on 06/05/2024 at 11:10 AM, Staff B, Director of Nursing Services, stated the expectation was to date open insulins with the open date and expiration date. Reference WAC 388-97-1300(2) .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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. Based on observation and interview, the facility failed to ensure foods were sanitarily stored in the kitchen and 3 of 4 resident refrigerators (Ocean, Mountain, and Narrows Dining) when reviewed for kitchen. These failures placed residents at risk of consuming contaminated foods, avoidable foodborne illness, and a diminished quality of life. Findings included . Observation on 06/02/2024 at 9:38 AM showed the facility walk-in refrigerator had four bags of raw chicken sitting in approximately one inch of bloodied water, one container of minced garlic without date label, a container of pudding with no date, a package of bacon with a use by date of 05/30, a salad uncovered, undated, and severely dried, four trays of raw fish on a rack uncovered and undated, and a container of sliced tomato without date label. The walk-in freezer showed a rack with several types of raw meat left exposed to the air and severely dried. During an interview on 06/02/2024 at 9:47 AM, Staff Q, Dietary Aid, stated the container of garlic, pudding, and bacon needed to be thrown out. Staff Q stated the rack of meats in the freezer did not look right. Observation on 06/02/2024 at 9:48 AM showed a container of granola with no date and NR, a bottle of syrup with a use by date of 10/06/2023, and a container with croutons with a date of 02/29. Observation on 06/02/2024 at 10:07 AM showed the Narrows dining room resident refrigerator had two packaged lunches with no name or date. Observation on 06/02/2024 at 10:12 AM showed the Mountain resident refrigerator had a Styrofoam container with unidentifiable food inside with a foul smell and white substance growing, a bag of foods all with a 05/31/2024 use by date, a facility meal tray with dried food covered with dome with no date, a bag of fast food with no date, a plate with a sandwich and salad with tomato with white substance growing, and a bag with raspberries growing white substance with no date. Observation on 06/02/2024 at 10:21 AM showed the Ocean resident refrigerator had a sandwich with use by date of 05/26, a plate of lasagna stored on paper plate and loosely covered with tinfoil with no date, a paper plate with an omelet, rice, and a sausage which was soaked through without date, a container of unidentifiable food with white growth and no date, a plate of meatloaf, gravy and green beans covered with tin foil with white growth and no date. During an interview on 06/02/2024 at 10:42 AM, Staff A, Administrator, stated that expired foods should not be in the resident refrigerators. Staff A stated that the lunch bag in the Narrows dining resident refrigerator belonged to staff and should not be stored in the resident refrigerator. During an interview on 06/02/2024 at 10:52 AM, Staff O, Executive Chef, stated the rack of meats exposed to the air and dried out in the walk-in freezer were from a party, were freezer burned, and should have been thrown out. Staff O stated that the chicken in bloody water was defrosting and had been received on 05/31/2024. Observation on 06/04/2024 at 11:23 AM showed a container of granola with no date and NR in dry storage. Observation on 06/04/2024 at 11:26 AM showed four bags of raw chicken sitting in a container with approximately one inch of bloodied water. During an interview on 06/05/2024 at 12:04 PM, Staff P, Senior Food and Nutrition Services Director, stated stored foods should be labeled and dated and thrown away when expired. Staff P stated that the facility's food storage did not meet expectation. During an interview on 06/05/2024 at 12:19 PM, Staff A stated the facility followed the 2024 Food Code and that the storage of resident foods did not meet expectation. Reference WAC 388-97-1100 (3), -2980 .

Mar 2024 2 deficiencies

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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. Based on observation and interview, the facility failed to maintain the alarm function of two of three emergency exits, open to the outside and leading off the facility property, (600 hall and 700 hall) reviewed for safety/accident prevention. This failure placed cognitively impaired residents, residents who wander and have exit-seeking behaviors, at risk for being able to leave the facility unnoticed by staff, placing their safety at risk. Findings included . In observation on 03/12/2024 at 3:46 PM, at the end of the 700 hall, there was a double door exiting to an open unsecured side of the facility property, with the sidewalk and street beyond. Signs on the door read, Emergency exit only. Alarm will sound. When the door was opened by Staff E, Maintenance Staff, the alarm did not sound. In observation on 03/12/2024 at 3:51 PM, at the end of the 600 hall, there was a double door, leading to a small fenced area, with a gate exiting to the main parking lot in the front of the facility, which was open to the sidewalk and street beyond. Signs on the door read, Emergency exit only. Alarm will sound. When the door was opened by Staff F, Maintenance Staff, the alarm did not sound. Staff F, Maintenance Staff, stated that the alarm was turned off. Staff F turned the alarm on, and re-tested the double door - it still did not alarm. Staff E, Maintenace Staff, then tested the gate, beyond the 600 hall double doors, that opened to the parking lot, and once it was opened half-way (to approximately 45 degrees), the alarm did sound. In interview on 03/12/2024 at 4:22 PM, Staff A, Administrator, stated that all of the emergency exit doors should be armed with an alarm that would sound if opened, and that the double door at the end of 600 hall should have alarmed when it was opened. WAC referrence 388-97-3220(1) .

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 interview and record review, the facility failed to implement an infection control and prevention program that ensured that staff were fit tested (a process for determining whether a respirator properly fits the face of the person who wears it) for N-95 respirators (a type of disposable face mask that forms a tight seal to the face and is able to filter out airborn particles and pathogens [bacteria, virus, or other microorganism that can cause disease]) upon hire, and annually thereafter, for six of six staff (Staff D, G, H, I, J, and K) reviewed for N-95 respirator fit testing. In addition, these staff were working with residents during a COVID-19 (contagious respiratory disease caused by the SARS-CoV-2 virus) outbreak in the facility. This failure placed residents and staff at risk for exposure to, and spread of, communicable diseases such as COVID-19. Findings included . Review of the facility COVID-19 outbreak line list (a table that contains information about each case in an outbreak), on 03/06/2024, showed that the facility was currently experiencing a COVID-19 outbreak that began on 01/20/2024. STAFF D In interview on 03/06/2024 at 2:19 PM, Staff D, Licensed Practical Nurse (LPN), stated that they had worked for the facility for many years, and had been fit tested for a N-95 respirator once. Staff D, LPN, did not recall being fit tested, again, after the first time. Review of the all-staff list, on 03/06/2024, showed that Staff D, LPN, was hired on 06/23/2009. During interview on 03/12/2024 at 3:00 PM, Staff B Director of Nursing Services (DNS), stated that they were not able to find documentation to show that Staff D, LPN, had been fit tested for a N-95 respirator annually. STAFF G Review of the all-staff list, on 03/06/2024, showed that Staff G, Nursing Staff, was hired on 02/01/2024. Review of fit testing records showed that Staff G, Nursing Staff, was fit tested for a N-95 respirator on 02/22/2024 (21 days after hire). During interview on 03/12/2024 at 3:00 PM, Staff B, DNS, stated that Staff G, Nursing Staff, had been working with residents since 02/04/2024, but that they had worked on a unit where there were no known COVID-positive residents. STAFF H Review of the all-staff list, on 03/06/2024, showed that Staff H, Nursing Staff, was hired on 02/20/2024. Review of fit testing records showed that Staff H, Nursing Staff, was fit tested for a N-95 respirator on 02/22/2024. During interview on 03/12/2024 at 3:00 PM, Staff B, DNS, stated that Staff H, Nursing Staff, had been working with residents since 02/20/2024, but that they had worked on a unit where there were no known COVID-positive residents. STAFF I Review of the all-staff list, on 03/06/2024, showed that Staff I, Nursing Staff, was hired on 02/27/2024. During interview on 03/12/2024 at 3:00 PM, Staff B, DNS, stated that they were not able to find documentation to show that Staff I, Nursing Staff, had been fit tested for a N-95 respirator. STAFF J Review of the all-staff list, on 03/06/2024, showed that Staff J, Nursing Staff, was hired on 01/20/2021. During interview on 03/12/2024 at 3:00 PM, Staff B, DNS, stated that they were not able to find documentation to show that Staff J, Nursing Staff, had been fit tested for a N-95 respirator upon hire or annually. STAFF K Review of the all-staff list, on 03/06/2024, showed that Staff K, Nursing Staff, was hired on 01/22/2019. During interview on 03/12/2024 at 3:00 PM, Staff B, DNS, stated that they were not able to find documentation to show that Staff K, Nursing Staff, had been fit tested for a N-95 respirator upon hire or annually. During interview on 03/12/2024 at 4:51 PM, Staff A, Administrator, stated that staff should have been fit tested for N-95 respirators upon hire, and annually thereafter, and before working with any residents. Referrence WAC 388-97-1320 (1)(a) .

