Every finding on record at Alderwood Post Acute & Rehabilitation

Based on observation, interview and record reviews, the facility failed to provide sufficient qualified staff to provide care and services for 15 of 24 sampled residents (Residents 8, 16, 19,24, 25, 28, 31, 42, 45, 46, 58, 61, 73, 94 and 99) and 1 of 3 family members that had concerns related to staffing. The facility had insufficient staff to ensure residents received prompt call light response, medications delivered timely, assistance with activities of daily livings (ADLs) including bathing/meal assistance, supervision to prevent accidents and altercations and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk of experiencing feelings of frustration, vulnerability, diminished quality of life, and unmet care needs Findings included. In an entrance conference interview on 07/08/2026 at 9:19 AM, Staff A, Administrator, stated the facility had no staffing issues and they were using agency only during emergencies. They stated there were no agency staff today. <FACILITY ASSESSMENT> Review of the facility assessment dated [DATE], documented staffing would be adequate to meet the needs of the residents in the facility as evidenced by staff's ability to assist residents with ADLs, medication administration, incontinence care, toileting and human needs according to the plan of care. The assessment documented staffing was adequate as evidenced by their ability to deliver food in a timely manner. The assessment documented the nurse aides to resident ratio was one to 10 on days and evenings and one to 16 on night shift. The assessment documented the nurse to resident ratio was one to 19 on days and evenings and one to 32 on night shifts. <STAFFING PATTERN> Review of the staffing pattern from 06/08/2026 to 07/08/2026 showed there was inconsistent staffing. There were five to 12 nurses on day shifts, five to six nurses on evening shifts and three nurses on night shift. There were nine to 10 aides on day shifts, eight to nine aides on evening shifts and five to six aides on night shift. <GRIEVANCE LOG> Review of the grievance log from 04/02/2026 through 07/04/2026 documented 11 missed care/poor hygiene or call bell concerns logged as follows: -Missed care concern/ poor hygiene 04/06/2026 -Missed care concern poor hygiene 04/23/2026 -Missed care concern 04/30/2026 -2 Missed care concern/poor hygiene 05/11/2026 -2 Missed care concern 05/21/2026 -2 Missed care concern/poor hygiene 06/25/2026 -Call bell delays -07/03/2026 -Missed care concern/poor hygiene 07/04/2026 <RESIDENT INTERVIEWS> <RESIDENT 94> In an interview on 07/08/2026 at 9:40 AM, Resident 94 stated some nurses were not the most helpful and they waited for Nursing Aide Certified (NAC)'s to help them. They stated the nurses would try to turn their call light off and they told them not to turn it off until their needs were met. They stated on their second or third night there, their call light fell to the floor and they had to yell for help. <RESIDENT 25> In an interview on 07/08/2026 at 10:06 AM, Resident 25 stated they waited two to three hours for medication. They stated night shift was the worst, day shift was better and evening shift medications were not on time. They stated two to three times a week they wait three hours and their pain had got worse. They stated there should not be any lapses for pain medication requests. <RESIDENT 45> In an interview on 07/08/2026 at 10:06 AM, Resident 45 stated staffing was a problem on the weekends. They stated their old roommate would fall and they would have to go find staff to help them. They stated one time a lady down the hall told them they were having a heart attack. They stated they went racing to the nurse's station and there was no one there and they had to go find staff for the code blue. The resident stated other residents tell them it took too long to get help. <RESIDENT 61> In an interview on 07/08/2026 11:21 AM, Resident 61 stated there were not enough staff and they had to call and call for pain pills. <RESIDENT 8> In an interview on 07/08/2026 at 12:00 PM, Resident 8 stated the facility was short staffed. They stated they waited fifteen to thirty minutes for help. They stated there were two instances where they waited for over two hours to get help into bed after returning from dialysis. They stated they didn't think the staff understood when they returned from dialysis, they were cold, tired and ready for bed. <RESIDENT 99> In an interview on 07/08/2026 at 12:28 PM, Resident 99 stated staff were not answering call lights timely and they could not take themself to the bathroom, so they wet themselves. The resident stated it was humiliating to wet themselves. They stated at times they waited two hours for help. They stated it was especially bad at shift change between day and evening shift and evening to night shift and waiting was worse between 2 AM to 6 AM. <RESIDENT 31> In an interview on 07/08/2026 at 1:29 PM, Resident 31 stated the resident across the hall frequently yelled Help me, help me. They stated they thought the staff should come around every hour or so to check on them and see if they needed anything. They stated their medications were late today because the nurse arrived late. <RESIDENT 58> In an interview on 07/08/2026 at 2:13 PM, Resident 58 stated at nighttime no one answers their call light. They stated they waited for two hours for help. They stated the