Every finding on record at Alderwood Manor

Based on interview and record review, the facility failed to ensure an allegation of abuse was investigated and reported to the State Agency as required for 1 of 3 sampled residents (Resident 1) reviewed for abuse. The facility failed to investigate and report an allegation that Resident 1's hands and wrists were bruised from rough handling and being held down during care. This failure placed the resident at risk for abuse, unmet care needs and a diminished quality of life. Findings included .Review of the facility Abuse Prevention policy, last reviewed on 06/17/2024, documented facility was to prevent, prohibit, identify, and thoroughly investigate allegations of abuse, neglect, exploitation of residents, and misappropriation of resident property. The policy further stated, The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. The facility will ensure that all staff are aware of reporting requirements. <Resident 1>The 05/05/2026 admission assessment documented Resident 1 had moderate cognitive impairment, was usually able to make their needs known, and had diagnoses which included vascular dementia, stroke and memory impairment. Review of Resident 1's record showed a progress note on 04/17/2026 at 9:19 AM by Staff C, Social Service Director, documented during a conversation with a family member of Resident 1 they alleged that bruises on Resident 1's hands were caused from someone being too aggressive. Review of the facility's reporting log for April 2026 showed no entries had been made related to the allegation of abuse to Resident 1. Further record review found no documentation that the facility investigated the allegation of abuse. Review of STARS, the secure tracking and reporting system for Washington State, which was used to report allegations of abuse, found no reports had been made for Resident 1 in April 2026. In an interview on 07/22/2026 at 7:54 AM, Staff C, acknowledged the allegation of abuse related to the bruising and the family members belief that the resident was being abused should have been investigated and reported. During an interview with Staff A, Administrator, and Staff B, Director of Nursing on 07/22/2026 at 10:30 AM, Staff A stated abuse/neglect and mandatory reporting training was provided to staff when hired, yearly, and as changes or incidents occurred. Staff A confirmed the allegation should have been investigated and reported to the State Agency. Reference WAC: 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to provide within 24 hours of transfer to the hospital, a bed hold notice, a notice that informed the resident/representative of their right to pay for their room to be held while they were hospitalized , for 2 of 3 sampled residents (Residents 1 and 2), and failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer for 2 of 3 sampled residents, (Residents 1 and 3), reviewed for admission, transfer and discharge. Findings included .<Resident 1>The 05/05/2026 admission assessment documented Resident 1 had moderate cognitive impairment, was usually able to make their needs known, and had diagnoses which included vascular dementia, stroke and memory impairment. Review of Resident 1's record showed a progress note on 07/03/2026 at 6:36 PM documented the resident was being sent to the hospital for evaluation due to changes in the resident's behavior. The documentation showed the resident representative was notified of the hospital transfer, but no documentation was found that a bed hold was offered or discussed, nor was there documentation found that showed the Office of the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital as required. <Resident 2>The 06/11/2026 admission assessment documented Resident 2 had moderate cognitive impairment, was able to make their needs known, and had diagnoses which included seizures, and diabetes mellitus, a condition caused when the body cannot convert food into energy. Review of Resident 2's record showed a progress note on 06/08/2026 at 1:33 PM documented the resident was being transferred to the hospital to be evaluated for lethargy, a decrease in energy and consciousness. Additional record review found no documentation that the resident and/or representative had been offered a bed hold prior to being transferred within the 24-hour time frame as required. <Resident 3>The 05/21/2026 admission assessment documented Resident 3 had moderate cognitive impairment, was able to make their needs known, and had diagnoses which included liver disease and malnutrition. Review of Resident 3's record showed a progress note on 06/12/2026 at 11:51 AM documented the resident was being transferred to the hospital to be evaluated for unresponsiveness. Additional review of the resident's record found no documentation that the Office of the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital as required. In an interview on 07/22/2026 at 7:00 AM, Staff B, Director of Nursing, stated bed hold notifications needed to be completed at the time of transfer to the hospital if possible, and within 24 hours of transfer. Staff B further stated notifications to the Office of the State Long-Term Care Ombudsman was completed via fax and the documentation was scanned into the resident's record. In an interview on 07/22/2026 at 8:34 AM, Staff A, Administrator, confirmed no documentation was found that showed bed hold notifications were offered to Residents 1 and 2, and no notifications had been sent to the Office of the State Long-Term Care Ombudsman for the hospital transfers for Residents 1 and 3. Reference (WAC): 388-97-0120(3)(c)(4)(a)(b)(c)

Based on observation, interview and record review, the facility failed to ensure hand hygiene was completed when indicated for 2 of 4 staff (Staff members W and R) observed during medication administration and failed to ensure enhanced barrier precautions (EBP, the use of gowns and gloves during high-contact care activities for residents infected or colonized with multi-drug-resistant organisms, or those with chronic wounds or indwelling medical devices) were implemented when indicated for 2 of 6 sampled residents (Resident 61 and 48) reviewed. Additionally, the facility failed to ensure interventions were developed and completed to prevent the growth of waterborne bacteria or Legionella (a contagious bacteria that caused respiratory illness when water droplets or mist containing the bacteria were inhaled) as part of the Water Management Plan as required. These failures placed all residents and staff at risk of spreading multi-drug-resistant organisms, cross-contamination, or risk of developing severe respiratory illnesses. Findings included.<Water Management Plan> Review of the 08/22/2025 Water Management Plan showed areas in the facility identified that could encourage growth and spread of water borne bacteria or Legionella included rooms vacant over seven days, eye wash stations, ice machines, standing water coolers, unused unit whirlpool bathtub, and various locations in the facility basement that included an unused shower, toilet, and sink. Specific measures currently used to control the spread included: Wipe down water dispenser daily, Run water in unused sinks weekly, Flush unused toilets weekly, and Clean ice machines monthly During interview and record review on 02/11/2026 at 12:55 PM, Staff A, Administrator, reviewed the water management plan. Staff A explained there were some capped off waterlines in the basement that could also be a potential hot spot for water borne bacteria growth, but those were unable to be flushed and required removal. Staff A stated housekeeping ran water in unused showers and flushed unused toilets weekly. Logs that contained the water flushes was requested at this time. The Administrator stated the facility had no documentation to show routine measures to minimize the risk of Legionella were completed. Staff A acknowledged if it wasn't documented then it wasn't done.< <Medication Administration> In an observation on 02/09/2026 at 9:50 AM, Staff W, Registered Nurse, prepared Resident 8's medications. At 10:00 AM, Staff W sanitized their hands, put on a gown, gloves and entered Resident 8's room. Staff W then assisted the nursing assistant to remove Resident 8's unclean shirt and put on a clean shirt. Staff W, wearing the same gloves, then placed Resident 8's breathing mask on their face. Staff W then accessed Resident 8's gastrostomy tube, (g-tube, a device surgically inserted into one's abdomen that was used to administer liquid food or medications when one was unable to swallow) stopped their tube feeding, pulled up their liquid medication in a syringe, and assisted the nursing assistant to pull the resident up in bed using their incontinence pad. Staff W wearing those same gloves, connected the syringe of medications to the resident's g-tube and administered their medication. In an interview on 02/10/2026 at 10:18 AM, Staff W stated hand hygiene was to be completed prior to the medication pass and after. When Staff W was asked if they should have removed their gloves and performed hand hygiene after they removed Resident 8's unclean shirt and touched their incontinence pad, Staff W stated yes and this was important to prevent cross contamination. In an observation on 02/09/2026 at 4:48 AM, Staff R, Licensed Practical Nurse (LPN), prepared medications for Resident 15. Staff R pulled up the medication list on the computer screen, took a cup with two small syringes out of a drawer in the medication cart and brought them into the medication room. They took the liquid pain medication from the refrigerator and withdrew a measured amount with a syringe and did the same with the liquid anti-anxiety medication. Staff R wrote in the narcotic count book before bringing them back to the med cart. They then took a medication card from the drawer and placed one pill in a pill cup and brought the three medications into Resident 15's room and administered them. After leaving the resident's room. Staff R went into the medication room briefly, then returned and began preparing medications for another resident at 5:08 AM. Staff R did not perform hand hygiene during these observations. When interviewed immediately after the observations, Staff R stated hand hygiene was to be performed in-between residents or after touching unclean surfaces. During an interview on 02/13/2026 at 1:00 PM, Staff B, Director of Nursing, was informed of the observations during the medication administration. Staff B acknowledged that hand hygiene was not completed when indicated. ENHANCED BARRIER PRECAUTIONS < EBP Observations During Meal Service> During observation on 02/05/2026 at 12:29 PM, room [ROOM NUMBER] had an EBP sign posted outside the room door with a tote filled with personal protective equipment (PPE- gloves, gowns, mask and eye protection) readily available outside the room. Staff F, Nursing Assistant, put on a pair of gloves and a gown to deliver a lunch tray to the first resident in the room. Staff F remained in the room, did not remove their gloves or gown, an unidentified staff handed Staff F the meal tray for the second resident in room [ROOM NUMBER]. Without changing PPE or performing hand hygiene between different residents, Staff F delivered and set up the second tray. During observation and interview on 02/09/2026 at 8:40 AM, room [ROOM NUMBER] had an EBP sign posted outside the room door with a tote filled with PPE readily available outside the room. Staff G, Nursing Assistant, put on a pair of gloves and a gown to deliver a breakfast tray to the resident with the window bed. Staff G removed their gloves but did not remove their gown and performed hand hygiene. While still wearing the same gown, Staff F handed Staff G the breakfast tray for the other resident in room [ROOM NUMBER], Staff G delivered and set up the second tray. At 8:42 AM, Staff G acknowledged they did not change gowns between residents and should change out PPE when providing care to different residents. In an interview on 02/09/2026 at 8:47 AM, Staff F, acknowledged they should change PPE when providing care to different residents. In an interview on 02/11/2026 at 3:22 PM, Staff C, Infection Preventionist, stated EBP were implemented to protect residents with artificially implanted devices such as catheters and feeding tubes. Staff C explained EBP was the use of gloves and gowns during direct patient contact and was not required when dropping off a meal tray. Staff C further stated if staff chose to utilize PPE, then it needed to be changed between residents. Staff C stated they expect staff to implement and follow EBP when required. <Resident 48> According to the 12/10/2025 admission assessment, Resident 48 admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD). The assessment further showed Resident 48 received dialysis (medical treatment that removed waste, toxins and excess fluid from the blood when the kidneys were unable to do so) upon admission and while a resident. Review of the 12/04/2025 hospital discharge summary showed Resident 48 admitted to the hospital with worsening kidney disease, a tunneled line (long-term intravenous tube inserted into a large vein, usually in the neck or chest, and then tunneled under the skin to exit a few inches away on the chest or shoulder) was placed, and dialysis was initiated. Review of the 12/04/2025 admission assessment showed Resident 48 admitted related to ESRD, had a dialysis catheter (tube placed into a large vein to act as a temporary or sometimes long-term access point for cleaning the blood), and received dialysis. An included progress note showed Resident 48 had a hemodialysis catheter placed 11/26/2025. Review of the care plan initiated 01/01/2026 showed Resident 48 had a tunneled vascular device to their right chest for dialysis use. A 01/07/2026 intervention instructed staff to follow EBP related to an indwelling medical device (dialysis catheter). A 01/15/2026 provider order instructed staff to assess Resident 48's right chest dialysis catheter site for bleeding, signs and symptoms of infection. No documentation was found to show Resident 48 required EBP. In an observation on 02/05/2026 at 9:35 AM, no EBP signage was observed to be posted and a tote containing PPE was not readily available outside of Resident 48's room. Similar observations were made at 10:54 AM, on 02/16/2026 at 8:45 AM and 2:24 PM, on 02/09/2026 at 8:47 AM, on 02/10/2026 at 9:04 AM and 12:56 PM, on 02/11/2026 at 8:38 AM, on 02/12/2026 at 1:24 PM, and on 02/13/2026 at 10:10 AM. During observation and interview on 02/13/2026 at 11:00 AM, Staff D, Resident Care Manager, stated Resident 48 had a dialysis access line to their right chest that exited their body. Staff D acknowledged EBP was indicated but had not been implemented. <Resident 61> According to the 01/29/2026 admission assessment, Resident 61 admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and malnutrition. The assessment further showed Resident 61 received nutrition via a feeding tube (tube placed into the stomach or intestine to deliver liquid nutrition when a person was unable to swallow safely) while a resident. Review of the 01/23/2026 hospital discharge summary showed Resident 61 was only to receive ice chips orally and received liquid nutrition via their tube feeding. A 01/23/2026 provider order instructed staff to assess Resident 61's skin integrity of the abdomen around the feeding tube insertion site for signs and symptoms of infection. No documentation was found to show Resident 61 required EBP. Review of the care plan initiated 01/23/2026 showed Resident 61 received nutrition via a feeding tube related to swallowing difficulties and instructed staff to follow EBP. In an interview on 02/05/2026 at 8:57 AM, Resident 61 stated they received nutrition via a feeding tube because of difficulty swallowing. Resident 61 further stated staff wore gloves but did not wear gowns when managing their feeding tube. During observation on 02/05/2026 at 11:13 AM, no EBP signage was observed to be posted and a tote containing PPE was not readily available outside of Resident 61's room. Similar observations were made at 2:34 PM, on 02/06/2026 at 8:43 AM and 2:51 PM, on 02/09/2026 at 4:46 AM, and on 02/10/2026 at 8:48 AM. In an interview on 02/10/2026 at 1:06 PM, Staff E, Registered Nurse, explained that residents that had an indwelling medical device such as a catheter or feeding tube required the use of EBP. Staff E was unsure why Resident 61 was not on EBP as required. In an interview on 02/11/2026 at 3:47 PM, Staff A, Administrator, stated they expected staff to implement and follow EBP when required. Staff A further stated if staff chose to wear PPE when it was not required then they expected staff to utilize PPE properly. Reference WAC 388-97-1320 (1)(a)

Based on observation, interview and record review, the facility failed to ensure medications were given as ordered on days the residents were out of the facility for dialysis treatments (a mechanical way of eliminating waste from the body when the kidneys no longer functioned) for 3 of 3 sampled residents (Residents 4, 5 and 48) reviewed for dialysis care. Additionally, fluid restrictions (when oral fluid intake was limited to a specific amount daily by the provider to help maintain fluid balance for those that required dialysis) for Residents 5 and 48 were not documented or monitored for accuracy as ordered. This failure placed the residents at risk for unintended health consequences and decreased quality of life. Findings included .Review of the facility policy titled, Hemodialysis Offsite Policy dated September 2024, showed the facility was to assure each resident received care and services for the provision of offsite dialysis to include arrangements for safe transportation, ongoing assessments of the resident's condition, monitoring for complications before and after dialysis treatments, and ongoing communication and collaboration with the dialysis facility. The facility and dialysis center dieticians were to coordinate nutritional care including monitoring, documenting, and deciding how and when to address weight changes and nutrition issues to include identifying weight fluctuations due to fluid retention between sessions, possible fluid volume depletions and observe fluid restrictions as ordered by the provider. Communication between the dialysis center and the facility should include and document medication administered, held or discontinued by the nursing home and/or dialysis center, nutritional/fluid management including weights, and a resident's compliance with food/fluid restrictions. The policy instructed staff to follow physician orders regarding medication administration pre [before] and post [after] dialysis, especially blood pressure and cardiac medications. <Resident 48> According to the 12/10/2025 admission assessment, Resident 48 admitted to the facility on [DATE] with diagnoses including ischemic cardiomyopathy (weak and enlarged heart due to lack of oxygen rich blood caused by blockage, narrowed vessels, or heart attack damage), heart failure (when the heart was too weak to pump blood efficiently failing to meet the body's needs), and end stage renal disease (ESRD). The assessment further showed Resident 48 received dialysis treatments from admission. Review of the ESRD care plan initiated 12/05/2025 showed Resident 48 received dialysis treatments three times weekly on Mondays, Wednesdays and Fridays and was at risk for weight fluctuations. A 01/21/2026 intervention showed Resident 48 was to follow a 1800 milliliters (ml)/day fluid restriction. The dietary department was to provide 240 ml per meal for a total of 720 ml dispensed, leaving a balance of 1080 ml fluid intake allowed. Review of January 2026 nursing progress notes showed on 01/07/2026 Resident 48 was hospitalized for pulmonary edema (abnormal buildup of excess fluid in the lungs) with shortness of breath and chest discomfort. On 01/14/2026 the administration time of some medications was changed due to dialysis schedule. On 01/21/2026 daily weights and an 1800 ml/day fluid restriction were implemented for closer fluid monitoring related to dialysis recommendation and resident refusing multiple dialysis days. Review of a 01/12/2026 provider order showed Resident 48 was to receive dialysis treatments three times weekly. A 01/21/2026 provider order showed Resident 48 was to follow an 1800 ml per day fluid restriction related to ESRD. Review of the January through February 2026 medication administration records (MAR) showed the following: In January, Resident 48 did not receive Isosorbide (medication used to treat chest pain caused by heart disease) or Sevelamer (phosphate binding vitamin) on Friday 01/16/2026, Monday 01/19/2026, 01/20/2026, or on Friday 01/23/2026. Resident 48 did not receive Metoprolol (medication used to treat heart failure) on Friday 01/02/2026, Wednesday 01/07/2026, Friday 01/16/2026, Monday 01/19/2026, Friday 01/23/2026, Wednesday 01/28/2026 or on Friday 01/30/2026. A fluid restriction intake monitor showed Resident 48 consumed a total of 490 ml on 01/22/2026, 320 ml on 01/23/2026, 390 ml on 01/24/2026, 360 ml on 01/25/2026 and 01/26/2026, 490 ml on 01/27/2026, 440 ml on 01/28/2026 and 01/29/2026, 480 ml on 01/30/2026, and 860 ml on 01/31/2026. All intake documented was significantly below the 1800 ml/day fluid restriction ordered. In February, Resident 48 did not receive Metoprolol on Friday 02/06/2026, or Sevelamer on Wednesday 02/24/2026, Friday 02/06/2026, or on Wednesday 02/11/2026. Tramadol (pain medication) was not administered on Friday 02/06/2026 or on Wednesday 02/11/2026. Fluid restriction intake monitor showed Resident 48 consumed a total of 360 ml on 02/01/2026, 340 ml on 02/02/2026, 240 ml on 02/03/2026, 360 ml on 02/04/2026, 560 ml on 02/05/2026, 480 ml on 02/06/2026, 440 ml on 02/07/2026, 360 ml on 02/08/2026, 340 ml on 02/09/2026, 600 ml on 02/10/2026, 480 ml on 02/11/2026, and 350 ml on 02/12/2026. All intake documented was significantly below the 1800 ml/day fluid restriction ordered. <Resident 5> The 01/06/2026 quarterly assessment documented Resident 5 had diagnoses including ESRD, heart failure and diabetes. The assessment further showed Resident 5 was dependent on renal dialysis. A 01/15/2026 provider order showed Resident 8 was to receive dialysis treatments three times per week. A 04/17/2025 provider order showed Resident 8 was on a 1,200 ml fluid restriction. The dietary department was to provide 120 ml for breakfast, lunch and dinner. The nursing department was to provide 360 ml on day and evening shift and 120 ml on night shift. The 01/26/2024 ESRD care plan showed Resident 5 received dialysis treatments three times weekly on Mondays, Wednesdays and Fridays and instructed nursing staff to document before and after treatments in a dialysis book (a book that contained a form to document the resident's vital signs, lung sounds, if the resident was on an antibiotic, and whether or not the resident had been given medications or a meal to eat while at dialysis). The form also had a section for dialysis to fill out after the resident's treatment that listed vital signs, weights, condition of the resident's dialysis access site, type of access, and if the resident ate lunch at the center and how much they consumed). A 06/19/2024 intervention instructed nursing staff to follow the fluid restriction as ordered. Review of the dialysis communication book from 01/01/2026 through 02/09/2026 showed the dialysis portion of the form was blank on 01/02/2026, 01/07/2026, 02/04/2026 and 02/06/2026. The facility portion of the form was blank on 02/02/2026, and on an unknown date as this area was not filled out. There were no communication sheets for 01/28/2026 and 01/30/2026. A review of the January through February 2026 MAR showed the following for Resident 5's Calcium Acetate (phosphate binder): The following dates had code 5, which meant the resident was absent from the facility without their medication: -01/07/2026, 01/09/2026, 01/12/2026, 01/14/2026, and 01/20/2026. The following dates had code 10, which meant a progress note should have been made: 02/06/2026, 02/07/2026, 02/08/2026, 02/09/2026, 02/10/2026 and 02/11/2026. On 02/10/2026 and 02/11/2026 there was a progress note that said the medication was unavailable. Resident 8's Xarelto (a blood thinning medication): A code 10 was present on 01/19/2026, 01/20/2026 and 02/08/2026. On 01/20/2026 there was a progress note that stated the medication was on order. Resident 8's Calcium Carbonate (antacid medications): A code 5 was present 01/02/2026, 01/05/2026, 01/07/2026 and 01/09/2026. Resident 8's Restasis (medication used to treat dry eyes): A code 7 was present on 01/14/2026 and the progress note stated the medication was on order. Resident 8's Reglan (medication used to treat heartburn): A code 5 was present on 02/07/2026 and a code 10 on 02/08/2026. A review of the January through February 2026 MAR's showed the following for Resident 5's fluid restriction: Resident 8 had an order for 120 ml of 2cal med pass (nutritional supplement) daily and consumed 50-100 percent. The nursing assistant task record from 01/17/2026 through 02/12/2026 showed Resident 8 received fluids ranging from 240 ml to 1,770 ml daily. The January through February 2026 MAR showed nursing administered fluids ranging from 360 ml to 1,160 ml daily. There was no total to show the amount of fluids Resident 8 consumed each day. <Resident 4> The 01/13/2026 quarterly assessment documented Resident 4 had diagnoses including ESRD, diabetes and was dependent on renal dialysis. A 01/05/2026 provider order showed Resident 4's medications were to be given two hours before or after dialysis. The 09/27/2024 ESRD care plan showed Resident 4 received dialysis treatments three times weekly on Mondays, Wednesdays and Fridays and instructed nursing staff to administer medications as ordered. A review of the January through February 2026 MAR showed the following for Resident 4's Velphoro (phosphate binder): A code 5 was present on 01/05/2026, 01/07/2026, 01/09/2026, 01/14/2026, 01/21/2026, 01/23/2026, and 02/07/2026 at 8:00 AM. A code 10 was present on 01/19.2026, 02/04/2026, 02/05/2026, 02/07/2026 at 12:00 PM and 5:00 PM, 02/08/2026, and 02/10/2026. Resident 4's warfarin (blood thinning medication): A code 10 was present on 02/08/2026. Resident 4's Prosource (nutritional supplement): A code 5 was present on 02/04/2026, 02/06/2026, 02/07/2026, and 02/08/2026. Resident 4's Amlodipine (used to treat high blood pressure): A code 10 was present on 02/08/2026. Resident 4's artificial tears (used to treat dry eyes): A code 5 was present on 02/07/2026 and a code 10 was present on 02/08/2026. Resident 4's Atorvastatin (used to treat high cholesterol levels): A code 10 was present on 02/08/2026. Resident 4's Hydralazine (used to treat high blood pressure): A code 5 was present on 01/09/2026, 01/14/2026, 01/21/2026, 01/23/2026, 01/28/2026, and 02/07/2026. Resident 4's Omeprazole (used to treat heartburn): A code 5 was present on 01/05/2026, 01/07/2026, 01/09/2026, and 02/07/2026. A code 10 was present on 01/13/2026. Resident 4's Renal vitamin (multivitamin given to residents with kidney disease): A code 5 was present on 01/09/2026 and 01/14/2026. A code 10 was present on 02/08/2026. Resident 4's Thiamine (vitamin B vitamin): A code 5 was present on 01/05/2026, 01/07/2026, 01/09/2026, 01/13/2026 and 01/15/2026. A code 10 was present on 02/08/2026. Resident 4's insulin (used to treat high or low blood sugars): A code 5 was present on 01/02/2026, 01/07/2026 and 01/09/2026. Resident 4's Systane eye drops (used to treat dry eye): A code 5 was present on 01/09/2026 and a code 10 was present on 01/10/2026. Resident 4's skin prep to their left third distal finger: The MAR was blank on 01/10/2026, 01/18/2026, 01/30/2026, 02/02/2026 and 02/07/2026. There was a code 10 on 02/08/2026. Resident 4's betadine to their right hand and palm: The MAR was blank on 01/10/2026, 01/18/2026, 02/02/2026, 02/03/2026 and 02/07/2026. There were code 10's on 02/05/2026 and 02/08/2026. Resident 4's skin prep to their left knee/shin: The MAR was blank on 01/18/2026, 01/19/2026, 01/30/2026, 02/02/2026, 02/03/2026, and 02/07/2026. There was a code 10 on 02/08/2026. In an interview on 02/12/2026 at 8:15 AM, Staff N, Nursing Assistant (NA), stated they knew when a resident was on a fluid restriction by looking at their Kardex (part of the resident's plan of care). Staff N stated they gave Resident 5 a cup of coffee at breakfast time and documented the amount in the plan of care. In an interview on 02/13/2026 at 9:53 AM, Staff BB, NA, stated they served meal trays in the dining room where Resident 5 ate. Staff BB stated there were no residents on a fluid restriction. Staff BB stated they gave Resident 5 a cup of coffee and did not document the amount of fluids consumed. In an interview on 02/12/2026 at 12:07 PM, Staff W, Registered Nurse, stated medications for dialysis residents were tailored to their schedule. Staff W stated Resident 4 left very early in the morning, so the night nurse administered some of their medications. Staff W stated the other dialysis residents received their medications before they left and when they returned from dialysis. Staff W stated the amount of fluids consumed by dialysis residents were documented in the MAR. Staff W explained that the fluids came on the resident's meal trays and nursing had a certain amount they were able to provide. Staff W stated nursing assistants were not to give dialysis residents any fluids. Staff W was unaware Resident 5 had a large blue cup in their room and a can of beer. Staff W stated they relied on the documentation in the MAR for the amount of fluids consumed by Resident 5 and did not have a good reliable way to know how much water they drank daily. Staff W stated it was important to get the dialysis communication sheets back from the dialysis facility because they had good information including vital signs (blood pressure, heart rate, respiratory rate and temperature), weights, and if there were any complications during their treatment. At 10:01 AM, Staff W acknowledged Resident 4 and 5 were not getting their medications as ordered and there needed to be a progress note explaining why. Staff W stated medications needed to be reordered when they had three to seven pills left. Staff W explained nursing staff reordered medication via the computer. Staff W stated it was important for the residents to receive their medications for their overall health. In an interview on 02/13/2026 at 11:53 AM, Staff B, Director of Nursing, stated it was important to fill out the dialysis pre/post visit forms and ensure the forms were returned back to the facility so they could ensure orders were processed, and weights and vital signs were monitored. Staff B stated the nurse on the cart was responsible for filling out the dialysis communication form and notifying the Resident Care Manager if the form was not returned. Staff B stated medications were scheduled around dialysis treatments to ensure residents received their medications. Staff B acknowledged Residents 4 and 5 did not receive their medications as ordered and should have for their health and wellness. Staff B stated they combined the total amount of fluids sent on the meal tray and what was given by nursing. Staff B stated it was important to give the amount of fluids ordered to prevent fluid overload. Staff B stated the total amount of fluids consumed needed to be calculated at the end of the day and if there were inaccuracies, follow-up needed to be completed. Reference WAC 388-97-1900(1)(6)(a-c)