Dec 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

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 interviews and record reviews, facility failed to ensure a resident-to-resident altercation was identified and investigated for 1 of 4 residents (Resident 1) reviewed for abuse allegations. Failure to identify and thoroughly investigate an abuse allegation placed residents at risk for recurrence of alleged abuse and a diminished quality of life. Findings included . Review of the facility policy, Abuse, Neglect and Exploitation, dated October 2022, showed that when suspicion or reports of abuse, neglect or exploitation occur, an immediate investigation was warranted. According to the policy, the facility would, during and after investigation: • Respond immediately to protect the alleged victim. • Examine the alleged victim for sign of injury. • Increase supervision of alleged victim and residents. • Make room or staffing changes if needed to protect the resident. • Provide emotional support. • Revise care plan if resident's medical, nursing, physical, mental or psychosocial needs or preferences changed as a result of an incident of abuse. • Report allegations to the administrator, state agency, adult protective services and law enforcement (when applicable) immediately but not later than 2 hours after the allegation was made if the event involved abuse. • Analyze the occurrence to determine why abuse occurred and what changes were needed. • Define how care provision would be changed and/or improved to protect residents. Resident 7 was admitted [DATE] with diagnoses that included heart disease and anxiety disorder. Resident 8 was admitted [DATE] with diagnoses that included heart failure and anxiety disorder. Nursing Progress Note, dated 10/15/2023, documented Resident 7 was very upset and voiced complaints about roommate, Resident 8. Nursing Progress Note, dated 10/16/2023 at 1:51 AM, documented Resident 7 and Resident 8 had periods of shouting at each other. Nursing Note documented Resident 7 alleged Resident 8 shouted and called Resident 7 a liar. Social Services Progress Note, dated 10/16/2023 at 4:04 PM, documented Resident 7 had verbal disagreements with roommate. Social Services Note showed Resident 7 was offered but declined a room change. Social Services Note documented Resident 7 was told Social Services would follow up the next day after the resident had time to think things over. Nursing Progress Note, dated 10/17/2023 at 4:01 AM, documented Resident 7 stated that Resident 8 threatened to beat the $#!% out of Resident 7 and cut Resident 7 with a knife. Nursing Note documented Resident 7 was convinced to move to another room for the night. Nursing Note documented Resident 7 was visibly upset and voiced fearfulness. During an interview on 11/30/2023 at 12:19 PM, Resident 7 described verbal altercations with Resident 8 on two consecutive days (10/15/2023 & 10/16/2023) leading to the alleged threat against Resident 7 on 10/17/2023. During an interview on 11/30/2023 at 4:24 PM, Staff C, Registered Nurse, stated that the resident-to-resident altercation involving Residents 7 and 8 that occurred on 10/16/2023 should have been investigated and acted upon immediately per the facility's abuse prevention and investigation policy. Staff C indicated an altercation between Residents 7 and 8 was investigated on 10/17/2023, after a second altercation. Staff C indicated the benefit of identifying the first altercation would have been to put interventions in place to mitigate the risk for recurrence of a second altercation. During an interview on 12/04/2023 at 2:00 PM, Staff D, Licensed Practical Nurse (LPN) and Charge Nurse, stated that when the altercation between Resident 7 and Resident 8 was known, the residents should have been separated and if they refused, the abuse coordinator should have been notified and a staff member should have been assigned to be present in the room to ensure no escalation between residents. During an interview at 2:47 PM, Staff B, RN and Director of Nursing Services, indicated the expectation for abuse investigations was that facility policy would be followed and allegations/suspected abuse would first involve intervention for resident safety, physical and/or psychosocial assessment, thorough investigation, reporting to state agency and abuse coordinator, care planning to identify risk and prevent recurrence of abuse and post-event monitoring of residents. During an interview on 12/04/2023 at 3:30 PM, Staff A, Administrator, stated facility staff trainings regarding abuse investigations were ongoing and that re-education would be planned. Reference WAC 388-97-0640(6)(a) .

Aug 2023 9 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 F0578 (Tag F0578)

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 that an establish advanced directive (AD) was enacted as directed for 1 of 5 residents (Resident 19) reviewed for AD. This failure denied the resident the opportunity to direct their healthcare during an event when they were unable to make decisions or communicate their healthcare preferences. Findings included . ADVANCE DIRECTIVES (AD) An AD is a written instruction, such as a living will or durable power of attorney [DPOA] for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) Federal regulation defined a POLST as .a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an AD. The regulations also showed, If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. Review of the facility's policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST), dated [DATE] showed an assessment and review of the POLST must occur for those residents arriving with a completed POLST, and that the form with the resident and/or legal surrogate decision maker needed to take place to assure its continued accuracy. Review of the facility's policy and procedure titled, Advance Directives, dated 04/1998, showed, In accordance with federal laws and regulations related to resident rights, free choice quality of life, dignity, self-determination and participation and the Patient Self Determination Act (PSDA) of 1991, [NAME] respects a resident's right to make treatment decisions and to execute Advance Directives. Review of Resident 19's entry tracking Minimum Data Set (MDS, a required assessment tool) dated [DATE] showed that the resident admitted to the facility on [DATE]. The resident's electronic health record (EHR) showed multiple diagnoses to include heart, lung, and kidney disease. In addition, the resident was diagnosed with metabolic encephalopathy (a condition in which the brain is disturbed either temporarily or permanently due to different diseases or toxins in the body). Review of a document titled, Physician Orders for Life-Sustaining Treatment (POLST), showed that Resident 19's son and power of attorney (POA) and provider had a signed a Do Not Attempt Resuscitation (DNAR) and Allow Natural Death on [DATE]. The EHR showed that the document was scanned into Resident 19's EHR on [DATE]. Review of Resident 19's EHR progress note dated [DATE] showed that a Registered Nurse (RN) had documented a code blue was called (when a resident requires resuscitation or in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest), for the resident. Cardiopulmonary Resuscitation (CPR) had already been started and 911 was already called and were on their way. Further documentation showed that the RN went back to the nurse's station to print out documentation for emergency personnel; however, it was discovered at that time Resident 19 had a DNR (scanned POLST indicated DNR) but was listed as a full code on the computer screen. During an interview on [DATE] at 1:27 PM, when asked what the procedure was if a resident required life support, i.e. CPR, Staff EE, Licensed Practical Nurse (LPN), stated that they would check a resident's POLST documentation to see what the resident's code status was in the medical records. During an interview on [DATE] at 1:39 PM, Staff X, Unit Manager, stated that there was a lot of confusion as to Resident 19's code status during the time of the code blue. The LN who initiated the code blue just checked the information in the residents' EHR (face sheet) that showed a full code and did not check Resident 19's POLST which showed the resident was a DNR. In addition, the provider who had admitted the resident did not note the residents DNR-POLST that was signed on [DATE]. Furthermore, the staff who had scanned the POLST into the EHR did not update the EHR in the face sheet section to indicate that Resident 19 was a DNR. During an interview on [DATE] at 1:55 PM Staff B, Director of Nursing Service (DNS) stated that it was the expectation that the admission nurse reviewed the POLST with the resident or their representative and ensured that the code status was correct on the EHR face sheet screen. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c) .

