Orchard Park Health Care & Rehab Center

Review of the EHR showed Resident 11 admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain dysfunction caused by chemical imbalances or underlying systemic diseases in the body) and diabetes. Resident 11 was able to make needs known.

Review showed Resident 11 was their own responsible party but did not show the facility had reviewed their AD decisions.

Review of the EHR showed Resident 141 admitted to the facility on [DATE] with diagnoses to include acute kidney failure and diabetes. Resident 141 was able to make needs known.

Review showed Resident 141 was their own responsible party but did not show the facility had reviewed their AD decisions.

During an interview on 05/21/2026 at 10:50 AM, Staff H, Social Services Director, stated residents' AD decisions should be reviewed on admission, with quarterly care conferences, and at residents' request.

During a follow-up interview on 05/21/2026 at 2:09 PM, Staff H stated Resident 6 had a care conference most recently on 02/24/2026 and their AD decision was not reviewed.

Staff H stated Resident 11 had an initial care conference on 04/07/2026 and their AD decision was not reviewed.

Staff H stated Resident 141 had a care conference most recently on 11/17/2025 and their AD decision was not reviewed.

Staff H stated Residents 6, 11, and 141's lack of AD review did not meet expectations.

During an interview on 05/26/2026 at 9:27 AM, Staff A, Administrator, stated social services would review AD decisions with residents on admission and with quarterly care conferences.

Staff A stated Residents 6, 11, and 141's lack of AD review did not meet expectations.

Reference WAC 388-97-0280(3)(c)(i)(ii), -0300(1)(b)(3)(a)-(c)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included .

Resident 27

Review of the electronic health record (EHR) showed Resident 27 was admitted to the facility on [DATE] and discharged on 04/27/2026 to an adult family home.

Review of records showed Resident 27 was not provided with a NOMNC form prior to discharge.

Resident 161

Review of the EHR showed Resident 161 was admitted to the facility on [DATE] and was discharged on 12/02/2025 to home.

Review of records showed Resident 161 was not provided with a NOMNC form prior to discharge.

During an interview on 05/22/2026 at 10:18 AM, Staff N, Business Office Manager, stated they were responsible for issuing the MOMNC notices and there was none to be found for Resident 27 and 161.

During an interview on 05/26/2026 at 11:54 AM, Staff A, Administrator, stated the process was for Medicare insured residents to have NOMNC notice given in advance and the lack of notices for Residents 27 and 161 did not meet expectations.

Reference WAC 388-97-0300(1)(e),(5),(6)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the electronic health record (EHR) showed that Resident 2 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar) and high blood pressure and was able to make needs known.

During an interview on 05/18/2026 at 10:26 AM, Resident 2 stated their cell phone went missing and staff were aware; however, it had not been found or replaced.

Review of Resident 2's Inventory of Personal Effects, form dated 04/17/2026 showed Resident 2 had a cell phone with charger and black bag listed among their personal items.

Review of the facility's grievance/concern log dated April 2026 showed a grievance logged on 04/27/2026 that Resident 2's family reported missing items and showed it was resolved on 05/08.

Review of Resident 2's Complaint/Grievance Report, dated 05/08/2026 showed Resident 2's family member reported on 04/26/2026 that Resident 2 had missing clothing items and a phone. It showed the clothing items were found and the issue was resolved on 05/08/2026; however, it did not address the missing phone.

During an interview on 05/20/2026 at 12:42 PM, Staff O, Licensed Practical Nurse/Resident Care Manager, stated Resident 2's inventory list showed the resident had a cell phone and charger.

Staff O stated Resident 2's Complaint/Grievance Report, dated 05/08/2026 should have addressed the missing phone and this did not meet their expectations.

During an interview on 05/20/2026 at 12:53 PM, Staff A, Administrator, stated they were not aware that Resident 2 was still without a cell phone and had thought it had been found along with their missing clothing items and this did not meet their expectations.

Staff A stated Resident 2's phone needed to be replaced, or the resident compensated for the missing phone.

Reference WAC 388-97-0880, -2040

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

During an interview on 06/01/2026 at 4:23 PM, Saff B, Director of Nursing, stated due to lack of staff, the one-on-one supervision for safety of Resident 7 had not been consistent.

Staff B stated it did not meet their expectations that Resident 7 was still subjected to Resident 151 during smoke breaks and that the interventions had not been implemented.

Staff B was asked why the one-to-one was not on Resident 151 and how the facility planned to keep other residents safe, Staff B said they were not.

Staff B stated the facility had a hard time dealing with Resident 151 and their aggressive behaviors towards staff.