Based 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 2 medication storage rooms. Additionally, the facility failed to maintain appropriate temperatures in 2 of 2 medication rooms to ensure medications were properly stored. This failure placed residents at risk for receiving compromised or ineffective medication.Findings included .The United States Pharmacopeia retrieved from http: www.USP.org documented medications were to be stored at controlled room temperatures of 20 degrees Celsius (C) to 25 C (68 degrees Fahrenheit (F) to 77 F), with excursions permitted between 15 C and 30 C (between 59 F and 86 F) and brief exposure to temperatures up to 40 C (104 F) may be tolerated provided the mean temperature did not exceed 25 C (77 F); however, such exposure was to be minimized. During an observation of the [NAME] Medication room on 02/06/2026 at 12:35 PM, with Staff AA, Licensed Practical Nurse, there was a fan blowing and the temperature of the medication room was 82 degrees Fahrenheit (F), higher than the recommended range. Review of the refrigerator temperature logs from September 2025 through February 2026 showed the temperatures were not monitored consistently as required. In an observation of the East Medication room on 02/06/2026 at 1:06 PM, with Staff W, Registered Nurse, the refrigerator contained influenza, hepatitis and respiratory syncytial virus (RSV) vaccines. The RSV vaccines had expired on 10/25/2025. Review of the refrigerator temperature logs from November 2025 through February 2026 showed the temperatures were not monitored consistently as required. In an interview on 02/06/2026 at 12:45 PM, Staff AA stated it was important to monitor the temperature of the refrigerator because medications were kept in there and the temperature had to stay within range or the effectiveness of the medication could be altered. At 12:54 PM, Staff AA stated it was important to keep the medication room at an appropriate temperature to prevent the medications from losing their effectiveness. In an interview on 02/06/2026 at 1:13 PM, Staff W stated audits were completed on the medication rooms monthly. Also, expired vaccines were at risk for losing their efficacy. In an interview on 02/06/2026 at 1:18 PM, Staff B, Director of Nursing, stated they had provided education to the staff and were trying to correct the issue of the temperatures not being monitored. Staff B stated it was important to monitor the refrigerator temperatures because it rendered the vaccines useless when not stored at the correct temperature. Staff B added the temperature of the medication room needed to be within normal limits because it may alter the effectiveness of the medications. In an observation on 02/12/2026 at 10:53 AM with Staff B, vaccines remained present and available for use in the refrigerators that had not had the temperatures monitored. In an observation on 02/12/2026 at 10:56 AM with Staff C, Infection Preventionist, the [NAME] Medication room temperature was 80 degrees F, higher than the recommended range. Reference: WAC 388-97-1300 (2)

Based on interview and record review the facility failed to provide education regarding the risks versus benefits and offer the COVID (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization) vaccine if desired to 4 of 7 sampled staff (Staff F, I, J, and K) and 1 of 5 sampled residents (Resident 63), reviewed for immunizations. This failure placed staff and residents at risk of exposure to and illness from COVID-19.Findings included .According to The Centers for Disease Control and Prevention website www.cdc.org Recommended Adult Immunization Schedule 2026 for ages 19 years or older adults age [AGE]-64 years, or adults age [AGE] or older who were unvaccinated for COVID-19, were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of COVID-19 vaccine unless contraindicated. Those previously vaccinated before 2024-2025 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of 2025-2026 COVID-19 vaccine unless contraindicated.<Staff F>Review of Staff F's employee file showed no documentation Staff F was provided education on the potential risks versus benefits or offered the COVID vaccination.<Staff I>Review of Staff I's employee file showed no documentation Staff I was provided education on the potential risks versus benefits or offered the COVID vaccination.<Staff J>Review of Staff J's employee file showed no documentation Staff J was provided education on the potential risks versus benefits or offered the COVID vaccination.<Staff K>Review of Staff K's employee file showed no documentation Staff K was provided education on the potential risks versus benefits or offered the COVID vaccination.<Resident 63>According to the 11/11/2025 quarterly assessment, Resident 63's most recent admission to the facility was on 06/06/2025.Additional review of Resident 63's medical record showed no documentation Resident 63 was provided education on the potential risks versus benefits or offered the COVID vaccination.In an interview and record review on 02/11/2026 at 1:24 PM, Staff H, Staff Development Coordinator, explained when new staff were hired, they completed a vaccination questionnaire, the completed questionnaire was reviewed, printed and placed in the employee file. Staff H reviewed Staff F, I, J, and K's employee files. Staff H acknowledged the employees files contained no documentation employees were provided education on the potential risks versus benefits or offered the COVID vaccination, as required.In an interview on 02/11/2026 at 3:18 PM, Staff C, Infection Preventionist, explained employees were educated and offered vaccines during new employee orientation, residents were educated and offered vaccines upon admission, and residents/staff were again educated and offered the COVID vaccine yearly, in October, when the facility held an immunization clinic. Staff C further stated the facility was able to obtain the COVID vaccine but required a minimum of 10 staff to obtain and administer the vaccine. Staff C stated the facility was unable to hold their immunization clinic last October related to a facility illness outbreak. Staff C acknowledged documentation of education and vaccine consent or declination should be documented, as required.In an interview on 02/11/2026 at 3:44 PM, Staff A, Administrator, stated the facility typically held a vaccination clinic in October but were unable to hold it last October due to an illness outbreak. Staff A acknowledged vaccine education and vaccine consent or declination should be documented, as required.Reference: WAC 388-97-1320(1)

Based on observation, interview and record review, the facility failed to follow food code regulations that prevent the potential of foodborne illness. Specifically, the kitchen was not maintained in a clean manner, dietary staff did not perform hand hygiene when indicated during food services and 2 of 2 nourishment refrigerators were not consistently monitored for appropriate temperatures and contained unlabeled and expired food. These failures placed residents at risk for foodborne illness.Findings included. A review of the facility policy Food from Outside Sources revised July 2025 documented foods stored in designated refrigerators were to be labeled with the resident name and room number and discarded if past the expiration date. Additionally, the refrigerator temperature was not to exceed 41 degrees Fahrenheit (F) and the freezer temperature was not to exceed 0 degrees F.<Kitchen Cleanliness>On 02/05/2026 at 8:48 AM, the kitchen floor was observed to be grimy and dingy with crumbs and food debris. There were also crumbs and food debris on the counter containing the toaster. The wall to the right of the stove was dirty with dried splashes of food debris and grease.During a subsequent visit to the kitchen on 02/11/2026 at 11:27 AM, the wall next to the stove and the counter with the toaster were again observed with crumbs and food debris, dried splashes and grease. The plate warmer that contained the clean plates being used for the lunch service and the surrounding area contained food crumbs. Plastic drawers/storage bins that contained utensils in the small pantry on the right side of the stove were soiled on the fronts and handles.<Hand Hygiene>On 02/11/2026 at 11:27 AM, dietary staff were observed preparing plates of food for the resident's lunch. On 02/11/2026 at 12:05 PM, Staff U, Nutrition Coordinator, stopped plating the food, put oven mitts on over their plastic gloves and took a foiled wrapped portion of food out of the oven. They closed the oven door, removed the foil and put the food on a plate, then removed the oven mitts, and changed their plastic gloves. They did not complete hand hygiene before they put on new gloves and resumed the meal service.On 02/11/2026 at 12:45 PM, Staff U put on oven mitts over their plastic gloves, retrieved another pan of meatloaf from the oven and placed it on the steam table, before removing the oven mitts and changing their gloves. Hand hygiene was not performed with the glove change, and Staff U resumed plating the food.On 02/11/2026 at 1:00 PM, Staff U opened one of the plastic drawers/bins next to the oven, took out a needed utensil and closed the drawer then resumed serving the food with the same gloves. The drawer front and handle were visibly dirty. During an interview immediately following the meal service when asked about hand hygiene in the kitchen, Staff U stated they were told they could just change gloves.<Nourishment Refrigerators>On 02/12/2026 at 7:55 AM, during an inspection of the refrigerator in the east nourishment room, the following was noted: The February 2026 temperature log was missing entries for six of 12 days. The refrigerator contained a box of Lunchables with a first name and date of 11/19/2025 in black marker.There was an unlabeled glass container with noodles and sauce, and an unlabeled plastic bag of slimy chicken. The freezer had containers of sherbet and pistachio ice cream, neither labeled with a name or date.On 02/12/2026 at 8:18 AM, during an inspection of the refrigerator in the west nourishment room, the following was noted:The February 2026 temperature log was missing entries for four of 12 days.The refrigerator contained 3 small plastic containers of a clear red substance, in a gift bag, with a resident name but no date.In the lower left crisper drawer, was a greasy looking paper napkin wrapped around chicken strips. The napkin was stuck and dried to the food. There was no name or date.During an interview on 02/12/2026 at 2:01 PM, Staff V, Registered Dietician, stated that dietary staff were expected to wash their hands before handling food, and after touching their face, body or any surface that could be contaminated, such as a door handle. They further stated that they always needed to perform hand hygiene (handwashing or hand sanitizer) with glove changes.During an interview on 02/12/2026 at 2:31 PM, Staff T, Dietary Kitchen Manager, was informed of unclean areas in the kitchen, observations of the nourishment refrigerators and observations of gloves changes during the meal preparation visit. Staff T stated they expected the kitchen to be clean, dietary staff to log refrigerator temperatures and to discard expired food. Staff T also expected staff to wash their hands with any glove changes.Reference: WAC 388-97-1100(3), 2980

Based on interview and record review, the facility failed to consistently monitor a resident for latent injuries after numerous falls for 1 of 5 residents (Resident 10), reviewed for accidents/falls. Specifically, the facility did not complete vital signs (VS- temperature, heart rate, respiratory rate and blood pressure) and neurological checks (neuro checks, an assessment used to evaluate the residents' level of consciousness, movement, hand grasps, pupil size and reaction) after unwitnessed falls, nor consistently monitored the residents' condition after each fall. This failed practice placed residents at risk for unidentified injuries and diminished quality of life.Findings included .A review of the facility policy titled, Fall Management reviewed September 2025, showed how to identify fall risk and monitor resident indicators of falls. The document did not include the process of what staff were to do after a resident fell. A review of the facility document titled Neurological Checks on 02/10/2026 showed that VS and neuro checks should be completed when a provider ordered them or when indicated by the resident's assessment, such as a head injury or fall. The form specified that VS and neuro checks were to be completed every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every four hours for 24 hours. According to a comprehensive assessment dated [DATE], Resident 10 had diagnoses that included dementia and repeat falls. The assessment further showed they had some moderate cognitive impairment and rejected cares numerous times per week. The assessment further showed Resident 10 was independent with transfers and walking but required supervision for longer distances.Review of the 12/08/2023 care plan documented Resident 10 was at risk for falls related to shuffling gait, weakness, and a history of falls. On 11/27/2025 the care plan was updated, and staff were instructed to observe and monitor the resident for 72 hours such for latent injuries such as a change in mental status. A review of the facility Accident/Incident log from August 2025 through February 2026 showed Resident 10 sustained 15 falls, which included four falls on the same day.A review of the fall investigations referenced in the Accident/Incident log and Resident 10's medical record showed the following:VS and neuro checks were not done per the flowsheet timeline for falls on 08/11/2025, 08/13/2025, 10/23/2025, 12/12/2025,12/13/2025, 01/02/2026, and numerous falls on 01/15/2025.Alert or progress notes were not completed every shift, for at least 72 hours after falls, on 10/23/2025, 12/12/2025, 12/13/2025, 01/02/2026, 01/04/2026 and numerous falls on 01/15/2026. No progress/alert notes after a fall were found after 72 hours.VS and neuro checks were not restarted at every 15-minute intervals (when the resident fell again while on VS and neuro checks) on 12/13/2025 and after numerous falls on 01/15/2026. During an interview on 02/10/2026 at 2:57 PM, Staff Q, Licensed Practical Nurse, stated that if a resident fell and hit their head or if the fall was unwitnessed, the resident was to have neuro checks implemented. Staff Q reviewed the form Neurological Flow Sheet and said the staff followed the instructions for the frequency and duration of when to do the VS and neuro checks. During an interview on 02/10/2026 at 3:07 PM, Staff B, Director of Nursing, stated that after an unwitnessed resident fall, neuro checks needed to be done according to the schedule on the neuro flow sheet for 24 hours. Additionally, after any fall, the resident was put on alert charting for seven days. Staff B explained that alert charting meant that staff needed to make a progress note every shift, to monitor for any latent injuries that may not have been noticed immediately after the fall. During a follow-up interview on 02/11/2026 at 10:03 AM, Staff B stated that if the resident had another fall before the neuro checks were completed, that the checks should be restarted at every 15 minutes. Staff B was informed of the missing VS and neuro checks, missing alert notes after falls and that checks were not restarted after additional falls for Resident 10. Staff B acknowledged that nursing staff did not follow the facility process for monitoring the resident's condition after their falls.Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to maintain urinary catheters (a tube inserted in the bladder that drained urine into an external collection bag)in a dignified manner for 2 of 5 sampled residents (Residents 8 and 65) reviewed for dignity. This failure put the residents at risk for loss of dignity and decreased quality of life. Findings included .Review of the facility policy titled, Indwelling Urinary Catheter Management reviewed on 09/04/2025, instructed staff to keep the catheter bag off the floor. The policy did not address concerns regarding a resident's dignity when catheters were required. <Resident 8>The 01/13/2026 admission assessment documented Resident 8 had diagnoses that included cancer, respiratory failure and obstructive uropathy (a blockage that made it difficult to urinate). The resident had an indwelling urinary catheter, was dependent on staff for toileting and had severe cognitive impairments. In an observation on 02/05/2026 at 11:31 AM, Resident 8 was lying in bed. Their urine collection bag was seen from the doorway and was not covered by a privacy bag. Subsequent observations of Resident 8's urine collection bag without a privacy bag were made on 02/06/2026 at 10:59 AM, and 02/10/2026 at 3:12 PM. <Resident 65>The 02/02/2026 quarterly assessment documented Resident 65 had diagnoses that included benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement) and obstructive uropathy. The resident had an indwelling urinary catheter, was dependent on staff for toileting and was able to make their needs known. In an observation on 02/05/2026 at 9:49 AM, Resident 65 was lying in bed. Their urine collection bag was hung on the side of the bed, not in a privacy bag. In an observation on 02/06/2026 at 2:39 AM, Resident 65 was sitting in their room in their wheelchair. Their urine collection bag was not in a privacy bag and could be seen from the doorway. In an observation and interview on 02/10/2026 at 08:56 AM, Resident 65 was sitting up in bed. Their urine collection bag was hung on the side of the bed, not in a privacy bag. Resident 65 stated they got into their wheelchair daily and preferred the staff covered their catheter if they had something to cover it with. In an observation on 02/10/2026 at 12:35 PM, Resident 65 sat in the dining room at the table. The urine collection bag was not in a privacy bag and touched the ground. In an observation on 02/10/2026 at 12:46 PM, Resident 65 wheeled out of the dining room and their urine collection bag dragged on the ground.In an observation and interview on 02/11/2026 at 8:41 AM, Resident 65 was sitting up in bed. Their urine collection bag was not in a privacy bag. Resident 65 had a privacy bag under their wheelchair and stated it was probably there now because the surveyor had asked about it. In an interview on 02/12/2026 at 7:50 AM, Staff N, Nursing Assistant, stated urinary catheters were to be stored in a privacy bag and it was important for dignity and cleanliness. In an interview on 02/12/2026 at 1:49 PM, Staff W, Registered Nurse, stated urinary catheters were kept in privacy bags and it was important for dignity. In an interview on 02/12/2026 at 2:47 PM, Staff B, Director of Nursing, stated urinary catheters were stored in privacy bags and it was important to maintain a resident's dignity. Reference: WAC 388-97-0180(1-4)

Based on interview and record review, the facility failed to exercise reasonable care for the protection of residents' property from loss or theft for 1 of 3 sampled residents (Resident 17), reviewed for personal property. This failure placed residents at risk of loss or theft of property and did not create a homelike environment.Findings included.Review of the facility policy titled, Inventory of Personal Effects dated August 2025, showed the facility would protect residents' personal property and prevent loss. Items brought into the facility would be documented on an inventory of personal effects form upon admission. The form was to be updated if/when additional items were brought into the facility. Upon discharge, the resident and/or responsible party was to verify and sign that personal property was received. According to the 01/23/2026 admission assessment, Resident 17 admitted to the facility on [DATE] with diagnoses that included cancer. The assessment further showed it was very important for Resident 17 to choose what clothes to wear and take care of their personal belongings. Resident 17 was cognitively intact and able to clearly verbalize their needs. In an interview on 02/05/2026 at 1:48 PM, Resident 17 stated they had a bag of clothes go missing, they informed staff, but items were not found, replaced, or reimbursed.Review of Resident 17's medical record showed no documentation of a personal effects inventory form on file.Review of the inventory sheet binder, on each unit, showed no documentation of a personal inventory sheet for Resident 17 on file. Review of the August 2025 through January 2026 grievance log showed 12 out of 16 grievances filed were related to missing items. No documentation of Resident 17's missing clothing was found.In an interview on 02/12/2026 at 1:09 PM, Staff N, Nursing Assistant, explained the facility tracked resident items by completing an inventory sheet of personal possessions upon admission. The form was to be updated when items were brought in or removed from the facility. Staff N further stated if a resident reported missing items, a missing item form was completed and turned in. If the missing item was clothing, they spoke with laundry.In an interview on 02/12/2026 at 1:47 PM, Staff P, Social Service Assistant, stated a resident inventory sheet was completed upon admission and kept in an inventory sheet book on each unit. Staff P explained a missing item form was completed if/when items were reported missing, staff searched for the items, and item replaced or reimbursed if unable to be located. Staff P further explained each resident should have a personal inventory sheet on file, the inventory sheet was reviewed to determine if the item was brought into the facility, if the item was not listed on the inventory sheet then the facility would have to decide if the item would be replaced or reimbursed.During an interview and record review on 02/12/2026 at 2:31 PM, Staff D, Resident Care Manager, explained that a personal possession inventory sheet was completed upon admission and kept in a book on each unit; the form was to be updated if/or when items were brought in or removed from the facility. If items were reported missing, a missing item form was completed and submitted to social services for follow up. Staff D stated the inventory sheet would be reviewed to attempt to determine if the missing items were brought into the facility. Staff D reviewed the personal inventory sheet binder. Staff D acknowledged they were unable to find a personal possession inventory sheet for Resident 17, and they should have one on file.In an interview on 02/12/2026 at 2:41 PM, Staff B, Director of Nursing, explained the facility tracked resident property by completing an inventory sheet upon admission and updating the form if/when items were brought in or removed from the facility after. Staff B further stated each resident should have a personal inventory sheet on file that the facility referred to if/when items were reported missing. Staff B acknowledged it's mostly clothing that goes missing if things go missing.Reference WAC 388-97-2040