night shift staff need fired because they keep sleeping instead of working. <RESIDENT 16> In an interview on 7/08/2026 at 2:26 PM, Resident 16 stated staff slept during the night shift on the couch or in an empty room. They stated call lights were responded to in twenty minutes at a minimum and twenty to forty five minutes was not uncommon. They stated night nurses take their breaks together, leaving no nurse present on the floor. <RESIDENT 19> In an interview on 07/08/2026 at 3:16 PM, Resident 19 stated that staff no longer say they were not my resident after they were talked to, but they still didn't answer their call light if they were not assigned to them. <FAMILY INTERVIEW> In a family interview on 07/08/2026 12:21 PM, Resident 113's family Collateral Contact (CC) 3 stated there was not enough staff at all as you just saw now. Only one NAC helped when their family member just vomited and the nurse did not come. They stated they did not see any NAC from 2:00 PM to 6:00 PM yesterday. CC3 stated they were at the facility from 8 AM to 8 PM almost daily. They stated when their loved one was downstairs, they saw nurses all the time but now there was always nobody. They stated when they asked staff for help, they were told they worked in another hall, and they did not know who to ask for help. <STAFF INTERVIEWS> In an anonymous interview with date concealed for anonymity. Anonymous Staff (AS) stated they were glad survey was there because they now had a third nurse instead of two to care for the floor's 57 residents. AS stated, when they only had two nurses, they couldn't supervise the aides, get their work done and the residents didn't get the care they deserved. They stated they reported their concerns to management, but they had not responded. They stated that they get no assistance from the unit manager or other staff to help get medication pass done timely. They stated they tried to focus on the injections and time sensitive medications and then they gave the other meds, but they did not get done with medications until an hour and a half past when they were due. They stated they just would stay over two hours after their shift to ensure all of the medication and treatments were done. They stated there had been more falls when they were short staffed because the residents just didn't get the supervision they needed. In an interview on 07/10/2026 at 10:12 AM, Staff G, Licensed Practical Nurse (LPN)/Unit Manager (UM), stated they were pulled from their duties to work the floor three times in the past month. In an observation on 07/13/2026 at 11:02 AM, Staff G was pulled from their duties to work as a nurse on the floor. In an interview on 07/13/2026 at 9:35 AM, Staff AA, Staffing Coordinator, stated they staffed the facility based on what their administrator and what the company told them to. They stated they believed they based staffing numbers on census. They stated they staffed nine to ten aides on day and evening shifts and six aides on night shift. They stated the aides were also responsible for showering two residents each shift. They were unable to state why there were two nurses on the second floor when the first floor had three nurses with less number of residents. They stated they were not a decision maker for the number of staff on each floor or unit and asked them to inquire with Staff A, Administrator, for answers. <BATHING> <RESIDENT 61>Resident 61 admitted [DATE] with diagnoses to include obesity, pressure ulcers and lymphedema (condition where fluid builds up causing swelling and skin thickening). Review of the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 06/26/2026, showed shower or bath was not attempted in the past seven days for Resident 61 and they were dependent on staff for bathing. In an observation on 07/09/2026 at 11:50 AM and 1:09 PM, a strong body odor was present for Resident 61. In an observation on 07/10/2026 at 8:44 AM, 9:53 AM, 10:19 AM and 12:34 PM, a strong odor was present when entering the room. Body odor was present for Resident 61. At 12:34 PM, Resident 61 stated they felt stinky and did not get their bed bath yesterday (07/09/2026) and they had asked for one today. In an observation on 07/13/2026 at 12:50 PM, Resident 61 stated they never got their bed bath on Friday (07/10/2026) and they still had not received one. They stated the staff cleaned their wound but that was not the same thing as a bed bath. Review of Resident 61's shower records, dated 06/20/2026 through 07/13/2026, showed the resident received bed baths on 06/30/2026, 07/02/2026, 07/07/2026 and 07/09/2026. In an interview on 07/13/2026 at 1:19 PM, Staff N, LPN/UM, was notified Resident 61 stated they did not get a bed bath on 07/09/2026 and staff documented they provided a bed bath that day. Resident 61 was still awaiting a bed bath. Staff N stated there was an odor in the room, and they were not aware of missed bed baths. <RESIDENT 24> Resident 24 was admitted to the facility on [DATE] with diagnoses to include monoplegia of lower limb (partial or complete paralysis of a single leg). According to the admission MDS assessment, dated 04/21/2026, the resident was cognitively intact and dependent on shower. In an interview on 07/08/2026 at 1:56 PM, Resident 24 stated they preferred to have a shower twice a week, but the facility only offered one shower a week or no shower at all for the entire week. Resident 24 stated they could not