Staff B stated the facility had not implemented the intervention to monitor/document Resident 151's behaviors and that did not meet expectations.Review of Resident 151's progress note, dated 06/02/2026, showed during a scheduled smoke break, Resident 151 was observed engaging in inappropriate interactions with another resident.

Staff intervened and redirected the resident; however, the resident became verbally agitated, yelling and using abusive language toward staff.

Reference WAC 388-97-0640(1)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the electronic health record (EHR) showed Resident 65 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, diabetes (high blood sugar), dementia (decline in mental ability, memory and reasoning) and acute pyelonephritis (bacterial infection of kidneys). Resident 65 was not able to communicate their needs.

Observation on 05/20/2026 at 10:03 AM and 1:25 PM to 2:20 PM showed Resident 65 sitting in wheelchair by the nurse's station with head down to shoulder and eyes closed.

Observation on 05/21/2026 at 2:33 PM showed Resident 65 in their wheelchair with head down and eyes closed.

Review of EHR showed Resident 65 was prescribed and administered Seroquel (antipsychotic medication) dated 05/15/2026 for agitation.

Review of progress notes from 04/30/2026 to 05/15/2026 showed Resident 65 did not have behaviors or agitation documented.

Review of admission minimum data set (MDS, a required assessment) dated 03/26/2026 showed Resident 65 did not experience any behaviors or indications for use of antipsychotic medication.

During an interview on 05/21/2026 at 10:27 AM, Staff O, Licensed Practical Nurse/Resident Care Manager, stated the process for initiating antipsychotic medications at the facility was to first rule out any infection, environmental factors, pain and then refer to mental health.

Staff O stated the order for Seroquel for Resident 65 did not meet expectations.

During an interview on 05/22/2026 at 9:41 AM, Staff B, Director of Nursing Services, stated Resident 65 should have indications for use of antipsychotic medication and that did not meet expectation.

Reference WAC 388-97 -1060(3)(k)(i) -0620(1)(a)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

at all times.

When asked if the intervention was put in place to keep Resident 150 and other residents

when staff were not available.

During an interview on 05/26/2026 at 9:58 AM, Staff FF, Staffing

day.

Review of the staff schedule for 05/26/2026, 05/27/2026, 05/28/2026, 05/29/2026, 05/30/2026 and 05/31/2026 showed no scheduled one to one supervision for Resident 102.

During an interview on 05/26/2026 at 11:51 AM Saff B, Director of Nursing, stated the facility has not been able to implement the care planned one to one supervision due to lack of staffing.

Reference WAC 388-97-0640(2)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included .Resident 7 Review of the electronic health record (EHR) showed Resident 7 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease that affects ability to breathe), heart failure and muscle weakness. Resident 7 was able to make needs known.

Review of Resident 7's EHR showed hospitalization on 02/07/2026 and readmission to the facility on [DATE].

There was no documentation showing a bed hold was offered or the required transfer discharge form was completed and provided to the resident, or the Ombudsman notified. Resident 157 Review of the EHR showed Resident 157 admitted to the facility on [DATE] with respiratory failure, heart failure, and pneumonia. Resident 157 was able to make needs known.

Review of Resident 157's EHR showed a resident-initiated against medical advice discharge on [DATE].

There was no documentation the required transfer discharge form was completed and provided to the resident or the Ombudsman notified. Resident 155 Review of the electronic health record (EHR) showed Resident 155 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE].

Review of the EHR showed Resident 155 was not offered a bed hold, and there was no notice for the transfer to the hospital. In addition, the Office of the State Long-Term Care Ombudsman was not notified. Resident 8 Review of the EHR showed Resident 8 was admitted to the facility on [DATE].

During an interview on 05/18/2026 at 1:59 PM, Resident 8 stated they were hospitalized for about five days on 03/11/2026. Resident 8 stated they did not return to the same room and were not given a bed hold and transfer notice.

Review of the EHR showed Resident 8 did not have bed hold or transfer form and the Office of the State Long-Term Care Ombudsman was not notified.

During an interview on 05/20/2026 at 12:46 PM, Staff P, Licensed Practical Nurse (LPN), stated the process for transferring residents to the hospital included a paper form of bed hold located at the nurse's station.

Nurses were to fill it out and send it with the resident to the hospital or inform next of

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

F 0628 kin.

the hospital.

During an interview on 05/22/2026 at 9:32 AM, Staff B, Director of Nursing Services, stated lack of bed hold, transfer to hospital form and Ombudsman notifications did not meet expectations.

Reference WAC 388-97- 0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080, -0140(1)(a)-(c)(i)-(iii)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.Resident 114

Review of the electronic health record (EHR) showed Resident 114 admitted to the facility on [DATE] with diagnosis of kidney failure and bladder infection.