Based on observation, interview and record review, the facility failed to maintain a total medication error rate of five percent or less for 3 of 7 sampled residents (Residents 76, 42, and 8) observed during medication administration. Specifically, 3 of 25 medications were observed to be given incorrectly for an error rate of 12 percent. This failure placed residents at risk of medication errors, adverse side effects, and potential medical complications. Findings included.<Resident 42> The 02/04/2026 admission assessment documented Resident 42 had diagnoses that included cancer, heart failure and diabetes. The resident was cognitively intact and able to make their needs known. Review of the 01/22/2026 provider order instructed nursing staff to administer Preservision AREDS (medication used to slow the progression of vision loss) two tablets to Resident 42 daily. During an observation on 02/09/2026 at 8:12 AM, Staff Y, Registered Nurse (RN), administered a multivitamin with minerals instead of the Preservision AREDS to Resident 42. In an interview on 02/12/2026 at 10:46 AM, Staff B, Director of Nursing, stated Preservision AREDS and multi vitamins with minerals were two different medications. Staff B stated they had communication with the providers and were told they could substitute the medication for something comparable. Documentation of the provider's communication was requested from Staff B but was not provided. Staff B stated it was important to give the Preservision instead of the multi vitamins with minerals because if an equivalent medication was not given it did not address the resident's needs. <Resident 8> The 01/13/2026 admission assessment documented Resident 8 had diagnoses that included cancer, respiratory failure and obstructive uropathy (a blockage that made it difficult to urinate). Review of the 01/08/2026 provider order instructed staff to administer Lansoprazole Delayed Release Disintegrating tablets (medication with a special coating that slowed absorption, that was not able to be crushed and was used to decrease acid in the stomach) one tablet to Resident 8 twice daily. During an observation on 02/09/2026 at 9:50 AM, Staff W, RN, placed Resident 8's Lansoprazole Delayed Release Disintegrating tablet into a medication cup. Staff W then placed the Lansoprazole and another medication into a plastic bag and crushed the medications. At 10:00 AM, Staff W administered Resident 8 their medications. In an interview on 02/12/2026 at 10:46 AM, Staff B, Director of Nursing, stated the nurses needed to look up medications to determine if they could be crushed and would hope the provider order explained that in the order. Staff B stated it was important not to crush the medication because that caused the medication to be absorbed too quickly. <Resident 76> According to the 02/09/2026 admission assessment, Resident 76 admitted to the facility on Tuesday 02/03/2026. Review of the 02/05/2026 provider order instructed staff to administer Alendronate (medication used to strengthen bones and prevent fractures) to Resident 76 once weekly on Mondays. During observation and interview on Monday 02/09/2026 at 5:04 AM, Staff S, RN, attempted to dispense Alendronate to Resident 76 but was unable to locate the medication to administer. Staff S attempted to obtain the medication from the facility's electronic emergency medication machine, but it was not available and the dose was omitted. Staff S stated they would have to call the pharmacy to inquire about the medication and notify the provider that the medication was unavailable to administer. In an interview on 02/10/2026 at 1:18 PM, Staff B, DNS, explained the facility medication delivery process and stated if a medication was unavailable for administration staff could access the electronic emergency medication machine and obtain the medication if it was in stock. Staff B was unsure why Resident 76's weekly Alendronate was not available for administration. Staff B stated they expected staff to administer medications as ordered. In an interview on 02/13/2026 at 12:03 PM, Staff A, Administrator, stated they expected staff to administer medications as ordered. Reference WAC: 388-97-1060 (3)(k)(ii)

Based on interview and record review, the facility failed to ensure the pharmacist's recommendation for a resident's inhaler (a medication that helped ease the effort of breathing) was addressed timely for 1 of 5 residents (Resident 11) reviewed for monthly medication regimen reviews. This failure placed the resident at risk for unintended side effects of the medication, and decreased quality of life. Findings included .The 12/08/2025 annual assessment documented Resident 11 had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that caused inflammation and difficulty breathing). Review of Resident 11's record showed a physician order dated 11/12/2025 for Arnuity Ellipta (an inhaled medication for asthma, a chronic disease of the lungs that caused episodes of wheezing, coughing, chest tightness, and shortness of breath) to be given once daily beginning on 11/13/2025.A pharmacy consultation report dated 12/17/2025 recommended the Arnuity Ellipta order be updated to include rinsing the mouth with water after use to prevent thrush (a painful mouth and tongue yeast infection).Further review of orders on 02/10/2026 revealed the pharmacy recommendation had not been implemented.In an interview on 02/10/2026 at 11:58 AM, Staff B, Director of Nursing, acknowledged that some of the pharmacy recommendations had been missed. Staff B planned on completing audits for the previous months and assessing residents for any adverse side effects. Staff B stated they expected timely implementations of pharmacy recommendations. Reference: WAC 388-97-1300(4)(c)

Based on observation, interview and record review, the facility failed to maintain respiratory care equipment in a sanitary manner for 2 of 3 sampled residents (Residents 8 and 12), reviewed for respiratory care. This failure placed the residents at risk for respiratory infections and decreased quality of life.Findings included .<Resident 8> The 01/13/2026 admission assessment documented Resident 8 had diagnoses that included cancer, pneumonia and respiratory failure. The assessment further showed the resident required continuous oxygen. In an observation on 02/05/2026 at 11:31 AM, Resident 8's oxygen concentrator filter was covered in thick dust debris. A provider order dated 12/31/2025 instructed nursing staff to clean the oxygen concentrator filter with soap and water and to let it air dry weekly on Sundays. The 01/15/2026 care plan instructed staff to administer oxygen therapy as ordered. Subsequent observations of Resident 8's oxygen concentrator filter covered in thick dust debris were made on 02/06/2026 at 10:59 AM and 2:50 PM, 02/09/2026 at 7:53 AM, 02/10/2026 at 9:02 AM and 3:12 PM, 02/11/2026 at 8:54 AM and 12:55 PM, and 02/12/2026 at 8:38 AM. In an interview on 02/13/2026 at 11:44 AM, Staff Z, Registered Nurse (RN), stated oxygen filters were cleaned every 72 hours, and it was important to ensure the residents were getting the cleanest oxygen and to decrease respiratory infections. In an interview on 02/13/2026 at 11:48 AM, Staff B, Director of Nursing (DNS), stated oxygen filters were cleaned weekly, and it was important to keep the oxygen filters clean to prevent dust debris from entering the machine. <Resident 12> An admission assessment dated [DATE], documented Resident 12 had diagnoses that included respiratory failure which required use of supplemental oxygen equipment. The care plan dated 12/21/2025 instructed staff to administer oxygen therapy and to apply a CPAP (continuous positive airway pressure, a machine that used a hose and mask to deliver a steady, continuous stream of pressurized air that kept the airway open during sleep) nightly for Resident 12 per orders. Review of Resident 12's provider orders documented staff were to change oxygen tubing weekly every Sunday on night shift, clean CPAP reservoir every 7 days, and clean CPAP mask as needed. Review of Resident 12's TAR (treatment administration record) showed no documentation of oxygen tubing being replaced or CPAP being cleaned on 12/14/2025, 12/28/2025, 01/11/2026, 01/25/2026, and 02/08/2026. Review of the January 2026 TAR showed the mask had not been cleaned all month. On 02/05/2026 at 9:05 AM, Resident 12 was observed lying in bed wearing a nasal cannula that delivered oxygen. A CPAP machine and mask were observed on a cluttered nightstand. At 1:45 PM the CPAP mask was observed on the nightstand to have a greasy like film on it and the front of the CPAP machine was covered with dust and debris. Resident 12 stated staff did not wash the mask. On 02/09/2026 at 8:23 AM Resident 12 was observed sleeping with their CPAP mask on and it was cloudy and unclean. Similar observations were made on 02/09/2026 at 9:02 AM and on 02/12/2026 at 7:13 AM. In an interview on 02/10/2026 at 9:10 AM Resident 12 stated staff did not change the oxygen tubing or clean their CPAP machine on Sunday. In an interview on 02/10/2026 at 9:10 AM with Staff X, Licensed Practical Nurse, stated oxygen tubing was changed weekly by the night shift and documented on the TAR. In an interview on 02/12/2026 at 6:59 AM, Staff R, RN, stated oxygen tubing and CPAP cleaning was assigned to the RN. If Resident 12 wore their CPAP mask and oxygen at night when the order directed staff to change the tubing and mask, the time frame did not work to change and clean them. Staff R stated they would not want to wake Resident 12 to clean and change oxygen equipment during the night. Staff R stated if completed the documentation would have been on the TAR. In an interview on 02/12/2026 at 10:56 AM Staff B, DNS, stated nurses on the evening shift were responsible for changing oxygen tubing and cleaning CPAP equipment. They stated it would be a good idea to change oxygen tubing and clean CPAP equipment during the day when residents were not using them. Reference: WAC 388-97-1060(3)(j)(vi)

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for 2 of 4 sampled residents (Residents 8 and 73), reviewed for admission baseline care planning. This failure placed residents at risk of not receiving needed care, potentially avoidable accidents, and diminished quality of life.Findings included.Review of the facility policy titled, Baseline Care Plan dated August 2025, showed a baseline care plan would be developed for each resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care. The baseline care plan was to be updated as needed to reflect current needs until the comprehensive care plan was developed. The baseline care plan was to be reviewed with the resident and/or representative and a copy provided.<Resident 8> The 01/13/2026 admission assessment, documented Resident 8 admitted to the facility on [DATE] with diagnoses including respiratory failure, obstructive uropathy (a blockage that made it difficult to urinate) and had an indwelling catheter (a tube inserted in the bladder that drained urine into an external collection bag). Resident 8 admitted with the following orders on 01/08/2026: -Catheter care every shift -Flush foley catheter with normal saline twice a day -Indwelling catheter to straight drainage, change for infection, obstruction or when the closed system was compromised as needed -Oxygen at 3L per minute via nasal cannula Review of the baseline care plan initiated 01/08/2026 showed no documentation Resident 8 was at risk for respiratory complications and had a foley catheter. There were no interventions on the baseline care plan for staff to implement. <Resident 73> According to the 01/16/2026 admission assessment, Resident 73 entered the facility on 01/13/2026 with diagnoses that included muscle weakness and difficulty walking. The assessment further showed Resident 73 sustained falls in the month prior to admission and sustained fractures related to falls in the six months prior to facility admission. Resident 73 was cognitively intact. Review of the 01/13/2026 hospital discharge summary showed Resident 73 had a history of multiple falls with worsening shortness of breath over the past couple of days. Review of the care plan initiated 01/13/2026 showed no documentation Resident 73 was at risk for falls, had a history of falls, or fall prevention interventions for staff to implement. Review of the January 2026 facility incident log showed Resident 73 sustained a fall on 01/25/2026. Review of January 2026 nursing progress notes showed Resident 73 had a history of orthostatic hypotension (sudden drop in blood pressure when standing up from sitting or lying position) and noted residual debility that required therapy services. On 01/25/2026 Resident 73 was found sitting on the floor in their bathroom calling for help. In an interview on 02/12/2026 at 11:01 AM, Staff B, Director of Nursing, explained a baseline care plan that covered the residents' allergies, transfer status, diet, pain, falls, and any other important resident care needs staff needed to be informed of to immediately provide safe care to the resident, was initiated within 24 hours of an admission; staff should not leave the building without it being done. Staff B further stated falls should have been addressed in Resident 73's care plan. During interview and record review on 02/12/2026 at 2:30 PM, Staff D, Resident Care Manager, reviewed Resident 73's care plan initiated 01/13/2026. Staff D acknowledged Resident 73 was a high fall risk, falls were not addressed in the care plan and should have been. In an interview on 02/13/2026 at 12:03 PM, Staff A, Administrator, stated they expected staff to develop and implement an effective and person-centered baseline care plan for each resident, as required. Reference WAC 388-97-1020 (3)

Based on observation, interview, and record review, the facility failed to monitor a surgical wound for 1 of 3 sampled residents (Resident 1), reviewed for non-pressure wounds. This failure placed residents with surgical incisions at risk of potential worsening skin conditions and complications. Findings included .A facility document titled Documentation and Assessment of Wounds, revised 06/12/2025, showed the facility Policy was to guide nurses in the assessment of wounds to include pressure ulcer/injuries (damage to the skin and underlying tissue caused by unrelieved pressure that restricts blood flow), venous (open sore on the lower leg from impaired circulation), arterial (painful wounds caused by poor circulation), diabetic (sores, ulcers, or chronic conditions that develop in people with diabetes, often on the feet, due to poor circulation, nerve damage), and dehisced surgical wounds (surgical wound that split open or separate), and other wounds not otherwise specified. A wound observation was to be made with each dressing change. The provider would be notified of changes and updated with a treatment plan if applicable. The nurse that performed the treatment would do an as needed assessment and document if a change had occurred (if wound appeared to be infected or appeared to have declined).Review of a facility assessment, dated 06/10/2025, showed Resident 1 was admitted with diagnoses to include Peripheral Vascular Disease (PVD, a circulation disorder that affected the peripheral arteries and veins, most commonly in the legs and arms, due to a narrowing or blockage), below knee amputation on both legs, and Diabetes. The resident was able to make their needs known.Per record review, the resident had dry gangrene (caused by insufficient blood flow leading to tissue death) to their right fingertips and had them amputated on 06/19/2025. The resident arrived at the facility with a dressing on their right hand which was not to be removed until their follow up with the surgeon on 06/24/2025.Review of a surgical follow up visit on 06/24/2025 showed the resident had their dressing removed in the office and wound care was ordered to be done daily. Resident 1's next follow up was on 07/01/2025.Review of the resident's Treatment Administration Record (TAR) for June 2025 showed the resident's wound care included cleansing the wound, covering the wound with an ointment type gauze, and to secure it with self-adherent wrap. The wound care was marked as done daily from 06/24/2025 to 06/29/2025, on 06/30/2025 there was no signature. Nurse progress notes were reviewed from 06/24/2025 thru 06/30/2025 and no documentation was found about the resident's surgical wound on their right hand. Review of a surgical follow up on 07/01/2025, Resident 1 had their dressing removed and the surgeon noted the fingertips were healing but the resident had developed a large blister over the palm of their hand. The surgeon debrided (removal of dead skin) the blister. The surgeon documented there appeared to be a soft tissue infection. New wound care was ordered, the resident was to start on antibiotics, and the area was to be monitored for increased redness. The resident's next follow up appointment was 07/11/2025.The TAR for July 2025 showed the resident's new wound care orders were to wash the hand with water or normal saline, apply bacitracin (antibiotic ointment) to a non-adherent dressing, and cover with gauze. The dressings were marked as done from 07/02/2025 through 07/13/2025 daily. There was nothing on the TAR to show the resident's right hand was monitored for increased redness or signs of worsening infection. Review of nurses notes from 07/01/2025 to 07/11/2025 showed a note written by Staff D, Registered Nurse (RN), on 07/04/2025. It was documented the resident's right-hand wound infection had mild redness and odor which was resolving with antibiotics. Staff D had written a note on 07/05/2025 which showed the wound appeared less inflamed (red, swollen, hot) and redness appeared to have lessened. Review of a surgical follow up note on 07/11/2025 showed the resident rated their pain a 7 out of 10 (0 being no pain, 10 being the worst pain) and described the pain in the hand and into the wrist. It was noted the resident's hand was red and the resident had wound cellulitis (bacterial infection of the skin and underlying tissues, characterized by red, swollen, warm, and painful skin). The surgeon discussed going to the hospital for a CT scan (a scan that created a detailed image of the inside of the body to help in diagnoses such as an infection), but the resident wanted to wait and do the CT scan as outpatient. The resident was instructed to report to the hospital if symptoms worsened. The wound care remained the same. Review of nursing progress notes from 07/11/2025 to 07/13/2025 showed no documentation the resident's hand was monitored by staff which would include a description of the wound on the right hand or if the wound infection had worsened. A nurses note on 07/14/2025 showed the resident was sent to the hospital for a worsened infection of their right hand. There was no documentation to show the assessment of the wound and how the infection had worsened.Review of hospital notes on 07/14/2025 showed the resident arrived at the hospital with redness that had progressed on their hand and the resident had nausea/vomiting. The resident complained their hand and wrist were very painful and tender. The provider documented the resident's finger amputation wound was closed and there was a large purulent wound (drainage that is thick, cloudy, and typically white, yellow, or green which indicated an infection) and mass on the palm of their hand with tenderness and warmth on the palm and wrist. An emergent debridement was done. The resident remained in the hospital and had an additional surgery to amputate the right four fingers and palm. On 09/02/2025 at 1:30 PM, Resident 1 was up in their electric wheelchair in their room. The resident had both legs, below the knee, amputated. The resident's right hand was the thumb and base of the thumb. The surgical incision appeared to be healing. The resident stated they originally had their fingertips removed on the right hand. The resident said a large blister then developed on their palm, while at the facility, and the area became hotter and more painful. The resident was started on antibiotics for an infection. The resident went on to say they were right handed and had a difficult time feeding themselves. During an interview on 09/02/2025 at 11:10 AM, Staff A, Wound Nurse, stated residents with wounds would have a wound observation form filled out weekly. The form would include a description of the wound and measurements. If a resident had a surgical wound and an order for a dressing change, it would be documented on the TAR. If the surgical area opened, the staff would then do a wound observation form, and any abnormal findings would be charted in the progress notes. Staff A stated they were not familiar with Resident 1's wound due to being out of the facility at that time.On 09/02/2025 at 12:27 PM, Staff B, Resident Care Manager (RCM), stated if a resident had a surgical wound and there was a change with the surgical area, or signs and/or symptoms of an infection, the surgeon would be contacted. The TAR would be where staff monitored for redness or signs/symptoms of an infection. Staff B stated they knew Resident 1 was on antibiotics for an infection and the hand became more painful so was sent to the hospital. Staff B had not observed the wound prior to the last surgery since the resident was on a different unit.On 09/02/2025 at 1:07 PM, Staff F, RCM, stated Resident 1 was on their unit when they had dry gangrene on their right fingertips and then had them amputated. Staff F stated the floor nurses would do wound care if the wound nurse was not available. Staff F stated they had not observed the resident's wound but stated the resident had developed an infection. Staff F said if there was a concern with a surgical wound, staff contacted the surgeon.On 09/04/2025 at 1:50 PM, Staff C, Director of Nursing (DNS), stated when Resident 1 had their initial surgery and then amputation of their hand, they were being trained as the DNS. Staff C stated the facility did not do wound observation forms for surgical incisions; the surgeons would be the ones to monitor and follow up on the residents. Staff C stated the policy had since changed. On 09/12/2025 at 2:30 PM, Staff D, RN stated they had just started to work at the facility when Resident 1 had their hand surgery. Staff D remembered they were alerted to Resident 1's hand wound when they came to work but could not recall what the wound looked like. Staff D said they did do wound care on the resident's hand and if there was any abnormality, they would have documented it in the progress notes. On 09/12/2025 at 2:45 PM, Staff E, Licensed Nurse (LN), stated they would do wound care for Resident 1 if it had not been done on dayshift. Staff E recalled the resident was picky about the wound care if they had a follow up visit to the surgeon the following day. The resident would refuse the dressing to be changed because they preferred the surgeon do it. Staff E did not recall the resident had a blister on their hand and could not recall how the resident's wound appeared. Reference: WAC 388-97-1060(1)

Based on observation and interview, the facility failed to ensure proper hand hygiene and hair coverings were worn and implemented during food service. This failure placed the residents at risk for foodborne illness. Findings included . A 04/30/2024 facility policy titled Associate Conduct and Dress Code showed hair and beard coverings were used when cooking, preparing or assembling food, but not required when distributing foods to the residents at the dining tables or when assisting the residents to dine. An observation on 10/22/2024 at 8:08 AM showed Staff Z, a Dietary Aide, participated in the breakfast tray line. Staff Z had visible facial hair and no beard covering. An observation on 10/25/2024 from 11:30 AM to 11:53 AM showed Staff Y, a Cook, standing in front of the food prep counter. The kitchen staff were getting ready to start lunch tray line. Staff Y wore a pink bandana. About three inches of hair was observed flowing down Staff Y's forehead. The bandana failed to contain Staff Y's hair, with visible hair observed coming out of the bandana around the sides and the back of Staff Y's head. At 11:42 AM, Staff Y stood next to the food prep counter, hands were gloved. Staff Y moved towards the garbage can where they threw in a small indiscernible object, then wiped the right side of their head with their gloves, took a paper napkin and wiped off their gloves, then adjusted their shirt. Staff Y took the temperature of food items on the steamer table with the same gloves on. Staff Y then removed their gloves and tossed them in the garbage can, walked over to the sink where they washed their hands for seven seconds, wiped their hands with a paper towel, and with the same paper towel proceeded to wipe down the steamer table where food items were kept hot for the upcoming lunch. Staff Y then crunched the paper towel into a ball with their left hand and threw it in the garbage can. The above information was shared with Staff X, Dietary Manager, on 10/25/2024 at 12:30 PM. Staff X stated that the kitchen staff was required to always wear head and beard coverings, no matter what they're doing. Someone can be prepping food, and hair can come drifting over. Staff X stated, You gotta' wash your hands and change your gloves. Staff X stated that Staff Y should, wash [their] hands completely 30 seconds at least. Staff X stated that Staff Y should have thrown the paper towel in the garbage can after they dried their hands instead of using it to wipe down the steamer table. An observation on 10/28/2024 at 11:47 AM showed Staff Y with a hairnet. The hair net was placed above the ears exposing Staff Y's hair below the hair net line, with anywhere from one to four inches of hair hanging out, to include a tuft of hair hanging down the staff's forehead. Reference WAC 388-97-1100 (3), -2980.

