When surveyors requested monthly infection surveillance reports for 2025, nursing staff initially could not provide the documentation.
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The inspection resulted in citations under reference WAC 388-97-1100(1), which governs nursing home operational standards and resident care requirements.
Inspectors found that residents with diagnosed mental health conditions were not receiving the specialized care outlined in their treatment plans.
However, this admission highlighted a dangerous gap between knowledge and practice that could have exposed other residents to the influenza virus.
The violations occurred across several areas of the facility's food service operations, including storage, temperature monitoring, and handling procedures.
"RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated," according to the inspection report.
For patients with atrial fibrillation, blood thinners are essential medications that prevent potentially fatal blood clots from forming.
When staff finally identified the penile split in April 2024, they failed to measure it, update his care plan, or ensure immediate physician notification.
Despite receiving detailed referral information from a local hospital, the facility failed to take appropriate action to ensure the resident's safety.
Medical records showed the resident was unable to move his leg, and his knee and foot appeared severely swollen.
A housekeeper present in the room was cleaning and did not witness the fall.
Resident B1, who has diabetes and joint disease, told inspectors during the July 2 visit: **"Staff sometimes don't give me a shower.