Sullivan Park Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, and homelike environment for 2 of 3 residents (Residents 13 and 6) and 4 of 6 shower rooms (Halls 100, 200, 500, and 600), reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their living conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food at proper temperatures and palatable taste for 5 of 8 residents (Resident 4, 97, 92, 56 and 48) reviewed for food. This failure placed residents at risk for foodborne illness, decreased nutritional intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) ensure dry goods and refrigerated foods were properly stored, covered, and labeled with use-by dates for food safety tracking, and 2) maintain the kitchen, dishwashing area, entrance, and rear exit environments in a clean, sanitary, and repaired condition to prevent cross-contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP- precautions to protect residents from multidrug-resistant organisms [MDRO-a germs that are resistant to medications that treat infections]) were identified for 1 of 3 residents (Resident 148) reviewed for infection control. Additionally, the facility failed to ensure EBP, and hand hygiene were implemented for 2 of 2 residents (Resident 6 and 139) as required during urinary catheterizations (a flexible tube inserted through the urethra [a small duct that carries urine from the bladder] into the bladder to drain urine). This failure placed the residents at risk for the spread of infections, illnesses and unnecessary health consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had access to their personal trust fund money outside of normal business hours (Monday through Friday, 8:00 AM to 5:00 PM) and during weekends for 2 of 6 residents (Resident 4 and 76) reviewed for personal funds. This failure placed residents at risk for unmet financial needs and limited their right to self-determination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from physical restraints and had an evaluation and documented medical symptoms to validate the use of restraints for 1 of 2 residents (Resident 148) reviewed for restraints. Additionally, the resident's record did not show the least restrictive alternatives had been attempted prior to the restraint use or documentation of ongoing monitoring. This failure placed the residents at risk for injury, agitation and a decline in physical function.

Inspectors wroteBased on interview and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) had the required Level 2 referrals sent, or responded to in a timely manner by a licensed mental health professional when residents had a positive Level 1 PASARR for 2 of 5 residents (Resident 14, 97, ) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received treatment and services in accordance with professional standards of practice regarding implementation of resident directed care and treatment for a resident with a urostomy (a surgical opening in the abdomen that allows urine to exit through a stoma [an artificial opening] in a collection bag) for 1 of 2 residents (Resident 148) reviewed for quality of care. This failure placed residents at an increased risk for unidentified complications and a deterioration in their health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative (RNP-a specialized program to help long term care residents maintain or improve their maximum functional independence)nursing services programs were implemented for 1 of 4 residents (Resident 34), reviewed for restorative nursing and limited range of motion ( ROM-the extent the joint can move within the expected [normal] range of values). This failure placed the residents at risk for loss of ROM, deconditioning, pain, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen).

Inspectors wroteBased on interview and record review the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to cancel the agreement within 30 calendar days, in a manner and language that the resident understood for 2 of 3 residents (Resident 138, and 2) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 sampled residents (Resident 1) reviewed for medication management. The failure to ensure medications were acquired and administered as ordered placed residents at risk for adverse events related to missed medications. This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility educated staff, updated training methods, and monitored for additional missed medications, by 02/02/2026. The facility was notified of the past non-compliance on 06/18/2026.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate consents were obtained prior to the administration of psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior and are typically used to treat mental health conditions) medications for 3 of 5 sampled residents (Residents 91, 102 and 411) reviewed for unnecessary medications. This failure precluded the residents or their representatives to participate in decisions regarding their care and treatment.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's abuse prevention policy including identification of potential allegations, timely reporting allegations to the State Survey Agency as required, thoroughly investigating allegations, and monitoring residents for potential psychosocial harm after allegations were made for 6 of 10 sampled residents (Resident 42, 62, 63, 35, 311, and 20), reviewed for abuse. This failure placed residents at risk of potential abuse, neglect and/or misappropriation or their property and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 6 of 6 sampled residents (Resident 6, 23, 411, 416, 417, and 62) reviewed for trauma informed care, received culturally competent, trauma-informed care in accordance with professional standards of practice. The failure of the facility to adequately screen, assess, identify potential triggers (a psychological stimulus that prompts recall of a previous traumatic event), and develop and implement a Trauma Informed Care Plan to help limit the residents' exposure to potential trauma triggers, placed the residents at risk for re-traumatization