Based 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 2 of 2 medication carts, and needles and lab supplies were securely stored that were in a bistro. The facility failed to maintain temperatures to ensure medications were properly stored in 2 of 2 medication storage rooms. The facility further failed to ensure anti-anxiety medications were stored behind two locks as required and nursing staff were signing the narcotic logs verifying all medications were accounted for at shift change. This failure placed residents at risk for receiving compromised or ineffective medication, placed the facility at risk for potential diversion or misappropriation of psychotropic medications and potential for needlestick injuries. Findings included . On 10/22/2024 at 10:34 AM, an observation was made of a room called The Bistro. The room contained a kitchenette and had multiple cabinets and drawers. The lower unlocked cabinet contained two bottles of red liquid that was used to transport stool samples to assess for pathogens and the bottles were not sealed. The unlocked top drawer contained 8 intravenous (by vein) needles. A lower unlocked cabinet contained sanitizing wipes that stated to keep out of reach of children. There were 2 bottles of a solution that was used to fit test staff for a respirator (a mask) sitting on a stand. There were no residents wandering around the area. During an interview on 10/22/2024 at 11:26 AM, Staff B, Director of Nursing, stated The Bistro was used for family visits, staff breaks, interviews and corporate visits. Staff B stated the lab supplies were stored in that room for quick and easy access by the staff. In an interview at 11:44 AM, Staff B was asked if they were aware there were unsecured needles stored in the drawer and they stated yes. Staff B acknowledged this could be a potential for injury and stated the supplies should be locked up for resident safety. Staff B stated they were unaware there were vials that contained liquid in them. Staff B added the vials, fit testing solution and sanitizing wipes should have been locked up. Staff B stated they were going to remove the items to a locked room. On 10/30/2024 at 10:10 AM, the medication room on the east unit was observed with Staff I, Registered Nurse. The refrigerator contained 2 vials of hepatitis vaccine, 11 vials of influenza vaccine, and 1 vial of covid vaccine which must be stored between 35-46 degrees Fahrenheit. The temperature logs for October 2024 were sitting on the counter and had multiple omissions. In an interview on 10/30/2024 at 10:11 AM, Staff I stated the refrigerator temperatures needed to be monitored because if the vaccines were not in the correct temperature range it would impact the vaccines effectiveness. The unlocked refrigerator contained 2 vials of house stock Ativan (a medication used to treat anxiety) that were contained in an unlocked black box, not behind two locks as required. The only lock was the door leading into the medication room. In an interview on 10/30/2024 at 10:18 AM, Staff I stated they were aware the Ativan needed to be stored behind 2 locks, and this was important to prevent someone from taking the medication. During an interview on 10/30/2024 at 10:24 AM, Staff B stated the refrigerator temperatures needed to be monitored to ensure the viability of the vaccines, and the Ativan needed to be locked behind two locks for security. On 10/30/2024 at 10:31 AM, the medication room on the west unit was observed with Staff B, Director of Nursing. The refrigerator contained 20 vials of influenza vaccines and 3 vials of pneumonia vaccines. The temperature logs for October 2024 were sitting on the counter and had multiple omissions. On 10/30/2024 at 10:37 AM, the west medication cart 3 was observed with Staff J, Licensed Practical Nurse. There was an insulin pen dated 09/04/2024, that was not discarded after 28 days as required, two insulin pens and an Ozempic pen that had no date that had been used, and a bottle of allergy nasal spray that had expired 12/2023. Staff J stated the medication needed to be discarded because it may not be effective after the required timeframe. Review of the narcotic books on west cart 3 showed the nursing staff was not consistently signing at the change of each shift, which verified the narcotic count was accurate. In an interview on 10/30/2024 at 10:50 AM, Staff J stated it was important to count the narcotics to ensure the count was accurate and who was accountable. On 10/30/2024 at 10:59 AM, the west medication cart 1 was observed with Staff K, Registered Nurse. There was an inhaler used for asthma that expired on 04/2024, sodium chloride tablets that expired on 08/2024, calcium tablets that expired on 09/2024, an insulin pen dated 08/25/2024, an insulin pen dated 09/21/2024, an insulin pen dated 09/28/2024, and four insulin pens with no date that had been used. Review of the narcotic books on west cart 1 showed the nursing staff was not consistently signing at the change of each shift. In an interview on 10/30/2024 at 10:59 AM, Staff K stated the narcotic books needed to be signed every shift to ensure that the count was accurate, and drug diversion had not occurred. During an interview on 10/30/2024 at 11:24 AM, Staff B stated the narcotic books needed to be signed to verify who was on shift and who was responsible. Staff B added it was important that insulin and expired medications not be used outside of the required timeframe to ensure the viability of the medication. Reference: WAC 388-97-1300(2)

AMMENDED ON 11/18/2024. Based on observation, interview and record review, the facility failed to ensure residents identified at risk for elopement were accurately assessed and interventions implemented to prevent elopement for 4 of 5 sampled residents (Residents 7, 27, 25 and 254) reviewed for elopement. The facility failed to ensure 1 of 3 sampled residents (Resident 41) had adequate and prompt interventions and supervision to prevent falls. Also, the facility failed to ensure 2 of 2 sampled residents (Residents 24 and 41) reviewed for smoking were adequately supervised, to include safe keeping of smoking materials. These failures placed the residents at risk for injuries related to elopement, falls, and smoking. Findings included . <ELOPEMENT> <Resident 25> Review of a 09/25/2024 facility policy titled Unsafe Wandering and Elopement Prevention showed the facility would assess residents to determine their risk for elopement and implement interventions as appropriate to mitigate risks identified. The policy defined elopement when a resident left the premises or safe area without authorization or without the necessary supervision to do so. The policy identified some of the risks associated with an elopement included heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. The policy showed that a system to help identify residents with the potential for unsafe wandering and elopement included a current photograph of residents and responsible party contact information. The policy instructed the staff to complete an elopement assessment upon admission, re-admission, change in condition, quarterly, and with any unsafe wandering or elopement event. Review of a 10/11/2024 quarterly assessment showed Resident 25 readmitted to the facility on [DATE]. This assessment showed the staff identified Resident 25 wandered 1 to 3 days of the assessment reference period, did not place the resident at risk of getting to a potentially dangerous place, but significantly intruded on the privacy or activities of others. The assessment showed the wandering behavior worsened from the previous assessment. Review of 05/07/2024, 07/15/2024, and 09/10/2024 Elopement Risk Evaluations showed the staff did not find Resident 25 was at risk for elopement. A 10/23/2024 care plan showed the staff identified Resident 25 was, At risk for elopement. Impaired safety awareness, contrary to the evaluations, and instructed the staff to, Add resident to the Elopement Book. Review of the Elopement Books at the Receptionist Desk and the [NAME] Hall where Resident 25 resided showed no information that alerted the staff the resident was at risk for elopement. The facility provided the Surveyor a list of residents At risk for elopement the morning of 10/30/2024. Along with Resident 25, the list also included 4 other residents: Resident 254 - Review of a 10/24/2024 Elopement Risk evaluation showed the staff identified the resident was at risk for elopement. The 10/22/2024 care plan instructed the staff to, Add Resident to Elopement Book. Review of the Elopement Book at the receptionist area and the East Hall where Resident 254 resided showed no information to alert the staff the resident was at risk for elopement. Resident 27 - Review of a 10/23/2024 Elopement Risk evaluation showed the staff assessed the resident not at risk for elopement and, Pt [patient] wonders [sic] and tries to exit seek occasionally, Pt is easily redirected. The 10/23/2024 care plan showed Resident 27 was, At risk for elopement. Disoriented to place, Resident wanders aimlessly and Add Resident to Elopement Book. Review of the Elopement Book at the receptionist area and the East Hall where Resident 27 resided showed no information to alert the staff the resident was identified at risk for elopement. Resident 7 - Review of a 08/30/2024 Elopement Risk evaluation showed the staff assessed Resident 7 not at risk for elopement. The 10/23/2024 care plan showed the resident was At risk for elopement. Impaired Safety Awareness and Add Resident to Elopement Book. Review of the Elopement Book at the receptionist area and the [NAME] Hall where the resident resided showed no information to alert the staff the resident was identified at risk for elopement. In an interview on 10/30/2024 at 12:47 PM, Staff I, Registered Nurse on East Hall, identified only Resident 253 should be in the Elopement Book, contrary to the care plan instructions for Residents 27 and 254. In an interview on 10/30/2024 at 12:51 PM with three Nursing Assistants on the [NAME] Hall present, Staff Q stated that they knew which residents were at risk for elopement by checking in the Kardex (abbreviated instructions from the care plan) and we also have alarms on the doors. Staff G stated, There's a binder. Staff T answered, Don't we have wrist bands? The Nursing Assistants then brought out two Elopement Books from the [NAME] Hall. The black Elopement Book had a photo of a female resident. Review of the neon green Elopement Book showed the same photo of the female resident and a male resident. In an interview on 10/30/2024 around 12:55 PM, Staff C, Assistant Director of Nursing, confirmed that the female resident had recently passed and the male resident had recently discharged . Neither binder included resident information on Residents 7 and 25, as instructed by the care plan. The above information was shared with Staff A, Administrator, on 10/30/2024 at 9:02 AM. Staff A stated that an Elopement Book is used to help the staff, understand who is at risk for elopement and if we do have a missing resident, it's a reference for when we make the call to 911. Staff A stated that not including a resident who is at risk for elopement in the Elopement Book, could make it less likely for staff to be aware of the elopement. The above information was shared in a joint interview with Staff B, Director of Nursing, and Staff U, Corporate Nurse, on 10/30/2024 at 1:38 PM. Staff B acknowledged the inconsistencies between the Elopement Risk Evaluations, care plan instructions, and information in the Elopement Books. Staff U stated, We need to update it. <SMOKING> Review of an 11/30/2023 facility policy titled, Area of Focus: Smoking vs [versus] Non-Smoking documented that smoking was not allowed, at any time, inside or outside the building or on the facility property. <Resident 24> An admission assessment dated [DATE] documented Resident 24 had diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung conditions that cause inflammation and difficult breathing) and stroke with paralysis of one upper extremity. Resident 24 was cognitively intact and used tobacco. The 08/12/2024 comprehensive care plan documented Resident 24 was a smoker. Staff were instructed to complete a smoking safety evaluation, provide the resident education on the facility non-smoking policy, instruct the resident on the hazards of smoking and smoking cessation aids that were available, and notify the charge nurse immediately if it is suspected the resident has violated the facility smoking policy. The 08/13/2024 and 09/15/2024 Smoking Safety Evaluations documented Resident 24 was able to appropriately use an ashtray, had demonstrated the ability to safely smoke with supervision and was compliant with the smoking regulations in the facility. On 10/22/2024 at 10:21 AM, Resident 24 was observed in their wheelchair in their room. Resident 24 had a pressure reducing boot on their left foot, their left hand rested in their lap and the resident was unable to move it purposefully. The resident used their right foot to scoot and position their wheelchair. A strong odor of cigarettes could be smelled when standing next to Resident 24. Resident 24 stated when they smoked, they left the facility property because smoking was not allowed on the facility property. Staff did not accompany them. The resident stated they did not have smoking materials; a friend that lived close by met them outside and brought cigarettes and a lighter to them. Resident 24 stated the staff had educated them about the smoking policy. On 10/24/2024 at 3:37 PM, Resident 24 was observed scooting down the hall towards the exit. Resident 24 was met at the exit by Resident 41, and they exited the building, and scooted their wheelchairs directly behind the facility transport van next to the bumper. The van was parked directly outside the exit in the driveway. Resident 41 handed Resident 24 a lighter and cigarette, which Resident 24 lit with their right hand and handed the lighter back to Resident 41. Resident 24 took several long puffs off the cigarette and was observed flicking ashes on to the driveway where they landed on the ground just behind the tailpipe area of the van. Resident 24 extinguished their cigarette when it was half gone, but had their back to the facility entrance, so was unable to see where the cigarette was extinguished. There was no cigarette receptacle next to the resident. Resident 24 handed the half-smoked cigarette back to Resident 41, who put it in their front shirt pocket. Resident 24 went back in the facility and Resident 41 stayed in the driveway and continued to smoke. There were no staff present during the observation. Resident 24 was also observed smoking in the same area on 10/29/2024 at 8:10 AM. There were no staff present, and the resident did not put their cigarette butt in the receptacle by the entrance. During an interview on 10/30/2024 at 1:36 PM, Staff M, Resident Care Manager, stated the facility was a non-smoking facility. Residents were offered smoking cessation aids when they were admitted and a safety evaluation was completed. Staff M stated they assumed someone watched Resident 24 smoke to see if they were safe when smoking. Staff did not accompany residents when they left the facility to smoke. Staff M was unaware Resident 24 smoked in the driveway behind the facility van and was unaware they got their cigarettes from Resident 41. Staff M stated there was no designated smoking area on the property; they were unsure how to honor the resident's preference to smoke without violating the facility policy. <Resident 41> Review of a 09/03/2024 quarterly assessment showed Resident 41 admitted to the facility on [DATE] with medically complex conditions, to include a stroke with one sided paralysis or weakness, and an amputation of the left leg above the knee. This assessment showed the resident was homeless, cognitively intact, had limitation in their range of motion to both upper and lower extremities, used a wheelchair independently, and required supervision or touching assistance for transfers. The assessment showed Resident 41 was dependent on nicotine. In an interview on 10/22/2024 at 12:33 PM, Resident 41 stated that they, can't get back [in the building] in the middle of the night when they go outside to smoke. Resident 41 stated that they got cigarettes and in my pocket and nobody holds it for me, and I smoke on the sidewalk. Resident 41 stated that there was another door they used to access entry to the facility after hours with a code and, Am not supposed to. I knock on the door, and they have to stop and come and get me in. Some guy gave me the code to get back in. An observation on 10/22/2024 at 1:33 PM showed Resident 41 in his room sitting in their wheelchair, with a cigarette lighter in their shirt pocket. Resident 41 stated that they liked to go out and smoke after meals and at bedtime. An observation on 10/25/2024 at 4:05 PM showed Resident 41 outside of the facility in a wheelchair on the sidewalk. The resident leaned over and looked like he picked up something off the sidewalk, then wheeled themselves on to the main road around a black SUV. Cars were observed going around the resident and the SUV. Resident 41 was on the driver's side of the parked SUV. Resident 41 again leaned over a few times as if picking up something off the pavement. An observation on 10/29/2024 at 8:05 AM showed Resident 41 in his wheelchair and on the main road, going past a bulldozer parked next to the sidewalk. There was construction in progress next to the facility with heavy equipment. Traffic was observed going both ways on the road. Resident 41 wheeled himself on the edge of the facility entry way, faced the facility parking lot, and started smoking. Resident 41 put out his cigarette on the wheel of the wheelchair, licked the cigarette, then placed the cigarette in his shirt pocket. Observation and record review on 10/29/2024 at 12:33 PM at the receptionist area showed a binder with alphabetically listed forms titled, Release of Responsibility for Leave of Absence. Record review showed Resident 41 last signed out of the facility on 7/8 at 1PM. This record showed Resident 41 signed out a total of 13 times between 06/21/2024 and 07/08/2024. Review showed no documentation the resident signed back in to the facility. In an interview on 10/29/2024 at 2:04 PM, Staff F, Receptionist, stated that they observed Resident 41 and 2 other male residents, usually go out [to smoke] on the side walk throughout the day. Review of a 09/04/2024 Smoking Safety Evaluation showed the nurse answered Yes to Is resident non-compliant with smoking regulations in the facility? The Summary of Findings showed the nurse answered Yes to Resident has demonstrated ability to safely smoke with supervision. Additionally, the nurse was instructed to answer Yes to Resident exhibits poor safety awareness when smoking and interventions must be put in place to promote smoking safety but the nurse answered No. Under Smoking Cessation the nurse answered, Undecided at this time. In an interview on 10/29/2024 at 1:30 PM, when asked to clarify if Resident 41 required supervision while smoking and was noncompliant with smoking regulations in the facility, Staff C stated, This is not my favorite assessment. The interpretation of what they're asking could be different between nurses. Review of a 10/24/2024 Risks and Benefits forms showed the facility offered Resident 41 a smoking cessation program with identified health benefits and risks contingent on choice. This form was signed by both the resident and a facility staff. Review of a 05/30/2024 care plan showed, Resident is a smoker. The care plan showed no instruction on where Resident 41's smoking materials would be safely stored, or the level of supervision Resident 41 required during smoking. The care plan instructed the staff to, Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. The care plan showed no instruction to the staff on when Resident 41 would go outside to smoke or to encourage the use of the Sign In/Sign out book to account for Resident 41's whereabouts when they left the building to smoke. In an interview on 10/29/2024 at 12:10 PM, Staff G confirmed that Resident 41 smoked. When asked what interventions were in place to ensure safe smoking Staff G stated, I don't know. I know they have to be off premises 'cause it's a non-smoking facility. Staff G stated that Resident 41 had to let staff know when they are going outside to smoke but was unsure if the resident told others when they went outside. Staff G stated that Resident 41 went to smoke outside, all day. Different times, as soon as the door opens, with time outside of the facility between 20 to 30 minutes at a time. When asked where Resident 41 kept their smoking supplies, like the cigarettes or a lighter, Staff G said, I have no idea. I believe it's with the nurses I've never seen them with it, and that they did not know if the resident shared smoking materials with other residents. In an interview on 10/29/2024 at 12:28 PM, Staff V, Registered Nurse, assigned to the [NAME] Hall where Resident 41 resided stated, None of my residents smoke right now. In a joint interview on 10/29/2024 at 12:49 PM, with Staff C and Staff D, Registered Nurse/Resident Care Manager, Staff D stated that they educated the resident about the dangers of smoking in general and offered smoking cessation assistance after a recent fall Resident 41 experienced outside. Staff D stated that Resident 41 does not want to quit smoking and, doesn't want to stop going outside to smoke. Staff D was asked if they knew where Resident 41 kept their smoking supplies and stated, I don't know that [the resident] has any personal smoking belongings. Staff D stated a Risks and Benefits form was completed with Resident 41 because the resident, goes out there to smoke. Staff D stated that Resident 41 told them they did not smoke that much and did not ask Resident 41 where the cigarettes and a lighter were obtained from and kept. Staff D stated that as long as Resident 41 signs out of the facility, they can go outside. During after hours, Staff D described how Resident 41 would go to the employee access door at the East Nurses station, even though [the resident] is not supposed to go there, and knock on the door and staff will let [them] in. On 10/29/2024 at 1:32 PM, Staff C stated that Resident 41 did not have access to money and might be getting their cigarettes by, maybe bumming from construction workers. I never witnessed it, just a theory. In the joint interview, Staff D stated, I don't know, when asked where Resident 41 obtained cigarettes from. Staff D acknowledged the care plan did not reflect Resident 41's current smoking patterns, the level of supervision required, or instructions on how to keep smoking materials in safe keeping when not in use. The above information was shared with Staff B on 10/29/2024 at 2:41 PM. No further information was provided. <FALLS> Review of a 12/04/2023 facility policy titled Fall Management, showed the facility would promote resident safety and reduce falls by proactively identifying, care planning, and monitoring a resident's fall indicators. The policy showed that with each fall event or change in condition, it would identify appropriate interventions to minimize the risk of injury related to falls, and update the care plan, if indicated, upon a fall event and as needed thereafter. Review of progress notes showed the staff identified Resident 41 had poor balance and transferred self independently, despite reminders by staff to use the call light for assistance (05/31/2024, 06/01/2024, 06/01/2024, 06/02/2024, 06/02/2024, and 06/23/2024). Review of a 05/30/2024 Fall Risk Evaluation showed Resident 41 required assistance with toileting needs, was not able to attempt a balance test without physical help and had 3 or more health conditions and one to two medications that contributed to risk for falls. This evaluation showed a score of 18 and that for a score of 10 or above, interventions should be initiated by the staff. Review of the care plan showed Resident 41 required supervision for transfers, was independent with wheelchair locomotion, and was at risk for falls due to above knee amputation, left arm paralysis, incontinence and medication use. The interventions to prevent falls were dated 06/06/2024. The interventions instructed the staff to anticipate and meet the resident's needs, assist with Activities of Daily Living as needed, keep the call light within reach, complete a fall risk assessment, provide adaptive equipment or devices as needed, and refer to therapy to evaluate and treat as ordered or as needed. Review of a 09/05/2024 progress note showed that Resident 41, was found outside of facility laying on the ground next to a bush. The facility was alerted of the resident's fall when a bystander told a Nursing Assistant who was outside at the time that someone was on the ground outside of the facility. The note showed the resident told the staff that they were wheeling backwards in their wheelchair and had toppled over landing on the ground. Review of a 09/05/2024 Fall Risk Evaluation showed a score of 12. The evaluation instructed the staff to initiate interventions for a score of 10 or above. Review of a facility 09/07/2024 Incident Report (IR) associated with the 09/05/2024 fall, showed Resident 41 told the staff that they were attempting to move onto the sidewalk and their wheelchair got caught and fell out of the wheelchair. The IR showed the staff identified Resident 41 often went outside and self-propelled in their wheelchair in the parking lot and sidewalks around the building. The IR showed the facility completed education with Resident 41 and the resident, continues to state, 'I don't care if I get hurt'. The IR concluded Resident 41 often refused to abide by medical recommendations and has no safety awareness and very impulsive. The IR showed the facility reviewed the care plan and encouraged the staff to round frequently and monitor the resident's location. Review of the care plan interventions showed no change or addition to prevent fall recurrence after the 06/06/2024 interventions. Record review showed no documentation the facility referred Resident 41 to therapy services to help ascertain why the resident chose to wheel themselves backwards and if the resident was cleared for safe navigation on uneven terrain. The care plan showed no direction to the staff on how to compensate for the resident's poor safety awareness and impulsivity they identified since 05/31/2024, how to anticipate their needs, or what round frequently should look like to the staff. Review of a 10/20/2024 progress note showed Resident 41 fell out of their wheelchair. Review of a 10/21/2024 associated IR showed the resident fell during the morning hours outside the facility and with no injury. The IR showed that someone driving by let staff know the resident was outside on the cement. Resident 41 told the staff that while they were going up the facility ramp backwards in their wheelchair, the bottom of the ramp caught the wheelchair tire and flipped over the resident, dumping them on their back. The IR showed that the staff identified Resident 41, knows how to get outside . encouraged not to go out the ramp way, but still does. This IR showed the resident was seen at a grocery store half a mile away shortly after they ate their breakfast. The IR showed no conclusion to the investigation or changes to prevent recurrence of falls and associated injury, whether the facility referred the resident to therapy to assess safe wheelchair mobility on out of facility terrain, ascertain why the resident chose to continued to wheel themselves backwards, or how the facility compensated for the resident's poor safety awareness and impulsivity to prevent fall recurrence. Review of a 10/20/2024 Fall Risk Evaluation showed a score of 14. The evaluation instructed the staff to initiate interventions for a score of 10 or above. Review of the care plan interventions showed no change or addition to prevent fall recurrence after 06/06/2024. Review of Occupational and Physical Therapy Discharge Summaries dated 06/07/2024 showed no documentation therapy services assessed and cleared Resident 41 for safe navigation on out of facility or uneven terrain, like the sidewalk or propelling self via wheel hair half a mile to the grocery store, or identified and addressed why Resident 41 would wheel themselves backwards when outside of the facility. In an interview on 10/29/2024 at 2:02 PM, Staff W, Therapist, stated that Resident 41 was not receiving therapy services and, hasn't been on therapy for quite a while. I don't know if there's anyone here who knows [the resident] really well. Review of a 10/20/2024 progress note showed the staff were aware Resident 41 continued to go outside of the facility multiple times a day. The above findings were shared with Staff B on 10/29/2024 at 2:25 PM. Staff B stated Resident 41 started going outside shortly after their admission to the facility. Staff B stated that both of Resident 41's falls were related to the resident hitting something when propelling backwards in their wheelchair outside and the reason the resident propelled backwards in the wheelchair is because they, only got one leg so it's easier to navigate backwards with the one leg. Staff B stated that Resident 41 was referred to therapy services verbally but showed no documentation the facility followed through to ensure closure with the referral, to include recommendations to prevent fall recurrence or their associated injuries. Staff B was asked if the care plan was updated with interventions to prevent fall recurrence as instructed by the Fall Risk Evaluations and stated, I felt all the interventions were already there. Reference WAC 388-97-1060 (3)(g). 46033