CONCERN (D)

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 observation, interview, record review, and policy review, the facility failed to notify one of 31 sampled residents (Resident (R)109) physician and family member of an injury sustained to R109's toe first discovered on 06/20/23. This resulted in a delay for a referral to the podiatrist. Findings include: Review of the facility's policy titled, Skin Care Protocol & Monitoring dated 08/2019 and provided by the facility revealed, Complete resident incident report. Incident Report must include the following: vi. Notification of MD [medical doctor] and family. Review of the facility policy titled, Notification of Resident Change of Condition dated 02/2012 and provided by the facility revealed, Unit Coordinators are responsible to ensure that residents' physician and responsible party are notified whenever there is a significant change of condition in a resident's physical, mental or psychological status including accidents . Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R109 was admitted to the facility on [DATE] with diagnoses including aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (stroke) and hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis. Family member (F)109 was R109's emergency contact #1 and R109's health care and financial Power of Attorney (POA). Review of the Wound tab in the EMR revealed R109 sustained a bruise on her right second toe caused from trauma first observed on 06/20/23 and healed as of 07/24/23. Review of the Wound Assessment Details Report provided by the facility dated 06/20/23 revealed R109 sustained a bruise from trauma to her right second toe, acquired in the facility. The photograph showed the top resident's right second toe/toenail was purple. The section on the form indicating the physician and F109had been notified was blank (not filled out). Review of Progress Notes from 06/20/23 through 08/11/23 in the EMR under the Progress Notes tab revealed no documentation to show the physician or F109 were notified of the injury to R109's right second toe. Review of the Wound Assessment Details Reports provided by the facility dated 07/05/23, and 07/14/23 revealed R109's right second toe/toenail continued to be purple. Review of the Wound Assessment Details Report provided by the facility dated 07/24/23 revealed the right second toe/toenail injury was healed. Review of the Skin/Wound Note dated 08/12/23 at 05:47 AM in the EMR under the Progress Notes tab revealed, Black toenail noted to R [right] 2nd toe. [Name] provider notified. There was no documentation showing that F109 was notified. During an interview on 08/17/23 at 10:14 AM, Staff J, Registered Nurse (RN) Unit Manager reviewed R109's medical record and stated an Incident Report should have been completed when the new skin injury to R109's right second toe was first noted on 06/20/23. Staff J stated this would have prompted the nurse to notify the physician and F109 Staff J stated there was no documentation in R109 progress notes showing this occurred when the toe injury was first observed on 06/20/23. During an observation on 08/17/23 at 11:19 AM, Staff J and surveyor observed R109's right second toe. R109's toe was black in color underneath the toenail. F109 was in the room. F109 stated the facility had not notified her of the injury to R109's toe; she verified she was the designated emergency contact for R109. During an interview on 08/17/23 at 1:16 PM, Staff B, the Director of Nursing (DON) stated each resident's skin should be assessed weekly and if there was a new injury, the nurse should assess it and notify the physician and the family. Staff B stated she would review further to determine if there was additional information related to notification of the physician and responsible party regarding R109's toe injury. No additional information was provided as of the survey exit. Referene WAC 388-97-0320 .

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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Based on observation, record review, interview and facility policy review, the facility failed to ensure resident equipment was maintained and in good repair for four (Resident (R)11, R51, R69, and R100) of 31 sampled residents. The resident's wheelchair arms had cracked or missing protective material exposing the cloth like material. This deficient practice had the potential to allow residents with frail skin to receive soars or prevent the wheelchairs from being thoroughly clean, increasing risk of infection. Finding include: Review of the facility policy titled, Resident Transport Wheelchair Cleaning dated 01/28/22 revealed, Policy: The intent of this policy is to establish a procedure for the proper and safe technique to be used for cleaning manually operated transport wheelchairs. Review of R11's undated admission Record under the Profile tab in the electronic medical record (EMR) revealed and admission date of 09/13/12 with diagnoses of Alzheimer's disease and dementia. During observations on 08/14/23 at 11:33 AM, 08/15/23 at 12:45 PM, 08/16/23 at 11:14 AM, and 08/17/23 at 11:58 AM, revealed both arms on the wheelchair missing some of the protective material exposing the cloth like material underneath. Review of R51's admission Record under the Profile tab located in the EMR indicated an admission date 07/31/19 with diagnoses of Alzheimer's disease, chronic pain syndrome, and osteoporosis. During observations on 08/15/23 at 12:45 PM, 08/16/23 at 11:14 AM, and 08/17/23 at 11:58 AM, revealed both arms on the wheelchair had a cracked protective material exposing the cloth like material underneath. The right arm had missing protective material with jagged edges. Review of R69's undated admission Record under the Profile tab in the EMR indicated an admission date of 05/24/19 with osteoarthritis, dementia, and rheumatoid arthritis. During observations on 08/14/23 at 11:33 AM, 08/15/23 at 12:45 PM, 08/16/23 at 11:14 AM, and 08/17/23 at 11:58 AM, revealed both arms on the wheelchair had a cracked protective material exposing the cloth like material underneath. Review of R100's undated admission Record under the Profile tab in the EMR indicated an admission date of 1017/20 with diagnoses of dementia, muscle weakness, and unsteadiness on feet. During observations on 08/14/23 at 11:33 AM, 08/15/23 at 12:45 PM, 08/16/23 at 11:14 AM, and 08/17/23 at 11:58 AM, revealed both arms on the wheelchair had a cracked protective material exposing the cloth like material underneath. The left arm was missing a piece of protective material exposing the cloth like material beneath. During an interview on 08/17/23 at 10:44 AM, Staff B, the acting Director of Nursing Services/ Infection Preventionist was asked about the condition of the wheelchair arms. Staff B stated the arms on the wheelchairs should be intact to prevent infection control issues and skin issues. Staff B also stated, Rehab should be taking care of those issues. During an interview 0n 08/17/23 at 12:04 PM, Staff C, Unit Coordinator Licensed Practical Nurse was shown the arms on the wheelchairs. Staff C stated, I was not aware of the wheelchair arms being cracked or missing the material. Staff C stated, The missing pieces could cause damage to frail skin and/or an infection control issue because the wheelchair arms cannot be cleaned appropriately. During an interview on 08/17/23 at 12:21 PM, Staff F, the Director of Rehabilitation was shown the arms of the four wheelchairs. Staff F stated, The wheelchairs are owned by the facility and should be maintained by the facility. Staff F agreed the missing and cracked protective material could be an issue for skin injury and an infection control issue. Reference WAC 388-97-0880 .

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 refer one (Resident (R) 70) of one resident reviewed for Preadmission Screening and Resident Review (PASRR) residents for a Level II, with a qualifying diagnosis of mental illness in the sample of 31. This had the potential to cause R70 to not receive necessary mental health services. Findings include: Review of R70's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed R70 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, anxiety disorder unspecified and post-traumatic stress disorder (PTSD), unspecified. Review of R70's Preadmission Screening and Resident Review (PASRR) Level I Screening Tool, dated 07/24/23 and located under the Misc (Miscellaneous) tab of the EMR, revealed R70 did not have a diagnosis or evidence of a major mental illness and had no significant impairment in functioning related to a suspected or known diagnosis of mental illness. Review of R70's Diagnoses, listed under the Med Diag (Medical Diagnoses) tab of the EMR, revealed R70 was diagnosed as having PTSD unspecified on 07/21/23, as part of her entry into the facility. An interview on 08/15/23 at 3:17 PM, the Social Services (Staff SS) revealed the resident was transiting to long term care placement. The transiting paperwork has been sent to the Department of State Health Services (DSHS). She will be staying in the building and will not be leaving until DSHS finds a placement. When asked about the services for PTSD, Staff SS revealed she was not aware of a PTSD diagnosis, nor the resident PASRR I not identifying the diagnosis. An interview 08/17/23 at 9:10 AM, Staff BB, admission (Staff BB) revealed when the initial paperwork was completed, Staff BB was not aware of R70's PTSD diagnosis. An interview on 08/17/23 with the Administrator at 12:12 PM revealed R70 did trigger for PASRR level II, once her correct diagnosis was indicated. R70's PASRR Level I was provided indicating R70's needed a PASRR Level II. Reference WAC 388-97-1915 (1)(2)(a-c) .