and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility had enough staff to provide care according to facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 5 of 10 sampled resident's, (Resident 63, 62, 91, 89, and 42), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 4 of 6 sampled staff (Staff I, BB, N, and UU), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appetizing and palatable food for 5 of 14 sampled residents (Residents 35, 46, 211, 20, and 17) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, potential weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, discard and distribute food, monitored temperatures of foods being served, ensure accuracy of preparation of thickened liquids, and maintain a cleaning schedule in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed during wound care to include removal of gloves and performing hand hygiene (HH) when indicated for 2 of 5 sampled residents (Residents 101 and 105), reviewed for pressure ulcers. Specifically, staff did not implement or follow Enhanced Barrier and Contact Precautions when indicated. Additionally, staff failed to notify the Infection Preventionist (IP) of a potential gastrointestinal (GI) outbreak in 1 of 4 units in the facility. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was evaluated to self-administer their medications for 1 of 5 sampled residents (Resident 20), observed during medication administration. This failure placed residents at risk for missed medication doses or unintended health consequences. According to a 01/10/2025 comprehensive assessment, Resident 20 had diagnoses that included diabetes, heart failure and aphasia (a partial or total loss of the ability to articulate or comprehend language). Per the assessment, they could usually understand and made their needs known. Their Brief Interview for Mental Status (BIMS, a cognitive test) score was 00 (out of a maximum of 15), and all responses were either: no answer, missed, incorrect or could not recall. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to make reasonable efforts to accommodate a resident's visual impairment needs for 1 of 4 sampled resident (Resident 46), reviewed for personal property. This failure placed residents at risk of eye strain, potentially avoidable accidents, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure advanced directive documents were completed accurately and the correct information was entered into the medical record for 3 of 3 sampled residents (Residents 102, 91 and 63), reviewed for advanced directives. Specifically, Resident 102 had conflicting information regarding what interventions staff were to take during a code situation (an emergency where one would die if cardio-pulmonary rescusitation, CPR, was not started) and Resident 91 had severe cognitive impairement and signed their own advanced directive documents. These failures created potential for confusion during medical emergencies and for resident decision makers to be uninformed of a resident's care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, comfortable, safe and homelike environment for 1 of 2 sampled residents (Resident 20), reviewed for environment. Specifically, Resident 20's walls in their room were in disrepair and chemicals were not properly secured in a storage room. These failures placed all residents at risk for potentially avoidable injuries and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently supervise and/or monitor cognitively impaired residents' behaviors to prevent verbal and/or physical resident-to-resident altercations to the extent possible for 2 of 10 sampled residents (Resident 89 and 63), reviewed for abuse. This failure placed residents at risk of potential abuse, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (Resident 110 and 104), reviewed for hospitalizations. This failure placed residents at risk for a disruptive, ineffective transition from the facility to the hospital setting and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of a required Pre-admission Screening and Resident Review (PASRR) Level 2 evaluation (a person-centered evaluation that is completed for anyone identified as having or suspected of having a serious mental illness, intellectual disability, developmental disability, or related condition) prior to admission for 2 of 5 sampled residents (Resident 6 and 102), reviewed for PASRR. Additionally, the facility failed to ensure Resident 52's PASRR Level 2 recommendations were implemented. These failures placed the residents at risk for unmet mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review Level I (PASRR, determines if an individual had or was suspected of having a serious mental illness [SMI], intellectual or developmental disability or related condition) were accurately completed for 3 of 5 sampled residents (Residents 6, 411, and 63 ) reviewed for PASRR. This failure placed the residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that documented resident specific goals and treatment plans for 2 of 3 residents (Resident 6 and 411), reviewed for new admissions. This failure placed residents at risk for unmet care needs, possible medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to develop the care plans and implement interventions for 3 of 24 sampled residents (Resident 78, 62, and 41), reviewed for care planning. This failure placed the residents at risk for inadequate care, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plans in response to changing goals, needs of the residents or in response to current interventions for 2 of 33 sampled residents (Residents 44 and 35) reviewed. Specifically, Resident 44 fell and broke their hip, and had continued falls and the care plan was not updated. Additionally, Resident 35 was newly diagnosed with Addison's disease (when the adrenal glands are damaged and do not produce enough hormones to regulate blood pressure, water and salt balance, and respond to stress), and disease related interventions were not added to the residents care plan. These failures put the residents at risk for unmet care needs and unintended health consequences.