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) related to cleanliness and grooming for 4 of 6 sampled residents (Residents 44, 37, 9, and 19) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 37), nail care (Resident 9), and bathing (Resident 44 and 19), placed the residents at risk for poor hygiene, embarrassment, and a diminished quality of life. Findings included . <Resident 44> Review of a 10/17/2024 assessment showed Resident 44 admitted with medically complex conditions. This assessment showed the staff assessed the resident to be cognitively intact and dependent on the staff for bathing. In an interview on 10/22/2024 at 8:36 AM, Resident 44 stated, Bathing dwindled down to once a week. Resident 44 stated that they preferred a bed bath twice a week. Review of the electronic medical record under Tasks showed an instruction to the staff to provide bathing to Resident 44 twice a week on Mondays and Thursdays. Review of the medical record from 09/27/2024 to 10/26/2024, showed no documentation the staff provided assistance to complete Resident 44's bathing twice a week on 09/30/2024, 10/10/2024, 10/17/2024, and 10/24/2024. Review of a bathing sheets binder maintained on the East Hall of the facility was reviewed with Staff M, Licensed Practical Nurse/ Resident Care Manager on 10/28/2024 at 11:26 AM. Staff M confirmed the binder showed no documentation the staff provided Resident 44 bathing twice a week for the month of October 2024. The above information was shared with Staff B, Director of Nursing, on 10/29/2024 at 10:27 AM. No further information was provided. 46033 <Resident 37> A review of the 07/16/2024 quarterly assessment documented Resident 37 had diagnoses including dementia and paralysis on one side of the body after a stroke. Resident 37 was severely cognitively impaired and required moderate assistance for personal hygiene and extensive assistance for showering. The 10/21/2022 ADL self-care deficit care plan documented Resident 37 was dependent on staff for bathing/showering and was to be given showers twice weekly on Wednesdays and Sundays. The care plan did not provide instructions for staff regarding shaving preferences. Review of the shower binder documentation from 09/25/2024 to 10/24/2024 showed Resident 37 was provided showers on 09/25/2024, 10/02/2024, 10/09/2024, 10/16/2024, 10/20/2024, and 10/23/2024; weekly, not twice weekly as care planned. There was no documentation Resident 37 refused showers. The documentation showed Resident 37 was shaved on 10/09/2024. On 10/22/2024 at 9:10 AM, Resident 37 was observed scooting in the hall in their wheelchair. The resident had several days of whisker growth on their face and neck, and they had a full mustache. Their hair was unkempt. Additional observations of Resident 37 being unshaven were made on 10/23/2024 at 2:05 PM, 10/24/2024 at 8:15 AM, 10/25/2024 at 10:42 AM, and 10/28/2024 at 9:46 AM. During an interview on 10/24/2024 at 8:15 AM, Resident 37 stated they liked their hair kept short so that it was not hanging on their ears. They preferred to be clean shaven but liked to keep their mustache. Resident 37 was unable to recall when they had been showered last. During an interview on 10/28/2024 at 10:38 AM, Staff N, Nursing Assistant/Shower Aide, stated residents were to be showered twice weekly, but showers were not completed on Sundays. If they were care planned to have a shower on Sundays, it would be made up on a Saturday instead. Shaving was completed during showers. Staff N stated Resident 37 was asked when they wanted to be shaved and if the resident refused, other staff offered at a different time. Staff N stated showers were important to keep residents skin intact. This was especially important for Resident 37 because they had frequent periods of incontinence and their skin needed to be kept clean. During an interview on 10/29/2024 at 2:12 PM, Staff C, Assistant Director of Nursing, stated ideally the care plan would have instructions for shaving written out specifically. Each unit had a shower aide, and if unable to be completed on the day shift, the evening shift staff could make them up. Staff C stated they expected the staff to complete the showers as care planned. 46115 <Resident 9> According to the 07/29/2024 quarterly assessment, Resident 9 had moderate cognitive impairments and needed substantial assistance from staff for ADL's, such as personal hygiene. Per the 04/29/2021 care plan, Resident 9 was to have nail care completed twice weekly during bathing and as necessary. Review of the bathing documentation from 10/03/2024 to 10/28/2024 showed the resident had not refused to be bathed. In an observation on 10/22/2024 at 10:27 AM, Resident 9 was sitting in their wheelchair in their room. Resident 9's nails were unclean with a brown substance underneath them. Subsequent observations of Resident 9's nails being unclean with a brown substance underneath them were made on 10/23/2024 at 8:16 AM and 3:21 PM, 10/24/2024 at 10:07 AM and 12:36 PM, and 10/25/2024 at 8:42 AM and 10/25/2024 at 2:04 PM. In addition, Resident 9's nasal hair was protruding past their nose on 10/23/2024 at 3:21 PM. During an interview on 10/23/2024 at 3:21 PM, Resident 9 was unaware their nasal hair protruded past their nose. The resident stated the staff had not offered to trim it and they would have accepted because they liked to be well kempt. <Resident 19> According to the 10/01/2024 admission assessment, Resident 19 was cognitively intact and needed substantial assistance from staff for ADL's, such as bathing. In an interview on 10/22/2024 at 2:10 PM, Resident 19 stated they were supposed to have two showers per week and sometimes they only had one per week. Per the 09/11/2023 care plan, Resident 19 was to be assisted with showers twice weekly. Review of the bathing documentation from 09/28/2024 to 10/23/2024 documented Resident 19 had been given showers on 09/28/2024, 10/02/2024, 10/05/2024, 10/09/2024, 10/16/2024, 10/20/2024 and 10/23/2024. In addition, the documentation showed the resident had not refused to be bathed. In an interview on 10/28/2024 at 10:47 AM, Staff H, Nursing Assistant, stated showers were to be given twice weekly and this was important for hygiene and skin. During an interview on 10/28/2024 at 10:32 AM, Staff B, Director of Nursing, stated nasal hair was removed as needed during showers and showers were to be given twice weekly. Staff B added this was important because it would be a dignity issue for the residents. Reference: WAC 388-97-1060 (2)(c).

Based on interview and record review, the facility failed to ensure psychotropic medication consents were accurate and obtained prior to their administration (Residents 3, 13, 39) and failed to ensure a consent for treatment and admission were signed by someone able to make those decisions (Resident 27) for 4 of 5 sampled residents reviewed for unnecessary medications. This failure placed the residents or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications and care being provided at the facility. Findings included . <Resident 3> Review of Resident 3's medical record showed the provider ordered the medication sertraline on 07/01/2024 for depression. Review of the October 2024 Medication Administration Record showed the staff administered the sertraline to Resident 3 at bedtime. Review of Resident 3's care plan showed the resident used sertraline related to depression. Review of a 07/02/2024 Medication Informed Consent showed Resident 3 and a facility staff signed the form and the reason for the use of the sertraline was somatization, contrary to the physician order and the care plan. Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. On 10/28/2024 at 1:46 PM, Staff A, Administrator, acknowledged the inaccurate consent and stated that it should have been clarified. 46033 <Resident 13> A quarterly assessment dated [DATE] documented Resident 13 had diagnoses including end-stage kidney disease dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer work), dementia and anxiety. Resident 13 was moderately cognitively impaired and took medications for anxiety and depression. The 01/19/2024 care plan documented Resident 13 used anti-anxiety medication related to anxiety with dialysis. Staff were instructed to administer the medication as ordered, observe for and report any adverse reactions which could be associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looked like dementia. On 12/04/2023, a provider order was given to administer lorazepam (a medication used to treat anxiety that worked by slowing activity in the brain to allow relaxation), 0.5 milligrams every Monday, Wednesday and Friday prior to leaving for the resident's dialysis appointment. On 01/31/2024, a consent was signed by Resident 13's representative that agreed to the use of lorazepam to treat the resident's anxiety related to their dialysis treatment. The consent included why the medication was prescribed, risks and benefits, and non-drug approaches that had been ineffective. A consent dated prior to the initiation of the lorazepam on 12/04/2023 was requested. On 10/29/2024 at 3:27 PM, an email from Staff B, Director of Nursing, confirmed that there was no consent completed prior to the consent dated 01/31/2024. 46115 <Resident 27> A 07/26/2024 admission assessment documented Resident 27 had diagnoses including dementia, depression and agitation. Resident 27 was severely cognitively impaired and took medications for agitation and depression. The 07/26/2024 care plan documented Resident 27 used antidepressant medication related to depression and anxiety and antipsychotic medication for agitation. Staff were instructed to administer the medication as ordered, observe for and report any adverse reactions and to educate the resident/family/caregivers about the risks, benefits and the side effects of the medication. On 07/23/2024, a provider order was given to administer Lexapro (a medication used to treat depression and anxiety) and Zyprexa (an antipsychotic medication used to regulate mood and behaviors). On 07/23/2024, a consent was signed by Resident 27's representative that agreed to the use of Lexapro and Zyprexa. Resident 27's representative had moderate cognitive impairments and was also a resident of the facility. During an interview on 10/28/2024, Resident 27's representative stated they did not know what medications their family member was receiving and was unaware of the risks and benefits when asked about the Lexapro and Zyprexa. On 07/23/2024, Resident 27's representative signed Resident 27's admission packet, which included financial agreements, consent for treatment, rules and regulations, immunizations, pharmacy authorization and resident records. In an interview on 10/28/2024 at 2:28 PM, Staff B, Director of Nursing, stated consents needed to be signed by cognitively intact representatives and this was important, so they understood what they were signing. <Resident 39> A 10/10/2024 admission assessment documented Resident 39 had diagnoses including depression and insomnia. Resident 39 was cognitively intact and took medications for insomnia. The 10/08/2024 care plan documented Resident 39 used antidepressant medication related to insomnia. Staff were instructed to administer the medication as ordered, observe for and report any adverse reactions. On 10/10/2024, a provider order was given to administer Trazodone (a medication used to treat depression and insomnia). On 10/11/2024, a consent was signed by Resident 39 that agreed to the use of Trazodone. Per the October 2024 medication administration record, Resident 39 received their first dose of Trazodone on 10/10/2024, prior to the consent being signed. In an interview on 10/28/2024 at 10:08 AM, Staff M, Resident Care Manager, stated the consent for the Trazodone needed to be obtained prior to Resident 39 receiving their first dose. During an interview on 10/28/2024 at 10:10 AM, Staff B, Director of Nursing, stated the consent should have been signed prior to the administration of the medication and this was important because the resident needed education on what they were taking. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b).

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for accidents, was transferredas directed by the careplan. Resident 1 experienced harm when they were found to have a fractured arm and clavicle the next shift after being assisted to the floor when the wrong transfer method was used. This failure placed the residents at risk for falls and serious injury. Findings included . Review of the facility assessment, dated 05/02/2024, showed Resident 1 had diagnoses to include a stroke which affected their right side, and had difficulty with speech. The resident was alert and oriented. Resident 1 required substantial/maximal assist with transfers. The residents care plan, dated 12/09/2019 and revision date 07/05/2024, showed the resident required two staff to stand and pivot the resident with a gait belt, and/or use a sit to stand lift (designed to assist patients who have some mobility but need help to rise from a sitting position). In an interview and Observation on 07/18/2024 at 10:37 AM, Resident 1 was seated in a wheelchair in their room. The resident had a brace on their right arm. The resident was asked if they fell and they stated yes. When asked about the incident, the resident was not able to explain what happened. Review of the facility investigation, dated 07/03/2024, showed Staff A explained the resident asked to be transferred from their bed to the wheelchair. Staff A placed a gait belt around the resident and started to lift them. The resident's legs gave out and Staff A stated they assisted them to the floor. Staff A was questioned further during the investigation and stated the resident's wheelchair brake had been on but during the transfer, the brake extender was pushed while the resident was assisted to the floor, the wheelchair slid back, and the resident landed on the floor. At the time of the incident, the resident had no pain or abnormalities. Later in the day, the resident complained of pain and an x-ray showed a fractured right arm and clavicle. During an interview on 07/18/2024 at 12:45 PM, Staff B, Registered Nurse (RN), stated they had been told by Staff A that Resident 1 was assisted to the floor during a transfer. Staff B stated they completed an assessment on Resident 1 and they had no complaints of pain or signs of injury. On the following shift, the resident started to complain of pain and an x-ray showed a fractured arm and clavicle. Staff B stated they asked Staff A if they had reviewed the resident's Kardex ( informational filing system that is used as a quick reference for nurses and nursing assistants ) ,which showed the resident transferred with two staff, and Staff A stated they hadn't. During an interview on 07/18/2024 at 1:35 PM, Staff C, Director of Nursing, acknowledged Staff A had not followed Resident 1's care plan and the resident had sustained a fractured arm and clavicle. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to recognize pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), accurately and thoroughly assess skin integrity: which potentially delayed the initiation and treatment and thoroughly document or measure wounds for 1 of 2 sampled residents (Resident 202), reviewed for pressure ulcers. These failures resulted in actual harm to Resident 202, who developed additional pressure ulcers to the right medial ankle, left heel and great toe after being admitted to the facility, and placed other residents at risk for untreated skin issues, pressure ulcers, and a decreased quality of life Findings included . Review of the 03/31/2023 facility policy titled Skin Integrity and Pressure Ulcer/Injury Prevention and Management, showed staff should complete a comprehensive skin evaluation of the patient upon admission/re-admission to the facility, and then weekly thereafter. Skin observations were also to occur when providing care by the nursing assistants (NAs). Per the policy, any open areas were to be reported to the nurse. The NAs were to report to the nurse if a dressing over the wound was soiled, saturated (full of drainage), or came off. The nurse would then complete an inspection/assessment and provide treatment if needed. If nursing staff identified a new skin concern, they were to perform wound observations and measurements and complete a weekly Skin Integrity Report upon initial identification of altered skin integrity, and/or with the decline of a wound. A Braden scale (used to identify a resident's risk of skin breakdown) was to be completed upon admission, weekly for the first four weeks after admission, then monthly (or whenever there was a change in the resident's condition). Resident 202's Braden scale on 06/14/2023, the day of admission, was 12 (showing they were at high risk for skin breakdown). Per the 06/16/2023 admission assessment, Resident 202 had severe cognitive impairment, but was able to direct their own activities of daily living (ADL), and had medically complex conditions which included: malnutrition (an imbalance of nutrients from your food and drinks that are needed to keep your body healthy and functioning properly), and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). In addition, the assessment showed the resident required extensive to total assistance from staff for activities of daily living (ADL) such as repositioning, and toileting. Review of Resident 202's care plan, dated 06/14/2023 showed the resident had skin impairment of the right medial (inside) of the heel/ankle and coccyx/sacrum (a small triangular bone at the base of the spinal column). The interventions included assessing the location, size, and treatment of the skin injury, to report abnormalities, failure to heal, as well as reporting signs and symptoms of infection to the physician. There were no measurements of the coccyx or left heel until after the observation on 06/29/2023. A review of the Resident 202's orders on 06/14/2023 showed staff were to apply Prevalon boots (boots designed to reduce the risk of ulcers by keeping the heels floated) to the feet and to be worn at all times; cleanse the buttocks and perineal area with soap and water and apply calazyme (a cream to protect the skin from wetness urine or stool) every shift, and with incontinent episodes. Review of the admission/readmission collection tool, dated 06/14/2023, showed Resident 202 had a pressure ulcer to the coccyx and the right and left heel. No other descriptions or measurements of the wounds were documented on that date as required by the facility policy. Review of Resident 202's wound observation tool, dated 06/16/2023, showed the pressure ulcer to the right heel had resolved but there was no documentation of the left heel or coccyx pressure ulcers on that document. Review of 202's skin assessment, dated 06/19/2023, showed blanchable (i.e., redness disappears when light finger pressure is applied, indicating that the local capillaries are undamaged) redness to both heels and the coccyx. Review of Resident 202's 06/22/2023 and 06/26/2023 wound observation tools showed no documentation of pressure ulcers to the heels or the coccyx. During an observation on 06/29/2023 at 10:45am with Staff C, Assistant Director of Nursing (ADON), Resident 202 was lying in bed. Staff C stated there were no pressure ulcers on the resident's heels. During this time Staff C and the surveyor observed that the resident had a deep tissue injury (an injury to the underlying tissue below the skin surface that results from prolonged pressure in an area of the body) to their left heel, a pressure ulcer to the left great toe with an intact scab, bruising to the top of left foot, a stage I pressure ulcer (pressure related to alteration of intact skin with non-blanchable redness of a localized area, usually over a bony prominence) to the right medial ankle and a stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer) to the coccyx. New areas not previously identified by the facility included; the right medial ankle, left heel and left great toe. During an interview on 06/29/2023 at 11:05 AM, Staff C stated that upon admission the right heel pressure ulcer was identified, but not the left great toe. Staff C stated that if the pressure ulcer to the left great toe was new, it would not have a scab. On 06/29/2023 (after the observation), Staff C documented and measured the above pressure ulcers on a wound observation tool. The right medial ankle was 1.0 centimeter (cm.) x 0.6 cm., the left heel was 0.3 cm. x 1.0 cm., and the left great toe was 1.0 cm. x 0.7 cm., and the coccyx was 0.3 cm. x 0.6 cm. Observations made on 07/03/2023 at 11:31 AM and 1:58 PM showed Resident 202 was lying in bed without their Prevalon boots on, and both heels were resting on the mattress. During an interview on 07/05/2023 at 10:05 AM, Staff C stated that residents with pressure ulcers were seen weekly during wound rounds and were discussed in the resident at risk meeting (a meeting in which residents with skin issues are discussed). Staff C stated that a resident with a pressure ulcer on their buttocks or bedbound would qualify for an air mattress, and Resident 202 refused repositioning. During an interview on 07/06/2023 at 3:38 PM Staff B, Director of Nursing, stated NA's report skin issues to the nurse, and the nurse notifies management. Staff B added that pressure ulcers and wounds are measured by the nurse when found, and the wound healing (a team that evaluates skin issues and pressure ulcers) is notified, and completes all other measurements and assessments. Per the United Wound Healing record, Resident 202 was last assessed on 06/22/2023 for an elbow wound, but had not evaluated Resident 202 since that date. Staff B stated that pressure ulcers were to be assessed and measured weekly by nursing staff. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure a resident who experienced multiple accidents that resulted in injury was evaluated for the need for increased supervision, and resident-specific fall preventative measures were added timely to care plans for 2 of 3 sampled residents (Residents 31, 11), reviewed for falls. Resident 31 experienced harm when they had multiple falls resulting in a fractured arm, abrasions to the chin and elbow, and a fractured hip, and this failure placed other residents at risk for falls with injury. Findings included . <Resident 31> According to the 05/04/2023 admission assessment, Resident 31 had severely impaired cognitive skills and required assistance of one to two people with most activities of daily living (ADLs), including transfers and toileting. Per the assessment, the resident had some weakness and instability that put them at risk for falls, as well as a history of recent falls. A care plan related to the resident's fall risk was initiated on 05/02/2023. Interventions included to complete a fall risk assessment, assist with ADLs as needed, keep the call light within reach, and orient the resident to their room. No other safety interventions were included. A review of the accident log showed Resident 31 fell on [DATE], 06/12/2023 and 06/29/2023. Review of the facility investigations for the following dates showed the fall on 05/25/2023 resulted in a humerus fracture (upper arm) and a right periorbital (around the eye) contusion. The resident was transferred to the hospital for care. The fall on 06/12/2023 resulted in four abrasions to their chin and elbow. The fall on 06/29/2023 resulted in a left hip fracture in which resident was transferred to the hospital and had surgery. Review of the facility investigations for the falls on 05/25/2023, 06/12/2023 and 06/29/2023 showed that the Resident 31 was cognitively impaired, did not wait for assistance, and attempted to self-transfer without staff present. Review of the care plan dated 05/02/2023 showed interventions were added, after each fall, however, the care plan was not updated to include the need for increased supervision or measures to prevent the resident from transferring unassisted. The interventions of reminding the resident to ask for help and to use their call light were on the care plan; however, the resident was not cognitively intact and could not remember to use the call light or ask for help. In an interview on 07/03/2023 at 3:10 PM Staff B, Director of Nursing Services (DNS), was made aware that Resident 31 had a fall risk assessment completed on 06/14/2023 with a score of 28, indicating they were a high risk for falls. Staff B was asked why the resident's current fall risk assessment after the hip fracture showed a score of 13. Staff B stated the assessment was inaccurate, and the assessment on 06/14/2023 remained accurate. In an interview on 07/05/2023 at 2:26 PM Staff H, Nursing Assistant, stated Resident 31 was impulsive. In an interview on 07/05/2023 at 2:29 PM Staff G, Registered Nurse, stated Resident 31 was very forgetful and they continued to self-ambulate after being reminded not to do so. Additionally, Staff G stated nursing staff would assist the resident to the bathroom, but Resident 31 continued to attempt to take themselves. In an interview on 07/05/2023 at 2:37 PM Staff B was asked when a resident would need increased supervision to prevent falls . Staff B stated with the facility's current staffing issues, they thought increased supervision would not be possible. Staff B stated Resident 31 was not cognitively intact enough to realize their risk for falls. In an interview on 07/06/2023 at 4:04 PM, Staff B was asked if increased supervision would have decreased Resident 31's falls, and they stated it may have. Resident 31 readmitted to the facility on [DATE], after having surgery and hospitalization for a left hip fracture on 06/29/2023; no care plan updates/revisions were completed upon their return. 37544 <Resident 11> Per the 05/30/2023 admission assessment, Resident 11 was able to make decisions regarding their care, had diagnoses which included a fractured left arm, and needed assistance from staff to complete ADLs such as repositioning and moving from one position to another, and moving from the bed to the wheelchair. In addition, the assessment showed the resident utilized a wheelchair to move about the facility, had fallen prior to admission, and had one fall without injury since admission on 05/26/2023. On 06/26/2023 at 10:18 AM, the resident was observed lying on a stretcher being wheeled down the hallway by emergency personnel, who were transporting the resident to the hospital to be evaluated after falling out of their wheelchair. The resident was observed to have yellow, purple, and blue bruising to the eyes, nose and cheek areas of their face. Per Staff EE, Registered Nurse, the resident had fallen six times since admission. A review of the facility investigations, progress notes, and Resident 11's record from 05/26/2023 through 07/05/2023 showed the following: - On 05/27/2023 at 6:09 PM, the facility investigation showed the resident attempted to self-transfer from the wheelchair to the bed and was assisted to the floor by a family member. The care plan was revised at that time to inform staff a sign was placed in the resident's room, to remind the resident to use the call light and wait for assistance. -On 06/13/2023 at 1:20 PM, the facility investigation showed the resident fell out of the wheelchair while reaching for an item on the floor. The resident was given a reacher (a long pole with a claw-like grabber on the end) to assist with picking items off the floor. - On 06/16/2023 at 11:00 PM, the facility investigation showed the Resident 11 was found on the floor beside the bed, was unable to transfer into the bed, and laid on the floor. Per the investigation, the resident continued to be a high risk for falls. At 2:50 PM the same day, a progress note showed the resident had taken themselves to the bathroom, and was sitting in their wheelchair looking at the toilet. The staff then assisted the resident onto the toilet. - A progress note on 06/21/2023 at 9:03 PM showed the resident was scared these falls were going to cause them to get kicked out of the facility, and staff provided reassurance to the resident and their spouse that the facility's goal was to determine why the falls were occurring and to find a way to keep the resident safe. - On 06/23/2023 at 9:49 AM, a progress note showed an occupational therapy consult was ordered to evaluate the wheelchair for safety, due to the Resident 11's recent falls. - On 06/24/2023 at 2:58 PM, the facility investigation showed Resident 11 stated they blacked out and fell from the wheelchair after reaching down to pick up their glasses from the floor. The investigation documented the care plan was revised to include educating the resident to use the call light when assistance was needed, remind the resident to use the reacher to get items that were hard to get, and to encourage the resident to be in areas of high visibility. - On 06/26/2023 at 10:41 PM, the facility investigation showed the resident fell out of their wheelchair hitting their forehead, which was swelling. According to the investigation, the care plan was revised to instruct staff to put the bed in the lowest position and a place a fall mat on the floor next to the bed while the resident was sleeping. Review of a progress note dated 06/27/2023 at 11:52 AM by Staff FF, Physician's Assistant, showed Resident 11 had been assessed and stated the facial bruising was due to recurrent falls, that the resident's impulisve nature was a challenge, but the resident's current medication and environment did not seem to be a problem. Review of a progress note dated 06/27/2023 at 4:14 PM showed Resident 11's spouse expressed frustration with the continued falls, and expressed worry that continued falls would end up badly. Review of a progress note dated 06/28/2023 at 6:42 PM showed the occupational therapy evaluation of the wheelchair that was ordered five days previously (on 06/23/2023), and had been completed - two days after the resident had again fallen out of their wheelchair. Review of the care plan dated 07/05/2023 showed fall interventions were implemented at admission on 05/26/2023, but only instructed staff to assist with activities of daily living as needed, have the call light within reach, and orient the resident to the room. The care plan informed the licensed nursing staff that the resident had poor insight, judgement, and awareness, but did not inform the nursing assistant staff, nor was the information regarding the resident having poor insight, judgement, and awareness found on the NA's kardex (a care card that contained the interventions and tasks from the resident's care plan that the NA's were responsible for). Further review of the care plan showed the fall care plan had not been revised to include the additional fall interventions that were stated in the facility investigations and the progress notes. Additional fall interventions were not added until 06/25/2023, 06/27/2023, and 06/28/2023. In an interview with Staff N, Restorative Assistant, the care plan and kardex had the information to inform the staff what the resident care needs were. On 07/05/2023 at 9:51 AM Staff F, Resident Care Coordinator, confirmed Resident 11's care plan had not been updated timely to include additional fall prevention interventions. In an interview on 07/07/2023 at 10:15 AM Staff B, Director of Nursing, stated the fall care plan did not include resident-specific goals and interventions, did not provide instructions to all appropriate nursing staff, nor had it been updated timely to include additional fall interventions. When asked if other interventions had been considered to increase the supervision, such as frequent checks or one on one monitoring for Resident 11 to mitigate further falls, Staff B stated the facility had a staffing shortage, and did not have the staff to be able to do that. See F725 for additional information. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure falls were thoroughly investigated, and fall prevention interventions specific to resident needs were identified and implemented for one of four sample residents (#2), reviewed for accidents. Failure to evaluate possible root causes, and revise and implement fall prevention interventions, resulted in actual harm for Resident #2 who suffered a fall with a fracture. Findings included . According to a 10/22/2020 admission assessment, Resident #2 was cognitively intact and required assistance of one person with most activities of daily living, including toileting. Per the assessment, the resident had some weakness and instability that put him at risk for falls, as well as a history of recent falls. A care plan related to the resident's fall risk was initiated on 10/15/2020. Interventions included anticipating and meeting the resident's needs, assisting with activities of daily living as needed, keeping the call light within reach, and orienting the resident to his room. An 11/12/2020 day shift progress note showed the resident was alert, continent, able to make his needs known, and required one person assist for all cares and transfers. An 11/12/2020 evening shift progress note showed the resident was found on the floor on his left side, with his pants down around his knees. Per the note, the resident stated he was trying to go to the bathroom. A fall investigation ruled out abuse/neglect, and concluded the fall was an isolated event related to the resident's overall weakness, intermittent confusion, poor judgement, and issues with his pants and non-skid socks. No care plan revisions were made. Per an 11/14/2020 progress note, the resident was found attempting to self-transfer. The resident was reminded to use his call light and wait for assistance. A 12/03/2021 progress note showed the resident was very confused and attempting to self-transfer often. According to a 12/03/2020 fall investigation, staff witnessed the resident slide down the bed to the floor. Per the investigation, the resident stated he was trying to get to the bathroom, but it did not include when the resident was last toileted or seen by staff. Despite the fall being witnessed, no witness statements were found. Abuse/neglect were ruled out, the fall was determined to be reasonably related to the resident needing to use the bathroom, and the care plan was reviewed and updated as needed. No care plan revisions were made. A 12/10/2020 progress note showed the resident was slightly confused, and continued to self-transfer causing him to be a fall risk as he is not able to transfer on his own. A 12/12/2020 fall investigation showed the resident was, once again, found on the floor in his room that morning. Per the investigation, the resident stated he slid off the bed, then tried to stand up to walk to the bathroom, but was unable, and fell . The investigation did not include any information regarding when the resident had last been toileted, or seen by staff. Abuse/neglect was ruled out, the fall was determined to be reasonably related to the resident needing to go to the bathroom, and the care plan reviewed and updated as needed. Despite the fact that this was the resident's third fall related to attempting to walk to the bathroom without assistance, no care plan revisions were made. A progress note from later that day showed the resident was too weak to walk by himself, but continued to self-transfer multiple times. Per a 12/14/2020 progress note, the resident was seen self-transferring from his wheelchair to his bed. The resident's care plan related to his fall risk was revised on 12/28/2020 to instruct staff to provide the resident with appropriate footwear, or non-skid socks, when he was up in his wheelchair, or walking. No revisions related to the resident's continued practice of self-transferring were made. A 12/31/2020 progress note showed the resident required the assistance of one person for transfers and toileting, and was a fall risk as he takes himself to the bathroom. Review of a fall investigation showed the resident was found on the floor of his room during the early morning hours of 01/01/2021. Per the investigation, the resident had skin tears to his right forearm and left elbow, and complained of nine out of 10 pain to his right hip (based on a numeric pain scale where 10 represents the worst pain possible). The resident had on regular socks (not non-skid socks), and his incontinence brief was wet. The investigation did not include an analysis of the cause of the fall, or any conclusions related to the incident. Review of progress notes for 01/01/2021 showed the provider was notified of the resident's fall, and orders for pain medication and x-rays were obtained. Per the notes, the resident was transferred to the hospital later that day with a right [MEDICAL CONDITION]. The resident did not return to the facility, and was not available for interview or observation. In an interview on 02/17/2021 at 9:54 AM, Staff C, Registered Nurse, stated the resident would self-transfer quite a bit, usually in the bathroom. Staff C stated staff would try to walk by his room frequently to look in on him and make sure his call light was in reach. Staff C added the resident was capable of remembering to use his call light, but chose not to use it. In an interview on 02/17/2021 at 10:20 AM, Staff B, Director of Nursing, stated she was the one who completed fall investigations most of the time. She added that the investigations included a root cause analysis, and a review of the resident's care plan to ensure it was up to date. Staff B stated the facility had been struggling with ensuring witness statements were obtained, and had been working on educating staff. The lack of thoroughness of the investigations of Resident #2's multiple falls was reviewed with Staff B. Staff B confirmed the resident's care plan had not been revised after each fall, and should have been. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, staff failed to perform cardio-pulmonary resuscitation (CPR) on one of three sample residents (#1), who died while in the facility. Staff A, Licensed Practical Nurse, and Staff B, Registered Nurse, failed to perform basic life support measures, and did not notify emergency personnel for Resident #1, who requested to receive CPR if needed. Failure to perform potentially life-saving measures, for a resident who had requested them, constituted a Past Non-Compliance Immediate Jeopardy. The facility was notified on [DATE]. Findings included . Per a [DATE] assessment, Resident #1 had [DIAGNOSES REDACTED]. The resident was able to make his needs known. Review of the [DATE] Resident's POLST (physician's orders [REDACTED].e., a full code). The [DATE] facility investigation had a timeline completed by Staff C, Director of Nursing, related to the sequence of events that occurred on [DATE] involving the resident, which were as follows: - On night shift the resident had three large episodes of emesis (vomiting), and was administered anti-nausea medication. After the medication was administered, Resident #1 had another round of emesis. The resident was placed on a clear liquid diet. - At 1:30 p.m. the resident had vomited one time, was alert and able to communicate his needs, and remained on a clear liquid diet. - At 2:00 p.m. the resident vomited twice, and was medicated for nausea. The oncoming Licensed Practical Nurse, Staff A, was notified by Staff D, Registered Nurse, that the resident had been medicated with anti-nausea medication, and that Staff A needed to contact the doctor to send Resident #1 to the hospital. Staff D began to gather paperwork to transfer the resident to the hospital. At that time, Staff D told Staff A, Resident #1 was a full code. - At 2:45 p.m. Staff A informed Staff D she would not be sending Resident #1 to the hospital at that time, because Resident #1's vital signs were within normal limits. Staff A stated she was going to keep an eye on him. Staff A did not consult with the physician regarding the resident's condition at that time. - At 3:00 p.m., Staff E, Nursing Assistant, reported to Staff A that Resident #1 had vomited. - At 5:00 p.m., the resident ate 100% of a clear liquid dinner. Per the progress note, the resident had been upright while eating. - At 6:15 p.m. Staff E, Nursing Assistant, reported to Staff A that Resident #1 had vomited, and had pale colored skin. Staff A went into Resident #1's room and noted the resident was pale in color, and cool/clammy, with clear lung sounds. No vital signs were taken. Staff A explained to the resident she was going to contact the physician. - At 6:20 p.m. Staff A contacted the physician. Orders were received to start an IV (intravenous) line to administer fluids for hydration, give anti-nausea medication in scheduled doses, and give anti-anxiety medication. - At 6:30 p.m., Staff A and Staff E returned to Resident #1's room, where they found him without a pulse or respirations. Staff A remained in the room while Staff E went to get Staff B, who was the registered nurse on duty. Neither Staff A or Staff B verified Resident #1's code status. - At 6:34 p.m. Staff B and Staff E entered Resident #1's room. Staff B stated she verified with a stethoscope that Resident #1 had no pulse or respirations. The resident's skin was yellow/gray in color. At that time, stomach contents were still coming out of the resident's mouth. - At 6:38 p.m. Staff B prounounced the resident deceased . The investigation concluded staff found the resident unresponsive, did not obtain the facility's emergency cart, did not call emergency personnel, and did not initiate chest compressions. Staff A and Staff B's employment was terminated. During an interview on [DATE] at 2:30 p.m., Staff G, Executive Director, stated the nurses started the CPR but did not do a good job. Staff G stated, per the investigation, the nurses should have called 911 and didn't. On [DATE] at 3:00 p.m. Staff C stated during the investigation, she was told multiple stories by Staff A and Staff B. Staff A and B at one point said they did initiate chest compressions, without a backboard or ambu (a breathing mask). Per Staff C, later Staff B stated she didn't do chest compressions. Staff C also stated that Staff E was in the room during the incident, and also stated chest compressions were never initiated. Prior to the onsite visit on [DATE], the facility provided documentation which revealed Staff A and Staff B were immediately suspended pending the investigation, and later their employment was terminated. All nursing staff had been re-educated on CPR, on where to find resident code status, and contacting emergency personnel immediately. Audits were conducted on all current residents, and their POLST forms were updated if needed. The facility would also be conducting code blue drills monthly, to ensure that employees were competent with following the facility policy and procedures. Multiple interviews were done on [DATE], which showed staff were knowledgeable of the protocols for responding to unresponsive residents, how to find the code status on a resident, and the protocol for CPR. Reference: WAC [DATE](1)