The resident was able to make needs known.

Review of the EHR on 05/19/2026 at 10:20 AM showed the admission comprehensive MDS assessment was still in process 29 days after admission with multiple sections unanswered.

During an interview on 05/20/2026 at 10:42 AM, Staff J, Minimum Data Set/Registered Nurse (MDS/RN), stated Resident 114 should have had the admission MDS assessment completed within 14 days of admission but did not.

During an interview on 05/20/2026 at 11:01 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that the MDS was completed per the schedule and Resident 114 should have had their admission MDS assessment completed within 14 days of admission.

Reference WAC 388-97 -1000(3)(a)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the electronic health record (EHR) showed Resident 123 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a brain malfunction caused by an underlying chemical imbalance or disease in the body) and dysphagia (difficulty swallowing). Resident 123 was able to make needs known and sometimes able to understand others.

Review of the provider order dated 01/02/2026 showed Resident 123 was admitted to Hospice on 12/26/2025 related to a terminal diagnosis of cerebrovascular accident (a stroke, blood flow to an area of the brain is interrupted which causes brain cells to die).

Review of the EHR showed Resident 123 received Hospice services; however, a significant change in condition minimum data set assessment (MDS) was not completed within 14 days of being admitted to Hospice services.

During an interview on 05/22/2026 at 10:14 AM, Staff J, Minimum Data Set/Registered Nurse (MDS/RN), stated Resident 123 did not have a significant change in condition MDS done timely after being admitted to Hospice services.

During an interview on 05/22/2026 at 10:29 AM, Staff B, Director of Nursing Services, stated Resident 123 should have had a significant change in condition MDS when the resident admitted to Hospice services and that this did not meet expectations.

Reference WAC 388-97-1000(3)(b)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included .

Review of the Resident Assessment Instrument (RAI, a manual that directs staff on requirements for completion of MDS) showed quarterly assessments and discharge assessments must be completed no later than the ARD plus 14 calendar days.

Resident 46Review of the electronic health record (EHR) showed Resident 46's annual MDS had an ARD of 04/09/2026 and completion date of 05/18/2026 (39 days after ARD).

Resident 55

Review of the EHR showed Resident 55's quarterly MDS had an ARD of 04/06/2026 and completion date of 05/15/2026 (39 days after ARD).

Resident 70Review of EHR showed Resident 70's quarterly MDS had an ARD of 04/07/2026 and completion date of 05/15/2026 (38 days after ARD).

Resident 73Review of EHR showed Resident 73's discharge MDS had an ARD of 04/06/2026 and completion date of 05/13/2026 (37 days after ARD).

Resident 99Review of EHR showed Resident 99's quarterly MDS had an ARD of 04/06/2026 and completion date of 05/15/2026 (37 days after ARD).

Resident 5Review of EHR showed Resident 5's quarterly MDS had an ARD of 04/13/2026 and completion date of 05/19/2026 (36 days after ARD).

Resident 118Review of EHR showed Resident 118's quarterly MDS had an ARD of 04/03/2026 and completion date of 05/13/2026 (40 days after ARD).

Resident 121Review of EHR showed Resident 121's quarterly MDS had an ARD of 04/08/2026 and completion date of 05/13/2026 (35 days after ARD).

Resident 128Review of EHR showed Resident 128's quarterly MDS had an ARD of 04/14/2026 and completion date of 05/19/2026 (35 days after ARD).

Resident 142Review of EHR showed Resident 142's quarterly MDS had an ARD of 04/07/2026 and completion date of 05/15/2026 (38 days after ARD).

Resident 153Review of EHR showed Resident 153's quarterly MDS had an ARD of 04/15/2026 and completion date of 05/19/2026 (34 days after ARD).

During an interview on 05/22/2026 at 10:53 AM, Staff Q, Registered Nurse/MDS Coordinator, stated remote corporate staff were doing the MDS and had control over the schedule.

During an interview on 05/26/2026 at 11:56 AM, Staff A, Administrator, stated the expectation was for MDS to be completed timely and accurately.

Reference WAC 388-97 -1000(4)(a)(5)(d)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included .Resident 13

Review of the electronic health record (EHR) showed Resident 13 admitted to the facility on [DATE] with diagnoses that included paranoid personality disorder (mental health condition characterized by a long-term pattern of distrust and suspicion of others without sufficient reason), delusional disorders (having one or more false beliefs based on an incorrect interpretation of reality), dementia, and heart failure. Resident 13 was able to make needs known.

Review of Resident 13's EHR showed a Level I PASRR was completed on 11/29/2022 indicating a Level II evaluation referral was required due to serious functional limitations during the past 6 months related to mental illness.