Inspectors wroteBased on observation, interview and record review the facility failed to implement the bowel management protocol when indicated for 2 of 3 sampled residents (Resident 18 and 71), reviewed for constipation. In addition, the facility failed to identify changes in a resident's skin condition timely for 1 of 2 sampled residents, (Resident 15), reviewed for skin conditions. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who admitted without pressure injuries did not develop pressure injuries and residents with pressure injuries did not worsen. Specifically, the facility failed to communicate interventions to the staff including settings of specialty mattresses, the correct use of positioning devices, and to address the identification of refusals of care for 3 of 5 residents (Residents 101, 1, and 105), reviewed for pressure injury. These failures placed residents at risk for pressure injury development, wound infections and/or complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure smoking materials were secured as care planned for 1 of 3 sampled residents (Resident 18), reviewed for smoking. In Addition, the facility failed to assessed and monitored for the safe use of an electrical heating appliance for 1 of 5 sampled residents (Resident 78), reviewed for accident hazards. These failures placed residents at risk for potentially avoidable accident and placed the facility at risk of fire.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's peripherally inserted central catheter (PICC, also known as a central line, a catheter placed in a large vein in the arm that extended to a large vein in the heart, used if long term antibiotic therapy was required or if antiobiotics were damaging to smaller veins) was maintained according to standards for 1 of 1 sampled residents (Resident 52) reviewed. This failure placed the resident at risk for complications related to their PICC including blood stream infections, blood clots, or inflammation of the vein.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (Residents 35, 74) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and respond to each resident's individualized needs for 10 of 12 sampled staff (Staff I, S, N, BB, HH, JJ, LL, RR, SS, and UU), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that controlled medications were tracked, and controlled medications for discharged residents were discarded, in 1 of 2 medication rooms (North Hall) inspected. This failure placed the facility at risk for drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to identify and monitor target behaviors for the use of psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior and are typically used to treat mental health conditions) medications for 2 of 5 sampled residents (Resident 6 and 411), reviewed for unnecessary medications. This failure placed residents at risk for potential adverse consequences related to the use of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the provider's order for 2 of 7 sampled residents (Residents 95 and 102) reviewed for medication administration. Specifically, multiple doses of a medication that treated Resident 95's lupus (the body's immune system attacks it's own healthy tissues causing pain and swelling) were omitted. Additionally, medication to control Resident 102's heart rate was not held when hold parameters were met. This failure placed the residents at risk for unintended health consequences from omitted doses, and medication side effects when medications were not held as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff had the required qualifications (current Washington State Food Worker Cards) for 1 of 14 dietary staff (Staff Z), whose records were reviewed. This failed practice had the potential risk for unsafe food handling practices and placed residents at risk for developing foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 5 sampled residents (Resident 104) whose discharge records reviewed. Specifically, Resident 104 was sent to the local hospital for urgent treatment and the medical record did not include events leading to the resident's decline and need for transfer. This failure created a risk for incomplete sharing of vital information with care givers across levels of care and lack of evidence of care provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were educated regarding the risks and benefits of and provided the COVID (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization) vaccine if desired, and failed to ensure minimum documentation was maintained regarding staff COVID vaccination status for 1 of 1 sampled staff (Staff P) reviewed. This failure placed staff and residents at risk of exposure to and illness from COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 2 of 45sampled residents (Resident 1 and 3), reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included . <Resident 1> Per the admission assessment dated [DATE] Resident 1 admitted to the facility for therapy services after a fracture (arm). The assessment documented the resident required extensive staff assistance to perform ADLs. Review of the 11/06/2024 care plan showed Resident 1 was to work with therapies to meet goals of improvement in their functional abilities. Review of a physical therapy discharge summary, signed 12/06/2024, showed Resident 1 met one out of three short-term goals and zero out of three long-term goals. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 sampled residents (Resident 1) reviewed for medication management. The failure to ensure medications were acquired and administered as ordered placed residents at risk for adverse events related to missed medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 6 sampled residents (Resident 8) and their representatives and medical provider, reviewed for notification of changes, received timely notification of an incident. This failure placed the resident at risk of delayed access to care, inability to participate in care planning, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse, for 1 of 6 sampled residents (Resident 8), reviewed for abuse. The failure to provide timely follow-up medical care and to preserve potential evidence placed the resident at risk of unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident, their representative, and the State Long-Term Care Ombudsman for 1 of 5 sampled residents (Resident 10), reviewed for discharge. This failure placed the resident at risk of not having the opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary pain management for 2 of 3 sampled residents (Resident 3 and 4), reviewed for pain. Resident 3 and 4 each experienced harm when the facility did not ensure they had the ordered pain medication, or another effective alternative, to treat the residents timely, which resulted in each resident requiring to transfer to the hospital to relieve their pain. This failure placed residents at risk of uncontrolled pain and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 8 and 12), reviewed for meal intake, received assistance setting up their meals and continued supervision and cueing while eating. This failure placed the residents at risk of decreased dietary intake, potential weight loss, and decreased quality of life. Additionally, the facility failed to ensure 3 of 3 sampled residents (Resident 8, 1, and 5), reviewed for bathing, received the assistance they required with baths and/or showers. This failure placed the residents at risk for skin breakdown, discomfort, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to respond to call lights timely and to meet the care needs of 6 of 13 sampled residents (Residents 13, 8, 3, 4, 5, and 12), reviewed for sufficient nursing staff. This failure resulted in feelings of frustration and vulnerability, diminished quality of life and unmet care needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure significant medications were given as ordered for 3 of 3 sampled residents (Resident 3, 4, 5), reviewed for medication administration. This failure placed the residents at risk for worsening of their medical conditions and unintended consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal privacy for 2 of 2 sampled residents (Resident 5 and 8), reviewed for dignity. Failure to ensure the residents' personal privacy placed them at risk for lack of dignity and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential misappropriation were reported immediately to administration and the State Agency as required, for 1 of 3 sampled residents (Resident 4) reviewed for abuse. This failure placed residents at risk for possible misappropriation.

Inspectors wroteBased on interview, and record review, the facility failed to ensure necessary wound care supplies were available and staff were knowledgeable in their use for 1 of 14 sampled residents (Resident 4), reviewed for quality of care. This failure placed residents at risk of not receiving necessary care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 8), reviewed for accident hazards and staff supervision, were safely transferred with via the assistance devices and staff supervision level they were assessed to need. This placed the resident at risk for injury, decreased sense of safety and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals with assistive devices in the correct position for use for 1 of 3 sampled residents (Resident 8), reviewed for meal service. This failure placed the resident at risk for decreased meal intake, loss of dignity, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system was in place in which residents' records were complete and accurate for 1 of 11 sampled residents (Resident 4) reviewed for accurate and complete medical records. The facility failed to ensure the medical record included medications administered for pain control immediately prior to a transfer to a hospital for pain control. Failure to maintain complete and accurate medical records placed the resident at risk for medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one randomly observed staff (Staff L) wore personal protective equipment (PPE) in accordance with Centers for Disease Control (CDC) guidelines for prevention of spread of COVID-19 (a disease with a wide range of symptoms ranging from mild symptoms to severe illness caused by the SARS-CoV-2 virus). This failure placed residents (facility census 108) and staff at risk for spread of a contagious disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the identified transfer assistance required to prevent injury for 1 of 3 sampled residents (Resident 1), reviewed for accidents and supervision. This failure resulted in actual harm to Resident 1, who sustained a fracture and pain during a transfer without utilization of a two-person assist and appropriate equipment, as required.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care planned interventions for 1 of 4 sampled residents (Resident 1) reviewed for care planning. This failure left the resident at risk for unmet needs, falls and fall related injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three staff members (Staff F and G), reviewed for competency, were evaluated by the facility for competency with skills and techniques upon hire. This failure placed residents at risk to receive substandard care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent for 2 of 4 sampled residents (62,35) during 4 medication passes observed. Specifically, 3 errors were made during 27 medication administration opportunities, resulting in an error rate of 11.11 percent. Errors in medication administration placed residents at potential risk for not receiving the full therapeutic effect of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. Additionally, temperatures were not monitored consistently for refrigerators containing vaccines, narcotic books did not contain two verifying signatures that the count was correct, and insulin was expired and undated when opened. The facility further failed to ensure narcotics were locked in a permanently affixed narcotic container in 2 of 2 medication storage room refrigerators. These failures placed residents at risk for receiving compromised or ineffective medication and placed the facility at risk for potential diversion or misappropriation of narcotic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, perishable foods were not labeled with the opened on or discard date, expired foods were not discarded, refrigerator temperatures were not monitored, hand hygiene was not performed with glove changes, and facial hair was not covered in the food preparation area. These failures placed residents at risk for consuming contaminated foods