Based on observation, interview, and record review, the facility failed to ensure services to prevent a reduction in range of motion were provided for one of six sample residents (#3), reviewed for positioning and mobility. This failure caused actual harm to the resident, who developed an avoidable contracture (a muscle or tendon that remained too tight for too long, thus becoming permanently shorter). Additionally, the facility failed to implement a consistent restorative program (a program available in nursing homes, that helps residents maintain and/or improve in their ability to participate in activities of daily living) for five of six sample residents (#28, 60, 25, 54, 33), reviewed for restorative services. These failures placed the residents at risk for a decreased ability to perform activities of daily living, at risk to devlop contractures, and a diminished quality of life. Findings included: 1. Per the admission assessment, dated 11/08/17, Resident #3 admitted with [DIAGNOSES REDACTED]. Per the assessment, the resident did not have a contracture, and required extensive assistance of one or two staff for activities of daily living. Review of the care plan, initiated 11/01/17, showed interventions to provide physical and occupational therapy as ordered by the physician. No other interventions to address range of motion, for the resident's paralyzed side, were documented. Per the occupational therapy treatment plan, dated 02/01/18 through 03/04/18, the resident participated in therapy. A 02/24/18 daily therapy note showed the resident received education in self-performing range of motion exercises to the left fingers, wrist and elbow. At the conclusion of therapy, the resident was able to use her non-affected side to complete upper body dressing tasks with staff instruction. Twenty-four hour assistance at discharge was recommended. No recommendations for the resident, if she remained in the facility, were documented. Review of a 03/27/18 care conference record showed the resident requested restorative therapy services. Per the record, the resident's care plan was reviewed, and no changes were needed. Review of a rehabilitation services multidisciplinary screening tool, dated 04/17/18 (three weeks after the initial request), showed the resident requested therapy to assist her with walking. Per the screening tool, the resident was not receiving any restorative services, and would benefit from a restorative program or a referral to physical therapy. No notes regarding the resident's range of motion, or occupational therapy needs were included on the screening tool. No associated order for therapy, or care plan for restorative services, were documented in the resident's record. In an observation and interview on 08/02/18 at 8:36 a.m., Resident #3 was observed lying in bed with her left arm lying limp and unsupported next to her, with all five fingers of her left hand curled into a fist, and the left wrist bent. The resident used her right arm to pick up her left arm, and stated both her left arm and leg were paralyzed. Per the resident, she was no longer receiving therapy for range of motion or ambulation, though she had asked facility staff about receiving continued services. In an interview on 08/07/18 at 10:53 a.m., Staff AA, Nursing Assistant, stated she thought the resident's left hand had a contracture, but she was not sure what services were in place to prevent and/or treat the contracture, as therapy or restorative staff assisted residents with range of motion exercises. Per staff AA, the resident had not been in therapy for a while and did not have a splint or other device. Additionally, Staff AA stated the resident was compliant with care, but she was sometimes forgetful related to her [DIAGNOSES REDACTED]s. In an interview on 08/07/18 at 10:47 a.m., Staff N, Restorative Assistant, stated residents were typically referred to the restorative program at the completion of therapy, and Resident #3 had received therapy services for a while, but had never been on a restorative program in the facility. Per Staff N, the resident had been hoping to discharge home, but was still at the facility, and she did not know why the resident was not receiving a restorative program. In an interview on 08/07/18 at 3:29 p.m., Staff D, Restorative Manager, stated residents were referred to the restorative program primarily by therapy, but could also be referred by nursing staff, and a copy of the referral would be saved in a binder. Staff D stated she had recently taken over as the restorative manager, and did not know if therapy or nursing staff had referred the resident for a range of motion and/or ambulation program. After reviewing her binder, Staff D stated no referrals had been made for Resident #3, either at the conclusion of therapy services, or at the resident's request in the following months, and she did not know why. In an observation and interview on 08/08/18 at 11:08 a.m., Resident #3 was observed lying in bed in a darkened room with her face drawn in pain, and a rolled towel under her left hand, which remained bent at the wrist, with all five fingers in a fist. The resident stated therapy came in to work on her left hand that morning, and she was still experiencing pain from therapy, despite pain medications administered by the nurse. Resident #3 added that her hand used to open all the way, but she could not open it now. In an interview on 08/08/18 at 12:04 p.m., Staff BB, Occupational Therapist, stated the resident had been discharged from occupational therapy with a limp left hand (no contracture) several months previously. Per Staff BB, the resident had been re-evaluated that morning, and was found to have a shortened tendon (contracture), and pain, to the left arm and hand. Staff BB stated the resident would be restarted on therapy to address pain, range of motion, and hand hygiene. In an interview on 08/10/18 at 9:03 a.m., Staff V, Director of Rehabilitation, stated she had just begun working at the facility two months prior, after Resident #3 discharged from therapies. After reviewing the resident's record, Staff V verified the resident was discharged from occupational therapy on 03/04/18, due to exhausted Medicare benefits. Per Staff V, the resident required a high level of care at the end of therapy, and should have been referred for restorative services. 2. Review of the annual assessment, dated 06/09/18, showed Resident # 28 had [DIAGNOSES REDACTED]. Per the assessment, the resident had limited range of motion to all four extremities, and required extensive to total assistance of one to two staff for all activities of daily living. Per the range of motion care plan, with a target date of 10/31/18, the resident was on a restorative program for passive range of motion (exercises provided by another person or a machine) to her left arm and both legs, six days a week. Additionally, staff were to provide a resistance band, or one pound weights, for the resident to self-perform range of motion to her right arm, six days a week. In an interview on 08/02/18 at 10:36 a.m., Resident #28 stated she could not move herself in bed and required staff assistance to turn and move. She further stated when her husband came in to visit her, he would perform range of motion exercises and if he didn't do it, I wouldn't get it. Review of the restorative administration record for May, June, and (MONTH) (YEAR) showed one entry on 06/19/18 that stated no program today. All other dates were blank. In an interview on 08/19/18 at 12:57 p.m., Staff N, Restorative Assistant, stated Resident #28 received range of motion exercises in the past, but restorative staff had not worked with the resident for several months. Per Staff N, the resident was compliant with her program, but restorative staff were not able to see her due to time constraints. 3. According to her admission assessment dated [DATE], Resident #60 had [DIAGNOSES REDACTED]. The assessment showed she required extensive to total assistance with activities of daily living such as dressing, bed mobility, and transfers. Review of a progress note dated 07/05/18 showed Resident #60's physical therapy was discontinued as of 07/03/18, and that the restorative Nursing Assistant worked with the resident. In an interview on 08/03/18 at 9:10 a.m., Resident #60 stated the staff at the facility were supposed to be doing range of motion to her lower extremities daily, but it had not been done consistently. Review of her restorative program documentation from 06/27/18 through 07/31/18 showed her program was for passive range of motion to both of her lower extremities five times a week for 15 minutes each time. Documentation showed the program was not provided as indicated on 11 occasions during July. 4. According to her quarterly assessment dated [DATE], Resident #25 had [DIAGNOSES REDACTED]. In an interview on 08/03/18 at 10:40 a.m., Resident #25's representative stated staff used to walk with her, but he had not seen that in a long time. He said the facility was dependent upon wheelchairs, They're like a babysitter. Review of Resident #25's restorative documentation for 06/01/18 through 07/31/18 showed she was to have active range of motion (AROM) with resistance bands six times per week for approximately 15 minutes, and staff were to assist her to walk with a walker five times per week. According to the restorative record for (MONTH) (YEAR), Resident #25 received AROM 14 of 24 times it was indicated, and received the walking program 14 of 20 times. Review of the (MONTH) restorative documentation showed the AROM was offered (and either performed or refused by the resident) nine of the 24 times it was indicated, and walking was offered, and either performed or refused 13 of 20 times it was indicated. 5. According to his assessment dated [DATE], Resident #54 required extensive assistance with most of his activities of daily living, including bed mobility and transfers. The assessment showed he had functional limitations in range of motion on one side of his body. Observation and interview on 08/02/18 at 2:21 p.m. revealed Resident #54 had a splint on his left hand and arm. He stated he had left sided weakness due to a stroke. Resident #54 stated the facility staff sometimes missed putting the splint on. Review of Resident #54's (MONTH) (YEAR) restorative documentation showed he should receive his program five times per week. The program included providing range of motion to the left hand prior to applying his splint. The program was documented as offered, and administered or refused, 13 of 20 possible times. Additionally, the (MONTH) (YEAR) restorative documentation showed the program was documented as offered, and received or refused, on only five of the 20 times it was indicated. In an interview on 8/08/18 at 12:40 p.m., when asked about the instances when the restorative program was not documented as completed, Staff N, Restorative Aide, stated she worked the floor, or helped take residents to appointments, and when that happened, she could not complete the restorative program. In an interview on 08/10/18 at 9:34 a.m. with Staff D, Unit Manager, she stated she was responsible for overseeing the restorative nursing program as of the last few months. When asked about lack of documentation that the restorative program was provided as often as it was assessed to be required, she stated Staff N went on vacation in July, and other times had been pulled to work as a Nursing Assistant on the floor, or to take residents to appointments because the facility was so short staffed. When asked if there were any other staff who were trained to cover for Staff N when she was on vacation or working in another role, Staff D stated there were not. When asked about residents who had a program in place for six days a week, Staff D confirmed Staff N only worked five days a week, so that would be a maximum number of days the restorative program was provided. When asked if there were any evaluations done periodically to check the effectiveness of the restorative program, Staff D confirmed there had not been a system in place to evaluate the program for each resident. 6. The admission assessment dated [DATE] showed Resident #33 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, the assessment showed the resident needed extensive assistance for bed mobility, transfers and moving in her wheelchair. A physician's progress noted dated 07/23/18, documented the resident stated she was not getting therapy and wanted to be more active. The note further stated the resident was very debilitated with her [MEDICAL CONDITION] and a new order for restorative therapy would be written to see if they can treat her. A physician's orders [REDACTED]. In an interview on 08/07/18 at 10:19 a.m., Resident #33 stated she had not received restorative services yet, but was it supposed to start today (15 days after the physician order [REDACTED]. She further stated her left side does not work well and she was hoping therapy would help her be more mobile. In an interview on 08/09/18 at 9:22 a.m., Staff U, licensed physical therapy assistant, stated because Resident #33 had not qualified to receive physical therapy, the therapy department was unable to initiate a restorative program for her and nursing would be responsible to assess the resident and put a restorative program in place. On 08/09/18 at 10:44 a.m., Staff D, Unit Care Manger, was asked if the resident was receiving restorative services. She stated restorative was done by therapy and nursing does not have their own program. Reference: WAC 388-97-1060 (3)(d)