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure one out of one resident reviewed for non-pressure skin conditions (Resident (R)109) received adequate nursing care and services to address an injury to her toe. Specifically, the facility failed to complete an initial investigation in accordance with facility policy (Incident Report), initiate subsequent monitoring and documentation (alert charting), and determine if interventions were needed to protect the injured area and to prevent re-injury. Findings include . Review of the facility's policy titled, Skin Care Protocol & Monitoring dated 08/2019 and provided by the facility revealed, Purpose - To provide the Nursing staff with a planned, organized systematic approach to the identification, assessment, and treatment of residents at risk for or having impaired skin integrity .Procedure - Assess the skin integrity of every resident upon admission and weekly thereafter . The assessment must include the entire body check, including inspection of the feet . Indicate any site (s) of impaired skin integrity on the admission Assessment form and progress notes. Initiate a Wound Rounds Assessment Report and place in the TAR [treatment administration record] of Point Click Care [electronic medical record system] to cue staff of when weekly documentation is due . Assessment and Management of Skin Tears and Bruises . Procedure 1. NACs [Nurse Aide Certified] or any staff who discover skin tears or bruises during care activities must report these to the Licensed Nurse assigned to the hall. 2. Licensed Nurse inspects and assesses the resident. After initial treatment of injury, the following activities are required: a. Investigate the incident with the NACs and any other caregivers into how the injury might have occurred. Discuss how to prevent further injuries. b. Evaluate location and size of injury. Consider interaction of resident's functional level and care activities, and whether or not contributing factors might be altered to prevent future injury. Bruises that are 5 cm [centimeters] or greater must be pictured in Wound Rounds for weekly monitoring until healed . Evaluate transfer technique used - is it appropriate for resident safety? . Complete resident incident report. Incident Report must include the following: i. Location, size, and nature of the injury. ii. Detailed account of investigation, activities undertaken and any results . v. Interventions to prevent further injuries . Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R109 was admitted to the facility on [DATE] with diagnoses including aphasia (language disorder that affects a person's ability to communicate) following cerebral infarction (stroke) and hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness on one side) following cerebral infarction. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/30/23 in the EMR under the MDS tab revealed the Brief Interview for Mental Status (BIMS) test was not completed. The Staff Assessment for Mental Status revealed R109 could not complete the interview, was impaired in short term memory, long term memory, and was severely impaired in decision-making. R109 required extensive assistance with bed mobility, transfers, and locomotion on and off the unit. Review of the Discharge MDS with an ARD of 07/10/23 revealed R109 was discharged on this date (to the hospital) with return expected. Review of the PPS (Prospective Payment System) Five Day MDS with an ARD of 07/18/23 revealed R109 was readmitted to the facility from the hospital on [DATE]. Review of the Wound tab in the EMR revealed R109 sustained a bruise on her right second toe caused from trauma first observed on 06/20/23 and healed as of 07/24/23. Review of the Wound Assessment Details Report provided by the facility dated 06/20/23 revealed R109 sustained a bruise from trauma to her right second toe, acquired in the facility. The photograph showed the top resident's right second toe/toenail was purple. Review of a Daily Skilled Note dated 06/22/23 in the EMR under the Progress Notes tab revealed, Resident transfers with a transfer board with a two person assist. The resident was noted to have a small necrotic nail on her right second toe. It appears that it is from transferring . This note was the only documentation found with information related to how the injury to R109's second toe was sustained. There was no Incident Report completed as directed by the facility's policy for Skin Care Protocol & Monitoring. Furthermore, there was no indication of assessment to determine if intervention was necessary to protect the resident's toe or additional training might be necessary for staff regarding safe transfer technique. Review of the Wound Assessment Details Reports provided by the facility dated 07/05/23, and 07/14/23 revealed R109's right second toe/toenail continued to be purple. Review of the Wound Assessment Details Report provided by the facility dated 07/24/23 revealed the right second toe/toenail injury was healed; however, the picture showed a darkened area to the toenail continued to be present. Review of the Skin/Wound Note dated 08/12/23 at 05:47 AM in the EMR under the Progress Notes tab revealed, Black toenail noted to R [right] 2nd toe. [Name] provider notified. There was no Incident Report completed, or new Wound Assessment Details Report initiated. Review of the Skin/Wound Note dated 08/12/23 at 10:58 PM in the EMR under the Progress Notes tab revealed, This is not a new skin issue. Was identified 06/20/2023 and has not changed. It does not bother her, is not painful. Will see Podiatrist on his next visit. If the wound had been present consistently since 06/20/23, there was no documentation of the status after 07/24/23 until the Skin/Wound Notes dated 08/12/23. R109's Care Plan in the EMR under the Care Plan tab was reviewed and no care plan was found addressing the injury to her second right toe. During an interview on 08/17/23 at 10:14 AM, Staff J, Registered Nurse (RN) Unit Manager, reviewed R109's EMR and stated an Incident Report should have been completed when the new skin injury to R109's right second toe was first noted on 06/20/23. Staff J confirmed no Incident Report had been completed for the injury to R109's second toe. Staff J stated R109 was on weekly wound rounds until the toe was healed on 07/24/23. The Unit Manager verified a new wound sheet had not been initiated in response to the injury observed on 08/12/23. Staff J verified there was no description or measurements to accompany the nurse's notes on 08/12/23 noting the injury to R109's toe. During an observation on 08/17/23 at 11:19 AM, Staff J and surveyor observed R109's right second toe. R109's toe was black in color underneath the toenail. R109s family member (F)109 was in the room. During an interview on 08/17/23 at 1:16 PM, Staff B, the Director of Nursing (DON) stated residents' skin should be assessed weekly and if there was a new injury, the nurse should assess it. Staff B stated the nurse should complete an incident report and the injury should get added to wound rounds and an alert should be initiated. Staff B stated an alert should be activated in the EMR to trigger subsequent nursing staff to monitor and chart the status of the injured area. The alert charting could be for 24 hours or longer depending on the severity of the injury. Staff B stated she would review further to determine if there was additional information related to the toe injury. No additional information was provided as of the survey exit. Reference WAC 388-97-1060 (1) .

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 the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) had the catheter bag attached as ordered by the provider and a privacy bag for 1 of 1 resident (Resident 173) reviewed for urinary catheters. This failure placed the residents at risk for further complications, prolonged therapy, and unmet care needs. Findings included . Review of a facility's policy titled, Insertion, Removal and Maintenance of an Indwelling Urinary Catheter dated 10/2019, showed that policy and procedure for routine drainage bag care included staff to use either a drain or leg bag as ordered and provide privacy. Review of the admission Minimum Data Set (MDS, an assessment tool) dated 07/12/2023 showed that Resident 173 was admitted to the facility on [DATE] with multiple diagnoses to include heart, lung, and kidney disease. The resident's electronic health record (EHR) showed that the resident had an indwelling foley catheter related to neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem). In addition, the MDS showed that Resident 173 was able to make needs known and required extensive assistance with bed mobility. Review of Resident 173's Treatment Administration Record (TAR), dated August 2023, showed that the resident had an order dated 08/11/2023 for staff to change straight drainage to leg bag every morning, clean leg bag and tubing per protocol and to sign off when process was complete. Review of Resident 173's care plan initiated on 08/11/2023 showed that the resident had an indwelling urinary catheter related to neurogenic bladder diagnosis. Interventions included position covered catheter bag and tubing below the level of the bladder. Observation on 08/15/2023 at 8:55 AM showed Resident 173 sat up in chair at bedside with no privacy bag attached to the collection / drain bag and was not attached to the resident's leg as ordered. Observation on 08/15/2023 at 3:09 PM showed Resident 173 laid in bed with the catheter collection (drain) bag attached to the lower frame of the bed and without a privacy bag attached. During an interview on 08/15/2023 at 3:30 PM, Staff Z, Registered Nurse (RN), stated that Resident 173's urinary catheter had only a drain bag attached but should have been changed to a leg bag and a privacy bag applied. Review of Resident 173's August 2023 TAR on 08/15/2023 at 2:01 PM showed that another licensed staff had already signed off the document that indicated that the straight drainage bag was changed to a leg bag that morning. During an interview on 08/15/2023 at 3:31 PM, Staff X, Unit Manager (UM), stated that Resident 173's drain bag was from the hospital but should have had a privacy bag placed. In addition, Staff X, UM, stated that it was expected that if there was a treatment order to change the catheter from a drain bag to a leg back every AM then it should have been placed. In addition, Staff X, UM, stated that they did not know why another LN had already signed off the TAR but noted that documents should not have been signed off unless the catheter bag was changed to a leg bag. During an interview on 08/15/2023 at 3:46 PM, Staff B, Director of Nursing (DNS), stated that it was the expectation that if the resident had an order for the catheter drain bag to be changed to a leg bag every day shift, then the LN should have assessed and changed the bag as ordered and ensured that a privacy bag was applied. In addition, Staff B, DNS, stated that the previous LN should not have signed off the TAR unless the urinary catheter was changed to a leg back as ordered on day shift. Reference WAC 388-97-1060(3)(c) .