Further review showed the facility did not refer the resident to the appropriate state-designated authority for Level II PASARR evaluation and determination.

During an interview on 05/22/2026 at 10:20 AM, Staff H, Social Service Director (SSD), stated the expectation was for all residents with a mental health diagnosis to be referred for a Level II evaluation and determination.

Resident 14

Review of the EHR showed Resident 14 admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it), chronic obstructive pulmonary disease (difficulty breathing) and chronic kidney failure. Resident 14 was able to make needs known.

Review of Resident 14's EHR showed a Level I PASRR was completed on 03/17/2026 indicating The individual's attending physician certifies that the individual is likely to require fewer than 30 days of nursing facility services (exempted hospital discharge).

The PASRR showed No Level II evaluation indicated at this time due to exempt hospital discharge: Level II must be completed if scheduled discharge does not occur.

Review of the EHR showed no documentation the facility referred the resident to the appropriate state-designated authority for Level II PASARR evaluation and determination.

During an interview on 05/22/2026 at 10:20 AM, Staff H, SSD, stated since Resident 14 did not discharge as planned, a new PASRR and referral for a Level II evaluation should have been completed.

Resident 150

Review of the EHR showed Resident 150 re-admitted to the facility on [DATE] with diagnoses that included depression, anxiety and heart failure. Resident 150 was able to make needs known.

Review of Resident 150's EHR showed a Level I PASRR completed by the discharging hospital on [DATE].

Section I.

Serious Mental Illness Indicators showed no boxes checked.

Section IV.

Service Needs and Assessor Data showed No Level II indicated: Person does not show indicators of Serious Mental Illness.

During an interview on 05/26/2026 at 11:16 PM, Staff H, SSD, stated Resident 150's PASRR should have been corrected to reflect their diagnoses of depression and anxiety.

Staff H stated a referral for a Level II evaluation should have been completed.

During an interview on 05/26/2026 at 11:45 AM, Staff A, Administrator (ADM), stated that it was their expectation that the PASRR form obtained from the hospital prior to admission was accurate and that the Social Service staff were to assess for accuracy to ensure that the process was followed and refer for Level II evaluations if indicated.

Reference WAC 388-97-1975

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included .

Review of the electronic health record (EHR) showed Resident 159 was admitted to the facility on [DATE] with diagnoses to include traumatic subdural hemorrhage (brain injury), fractures of T5-6 vertebra (broken bones in mid back), and respiratory failure. Resident 159 was not able to communicate needs.

Observation on 05/18/2026 at 1:48 PM showed Resident 159 in bed with head of the bed (HOB) elevated and their body slouching down.

Observation on 05/20/2026 at 9:57 AM showed Resident 159 in bed with HOB elevated and their feet touching the lower bed frame.

Review of care plan dated 05/10/2026 showed Resident 159 had no instructions or directions on how to be positioned in bed, how to transfer or bed mobility.

Review of the Visual/bedside Kardex report (specific instructions for nursing assistants on how to provide care) showed no instructions on bed mobility and transfers.

During an interview on 05/21/2026 at 10:11 AM, Staff O, Licensed Practical Nurse/Resident Care Manager, stated the baseline care plan should have included directions and instructions on bed mobility and transferring for Resident 159.

During an interview on 05/22/2026 at 9:38 AM, Staff B, Director of Nursing Services, stated the care plan for Resident 159 did not meet expectations.

Reference WAC 388-97-1020(3)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

meet their expectations.

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

During an interview on 05/18/2026 at 10:17 AM, Resident 7 stated they could not remember when

Review of Resident 7's EHR showed the last care conference conducted was on 01/13/2026.

During an interview on 05/22/2026 at 10:20 AM, Staff H, SSD, stated Resident 7 should have had a care conference in April 2026. Resident 128 Review of the EHR showed Resident 128 admitted to the facility on [DATE] with diagnoses that included tremors and heart failure. Resident 128 was able to make needs known.

During an interview on 05/19/2026 at 10:01 AM, Resident 128 stated they could not remember when they last participated in a care conference.

Review of Resident 128's EHR showed the last care conference conducted was on 10/15/2025.

During an interview on 05/22/2026 at 10:20 AM, Staff H, SSD, stated the social service department was behind on care conferences.

Staff H stated care conferences should have been offered quarterly, and the residents and/or resident representative should have been included.

During an interview on 05/26/2026 at 12:14 PM, Staff A, Administrator, stated the expectation was that care conferences were offered at least quarterly.

The lack of timeliness did not meet expectations. Resident 141 Review of the EHR showed Resident 141 admitted to the facility on [DATE] with diagnoses to include acute kidney failure and diabetes. Resident 141 was able to make needs known.