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors, for two of five residents reviewed (1, 2). Failure to correctly transcribe and review physician's orders [REDACTED]. Findings included: According to Lippincott's Nursing Drug Guide (Lippincott, Williams & Wilkins, 2014, p.1), In the clinical setting, the monumental task of ensuring medication safety can be managed by consistently using the seven rights of drug administration: right drug, right route, right dose, right time, right patient, right response, and right documentation. 1. Resident #1 was admitted from the hospital with [DIAGNOSES REDACTED]. Per review of the hospital discharge orders dated 07/21/17, the resident was to receive [MEDICATION NAME] (a blood thinning medication), 6 mg. daily. The physican also ordered a daily blood test (PT/INR), to determine the effectiveness of the medication. According to Resident #1's current care plan, dated 07/21/17, she was a risk for abnormal bleeding secondary to the use of a blood thinning medication, and nursing staff were to directed to administer medications and labs as prescribed on the Medication Administration Record [REDACTED] The order for daily blood test was transcribed onto the Medication Administration Record [REDACTED]. The resident received the [MEDICATION NAME] as ordered, but the ordered blood test was not done for 18 days. On the 18th day (08/09/17), the error was discovered during a consulting pharmarcist review, and Resident #1's blood was tested . The INR was 8.0 (therapeutic range is 2.0-3.0), which indicated a slow clotting time, putting the resident at risk for bleeding. Resident #1 required an intramuscular injection (a deep muscle injection) of Vitamin K, related to the results of the elevated INR (to increase the INR/blood clotting effectiveness), and frequent monitoring throughout the night. In an interview on 08/17/17 at 1:30 p.m., Staff A, Director of Nursing, confirmed the order was missed by nursing staff. 2. Per the record, Resident #2 was admitted with [DIAGNOSES REDACTED]. According to the most recent assessment, dated 07/18/17, Resident #2 was alert, oriented, and able to make her needs know. The assessment also showed the resident required assistance with activities of daily living. Per the facility investigation dated 07/26/17, on the evening of 07/25/17, Staff B, licensed nurse, looked at the wrong resident's Medication Administration Record, [REDACTED]. A review of the July 2017 Medication Administration Record [REDACTED]. On 07/25/17, resident #2 received 53 units (38 units over the ordered dose). The facility physician was contacted, and ordered intravenous fluids containing sugar to be administered over 10 hours, to prevent a significant blood sugar drop, along with hourly blood sugar testing. In an interview on 08/17/17 at 1:30 p.m., Staff A, Director of Nursing, confirmed Staff B did not follow the rights of medication administration, resulting in a significant medication error. Reference: (WAC) [PHONE NUMBER](3)(k)(iii)

Based on observation, interview, and record review, the facility failed to provide care and services to prevent, accurately assess, monitor, or heal pressure ulcers for three of five sample residents (#46, 85, 127), reviewed for pressure ulcers. Failure to ensure skin was assessed thoroughly and weekly, follow prescribed treatment orders from the wound clinic physician, and have effective interventions in place to prevent worsening of the pressure ulcers, caused actual harm to Residents' #46 and 85, who had worsening pressure ulcers, and placed all three residents at risk for worsening skin conditions. Findings included: A facility policy titled, Evaluations, Screenings, and Assessments, revised 02/25/15, showed that staff were to evaluate each resident for any special needs related to skin care upon admission, and ensure all residents received a weekly skin integrity check, performed by a licensed nurse. If pressure ulcers were present, or developed after admission, they were to be treated according to medical orders. 1. Per the 04/10/17 quarterly assessment, Resident #85 was admitted to the facility with [DIAGNOSES REDACTED]. The assessment showed the resident was moderately impaired for daily decision-making, required extensive assistance to total dependence on staff for all activities of daily living, was incontinent of bowel and bladder, and had no pressure ulcers. A review of the skin integrity care plan, revised 04/10/17, showed the resident was at risk for developing pressure ulcers related to impaired mobility, incontinence, depression, diabetes, altered nutrition, and the need for assistance with activities of daily living. The care plan further indicated the resident currently had a pressure ulcer to the coccyx, and the facility had set a goal date for healing of 05/13/17. Interventions to aid in the healing of the pressure ulcer, and prevent additional pressure ulcers included: avoid prolonged periods of skin to skin contact, complete a braden scale assessment (a tool used to determine risk for skin breakdown) quarterly and as needed, weekly skin assessments, float heels when in bed (as the resident allowed), and minimize pressure over bony areas. The current Treatment Administration Record (TAR) showed the resident had an air mattress on her bed since 2015. Per record review, a 02/09/17 skin assessment body diagram showed the resident had a small open area on her right buttock. A 02/10/17 treatment order identified the open area as a coccyx rash, and staff were to clean the area with normal saline (a sterile mixture of salt and water), pat dry, apply skin prep, and cover with a dressing every other day. A 02/26/17 incident report showed staff had found and reported a large bruise-like area to the resident's coccyx. The cause was attributed to the sling on the full body lift, and Resident #85's clothing getting bunched up underneath her, while sitting in a wheelchair. A review of the nursing progress notes and skin assessment sheets, from 02/26/17 through 02/28/17, did not show the area was being monitored by nursing staff. After a short, unrelated hospitalization , a 02/28/17 pressure ulcer status record showed an unstageable area (full thickness tissue loss, in which the actual depth of the ulcer is completely obscured by dead/necrotic tissue), to the area previously identified as a bruise. The document showed the area was now open, measured 9.0 centimeters (cm.) x 7.0 cm., and contained 50% dead/necrotic tissue. A non-pressure skin condition record, dated 03/02/17, showed the wound as deteriorated, but did not identify it as a pressure ulcer. A NP visit note on the same day did not identify the presence of the wound, its appearance, or any change from the current treatment (i.e., the same treatment from 02/10/17). A review of the progress notes from 03/02/17 to 03/06/17, did not show monitoring, an assessment, or additional interventions related to the wound, which had grown in size and depth. On 03/06/17, a progress note documented the dressing to area was changed, and showed the resident expressed some discomfort during the dressing change. A 03/08/17 nursing progress note, written by the Director of Nursing, showed the resident had a new skin issue on her coccyx, related to the full body lift sling not being removed when the resident was up in her chair. The wound was noted to have slough (dead tissue that is cast off from the surface of the skin), without odor. The note indicated the wound care team would follow the progress of the wound weekly, and report any changes. Per review of the record, no new treatments were ordered at that time. On 03/13/17, a body diagram showed the one open area on Resident #85's buttocks was now three open areas. A new open area was noted on the resident's right hip, and the surrounding tissue, which measured 9.0 cm. x 10.0 cm., was red. There was no documentation the physician or nurse practitioner were updated on the status of the wound, and no new treatments were ordered. A nursing progress note, dated 03/20/17, showed the resident had complained of a sharp pain to her tailbone. The note further documented the dressing was changed at the time, with the wounds measuring 8.0 cm. x 6.0 cm., with two openings in the center. The note showed both of the wounds had tunneled (channels which extend from the central area of the wound into underlying tissue, such as muscle and skin). The physician was updated, and new treatment orders were obtained (almost 5 weeks after the initial identification of the wound), in addition to adding an alternating air flow mattress. Between 03/21/17 and 04/05/17, there was no documentation of a weekly skin assessment, except for initials on the TAR. The progress notes for that periord of time were also reviewed, and showed no assessment of the skin alterations. A 04/13/17 nursing progress note showed the resident was reviewed during wound rounds. The wounds were assessed, and described in detail. Because of the condition of the wounds, the resident was seen at the wound clinic on 04/14/17. A progress note by the physician at the clinic showed the coccyx wound was a stage three pressure ulcer (full thickness tissue loss), with a moderate amount of necrosis (dead tissue), the tissue was friable (easily crumbled), and the resident was experiencing pain when the wound was touched. The two smaller wounds were identified as stage two pressure ulcers. The clinic physician ordered new treatments, and several specific interventions to provide pressure relief to the wounds. The resident returned to the wound clinic on 05/24/17 for follow-up. The physician documented the wounds had improved, and new treatment orders were written. A 05/31/17 nursing progress note indicated the facility nurse practitioner changed the wound clinic treatment orders; there was no reason given. The resident returned to the wound clinic on 06/22/17 for follow-up. The physician note for the visit documented the resident underwent [REDACTED]. A physician's telephone order, dated 07/06/17, indicated the nurse practitioner had changed the wound clinic physician orders [REDACTED]. On 07/08/17, during the survey, Resident #85 was transferred to the hospital for a significant change in condition, related to [MEDICAL CONDITION] (a systemic infection). The resident remained in the hospital during the remainder of the survey, and the wound was not observed. In an interview on 07/12/17 at 12:52 p.m. Staff B, Unit Care Coordinator, stated back in February 2017, before she had started working at the facility, the resident had a bruise to her coccyx that had opened up. Staff B was asked if this open area was a pressure ulcer or deep tissue injury. She stated someone had said it was pressure, however, she was not totally clear about it. Staff B was asked when a wound was described as deteriorated, what was the responsiblity of the nurse. She stated the physician was to be notifed, and a progress note written. Staff B further stated when nursing staff see the nurse practitioner at the facility, they let him know what is going on with Resident #85's wounds. Staff B confirmed none of the information regarding the wound deterioration, consistent assesments, or rationale for changing treatment orders were documented. Staff B was asked why there were missing weekly skin assessments, and stated she didn't know. She was asked if the physician had been informed, when there were changes to the wound; she could not find any documentation in the record to show it occurred. Staff B was asked if the pressure ulcer was currently improving. She stated the wound was stable with marginal improvement. In a follow-up interview on 07/17/17 at 11:43 a.m., Staff B was asked why the nurse practitioner changed the treatment orders on two occassions, after the resident had been to the wound clinic in May and June 2017. She stated when facility staff did wound rounds, they felt the wounds were getting worse. She was asked if the wound clinic physician had been informed about the wound status deterioration; she stated no. She further stated she discussed the wound status with the nurse practitioner, after wound rounds, and he gave a verbal order for a new treatment. 2. Per the admission assessment dated [DATE], Resident # 46 had [DIAGNOSES REDACTED]. The assessment indicated the resident was incontinent of bowel, had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine), required extensive assistance of two staff members for most activities of daily living, and had no care refusals. The assessment also showed the resident had a stage two pressure ulcer (full thickness skin loss) on the coccyx, when she arrived at the facility. Review of the care plan, dated 02/01/17, showed the resident was at risk for worsening of the existing pressure ulcer, and for developing additional pressure ulcers, because of immobility, bilateral hip precautions, incontinence, and pain. The care plan further indicated goals that the pressure ulcer, present on admission, would exhibit signs of healing by 05/10/17, and the resident would not develop any new areas of skin breakdown, through 05/10/17. Interventions to aid in the healing of the pressure ulcer, and to prevent new pressure ulcer development included: assistance to shift weight (to relieve pressure), position with pillows or a wedge to maintain body alignment as needed, complete a braden scale assessment quarterly and as needed (a determination of risk for skin breakdown), weekly skin assessments, minimize pressure over bony areas, timely incontinent care, barrier cream as needed, a pressure relief cushion for the wheelchair/alternating air mattress to the bed, and observe/report the response to treatments as ordered. Review of a 02/01/17 skin assessment body diagram, showed the resident had a stage two pressure ulcer to the coccyx, which measured 3.0 cm. long and 2.0 cm. wide. No other pressure ulcers were identified. A treatment order, dated 02/03/17, directed staff to wash the coccyx wound with normal saline (a sterile mixture of salt and water), pat dry, and apply a dressing every three days and as needed. A treatment order, dated 02/15/17, directed staff to discontinue the previous wound care, clean the wound with normal saline, pat dry, apply santyl (a [MEDICATION NAME] ointment for dead tissue), and cover with a dressing every two days and as needed. There was no documentation on the appearance of the wound, or the rationale for the order change. Review of the pressure ulcer status records related to heels, dated 02/17/17, showed Resident #46 developed a 2.0 cm. x 2.0 cm. unstageable pressure ulcer to the left heel, and a 2.0 cm. x 2.0 cm. unstageable pressure ulcer to the right heel. A 02/17/17 treatment order directed staff to apply skin prep (a liquid film-forming dressing) to both heels twice daily, and apply soft boots at all times (as the resident would allow). Review of the treatment administration record (TAR) for February 2017 showed nursing staff initialed on the days weekly skin checks were to be completed; however, there was nothing describing the skin characteristics (i.e., any current wounds, their size, color, presence of drainage or odor). Nurse initials were also documented on the dates the coccyx wound dressing changes were due; however, documentation on wound characteristics, including response to treatments were not shown, throughout the medical record for February 2017. The TAR showed the twice daily skin prep to both heels was being done, as well as the use of the soft boots, but did not show use of a pressure relieving cushion to the wheelchair, or an alternating air mattress to the bed (at any time during the month). A progress note, dated 03/01/17, showed the resident complained of pain in both heels, for which he required pain medication. The note further documented the right heel had an approximate 1.0 x 1.0 cm. purple area which was intact, and showed the left heel had a similar discoloration (that was approximately 3.0 x 3.0 cm. in size), and was also intact. The open area to the coccyx was approximately 0.5 cm. x 0.5 cm. with a 3.0 cm. x 3.0 cm. non-blanchable area of redness around it (when pushing on the skin it stays red). Review of the pressure ulcer status records, updated 03/06/17 (5 days later), showed the coccyx wound had increased to a stage three (full thickness tissue loss), which now measured 12.0 cm. x 5.0 cm., with moderate drainage, 50% slough (a mass of dead tissue), and no odor. The record also noted the resident experienced pain to his tailbone (the area of the pressure ulcer). Per the pressure ulcer record, the left heel ulcer remained unstageable, and increased in size to 3.0 cm. x 3.0 cm., and the right heel ulcer remained unstageable, and again measured 2.0 cm x 2.0 cm. Review of the pressure ulcer status records, updated 03/13/17, showed the coccyx ulcer remained at stage three with an open area that measured 1.0 cm. x 0.7 cm., and a depth of 0.3 cm, with a surrounding area of [DIAGNOSES REDACTED] of 5.0 x 7.0 cm. The wound continued with 50% slough, had scant drainage and no odor. The record again noted the resident experienced pain to the tailbone, with non-verbal signs of moaning/crying. Per the pressure ulcer records, the left and right heel ulcers remained unstageable, without changes in size. A progress note, dated 03/20/17, showed the left heel continued to have a half-dollar sized darkened area, that had opened in the center, and had bled a scant amount that morning. A treatment order, dated 03/24/17, directed staff to discontinue using the soft boots and use black protective boots at all times, as the resident allowed. Review of the TAR for March 2017 showed use of heel protective boots as ordered, but did not show use of a pressure relieving cushion to the wheelchair, or alternating air mattress to bed. Review of the progress notes and pain flow sheets for March 2017 showed the resident had complaints of pain to the heels and/or coccyx, usually requiring pain medication administration, at least 14 times throughout the month. A 04/06/17 wound progress note, showed the right heel pressure ulcer had resolved, but the left heel wound still present, measuring at 1.5 cm. x 2.0 cm. Per the note, the coccyx wound was still present, and measured 0.5 x 0.25 (units of measurement not noted), and the wound bed was red and meaty, no foul odor. On 04/11/17, Resident #46 was admitted to the hospital for an unrelated medical concern. Per the hospital emergency department physician notes, dated 04/11/17, the resident's coccyx wound was a stage three pressure ulcer, and the left heel wound was an unstageable pressure ulcer. The notes further indicated the resident had complaints of pain to his heels, and pain to his tailbone, which he attributed to the pressure ulcers. The resident did not return to the facility following his hospital stay. In an interview on 07/14/17 at 11:27 a.m., with Staff A, Administrator, and Staff B, Unit Care Coordinator, Staff B was asked what interventions were in place, prior to the worsening of the coccyx ulcer, and development of the heel pressure ulcers. Staff B stated nursing staff floated the resident's heels (placing pillows under the legs to keep the heels of the feet from touching the surface of the bed) if possible, and used soft boots. Staff B was asked if the resident received an alternating air mattress. She stated she did not remember, but believed he received one very quickly after he admitted . Staff A stated all the facility's mattresses were pressure relieving. Staff B was asked for documentation showing use of the alternating air mattress. In a follow-up interview on 07/17/17 at 11:42 a.m., Staff B was asked if there was documentation of the resident's skin and wound conditions, during the times of the missing weekly skin checks. She replied there were no further records available. The facility failed to prevent an existing pressure ulcer from worsening, and failed to prevent the development of pressure ulcers to both heels. 3. The 06/09/17 admission assessment showed Resident #127 was admitted with [DIAGNOSES REDACTED]. The assessment showed the resident had stage two pressure ulcers, to the coccyx (tailbone), and right gluteal area (buttocks). The assessment also showed the resident required the extensive assistance of two staff for bed mobility. Treatments were ordered for the pressure ulcers upon admission. Review of the pressure ulcer records for June 2017 documented the right gluteal pressure ulcer was improving. Measurement upon admission was 2.0 cm. x 2.0 cm., with a depth of 0.1cm., and on 06/26/17, 0.5 cm. x 0.5 cm., with a depth of less than 0.1cm. The coccyx wound was identified as a stage two ulcer, and the treatment continued as ordered, however no assessment was documented. Neither pressure ulcer had an assessment (i.e., size, color of skin, drainage, odor), at the time of the weekly skin check on 07/03/17. On 07/10/17, a progress note documented wound rounds were completed. The note showed there had been a change in the coccyx wound, the doctor was notified timely, and a change in treatment was ordered. Three pressure ulcer records, dated 07/10/17, showed resident #127 had a stage 2 ulcer, measuring 1.3 cm. x 1.5 cm. on the inferior (lower) coccyx, and a stage 2 ulcer with 100% slough (dead tissue), measuring 1.8 cm. x 1.5 cm. on the superior (upper) coccyx area. The left gluteal area continued to improve, and was now a stage one pressure ulcer (intact skin with non-blanchable redness). The physician order [REDACTED]. On 07/13/17 at 1:37 p.m., an observation was made of the two open areas on Resident's #127's coccyx, during a dressing change. Staff U, Registered Nurse (RN), stated the upper wound measured 1.5 cm. x 1.5 cm., and the lower wound measured 1.1cm. The skin surrounding the wounds was red in color, and blanched (turned white) when touched by Staff U. After cleaning the areas with normal saline and patting dry, Staff U applied the Santyl ointment to the skin surrounding the wound (not to the slough area, as ordered by the physician). The wound was then covered with a dressing. In an interview on 07/13/17 at 2:05 p.m., when asked about the application of the Santyl ointment, Staff U, stated Santyl was to be applied to area around the wound, and gets to the slough as it's applied. When asked what the Santyl was used for, she replied, it helps to close the wound and keep it dry. In an interview on 07/13/17 at 2:35 p.m. Staff C, Director of Nursing, stated Santyl is used to debride, and should be placed directly on the slough. She stated it could potentially damage healthy tissue. During an interview on 07/14/17 at 11:54 a.m., with Staff B, Unit Care Coordinator, pressure ulcer documentation was reviewed. Staff B stated it was difficult, without consistent assessments of the coccyx pressure ulcer(s), to determine what stage they were in during the month of June 2017, up until 07/10/17. In reviewing the assessment of the upper coccyx pressure ulcer on 07/10/17, she stated any wound identified as having slough (dead tissue) did not meet the criteria of a stage two pressure ulcer, and acknowledged the wound was incorrectly staged.