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, interview, and record review, the facility failed to ensure that narcotics storage refrigerators were secured for 1 of 3 medication storage rooms (Ocean) and medication storage rooms were secured for 1 of 3 medication rooms (Alpine) when reviewed for medication storage. In addition, the facility failed to ensure a bottle of Virex (a germicidal / disinfectant cleaning material) was separately stored for 1 of 3 medication storage rooms (Mountain) and that personal staff hydration was not stored within a facility's medication cart (700 Hall). These failures placed residents at risk to have unintended access to drugs and biologicals that should have been locked, an increased risk of drug diversion, and potential drug misuse. Findings included . A document titled, Controlled Substance Administration and Accountability, dated 05/20/2023 showed that it was the facility's policy to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). Controlled medications were to be stored within a separately locked permanently affixed compartment when other medications were stored in the same area, such as in a refrigerator. External products: Disinfectants for external use were to be stored separately from internal and injectable medications. Ocean Medication Storage Room Observation and interview on 08/17/2023 at 8:36 AM showed the Ocean medication storage room refrigerator, which stored controlled substances, unlocked. A medium sized steel box located within the refrigerator was also unsecured/unlocked which contained lorazepam (a controlled substance used in the treatment of anxiety). During an interview, Staff J, Unit Manager (UM), stated that the medication should have been locked and secured while in the refrigerator medication room. Alpine Medication Storage Room Observation and interview on 08/17/2023 at 8:46 AM showed the Alpine (memory care unit) medication storage room unlocked and door open. Observation showed a bottle labeled Dakin's (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) and an antifungal ointment (used for external barrier cream). Staff J stated that the medication storage room should be closed and locked and did not contain any oral medication; however, if it had biological ointments and/or disinfectant solution stored within the room then the door should be locked and secured. In addition, Staff EE, Licensed Practical Nurse (LPN), stated that as an agency nurse they did not have access to the keycard to unlock the medication storage room door. Staff J stated that the door would be left open so that they would not have to get a full-time licensed nurse (LN) to unlock the door for access to the room. Mountain Medication Storage Room Observation and interview on 08/17/2023 at 9:13 AM showed the Mountain medication storage room contained a bottle labeled Virex solution. Staff C, Unit Coordinator Licensed Practical Nurse (UM/LPN), stated that the Virex bottle should not be stored in the mediation storage room. 700 Medication Cart Observation and interview on 08/17/2023 at 9:22 AM showed the 700 Medication cart bottom drawer contained a small can labeled goko sparkling coconut water. The water can was wrapped with two small cold chemical ice packs. Staff FF, LPN, stated that it was not for resident use and that personal drinks or food should not be in the medication carts. During an interview on 08/17/2023 at 10:21 AM, Staff B, Director of Nursing Services (DNS), stated that it was the expectation that the medication storage room refrigerators that contained narcotics were to be secured under double lock. In addition, Staff B, stated that the Alpine medication storage room was to be locked and secured if it stored biological ointments and disinfectant solutions. Furthermore, no personal foods or drinks were to be stored in the medications carts. Reference WAC 388-97-1300 (2), -2340 .

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 observations, interviews, record review, and policy review, the facility failed to ensure the kitchen was maintained and operated in a sanitary manner to prevent the potential spread of foodborne illness to all 130 residents. Specifically, the facility failed to ensure sanitizer solutions were at the proper concentration, tray line temperatures were within safe ranges, dishes were clean, hair coverings were worn, foods were labeled, and environmental surfaces were free of excessive grime, crumbs, and black substance. Findings include: Review of the Food Temperatures policy dated 01/02/23 and provided by the facility revealed, Food will be served at proper temperature to ensure food safety .Record reading on Food Temperature Log form at beginning of tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving. Acceptable serving temperatures are . hazardous salads and desserts <41 degrees (Fahrenheit) . Review of the Sanitation of Equipment policy dated 05/01/19 and provided by the facility revealed, Sanitation of Equipment: Frequency: Daily - Wipe up spills on shelves sides, and floor of refrigerator . Review of the Personal Hygiene policy dated 07/18/22 and provided by the facility revealed, Head covering worn: -Staff must wear hairnets or a cap when cooking, preparing, or assembling food . - If hair is long and not covered properly with a cap, a hairnet must be worn . Review of the Labeling Food Product policy dated 01/03/23 provided by the facility revealed, All prepared foods, leftovers and opened products stored for later use will be labeled according to food safety standards along with local and state regulations . All labels will contain a. The complete name of the product b. The date the product was prepared or opened . Review of the Product Specification Document - Oasis 146 Multi-Quat Sanitizer dated 2020 and provided by the facility revealed the solution should be mixed to a concentration between 150 parts per million (PPM) - 400 PPM for food contact surfaces. 1. The initial kitchen inspection was conducted with Staff L, Dietary Manager (DM) on 08/14/23 from 9:50 AM - 10:28 AM. The following concerns were noted: a. There was a black accumulated substance on the wall below the dish machine, approximately one foot by six inches in size, and on the floor under the dish machine covering an area of approximately two feet by two feet. b. Staff Q, Dietary Aide was observed with her hair net off the top of her head; it covered the bottom section of her long hair down. c. One rack of inverted plastic cereal bowls stored as clean was inspected. There were five bowls with significant amounts of hot cereal adhered to the inside of the bowls. A wet sugar packet was attached to the interior surface of one of the bowls. Staff L stated the bowls were disgusting and instructed Staff Q to check the bowls to ensure they were clean before removing them from the dish room. d. The stainless-steel table in the food preparation area, on which cutting boards were stored, had a sticky substance of approximately six inches in diameter and multiple food crumbs on the lower shelf below the table. e. Two buckets of wiping rag sanitizer solution were checked by the Staff L, using a test strip, for concentration of quaternary ammonia sanitizer. The concentration of the first bucket was 50 parts per million (PPM) and the concentration of the second bucket was 100 PPM; the solution in both buckets was insufficient in concentration of the sanitizer. Staff L stated the concentration should be 200 PPM. The name of the product was Oasis 146 Multi Quat with a specified sanitizer range of 150 - 400 PPM per label. f. There was a large undated and unlabeled container of shredded seafood/crab in the walk-in refrigerator. Staff L verified there was no label and stated the facility dated food with the date it was placed in the walk in or when the product was first opened. g. There was a red sticky substance adhered to the floor in the walk-in freezer of approximately four by three inches. Staff L stated she thought it was Sherbert. h. There were two bulk containers of food that had been removed from the original packages that were not labeled. Staff L stated one container held brown sugar and the other container held white sugar. Staff L stated the bins should be labeled with the name of the food. 2. A subsequent inspection of the kitchen was made with Staff L on 08/16/23 from 10:29 AM -11:10 AM. The following concerns were noted: a. The black accumulated substance on the wall below the dish machine of approximately one foot by six inches and on the floor under the dish machine covering an area of approximately two feet by two feet continued to be present. In addition, there was a plunger on the floor under the dish machine. Staff L stated the black substance could be mold, but she was not sure. Staff L stated the area needed to be cleaned. Staff R, Dietary Server was washing dishes and stated he used the plunger to unclog the disposal. b. The container of seafood, which had been prepared into seafood salad was in the walk-in refrigerator with a date of 8/15/23. Staff L verified it was the same seafood/crab that was observed on 08/14/23 and it should have been labeled with the date the seafood was placed in the refrigerator on 08/14/23. c. The stainless-steel shelf in the food preparation area was noted with a puddle of liquid and food crumbs. d. Staff L stated she noticed, on 08/14/23 during the initial kitchen inspection, that Staff Q had not been wearing her hairnet properly and she had talked to her about it. e. Tray line temperatures were observed to be measured immediately prior to meal service at 11:10 AM by Staff P, Dietary Lead Cook. Staff P stated he had taken the tray line food temperatures prior to the surveyor entering the kitchen at 10:25 AM and took them again for the surveyor at 11:10 AM. Staff P stated he usually took the tray line food temperatures about 10 minutes ahead of the start of meal service. The temperatures of all three batches of egg salad sandwiches were inadequate (not cold enough): egg salad on a croissant measured 47-degree Fahrenheit (F), egg salad on bread 43 degrees F, and egg salad on gluten free bread 43 degrees F. Staff P proceeded to serve the sandwiches. 3. Subsequent interviews and kitchen observations were made on 08/17/23 from 9:23 AM - 9:58 AM. a. During an interview on 08/17/23 at 9:23 AM, Staff L and Staff U, Executive Chef were interviewed. Staff U stated food temperatures on the tray line should be measured immediately prior to serving, not 30 minutes or more ahead of time. b. During an interview on 08/17/23 at 9:39 AM, Staff V, the Registered Dietitian stated tray line temperatures for cold foods should be under 40 degrees F or below. Staff V stated Staff P should not have served the egg salad sandwiches and should have substituted something else. Staff V stated a plunger in the dish room could be a concern. c. During an observation on 08/17/23 at 09:57 AM. Staff W, Dietary Aide was in the food preparation area and was not wearing any hair covering. Staff V and Staff U observed this and instructed Staff W to go and put a hair net on, which she did. d. The floor of the walk-in freezer was observed. The same red sticky Sherbert continued to be adhered to the floor. Staff L verified it had been there since 08/15/23 and needed to be cleaned up. Reference WAC 388-97-1100 (3), -2980