During an interview on 05/21/2026 at 2:09 PM, Staff H, Social Services Director, stated care conferences should be offered to residents quarterly.

Staff H stated Resident 141 had last had a care conference on 11/17/2025 and this did not meet expectations for timely care conferences.

During an interview on 05/26/2026 at 9:27 AM, Staff A, Administrator, stated residents were able to give input into their plan of care through the care conference process.

Staff A stated care conferences should be offered on admission, quarterly, and at resident request.

Staff A stated Resident 141's lack of care conference after 11/17/2025 did not meet expectations.

Reference WAC 388-97-1020(2)(c)(d), (e)(f)(4)(b)(d)-(f), (5)(b)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the facility policy and procedure titled Skin Integrity Management dated 05/26/2021 showed the facility would identify residents' skin integrity status and need for prevention intervention and the facility would perform wound observations and measurements upon initial identification of altered skin integrity, weekly and as needed.

The facility would develop a comprehensive plan of care to include pressure ulcer prevention and determine the need for offloading and repositioning.

Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of encephalopathy (inflammation of the brain), myocardial infarction (heart attack), and respiratory failure.

The resident was able to make needs known.

During an interview on 05/18/2026 at 3:12 PM, Resident 1 stated that their sitting bones were sore.

Review of the EHR showed Resident 1 was sent to the hospital on [DATE] through 04/17/2026 and returned to the facility.

Review on 05/20/2026 of the admission nursing assessment dated [DATE] showed Resident 1 had a 6 centimeter (CM) by 10 cm stage 2 pressure ulcer to their tail bone and a 3 cm by 2 cm stage 2 pressure ulcer to their left heel. No further monitoring was found in the EHR of Resident 1's pressure injuries.

Review of the body check assessment completed 04/24/2026 did not list the pressure injuries but showed pressure ulcer prevention measures included pillow, offloading and turning and positioning.

Review of the active plan of care on 05/21/2026 showed Resident 1 had declined a low air loss mattress, no other interventions such as offloading and repositioning for pressure reduction were listed in the care plan.

Observations on 05/19/2026 at 11:49 AM, 05/20/2026 at 11:30 AM and 1:48 PM, 05/21/2026 at 9:31 AM, and 05/26/2026 at 8:55 AM showed Resident 1 laid in bed on their back with no offloading devices (pillows) and their heels were pressed on the bed.

During an interview on 05/20/2026 at 11:30 AM, Resident 1 stated staff never put pillows under [their] feet or turn them on [their] side and stated that would probably help me be more comfortable.

There were no extra pillows or offloading/positioning devices observed near Resident 1's bed.

During an interview on 05/26/2026 at 10:12 AM, Staff C, Licensed Practical Nurse, stated residents with pressure injuries should have positioning devices to offload pressure and be assisted/encouraged to reposition frequently.

During an interview on 05/22/2026 at 8:42 AM, Staff B, Director of Nursing Services, stated it was their expectation that residents with pressure injuries had interventions in place for pressure reduction such as offloading and repositioning and had their pressure injuries monitored weekly, but this did not happen for Resident 1.

During an interview on 05/22/2026 at 12:23 PM, Staff A, Administrator, stated it was their expectation that residents with pressure injuries had weekly assessments completed and the care plans should have appropriate interventions.

Reference WAC 388-97-1060(3)(b)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

During an interview on 05/19/2026 at 1:10 PM, Resident 14 stated they had a Wander Guard on their left wrist when they first admitted to the facility, but they cut it off and threw it in the woods after a week or two. Resident 14 stated If they try to put another on me, I'll do the same thing.

Observations on 05/20/2026 at 11:09 AM and 05/21/2026 at 10:30 AM showed Resident 14 did not have a Wander Guard device on their arm.

During an interview on 05/21/2026 at 10:32 AM, Staff K, Licensed Practical Nurse (LPN), who was assigned to Resident 14's hall stated they were unaware of any residents who were an elopement risk or had a Wander Guard.

Staff K stated nursing staff would document that the device was working properly each shift on the treatment administration record (TAR) if a resident had a Wander Guard.

Review of Resident 14's TAR showed no area to document information related to a Wander Guard device.

Review of binders titled Elopement at nurse's stations on the [NAME] and South Hall showed a list that included Resident 14's name and a picture as an elopement risk.

The binder also listed residents who were no longer in the facility.

During an interview on 05/21/2026 at 10:59 AM, Staff M, Unit Manager, stated they were unaware Resident 14 no longer had the Wander Guard in place.