and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system for identifying, investigating and reporting infectious diseases for 1 of 5 sampled residents (82) reviewed for tuberculosis (TB) screening (a bacterial infectious disease spread through contact with or breathing in particles coughed into the air) and failed to ensure hand hygiene was completed when indicated during observations of three medication passes, one dressing change, and two meals in the South unit dining room. This failure placed residents at risk for spread of infectious illnesses and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to preserve a resident's dignity for 1 of 2 sampled residents (10) reviewed. Failure to ensure signage regarding Resident 10's personal care was not hung in public view placed Resident 10 at risk for embarassment and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care planned goals and interventions for 3 of 27 sampled residents (82, 53 and 81) reviewed and failed to ensure the care plan was implemented by staff for 1 of 27 sampled residents (81) reviewed for care planning. Specifically, Resident 82 was dependent on dialysis (a way of removing waste from the body when kidneys no longer function). Residents 53 and 80 had post-traumatic stress disorder (PTSD, condition triggered when one expierienced or witnessed shocking or terrifying events). These residents had no goals or interventions developed related to these diagnoses. Also, Resident 81 had a history of falling and their call bell was not left within their reach as care-planned. These failures left residents at risk for unmet needs, and at risk for fall related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was reviewed and revised for 1 of 27 sampled residents (62) reviewed for care planning. Specifically, Resident 62's care plan did not reflect that they were not to have their nutrition by mouth. This failures placed the resident at risk for adverse events related to receiving the wrong therapies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 sampled residents (16) reviewed for activities, received an ongoing program of activities that met their interests. This failure placed the resident at risk for boredom and diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents environment remained free of accident hazards, and that 1 of 5 sampled residents (29), reviewed for accidents/hazards, received adequate supervision to prevent accidents. Specifically, hazardous chemicals and materials were not secured on 5 of 5 halls where residents could access them, treatment and medication carts were left unlocked and unsupervised. In addition, Resident 29 had unsecured cigarettes and a lighter in a pouch on their wheelchair. These failures placed the residents at a potential risk of harm related to avoidable incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents that had significant weight loss were reassessed by the Registered Dietician (RD) timely for 2 of 6 sampled residents (10, 62) reviewed for nutrition. This failure placed residents at risk for further undesired weight loss, and a decline in their health.

Inspectors wroteBased on interview and record review, the facility failed to follow standards of care for 1 of 2 residents (62) reviewed for tube feedings. Specifically Resident 62 experienced vomiting and failure of staff to check gastric residual volumes (GRV - fluid/contents that remain undisgested in the stomach) prior to tube feeding administration. This failure placed the resident at risk for weight loss, continued vomiting, medical complications, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 2 of 4 sampled residents (16, 40) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were given as ordered for 1 of 6 sampled residents (53) reviewed for medication administration. This failure placed Resident 53 at risk for worsening depression and adverse health consequences when they missed doses of their medications.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate licensing necessary to carry out the functions of the nutritional services for 92 residents. Specifically, the Registered Dietician (RD) did not have a license to practice in Washington State. This failure placed residents at risk for unmet nutritional needs and possible unintended weight loss or gain.

Inspectors wroteBased on interview and record review, the facility failed to consistently monitor and/or accurately document condition changes for 2 of 3 sampled residents (Resident 2 and 3). These failures placed residents at risk of potential medical complications, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently monitor tolerance to dialysis (procedure to remove fluid and waste from the body when the kidneys stop working properly) treatments for 1 of 2 sampled residents (Resident 1), reviewed for dialysis care. In addition, the facility failed to communicate and collaborate care with the dialysis center. These failures placed residents at risk of unrecognized complications, unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to transcribe providers orders accurately and/or ensure residents routinely received their medications as ordered by the provider for 2 of 3 sampled residents (Resident 1 and 2), reviewed for significant medication errors. These failures placed residents at risk of potential adverse side effects, unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of personal property and funds for 3 of 4 sampled residents (Residents 2, 4, and 7), reviewed for misappropriation. This failure placed residents at risk for missing property, missing funds, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement measures to prevent the spread of communicable disease during a COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness]) outbreak on 2 of 2 affected units (200 & 300 halls). This failure placed residents at risk of contracting a communicable disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one staff member (Staff G) timely reported allegations of staff misappropriation of resident property, as required. This failure placed residents at risk of misappropriation and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate 1 of 3 (Resident 2) allegations of misappropriation of resident property. This failure placed residents at risk of unidentified misappropriation and diminished quality of life.