CONCERN (E)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 900 Hall Observation on 08/14/2023 at 9:45 AM showed 900 Hall with Personal Protective Equipment (PPE) signage on rooms 900, 902, 903, 908 and 910. Observation showed that this PPE signage instructed staff and visitors to wear face shield, gown, gloves, and N95 respirator when entering these rooms and to keep the door closed. Observation showed that rooms 900, 902, 903, and 910 had doors left open. Observation on 08/14/2023 at 10:18 AM showed rooms 900, 902, 903, and 910 with doors open. Observation on 08/14/2023 at 12:14 PM showed Staff TT, Nursing Assistant Certified (NAC), entered room [ROOM NUMBER] to deliver a lunch tray and did not don gown, gloves, or face shield. Further observation showed Staff TT exited room [ROOM NUMBER], took a new lunch tray, and entered room [ROOM NUMBER] without changing N95 respirator or donning gown, gloves, or face shield. Continued observation shows Staff TT exited room [ROOM NUMBER], took a new lunch tray, and entered room [ROOM NUMBER] without changing N95 respirator or donning gown, gloves, or face shield. Observation on 08/14/2023 at 12:22 PM showed Staff TT, NAC, exited room [ROOM NUMBER] and did not have a gown, gloves or face shield and did not change N95 respirator or complete hand hygiene. Observation showed Staff TT entered room [ROOM NUMBER] without applying gown, gloves, or face shield. Reference WAC 388-97-1320 (1)(a) Based on observation, document review, interview and facility policy review, the facility failed to ensure proper infection control in the following areas: proper infection control practices with residents on transmission-based precautions (TBP) for COVID and the timely notification of the health department of the COVID outbreak; providing diagrams for the water flow in the facility and testing waterborne pathogens; transporting uncovered clean clothing throughout the facility. These deficient practices had the potential to affect all 130 residents and to allow exposure to non-COVID residents to COVID, waterborne pathogens and their clothing to dust and germs. Findings include: 1. Review of the facility policy titled, Infection Prevention and Control dated 01/28/22 revealed, Policy: This facility will facilitate the safe care of all resident and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The Infection Prevention and Control Program will follow accepted national standards and is based on community assessment and includes prevention, identification, reporting, investigation and controlling infections and communicable disease for all resident's staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. a. Respiratory protection, i. A particulate respiratory mask will be worn when entering the room for all residents with airborne precautions. ii. All those entering the room will wear clean, non-sterile gloves when entering room a. Gowns i. All those entering the room will wear a disposable protective gown a. Door i. Keep door closed and the resident in the room. Review of the facility policy titled, COVID-19 Prevention and Response dated 01/28/22 revealed, Policy: This facility will respond promptly upon suspicion of Illness associated with a novel coronavirus. In efforts to Identify, treat, and prevent the spread of the virus. f. Notify local health department of suspected COVID-19. Review of the Residents (+) COVID list dated 08/15/23, provided by the facility, revealed there were five residents (R23, R34, R38, R18, R32) were positive with COVID out of 21 total residents on the 900 unit. Observations on 08/16/23 from 11:53 AM - 12:25 PM revealed two Nurse Aides Certified (NACs) were observed wearing only surgical masks, to enter COVID positive rooms, serving residents their meals, without donning required personal protective equipment (PPE) as directed on the precaution signs posted outside these rooms. These NACs went back and forth between COVID positive and COVID negative rooms during meal service. Observation on 08/16/23 at 11:53 AM revealed two meal carts arrived at the 900 hall. Staff O, NAC and Staff T, NAC were observed passing trays to residents. On 08/16/23 at 11:57 AM the first tray was removed from the cart. Staff O wore two surgical masks and went into a non-COVID room and delivered a meal tray. R14 resided in this room. On 08/16/23 at 12:02 PM, Staff T entered a COVID positive room wearing a surgical mask. Staff T was not wearing a gown or face shield/goggles. Staff T served lunch to one of the residents in the room and then returned to the cart. R23 and R34 resided in this room, and both had tested positive for COVID on 09/08/23 (per the Residents (+) COVID list dated 08/15/23). On 08/16/23 at 12:04 PM, Staff O entered a non-COVID room wearing the same surgical masks and delivered a meal tray. R37 resided in this room. On 08/16/23 at 12:05 PM, Staff T entered a non-COVID room wearing the same surgical mask and delivered a meal tray. R66 and R55 resided in this room. On 08/16/23 at 12:05 PM, Staff O also entered a non-COVID room wearing the same surgical masks. R66 and R55 resided in this room. On 08/16/23 at 12:07 PM, Staff T removed a meal tray and entered a COVID positive room where R38 and R79 resided. R38 had tested positive for COVID on 08/09/23. Staff T was wearing the same surgical mask and was not wearing a gown or face shield/eye protection. Staff T did not wash or sanitize his hands when he left the room. On 08/16/23 at 12:08 PM, Staff O removed a meal tray and entered a non-COVID room and delivered the tray. R89 resided in this room. On 08/16/23 at 12:09 PM, Staff T removed a tray and took it into a non-COVID room. Staff T did not wash or sanitize his hands when he left the room. R6 and R27 resided in this room. During an interview on 08/16/23 at 12:12 PM, Staff O stated the only PPE required for going into the COVID positive rooms was a surgical mask. Staff O verified she wore two surgical masks (one on top of the other). Staff O stated wearing an N-95 mask was optional. During an interview on 08/16/23 at 12:25 PM, Staff T stated he was supposed to wash his hands before entering the rooms and after coming out for the COVID positive residents. Staff T stated he washed his hands before entering the rooms. Staff T stated the only PPE required for entering COVID positive rooms was a surgical mask. During an observation on 08/17/23 at 9:13 AM, there were two signs posted on the wall right outside of the rooms of COVID positive residents on the 900 hall. The Quarantine Precautions sign read, Stop, in addition to standard precautions, only essential personnel should enter this room . clean hands when entering and leaving room, wear a mask, fit tested N-95 or higher required with aerosolizing procedures, wear eye protection (face shield), gown and gloves when entering room. The second sign for Special droplet/contact precautions read, In addition to standard precautions . wear mask, fit tested N-95 or higher required when doing aerosolizing procedures, wear eye protection (face shield or goggles) gown and glove at door. Keep door closed. There were PPE supplies hanging in containers on the doors into the rooms. During an interview on 08/16/23 at 12:47 PM, Staff B, the Acting Director of Nursing (DON) stated that the staff should be wearing gowns, N95 masks, gloves, and face shields when entering COVID positive rooms. SA to add findings: During an interview on 08/14/23 at 4:42 PM, Staff B and Staff EE, the Assistant Director of Nursing Services (Staff EE) were asked about the staff not wearing personal protective equipment (PPE) when entering rooms with COVID positive residents. Staff B stated all staff before entering should perform hand hygiene, put on a N-95 masks, gowns, face shields, and gloves. Even if they are going in to drop off a tray, staff should put on the PPE. Staff can wear surgical mask in the hall but N-95masks in the rooms with positive COVID residents. Staff B and Staff EE were asked about the time frame of the outbreak. Staff B stated, Wednesday on the ninth [of August] the first resident tested positive. A call was placed to the Department of Health (DOH), and they were notified of the positive results. When I returned on Monday, there had been more residents turn positive over the weekend. DOH was not called until I came in today and notified them that we had more residents. We had to place the residents on the 800 and 900 units in isolation. No one called DOH to notify them until I returned today. Staff B confirmed that DOH should have been called before she returned on Monday. 2. Review of the facility policy titled, Legionellosis: Risk Management for Building Water Systems dated 2018 reveled, Purpose: The purpose of the standard is to establish minimum legionellosis risk management requirements for building water systems. graphically described in step-by-step process flow diagrams. The process flow diagrams shall have detail that enables the identification, analysis, and management of the risk of legionellosis throughout the building water system. Team shall use the process flow diagrams to evaluate where hazardous conditions have the potential to occur in the building water systems and determine where control measures shall be applied to control potentially hazardous system conditions. During an interview on 08/16/23 at 2:42 PM, Staff G, the director of housekeeping and Staff H, Maintenance Director were asked about testing the facility for Legionellosis. Staff H stated the water system there has been no testing of the facility water lines. They were asked to review the diagrams and flow of the water system. Staff H stated, I have about 700 diagrams I have to go through to find them. During an interview on 08/17/23 at 10:44 AM, Staff B was asked about the testing for legionellosis and the diagrams. Staff B stated, I have asked about testing in the facility, but the former DNS always said it was not necessary. During an interview on 08/17/23 at 12:39 PM, Staff H stated he did not have the diagrams of the facility water flow. During an interview on 08/17/23 at 12:55 PM, Staff A, the Administrator was asked about the diagrams of the facility and testing. Staff A stated, He expected there to be diagrams of the water flow available in the facility. There should be a diagram that indicates the areas that are checked for Legionellosis. 3. Review of the facility policy titled, Transportation of Linen dated 08/14/23 revealed, Policy: Laundry staff will transport linens to the appropriate areas in ways to ensure no cross contamination of linens. 1. Whenever linen is transported from the laundry area to another area in the care center it must be covered to prevent contamination. During an observation on 08/14/23 at 10:13 AM, Staff D, Laundry Aide brought a cart of clothes through the doors and onto the unit. The clothes were hanging on the cart with no cover over the clothes. Staff D was observed to place clothes in multiple rooms taking them from the cart and touching closet door handles. During an interview on 08/14/23 at 10:24 AM, Staff D was asked about the delivery of clothes. Staff D stated, I deliver clothes to the different rooms throughout the facility. The cart does not go in the rooms and the closets are located just as I enter so I don't have to go all the way in the room. Staff D was asked about covering the clothes as they go through the facility. Staff D stated, When I go on the COVID units the clothes are covered, otherwise I do not cover them. Staff D was asked what the facility policy indicated. Staff D stated, I don't know what that is. During an interview on 08/17/23 at 8:53 AM, Staff E, Laundy Aide was asked about delivering clothes in the facility. Staff E stated that the clothes and linens should be covered when delivering them to the units. During an interview on 08/17/23 at 10:44 AM, Staff B was asked about the delivery of clothes and linens throughout the facility. Staff B stated, The items should be covered to prevent cross contamination.