Staff M stated the expectation was for the licensed nurses to document the functionality and skin (to prevent breakdown) surrounding the device every shift on Resident 14's TAR.

After review of the EHR, Staff M stated the order was entered incorrectly and did not show up on the TAR.

During an interview on 05/26/2026 at 12:02 PM, Staff B, Director of Nursing Services, stated the expectation for staff to ensure the Wander Guard device was in place, working properly and checking Resident 14 did not have skin breakdown due to the device each shift was not met.

Reference WAC 388-97-1060 (3)(g)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Review of Resident 2's provider's Cardiology [branch of medicine focused on the heart and blood

less than 2 grams per day (< 2g/day) and fluid restriction per nephrology [branch of medicine focused on kidney health] guidance.

During an interview on 05/20/2026 at 1:23 PM, Staff Y, RD, stated they had asked nursing to follow up to see if the provider wanted Resident 2 to be on a fluid restriction on 04/21/2026 via recommendation tool in the computer system.

Staff Y stated Resident 2 was not currently on a fluid restriction and they had not been informed by nursing that a provider recommended/ordered Resident 2 be placed on fluid restriction.

During an interview on 05/20/2026 at 1:45 PM, Staff M, Unit Manager (UM), stated Resident 2's fluid restriction discharge orders on 04/17/2026 from the hospital should have been put in place and/or clarified with the provider.

Staff M stated after Resident 2 saw cardiology on 05/18/2026 the diet order should have been updated for sodium restriction and fluid restriction.

Staff M stated Resident 2's fluid restriction should have been addressed earlier, and this did not meet expectations.

During an interview on 05/21/2026 at 11:34 AM, Staff B, DNS, stated Resident 2's liberal renal diet included less that 2 gram per day sodium restriction; however, fluid restriction of 1.6 liters should have been implemented upon admit.

Reference WAC 388-97-1060 (3)(h)(i)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Review of May 2026 MAR showed license nurses were documenting by initialing under day shift and

given.

During an interview on 05/21/2026 at 10:22 AM, Staff O, Licensed Practical Nurse/Resident Care Manager, stated the tube feeding should be documented with the specific start and stop times and should have amount given.

During an interview on 05/22/2026 at 9:47 AM, Staff B, Director of Nursing Services, stated the documentation record for Resident 4's tube feeding did not meet expectations.

Reference WAC 388-97 -1060(3)(f)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.Resident 103

Review of the electronic health record (EHR) showed Resident 103 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), amputation of leg, end stage renal disease (final stage of kidney disease) and was dependent on dialysis. Resident 103 was able to communicate needs.

Resident 2

Review of the EHR showed that Resident 2 was admitted to the facility on [DATE] with diagnoses to include diabetes and was dependent on renal dialysis. Resident 2 and was able to make needs known.

Review of facility contracts showed no active agreement and contract with the dialysis center where Residents 103 and 2 were being dialyzed.

During an interview on 05/26/2026 at 12:26 PM, Staff A, Administrator, stated they do not have an agreement or contract with the dialysis center for Residents 103 and 2 and were waiting to receive one.

Reference WAC 388-97-1900(1)(6)(a-c)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Review of the staff schedule for 05/26/2026, 05/27/2026, 05/28/2026, 05/29/2026, 05/30/2026 and 05/31/2026 showed no scheduled one to one supervision for Residents 102 and 7.

During an interview on 05/26/2026 at 11:51 AM Saff B, Director of Nursing, stated the facility has not been able to implement the care planned one to one supervision due to lack of staffing.See F-F600 and F-F607.

Reference WAC 388-97-1060(3)(d)

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Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the electronic health record (EHR) showed Resident 128 admitted to the facility on [DATE] with diagnoses that included tremors (neurological condition that includes shaking or trembling movements in one or more parts of the body) and heart failure. Resident 128 was able to make needs known.

Review of Resident 128's Care Plan dated 07/24/2025 showed a focus area that included: Resident is at risk for or is experiencing adjustment issues related to loss of social support network as a result of moving into the center.

Interventions showed, Review for impact on social involvement and provide assistance, as needed, to increase social involvement, monitor medical conditions that may contribute to social isolation, and evaluate mood state or behavioral symptoms impacting social isolation.

During an interview on 05/19/2026 at 8:49 AM Resident 128 stated they were told by a facility staff member that they were talking to reception staff for too long and interfering with their ability to get their work done. Resident 128 stated they were also informed they were no longer able to speak to facility staff unless it was related to their care and excessive social interaction should only be with activity staff members. Resident 128 stated they felt very depressed and confused by the situation and isolated to their room for several days before writing a grievance and submitting it to the facility.