Based on observation, interview, and record review, the facility failed to ensure the safety, privacy, and well-being for 5 residents (#4, 5, 6, 7, 8), in a facility with a census of 67 residents. Failure to supervise Resident #1, who had a known history of altercations, aggressive behavior, and wandering, and Resident #2, who had a know history of wandering and intrusive behavior, placed residents at risk for psychological harm, diminished quality of life, and injuries. After an incident on 04/04/16, with Resident #1, Resident #6 expressed continued fear for her physical safety, and was traumatized by the incident. As a result of this, and multiple incidents involving Resident #1, an immediate jeopardy was identified on 04/06/16 at 5:05 p.m. Findings include: 1. Resident #1 had [DIAGNOSES REDACTED]. Per record review, Resident #1 was able to self-propel his wheelchair throughout the facility. He had memory impairments, and was not able to make his needs know. Per record review, the resident had a history of [REDACTED]. The quarterly facility assessment of 03/08/16 documented the resident had physical behavioral symptoms toward others, 4 to 6 days a week. The assessment also identified the resident as putting others at significant risk for physical injury, and documented his wandering significantly intruded on the privacy of others. The resident's behavior had worsened since his prior assessment, 3 months ago (12/16/15). The care directive guide/care plan, dated 03/14/16, informed staff the resident was to be kept away from other residents, related to his aggression and irritability. The resident was easily startled, so staff were to approach him from the front, and not the side or back. Facility investigations were reviewed; Resident #1 was involved in resident-to-resident altercations on the following dates: -10/19/15 - Resident #1 was mobilizing in his wheelchair in the hallway, trying to pass another resident, who was sitting in her wheelchair sleeping. Resident #1's wheelchair got caught in the other resident's wheelchair, and he told her to move. She was unable to hear him, so he pushed her in the back of the head. -11/19/15 - Resident #1 entered Resident #4's room, and kicked Resident #4 in the shin, unprovoked. Resident #4 was interviewed by Social Services, and was asked if she felt safe - she said yes - as long as Resident #1 stayed out of her room. -11/24/15 - Resident #1 twisted the wrist of another resident in the hallway, trying to take a newspaper from her. -01/08/16 - Resident #1 was propelling independently in his wheelchair in the hallway, approached another resident who was in the hallway with a therapist, and blocked them. Resident #1 made a fist, so the therapist attempted to move the resident, but not before Resident #1 hit the other resident in the thigh. -01/18/16 - Resident #1 was sitting in his wheelchair in the hallway, facing the exit door. Another resident was attempting to pass him, because he was blocking the path. The resident's wheelchair accidentally bumped the back of Resident #1's wheelchair, he became startled, and raised his hands (appearing to be agitated). No physical contact was made during this incident. -02/11/16 - Resident #1 was combative and yelling in the hallway. Another resident was in the hallway at the time, and felt Resident #1 was directing it at her. -03/02/16 - a progress note from a licensed nurse documented she saw Resident #1 kicking at his 1:1 (a staff member assigned exclusively to a resident) several times. She wrote that when the staff member turned Resident #1's chair away from another resident, Resident #1 made a fist, and punched the 1:1 in the left jaw. -04/04/16 - Resident #1 entered Resident #6 and 7's room. Resident #6 stood from her recliner, and tried to push Resident #1 out of the room, using her walker. Resident #6 then took her bedside table, in an attempt to block him from coming further into the room. Resident #1 kicked at the bedside table before staff went to the room, and removed him The facility's system for monitoring behaviors included monthly behavior flow sheets. In January 2016, the target behaviors for Resident #1 were identified as hitting out/being fearful or paranoid, and tearfulness. On February 23, 2016 wandering was added to his behavior monitor, even though documentation showed he had been wandering in the facility for months prior. There was no documentation to indicate target behaviors were further updated, with additional interventions, after the resident had been involved in several resident-to-resident altercations, an incident with staff, and a facility assessment documenting his behaviors had worsened. (See F 250/F 280 for additional information). On 04/04/16 at 3:35 p.m., Resident #6 said she was happy with the care at the facility, except for an incident that happened earlier that day. She said a man came into her room, and she and her roommate screamed for him to get out, but he kept coming in and coming in. She stated she and her roommate were afraid, and she was fearful even now (4 hours after the incident had occurred). She stated her left hand was swollen from the incident. Per observation, there was swelling noted on the top of her left hand. On 04/04/16 at 4:25 p.m., Resident #7 (Resident #6's roommate) was also interviewed, and said a man came into their room, and they both told him to get out; he didn't move, and started kicking. She stated her roommate used her walker to push the resident out, and Resident #1 kicked it, almost causing her to fall. Resident #7 said after that, her roommate took her table, and pushed him out. I didn't' like it when he pushed her with his feet, I was afraid she was going to fall. She stated Resident #1 had come into the room before, but had never kicked like he did today. In a follow-up interview with Resident #6 on 04/04/16 at 4:30 p.m., She stated I am petrified .he came toward me and I did what I could do .I am afraid he will come in tonight when I am sleeping so I don't want to go to sleep. He kicked at me and grabbed me, I was holding on to anything I could .He was nasty and belligerent. Resident #4 and Resident #5 were interviewed on 04/04/16 at 4:40 p.m. Their room was located across the hall from Resident #6. When asked if other residents wander into their room, they both said that men have come into their room. They said about 2-3 months ago, a man came into their room (Resident #1), and they both screamed for help. Resident #4 stated It was horrible. Resident #5 stated It was the scariest thing that ever happened to me. Staff A, licensed nurse, was interviewed on 04/04/16 at 3:50 p.m. She was asked about the incident between Resident #1 and Resident #6. She said in report, she was told Resident #1 had gone into Resident #6's room earlier that day. She said Resident #1 could be violent, and staff had to keep him away from everyone. He scares me .(Resident #1) will turn on a dime and that is what is scary . (Resident #1) has tried to hit me before. She said her cart was parked next to Resident #6's room for the evening, to watch and make sure Resident #1 didn't go back in, and explained the aides were also trying to sit with him. Per observation on 04/04/16 at 3:55 p.m., Resident #1 was in the West hallway in his wheelchair. A staff member was sitting next to him talking with him. At 6:00 p.m, the resident was observed sitting in his wheelchair eating dinner in the West hallway, next to the nurse's station. At 6:10 p.m. Resident #1 was observed self-propelling in his wheelchair in the East hallway. No staff were observed supervising the resident. On 04/04/16 at 4:15 p.m., a licensed nurse, Staff B, said at 11:30 a.m. that morning, she looked down the hall, and saw Resident #1 in Resident #6's door way; he was kicking at something. When she went down the hallway, Resident #6 had a table, and was pushing it at Resident #1. Resident #6 was distraught. Staff B tried to pull Resident #1 back out of the room, but the more she tried to pull him back, the more he tried pushing back, and was agitated. Resident #6 was upset, breathing hard, and out of breath. Staff B said Resident #1's behaviors change quickly. She mentioned he had a 1:1 with him until about a week ago, and on the day the 1:1 was stopped, the staff had to all take 30 minute shifts in order watch him (due to his behaviors). On 04/07/16 at 9:15 a.m., Staff E, Social Services assistant, said Resident #1 would usually have behaviors in the afternoon. He stated the resident was very reactive to increased stimulation in his environment, and being in a large setting doesn't work real well. If you are careful and don't surround (Resident #1) he can be redirected, but if he has an increase in stimuli he doesn't respond well. During an interview with Staff F, Director of Nursing, on 04/07/16 at 12:10 p.m., she was not able to explain why the facility assessment of 03/08/16 showed the resident's behaviors had worsened, but the Resident at Risk team did assess the changes documented in the facility assessment. Staff F said the staff were aware of how to approach Resident #1 in a calm manner, from the front and not the side, in an effort to prevent him from striking out. When asked if it was realistic to expect residents in the facility know how to approach the resident to prevent potential behaviors, she stated no. 2. Resident #2 had [DIAGNOSES REDACTED].#2 was able to self-propel in his wheelchair throughout the facility. He had memory impairments, and difficulty making his needs known. Per record review, the resident had a history of [REDACTED]. The quarterly facility assessment of 02/06/16 documented the resident wandered 4 to 6 days a week. The assessment also indicated he was at risk to wander into potentially dangerous places, and his wandering significantly intruded on the privacy of others. The resident's behaviors had remained the same, since his prior assessment, 3 months ago. The Care Directive/care plan of 03/30/16, directed staff to monitor the resident in large crowds, due to potential increased agitation, and to check behind bathroom doors, because the resident liked to wander into other residents rooms. Per review of the behavior monitors for March and April 2016, the target behaviors for Resident #2 were identified as exit seeking, being inappropriate, delusional, and making sad statements. There was no documentation to indicate the resident was being monitored for wandering, and/or being intrusive to other residents, despite the fact it was an almost daily occurrence. (See F 250 for additional information). During an interview on 04/04/16 at 10:30 a.m., a family member said a resident (identified as Resident #2) continued to go into Resident #8's room. The last time was on 03/12/16. The family member had met with administration, who said they would make changes, and the family member had not heard anything since. I am told (Resident #2) has the right to roam the halls and they can't restrict him, but what about my mom's rights? He goes into her bathroom when she is in it! Staff G, a nursing assistant, was interviewed on 04/04/16 at 1:55 p.m., and verified Resident #2 wandered into other resident rooms. She said on occasion he would go in the rooms and open doors. On 04/04/16 at 3:25 p.m., Staff A, licensed nurse, said Resident #2 had erratic behaviors. She said he goes in the resident rooms near exit doors, and the rooms usually have females in them. Staff A said both female residents (#'s 6, 7), in a room down the hallway, were very alert, and got upset when residents wandered into their room. The nurse said she kept her cart near their room, to keep an eye on Resident #2. At the time of the interview, she told a staff member to go get Resident #2, as he was in the doorway of Resident #6 and 7's room. During an interview with Resident #6 on 04/04/16 at 3:35 p.m., Resident #2 had self-propelled to the doorway, and was looking in. Resident #6 noticed him at the doorway, and said to the surveyor don't try and look over, or he will come in. On 04/07/16 at 9:15 a.m., Staff E, Social Services assistant, said Resident #2 feels he can come and go in rooms as he pleases. He has wandered into other resident rooms frequently, which sometimes caused a resident-to-resident altercation. On 04/07/16 at 12:10 p.m., Staff F, Director of Nursing, said Resident #2 had gone in Resident #8's room in the past. She said in March 2016, a family member informed her Resident #2 had gone in to the room again. Staff F said they asked Resident #8 if she would like to shut her door, and she declined, so there wasn't a lot they could do to keep other residents out of her room. The facility was previously cited for failed practice related to Resident #2 wandering into resident rooms. See Statement of Deficiency (SOD) dated 01/13/16.

Based on observation, interview, and record review, the facility failed to provide medically-related social services for 3 of 3 residents (#1, 2, 3) related to wandering behavior, and intruding on the privacy of other residents. Failure to develop a comprehensive behavior management plan in a timely manner for known wanderers, placed other residents at risk for psychological harm, diminished quality of life, and injuries. Findings include: 1. Resident #1 had [DIAGNOSES REDACTED]. Per record review, Resident #1 was able to self propel his wheelchair throughout the facility. He had memory impairments, and was not able to make his needs know. Per record review, the resident had a history of [REDACTED]. The Care Directive guide/care plan, dated 03/14/16, directed staff to keep the resident away from other residents, related to his aggression and irritability. This intervention had been in place since September 2015. In addition, it was noted the resident was easily startled, so staff were to approach him from the front, and not the side or back. Per review of the quarterly facility assessment of 09/28/15, it was documented the resident had no wandering behaviors. The assessment of 12/16/15 (approximately 3 months later) documented the resident wandered daily, significantly intruded on the privacy of others, and documented these behaviors had worsened since his prior assessment on 09/28/15. The most recent assessment of 03/08/16 documented the resident now had physical behavioral symptoms toward others, 4 to 6 days per week. The assessment also identified the resident put others at significant risk for physical injury, and his continued wandering significantly intruded on the privacy of others. The behaviors were documented as worsening since the last assessment, 3 months prior. Per comprehensive record review, there was no assessment of the worsening of the resident's behavior, and/or increased aggression towards other residents and family members, when they had been identified on the 2 most recent facility assessments. The current behavioral interventions were not reviewed, in order to determine if they were still appropriate and/or effective, in order to protect the safety and well-being of other residents in the facility. (See F 323 for additional information). The facility's system for monitoring behaviors included monthly flowsheets. In January 2016, the target behaviors for Resident #1 were identified as hitting out, being fearful or paranoid, and tearfulness. On February 23, 2016 wandering was added to the behavior monitor, even though documentation showed the resident had been wandering in the facility for months prior. With the exception of that addition, target behaviors were not updated after the resident had been involved in several resident-to-resident altercations, an altercation with a visitor, an incident with staff, and facility assessments documenting his behaviors had worsened. (See F 323 for additional information). On 04/04/16 at 4:30 p.m., Resident #6 said, when referring to Resident #1: I am petrified .he came toward me and I did what I could do .I am afraid he will come in tonight when I am sleeping so I don't want to go to sleep. He kicked at me and grabbed me, I was holding on to anything I could .He was nasty and belligerent. (See F 323 for additional information). Resident #4 and Resident #5 were interviewed on 04/04/16 at 4:40 p.m. Their room was located across the hall from Resident #6. They said about 2-3 months ago, a man (Resident #1) came into their room, and they both screamed for help. Resident #4 stated It was horrible. Resident #5 stated It was the scariest thing that ever happened to me. During an interview on 04/04/16 at 3:50 p.m., Staff A, a licensed nurse, stated Resident #1 had to be kept away from everyone. Staff A said for a while Resident #1 was a 1:1 (when a staff member is assigned to be with the resident at all times), but wasn't sure why that was no longer the case. She said Resident #1's behaviors seemed to have worsened over the last several months, and he made her nervous because his behaviors would change so quickly. On 04/04/16 at 4:15 p.m., Staff B, a licensed nurse, said Resident #1 was assigned a 1:1 until about a week ago. Staff B also said Resident #1 had entered Resident #6's room earlier that same day, and said Resident #6 was distraught from the incident. She said Resident #1's behaviors would turn quickly, and being in groups was too much stimulation for him. On 04/07/16 at 9:15 a.m., Staff E, Social Services assistant, stated Resident #1 would usually have behaviors in the afternoon. He said the resident was very reactive to increased stimulation in his environment, and being in a large setting didn't work well. If you are careful and don't surround (Resident #1) he can be redirected, but if he has an increase in stimuli he doesn't respond well. In a follow-up interview at 10:45 a.m., Staff E confirmed he documented in the behavior section of the facility assessments, but was not sure where the information went from there. During an interview with Staff F, Director of Nursing, on 04/07/16 at 12:10 p.m., she was not able to explain why the facility assessments on 12/16/15 and 03/08/16 documented Resident #1's behaviors had worsened, but the reasons were not thoroughly assessed. Staff F said the Resident at Risk (RAR) team did not discuss the facility assessment information when reviewing resident behaviors. Staff F said the staff were aware of how to approach Resident #1 in a calm manner, from the front and not sides, in order for him not to strike out. When asked if it was realistic to expect residents in the facility know how to approach the resident to prevent potential behaviors, she stated no. 2. Resident #2 had [DIAGNOSES REDACTED].#2 was able to self-propel in his wheelchair throughout the facility. He had memory impairments, and difficulty making his needs known. Per record review, the resident had a history of [REDACTED]. The quarterly facility assessment of 11/16/15 identified the resident wandered daily, and significantly intruded on the privacy of others. His behavior had worsened since the last assessment, 3 months prior. On 02/06/16, it was documented the resident wandered 4 to 6 days a week. The assessment also indicated he was at risk to wander into potentially dangerous places, and significantly intruded on the privacy of others. Per record review, there was no evidence to indicate the increase in adverse behaviors, from both the 11/16/15 and 02/06/16 assessments, along with documentation of intrusive behaviors toward other residents, had been evaluated. No determination was made, to see if the resident's current interventions were appropriate and/or effective, and in order to protect the safety and well being of other residents in the facility. (See F 323 for additional information). The Care Directive guide/care plan, dated 03/30/16, directed staff to monitor the resident in large crowds, due to increasing his agitation, and to check behind bathroom doors, because the resident liked to wander into other residents rooms. According to the behavior monitors for March and April 2016, the target behaviors for Resident #2 were identified as exit seeking, being socially inappropriate, delusional, and making sad statements. The resident was not being monitored for wandering, and/or being intrusive to other residents, despite the fact it was an almost daily occurrence. During an interview on 04/04/16 at 10:30 a.m., a family member said a resident (identified as Resident #2) had a history of [REDACTED].#8's room, and opening the door when she was in the bathroom. She said she was told by the facility it was because of the location of Resident #8's room. The family member said Resident #8 then had a room change, and Resident #2 once again went into her room. The family member said, I was told that (Resident #2) has the right to roam the halls and they can't restrict him but what about my mom's rights? He goes into her bathroom when she is in it! Staff G, a nursing assistant, was interviewed on 04/04/16 at 1:55 p.m., and verified Resident #2 wandered into other resident rooms. She said on occasion, he would go in the rooms and open doors. On 04/04/16 at 3:25 p.m., Staff A, licensed nurse, said Resident #2 had erratic behaviors. She said he goes in resident rooms primarily near exit doors, and the rooms usually have females in them. She stated he goes throughout the facility, and thought he went into rooms in other parts of the facility as well. During an interview with Resident #6 on 04/04/16 at 3:35 p.m., Resident #2 had self-propelled to the doorway, and was looking in. Resident #6 noticed him at the doorway, and said to the surveyor don't try and look over, or he will come in. On 04/07/16 at 9:15 a.m., Staff E, Social Services assistant, said Resident #2 feels he can come and go in rooms as he pleases. He wanders into other resident rooms frequently, which sometimes causes resident-to-resident altercations. Staff E confirmed his behavior monitor should include exit seeking/wandering as a target behavior. Staff E said he determined target behaviors from observation of the resident, past behaviors, and medication they were taking. When asked how he determined if interventions were appropriate and/or effective, Staff E said he was not a trained social worker, so he reported whether there was an increase or decrease in resident behaviors to the Resident Care Manager and the Director of Nursing for follow-up. During an interview on 04/07/16 at 12:10 p.m., Staff F said all residents on psychotropic medications were discussed in Resident at Risk meetings. The team discussed what has happened with the resident behaviors which included observation, asking staff and behavior monitors, but not facility quarterly assessments (which in this case identified worsening behaviors over 2 quarters). 3. Resident #3 had [DIAGNOSES REDACTED]. The resident had memory impairments, and was unable to make his needs known. Per record review, he was independent with self-propelling in his wheelchair. The resident's 02/18/16 plan of care instructed staff to address the resident's wandering/exit seeking behavior by walking with the resident, redirecting him from inappropriate areas, and engage in diversional activity. The quarterly facility assessment of 12/11/15 documented the resident wandered daily and intruded on the privacy of others. This behavior was documented as worse than the previous assessment, 3 months prior. The 03/08/16 quarterly assessment also documented the resident wandered daily, was at risk to wander into potentially dangerous places, and significantly intruded on the privacy of others. Per record review, there was no evidence to indicate the worsened behaviors from previous facility assessments, and intrusive behaviors towards other residents, had been evaluated, to determine if the current interventions were appropriate and/or effective, and in order to protect the safety and well being of other residents in the facility. (see F 323 for additional information). The March 2016 behavioral flowsheets identified Resident #3's target behaviors as exit seeking, smearing feces, and increased agitation with staff. The daily wandering behavior was not being monitored. Per observation on 04/04/16 at 12:50 p.m., Resident #3 was self-propelling in his wheelchair, down the East hallway. He would stop at various resident rooms, look in, and then proceed forward. He was observed at 1:00 p.m. at the end of the West hall, and pushed on an exit door. The alarm sounded, and staff redirected him. At 1:15 p.m., he had propelled to the East hall, turned toward an exit door and started pushing on the handle. A resident in the hallway stated I wish he would quit that! At 2:10 p.m. and 6:00 p.m., Resident #3 was again observed self-propelling in the halls throughout the facility. On 04/04/16 at 3:25 p.m., Staff A, a licensed nurse, said Resident #3 goes into other resident rooms. She said the resident used to have a room in the East hall, so he tended to go on that hall. She stated Resident #3 was a challenge to redirect at times. On 04/07/16 at 9:15 a.m., Staff E, Social Services assistant, said target behaviors were determined from observation of the resident, past behaviors, and medication they are taking. He said if a resident wandered, that behavior should be included and monitored.

Based on interview and record review, it was determined the facility failed to provide adequate assistance during a transfer for 1 of 3 (#1) sample residents. Failure to provide the amount of assistance needed for a transfer as directed by the plan of care and failure to immediately report to a nurse when the caregiver should have known the resident may have sustained an injury. This resulted in harm for Resident #1 who sustained a leg fracture. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's plan of care, she required extensive assist of 2 for all transfers. According to the progress notes, on 1/17/14 the resident had complained of right knee discomfort and received Tylenol. She continued to complain of pain on 1/18 and 1/19/14. On 1/19/14 the physician was notified and the resident had an xray that showed an acute fracture of her lower right leg. Per review of the facility investigation dated 1/19/14, staff that cared for the resident were interviewed. During the interviews a nurse assistant stated she had transferred the resident with only 1 assist on 1/17/14 and reported when lifting the resident's legs up she heard a "popping" sound. The staff member stated she did not report the incident to the nurse. Per observation on 3/5/14, Resident #1 was in bed on her right side. She had a cast on her left lower leg. When interviewed, the resident was soft spoken and was not comprehensible. On 3/5/14 at 2:10 p.m., Staff #A confirmed the care plan had not been followed by staff and the incident had not been reported to the nurse after it occured. She stated the staff member in question had been terminated. The facility's failure to provide necessary assistance during a transfer resulted in harm to the resident who sustained a leg fracture and experienced increased pain.

Based on interview and record review, the facility failed to ensure 1 of 5 sample residents (#1), was transported in a safe manner. The failed practice resulted in harm to the resident who sustained a fracture while being pushed in a wheel chair by staff. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident was forgetful and required assistance for transfers and walking. The resident was working with Occupational Therapy to increase her ability to perform activities of daily living. According to the record, on 2/19/13 the resident was being transported to the rehabilitation gym by the Occupational Therapist. As there were no foot rests on the wheel chair, the therapist asked the resident to hold her feet up. During the transport, the resident dropped her left foot to the ground allowing momentum to force it backward under the wheel chair. Staff reported hearing an audible "popping" sound and the resident's leg was visibly misaligned. The resident was transferred to the hospital where she was treated for [REDACTED]. During an interview on 3/12/13 at 11:30 a.m., the therapist involved in the incident stated, "The resident's strength was variable and she wasn't strong enough to hold her legs up very long, in hind sight I should have had the leg rests on the chair so this wouldn't have happened." The facility's failure to use necessary assistive devices/foot rests while transporting the resident resulted in her foot being pushed back under the wheel chair with enough force to fracture her leg.

Based on interview, and record review the facility failed to provide interventions to prevent falls for 1 of 4 residents (#1) who fell and sustained a hematoma to her head and failed to assess 1 of 4 sampled residents (#1) living environment for safety related to wall heaters. Resident # 1 sustained 2 nd degree burns on her legs from the wall heater. Fall Resident # 1 had [DIAGNOSES REDACTED]. Per her admission record she required assistance of 1-2 persons for all activities of daily living. The resident had memory and cognitive deficits and was not able to use her call light appropriately. Per the resident's admission record she had a history of [REDACTED]. Review of the record noted there was no plan of care in place on admission to direct staff regarding fall prevention for the resident. There was no fall risk evaluation on admission even though the resident had a history of [REDACTED]. On 2/24/11 at approximately 2:10 PM, the resident was witnessed leaning in her wheelchair and required repositioning. The resident required repositioning again a little while later. At approximately 2:50 PM the resident's alarm sounded and she was found in her room on the floor. The resident had fallen out of her wheelchair and sustained a hematoma to her forehead and was sent to the hospital for evaluation. Per the resident's record she did not have a plan of care for falls in place until 2/24/11 (after the fall). Per interviews with Staff G on 3/24/11 she confirmed that the resident "always leaned to her side in the wheelchair and we had to put pillows under her arm and side in her wheelchair" Staff G said everyone knew the resident leaned to her right side in her wheelchair. Per Staff H, "if the resident was not in her wheelchair correctly she would lean to her right side. The License nurses knew she leaned to her side". Both Staff G and H, said the licensed nurses were aware of the resident leaning to her right side in her wheelchair. Per an interview with OT on 3/24/11 she said she did not use or recommend pillows for postioning the resident in her wheelchair. She confirmed she had given no instruction to the direct care staff on how to position the resident in her wheelchair, only how to transfer her in and out of the wheelchair/bed. Per OT, she became aware of the fall on 3/2/11 when she was asked to assess the wheel chair at which time she ordered a new wheelchair for the resident. The facility staff were aware of the resident leaning to her right side in her wheelchair. None of the staff notified the Occupational therapist to evaluate the resident's wheelchair positioning and determine if her wheelchair was a correct fit. On the day of the resident's fall several staff saw her leaning in her wheelchair and did not notify occupational therapy or a licensed nurse to evaluate her for safety. The resident fell and sustained a hematoma to her head and had to be sent to the hospital which resulted in harm. Burn Resident # 1 had [DIAGNOSES REDACTED]. The resident was totally dependent requiring 1-2 persons for bed mobility. Per the resident's physician orders [REDACTED]. On 3/2/11 per the resident's record at approximately 7:00 AM, the resident was found in bed with her legs lying on the heater vent by her bed. There were red areas were noted bilaterally on both shins. On the right shin the red area measured 30 centimeters (cm) X 11 cm with 5 blisters ranging from 4 by 2 centimeters (cm) to 1 by .5 cm. On the left shin the red area measured 23 cm X 13.5 cm and 4 blisters ranging from 4 cm X .5 cm to under a cm in size. There were also blisters and red areas on her left foot/toes. Blisters indicate the burn was 2nd degree. Per the facility investigation dated 3/21/11, Staff B said as soon as she touched the resident's legs she "felt the goo from the burns". Per Staff C, the resident's legs had blisters and [DIAGNOSES REDACTED] and the impression of the heater grate was on her skin. Staff C assessed the resident and called an ambulance. Per the facility investigation, the intervention in place prior to finding the resident with her legs on the heater were, a bed alarm (no mention of it sounding), low bed, and fall mats at bedside. Per an interview with Staff B on 3/23/11, she confirmed the bottom half of the resident's bed was against the heater/wall, the bed was in the lowest position (in the lowest position the bed does not lock in place), there was no fall mat on the floor. Staff B and other direct care staff said she was not aware of the resident moving around in bed a lot. Per administrative staff interviews on 3/24/11, resident # 1 was capable of moving without assistance around her bed. The facility did not complete a safety assessment to determine if the resident was safe to be in a bed next to the heater prior to placing the bed up against the heater. There was no temperature monitoring of the wall heater prior to placing a resident's bed against the wall where the heater was attached. Per interview with the Maintenance director on 3/24/11, temperature monitoring of the wall heaters began after the resident sustained [REDACTED].