Apr 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 F0660 (Tag F0660)

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 coordinate post-discharge care and services, and needed medical equipment, for one of three residents (Resident 1). In addition, the facility failed to obtain a doctor's order for discharge for one of three residents (Resident 1) reviewed for discharge planning. These failures placed the resident at risk for falls, injuries, decline in health, and lack of necessary on-going care and services. Findings included . Review of the discharge Minimum Data Set (MDS, a required assessment tool), dated 03/04/2023, showed that Resident 1 admitted to the facility on [DATE] with diagnoses to include difficulty walking, muscle weakness, need for assistance with personal care, and dementia. Further review of the discharge MDS showed that, at the time of Resident 1's discharge on [DATE], they required limited to extensive staff assistance with moving and repositioning in bed, transferring from one surface to another (such as from bed, chair, wheelchair, standing position, etc.), dressing and undressing, toilet use, walking, getting around in the facility, and personal hygiene needs. Review of the occupational therapy discharge summary, signed 03/03/2023, showed that it was recommended that occupational therapy continued, through home health services, after discharge. In addition, a shower chair with a back, and a walker were recommended pieces of medical equipment to have at home. Review of the physical therapy discharge summary, signed 03/03/2023, showed that it was recommended that physical therapy continued, through home health services, after discharge. In addition, a walker and wheelchair were recommended pieces of medical equipment to have at home. Review of the physician orders, dated March 2023, showed there was no order to discharge Resident 1 from the facility, therefore, there were no physician orders specifying the location to which Resident 1 was to be discharged , what services were required post-discharge, or what medical equipment, if any, was required. Review of the facility discharge summary, signed 03/04/2023, showed that Resident 1 was going home with family, and that the reason for discharge was that Resident 1 had completed therapies and was safe for discharge. The discharge summary further showed that Resident 1 required limited to extensive assistance with bathing, dressing, personal hygiene, transfers, bed mobility, walking and toileting. In addition, the discharge summary showed that Resident 1 needed a walker and wheelchair. Further review of the discharge summary showed the sections for medical equipment and community services agency were left blank, indicating there was no medical equipment arranged for Resident 1, such as a walker or a wheelchair, and there were no on-going services coordinated, such a home health physical therapy, occupational therapy, or caregiver. In interview, on 03/16/2023 at 10:26 AM, a family member stated that Resident 1 was discharged to a private apartment, to live alone, with no assistance. They stated that no home health services were set up for Resident 1, and there was no walker, or any medical equipment, arranged by the facility for home use. In interview on 03/17/2023 at 11:46 AM, Staff B, Director of Rehab (DOR), stated that Resident 1 should have discharged with home health services, and continuing therapy. Staff B, DOR, further stated that, based on their knowledge of Resident 1, they would not have been safe to discharge home independently. In interview on 04/04/2023 at 2:20 PM, Staff A, Director of Nursing (DNS), stated that there should have been a doctor's order for Resident 1 to discharge, and the recommended home health services and medical equipment should have been arranged by the facility prior to Resident 1 discharging home. Staff A, DNS, stated they are not sure why these things were not done. Reference WAC 388-97-0080 (2)(e)(iv) .