Review of a handwritten grievance dated 03/16/2026 showed Resident 128 reported they were told by Business office staff, nursing staff and social service staff that they were not to socialize with reception staff or others in the reception area.

The last part of the grievance showed I have been isolated for 15 days (8 due to COVID). It has not been made clear to me why I am being punished, could you please end this punishment.

Review of a 04/13/2026 progress note showed, Resident 128 went to social services to discuss the situation of feeling like they could not talk to staff, social services reiterated our previous discussion that they were welcome to talk to anyone in the building, but if they feel the need for long periods of one on one time they should check in with the activities department.

Review of a 04/01/2026 general progress note showed, a late entry note from the director of Admissions that stated, spoke with resident several weeks ago with My Receptionist that She is very busy with many things to please not spend long periods of time at the front desk. I assured him that he was allowed to greet and talk to anyone in the building and could always take his walks.

Review of a 04/01/2026 social service progress note showed, Note: Late entry for about 2 weeks ago.

Resident came to social services concerned that they were not allowed to talk to the front desk anymore, I assured them that they were allowed to greet and talk to anyone in the building and then told them if they were seeking longer one on one conversations they should talk to our activities department.

During an interview on 05/22/2026 at 9:59 AM, Staff H, Social Service Director (SSD), stated they were not the SSD at the time of the incident but based on Resident 128's statement of self-isolation and feeling punished social services should have assessed for any psychological social outcomes.

Staff H stated they would have discussed if the situation was an allegation of mental abuse with the Administrator to determine next steps.

During an interview on 05/22/2026 at 10:30 AM, Staff A, Administrator, stated they did not feel the grievance rose to the level of mental abuse.

Staff A stated social services should have been involved to determine if there was any psychosocial social outcome from the misunderstanding.

Reference WAC 388-97-1060(1)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

pharmacies and were unable to locate the MRR for March and April 2026 and this did not meet

Reference WAC 388-97-1300(4)(c)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the electronic health record showed Resident 16 admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mental health condition that causes extreme shifts between depression and mania) and dementia (a decline in mental ability that interferes with daily life). Resident 16 was able to make needs known.

Review of provider's orders showed Resident 16 had an order for oxycodone (a narcotic pain medication) PRN.

Review showed an order for Document Non-Pharmacological Interventions(s) A.

Heat B.

Repositioning C.

Relaxation breathing D.

Food/Fluid E.

Massage F.

Exercise G.

Immobilization of joint H.

Other: write in progress note.

Review of the medication administration record for May 2026 showed Resident 16 received their PRN oxycodone on nine occasions.

Review of progress notes for May 2026 did not show documentation of NPI used prior to providing PRN oxycodone.

During an interview on 05/26/2026 at 10:01 AM, Staff M, Unit Manager, stated the facility ensured PRN pain medications were necessary by providing NPI to determine whether the pain could be reduced without medication.

Staff M stated Resident 16 used PRN pain medications and had an order for NPI to be used.

During an interview on 05/26/2026 at 10:41 AM, Staff B, Director of Nursing Services, stated NPI should be attempted prior to providing PRN pain medications to ensure the medication was necessary.

Staff B stated Resident 16's lack of NPI prior to receiving PRN pain medications did not meet expectations.

Reference WAC 388-97-1060(3)(k)(i)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.

Review of the electronic health record (EHR) showed that Resident 85 admitted to the facility on [DATE] with diagnoses to include respiratory failure, generalized muscle weakness, and dysphagia (difficulty swallowing). Resident 85 was able to make needs known.

During an interview on 05/18/2026 at 12:53 PM, Resident 85 stated they had no dentures and would not mind getting dentures. Resident 85 stated they did not remember staff ever asking them if they wanted dentures, but, if they had, they would have told them Yes.

Review of the admission minimum data set assessment (MDS) dated [DATE] showed Resident 85 had no natural teeth or tooth fragments.

Review of the focused care plan for oral health or dental care problems created on 05/18/2026 showed Resident 85 had Broken/missing teeth, and interventions to include, Brush/clean dentures and Encourage resident to brush teeth and gums.

Review of Resident 85's provider progress note dated 05/13/2026 showed Resident 85 was edentulous (no natural teeth) with chewing/swallowing difficulties.

During an interview on 05/26/2026 at 11:13 AM, after looking at Resident 85's EHR, Staff J,Minimum Data Set/Registered Nurse, stated on 05/18/2026 they had sent an internal referral via email for dental services to social services for Resident 85; however, it should have been made sooner.

Staff J stated Resident 85's care plan for oral health/dental problems did not meet expectations because it was inaccurate for Resident 85 having broken or loose teeth and dentures.

During an interview on 05/26/2026 at 11:47 AM, staff DD, Central Supply/Transportation, stated they received messages in the internal communication board to set up appointments, and they had not received communication for them to set up a dental appointment for Resident 85.

Staff DD stated there were no scheduled appointments for Resident 85 to see a dentist at this time.

During an interview on 05/26/2026 at 11:47 AM, Staff EE, Social Services Assistant, stated there was an email received on 05/18/2026 to make a dental appointment for Resident 85; however, it was forwarded to the Social Services Director (SSD) on 05/19/2026.

During an interview on 05/26/2026 at 11:57 AM, Staff H, SSD, stated they received an email from the SSA about setting up an appointment for Resident 85 on 05/19/2026; however, the dentist was in the facility on 05/19/2026 and Resident 85 was not seen.

Staff H stated the dentist came to the facility every 60 days or so.

Staff H stated Resident 85 should have been seen by the dentist on 05/19/2026.

During an interview on 05/26/2026 at 12:33 PM, Staff B, Director of Nursing Services, stated Resident 85, needed to be seen by a dentist for dentures and this should have been addressed sooner.

Staff B stated Resident 85's care plan needed to be revised to reflect current oral/dental status, and this did not meet their expectations.

Reference WAC 388-97-1060 (2)(3)(j)(vii)

Findings included.

Review of the facility document titled Infection Prevention and Control Program dated 01/21/2025 showed they followed accepted infection prevention and control standards set by the Centers for Disease Control. <February>

Review of the facility provided infection control surveillance log for February 2026 showed 15 total infections listed which included two urinary tract infections (UTI).

Review of the facility provided infection control map labeled as February showed seven UTI.

Review of the facility document titled Infection Control Monthly/Quarterly Summary Report for the month of February 2026 showed number of healthcare acquired infections (HAI) [in house acquired] was 18 with seven UTIs.

The form did not include identification of trends or interventions to address the trends. <March>

Review of the facility provided infection control surveillance log for March 2026 showed 19 total in-house acquired infections with four UTIs.

Review of the facility document titled Infection Control Monthly/Quarterly Summary Report for the month of March 2026 showed a total of 14 in-house acquired infections and did not include identification of trends or interventions to address the trends. <April>

Review of the facility provided infection control surveillance log for April 2026 showed no identification of infectious organisms and included 29 in-house acquired infections.

Review of the facility provided infection control map labeled as April showed 13 total infections.

Review of the facility document titled Infection Control Monthly/Quarterly Summary Report for the month of April 2026 showed number of healthcare acquired infections (HAI) was 14 and did not include identification of trends or interventions to address the trends.

During an interview on 05/21/2026 at 12:43 PM, Staff W, Licensed Practical Nurse/Infection Preventionist (LPN/IP), stated they had recently started as the IP and were aware of the inaccurate infection surveillance.

During an interview on 05/22/2026 at 9:14 AM, Staff B, Director of Nursing Services, stated it was their expectation the infection surveillance be accurate and monthly summary should be completed to include tracking, trending, and interventions implemented.

Reference WAC 388-97-1320(2)(a)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409

Findings included.Resident 75

Review of the electronic health record (EHR) showed Resident 75 admitted to the facility on [DATE] with a diagnosis of a stroke (when blood/oxygen is cut off to a part of the brain).

The resident was not able to make needs known.

Review of the EHR showed no documentation that Resident 75 or their representative were educated on the risks and benefits of the Covid-19 vaccine and offered or administered the vaccine.

During an interview on 05/21/2026 at 12:43 PM, Staff W, Licensed Practical Nurse/Infection Preventionist (LPN/IP), stated the facility should have offered and educated the resident or their representative on the Covid-19 vaccine but did not see any records that it was done for Resident 75.

During an interview on 05/22/2026 at 9:11 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that Resident 75 or their representative received education on the risks and benefits and been offered the Covid-19 vaccine. <Staff Vaccines> During an interview on 05/22/2026 at 9:47 AM, Staff X, Human Resources Director, stated they request staff Covid-19 vaccine status on hire but did not educate them on the risks and benefits, offer or direct them where to obtain the Covid-19 vaccine.

During an interview on 05/22/2026 at 12:23 PM, Staff A, Administrator, stated it was their expectation that residents received education on the risks and benefits of the Covid-19 vaccine and offered as needed.

Staff A stated it was also their expectation that staff be provided education on the risks and benefits of the Covid-19 vaccine and offered or directed on where to obtain the vaccine on hire and this should be documented/tracked.

Reference WAC 388-97-1620(2)(b)(i)(ii)

505093 06/01/2026

Orchard Park Health Care & Rehab Center 4755 South 48th Tacoma, WA 98409