Jan 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to make prompt efforts to resolve the resident's grievance of missing property for one of three residents (Resident 1) reviewed for grievances of missing personal property. Failure to address and resolve grievances prevented the facility from determining if potential abuse or neglect occurred, if residents required protection, determine if additional changes to care plans were needed and decreased quality of life while a resident in the facility. Findings included . Review of the Discharge Minimum Data Set (MDS, a required assessment tool), dated 11/19/2022, showed that Resident 1 was admitted to the facility from 08/31/2022 to 11/19/2022 with diagnoses to include encephalopathy (disease that alters brain function or structure), altered mental status, and need for assistance with personal care. Review of a facility policy and procedure titled, Resident and Family Grievances, dated 10/22, showed that the facility would make prompt efforts to resolve grievances and that the grievance official, or designee, would keep the resident apprised of process toward resolution of the grievances. The policy further showed that a written decision would be issues to the resident or representative to include the date the grievance was received, the steps taken to investigate, a summary of the findings/conclusions, a statement as to whether the grievance was confirmed or not, any corrective action taken, and the date the decision was issued. Review of a facility policy and procedure titled, Missing Property, dated 07/22/2022, showed that the Missing Property Form would be used to document the loss and search for missing items, and that the facility would communicate with residents and family members. The policy further showed that if a reported missing item was not found within 30 days, the investigation would be closed, and that the facility would replace lost items if facility negligence was determined. Review of progress notes showed that Resident 1's POA discussed missing property with facility staff on 10/07/2022, 10/28/2022 and 11/04/2022. During interview on 12/20/2022 at 11:16 AM, Resident 1's Power of Attorney (POA, someone designated to represent or act on another's behalf) stated that she had reached out to the facility about Resident 1's missing property multiple times, and still had not heard from the facility about the missing property, nor had any reimbursement been offered. Review of a Missing Property Report, dated 11/18/2022, showed that Resident 1's POA reported, that on 10/07/2022, several clothing items were missing, to include pajamas, tops and pants, as well as a watercolor/drawing pad of paper. The report further showed that the POA had not been asked to log any of these items in the facility. Additional review of this Missing Property Report showed no follow-up with Resident 1's POA and no resolution of the grievance. In interview on 01/06/2023 at 3:17 PM, Staff B, Social Services Director, stated that they were not sure where the missing items reports were kept, and that if missing items were not found, then the report would be given to Administration to proceed with the next steps. In interview on 01/06/2023 at 3:52 PM, Staff A, Administrator in Training (AIT), stated that the facility's practice, regarding missing property, was to wait 30 days and if they were not found, the facility would consider reimbursement. Staff A, AIT, further stated that there was no follow-up attached to Resident 1's Missing Property Report, dated 11/18/2022, and that there should have been documented communication with Resident 1's POA, and resolution of the missing property. Reference WAC WAC 388-97-0460(2) .

Nov 2022 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 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** Based on interview and record review, the facility failed to assess and monitor vital signs, throughout the course and treatment of an infection, for one of five residents (Resident 1), and failed to follow physician orders for three of five residents (Residents 1, 2 and 5) reviewed for professional standards of practice. These failures placed the residents at risk for unidentified changes in condition, medical complications, and unmet needs. Findings included . ASSESSMENT and MONITORING RESIDENT 1 Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 09/06/2022, showed that Resident 1 admitted to the facility on [DATE] with diagnoses to include obstructive uropathy (a condition in which urine cannot drain through the urinary tract), and required the continuous use of an indwelling urinary catheter (a flexible tube that is inserted into the urinary tract to drain urine). Review of the progress notes, dated 11/06/2022, showed that staff identified Resident 1 as having conjunctivitis (inflammation or infection of the outer membrane of the eyeball and the inner eyelid) in the left eye. Review of the physician's chart note, and orders, dated 11/07/2022, showed that an antibiotic medication was ordered, for Resident 1, to treat the eye infection, to be given three times per day for seven days, beginning on 11/07/2022. Review of Resident 1's vital signs showed that there was no temperature documented from 11/09/2022, at 3pm, at which time Resident 1 did not have a fever, to 11/10/2022 at 7:43 PM, at which time Resident 1 had a fever of 104.0. Review of progress notes dated 11/10/2022 and 11/11/2022 showed that Resident 1 was sent to the emergency room, for evaluation of the elevated temperature, on 11/10/2022 at 8:45 PM, and returned to the facility, on 11/11/2022 at 1:14 AM, with a diagnosis of a urinary tract infection and new orders for an antibiotic to treat it. In interview on 11/16/2022 at 2:11 PM, Staff A, Director of Nursing Services (DNS), stated that Resident 1's vital signs, to include temperature, should have been monitored at least every shift, during treatment for Resident 1's eye infection, and that was not done from 11/09/2022, at 3pm, to 11/10/2022 at 7:43 PM. FOLLOWING PHYSICIAN ORDERS RESIDENT 1 Review of physician's orders, dated 08/31/2022, showed that Resident 1 was to have their indwelling urinary catheter changed every month on the 15th. Review of the treatment administration record (TAR), dated September 2022, showed that on 09/15/2022, the order to change the catheter was not completed due to Resident 1 being asleep. Further review of the TAR showed no additional attempts to reapproach and complete the order later. RESIDENT 2 Review of the hospital transfer orders, dated 10/17/2022, showed that Resident 2 admitted with diagnoses to include ureteral cancer (cancer of the ureters [the tubes that connect the kidneys to the bladder]), and required the continuous use of an indwelling urinary catheter. Review of physician's orders, dated 10/17/2022, showed that Resident 1 was to have their indwelling urinary catheter changed every month on the 15th. Review of the TAR, dated November 2022, showed that, on 11/15/2022, the order to change the catheter was not completed. Further review of the TAR showed no additional attempts to reapproach and complete the order later. Additionally, review of the progress notes showed no documentation explaining why the treatment was not carried out as ordered. RESIDENT 5 Review of the hospital Discharge summary, dated [DATE], showed that resident transferred to the facility with a diagnosis of bladder outlet obstruction (a condition in which urine cannot flow though the urinary tract in a normal manner) and required the continuous use of an indwelling urinary catheter. Review of physician's orders, dated 10/17/2022, showed that Resident 1 was to have their indwelling urinary catheter changed every month on the 15th. Review of the TAR, dated November 2022, showed that, on 11/15/2022, the order to change the catheter was not completed. Further review of the TAR showed no additional attempts to reapproach and complete the order later. Additionally, review of the progress notes showed no documentation explaining why the treatment was not carried out as ordered. In interview on 11/16/2022, at 3:40 PM, Staff A, DNS, stated that if a treatment was not able to be completed the expectation was that the reason would be documented, and the staff would reapproach later to complete the treatment. In addition, if the treatment was not able to be completed, the staff should notify the attending provider, and that should be documented as well. Staff A, DNS, stated that this process was not followed in the cases of Residents 1, 2 and 5. Reference WAC 388-97-1080 (10)(c) .

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

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Washington facilities.
• 39% turnover. Below Washington's 48% average. Good staff retention means consistent care.

Concerns

• 50 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.

Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.

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About This Facility

What is Eliseo's CMS Rating?

CMS assigns ELISEO an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Washington, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Eliseo Staffed?

CMS rates ELISEO's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 39%, compared to the Washington average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Eliseo?

State health inspectors documented 50 deficiencies at ELISEO during 2022 to 2025. These included: 1 that caused actual resident harm, 48 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Eliseo?

ELISEO is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 187 certified beds and approximately 125 residents (about 67% occupancy), it is a mid-sized facility located in TACOMA, Washington.

How Does Eliseo Compare to Other Washington Nursing Homes?

Compared to the 100 nursing homes in Washington, ELISEO's overall rating (4 stars) is above the state average of 3.2, staff turnover (39%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Eliseo?

Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"

Is Eliseo Safe?

Based on CMS inspection data, ELISEO has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Washington. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Eliseo Stick Around?

ELISEO has a staff turnover rate of 39%, which is about average for Washington nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Eliseo Ever Fined?

ELISEO has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Eliseo on Any Federal Watch List?

ELISEO 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: 187
Avg. Residents: 125
Occupancy: 67.3%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
1 Actual Harm citation: -5
50 Deficiencies: -10
Final Score: 65/100

Nearby Alternatives

TACOMA NURSING AND REHABILITAT... 5-star RAINIER REHABILITATION 5-star LIFE CARE CENTER OF PUYALLUP 5-star

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 505435