remember when their shower was last time. Review of Resident 24's shower record from 06/13/2026 to 07/08/2026, documented Resident 24 preferred to have shower on Wednesday and Saturday mornings. The record revealed the resident received only two showers during the last 30 days. The shower record also documented that the resident was given three bed baths and refused a shower on two occasions. In an interview on 07/09/2026 at 10:21AM, Resident 24 stated they had never refused a shower and emphasis that they preferred showers, but staff did not provide the necessary assistance. In an interview and record review on 07/10/2026 at 11:43 AM, Staff BB, NAC, stated Resident 24 required total assistance for showers. Staff BB admitted they provided the resident with bed baths on two occasions because they did not have enough time to provide a shower. Staff BB stated they usually were assigned 12 to 13 residents, which was a lot of work. Staff BB further stated that six NACs previously covered the floor, but staffing was reduced to five. In an interview and record review on 07/10/2026 at 11:54 AM, Staff W, NAC, stated they documented Resident Refused on 06/17/2026 because the resident wanted to attend an activity when the shower was offered. Staff W stated they had many residents to take care of and became too busy and failed to offer the resident a shower again during the remainder of their shift. In an interview and record review on 07/10/2026 at 11:59 AM, Staff Z, Licensed Practical Nurse (LPN), showed the census and stated that only two medication cart nurses were assigned to cover 57 to 58 residents for the entire floor, leaving them with no time to assist NACs. Staff Z stated that the NACs were overwhelmed with their workload, noting that floor staffing had been cut from six NACs down to five. In an interview and record review on 07/10/2026 at 4:25 PM, Staff K, LPN/UM, stated that NAC staff must provide showers instead of bed baths when a resident prefers showers. In an interview on 07/14/2026 at 12:25 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that staff provide the care and services residents need, including all ADLs, based on their individual preferences and established plan of care. <MEAL ASSISTANCE><RESIDENT 20>Resident 20 admitted to the facility on [DATE] with diagnoses to include Alzheimer's, malnutrition, and cognition impairment. The admission MDS dated [DATE] documented they had severe impaired cognition and required substantial to maximum assistance with meals. In a continuous observation on 07/08/2026 at 12:24 PM, the first-floor lunch trays were delivered to the floor in a cart. At 12:26 PM, an unnamed staff member entered Resident 20's room with a lunch tray and stated to the resident they had their tray and stated they were going to alert another staff member to come assist the resident to eat and then exited the room. At 1:11 PM, 45 minutes after the resident had been served their food another staff entered the room to assist the resident to eat. In an observation on 07/09/2026 at 8:15 AM, unnamed staff delivered breakfast tray to Resident 20 and placed the tray on the over the bed table. The resident was observed to be asleep in bed. At 8:59 AM, staff entered Resident 20's room and closed the door, 44 minutes after the tray was delivered. In an observation on 07/09/2026 at 12:20 PM, unnamed staff were observed to deliver Resident 20's lunch tray to their room, the tray was sat on the sink in their room. At 1:09 PM staff were observed to enter the room to assist Resident 20 to eat lunch, the resident's food sat for 49 minutes. In an observation on 07/10/2026 at 7:59 AM, the resident was observed to be asleep in bed, an unnamed staff were observed to enter the room and place their breakfast tray on the sink. At 8:38 AM, the resident was observed to have sat on the side of the bed, call light was on. At 8:41 AM, Staff E, NAC, entered the room to assist the resident with personal care and breakfast, 52 minutes after their breakfast was delivered. In an interview on 07/10/2026 at 9:24 AM, Staff E stated that there were two carts that were delivered to the first floor. The NACs were responsible for passing the meal trays out before they could assist any residents that needed assistance with meals. Staff E stated that Resident 20's tray was one of the first trays that was delivered on the floor, so they just set it on the sink or table next to their bed until they were done passing all the trays. Staff E stated Resident 20 required one-to-one assistance with meals as they had severe cognitive impairment and needed someone to help them. Staff E stated unfortunately, the food just sits there until we have the time to feed them. In a joint interview on 07/14/2026 at 10:12 AM, Staff N, LPN/UM, and Staff G LPN/UM, Staff G stated the NACs were the primary staff that passed out meal trays to the residents. Staff N was told of the observations for Resident 20 having to wait at least 45 minutes for meals due to staff not being able to assist until all the trays were passed. Staff G stated well, that's not okay. Staff N and Staff G were not aware Resident 20 did not receive adequate and timely assistance with meals. In an interview on 07/14/2026 at 10:19 AM, Staff C, Director of Nursing, was made aware of observations and interviews with staff related to Resident 20's lack of timely assistance with meals. Staff C stated that was an issue and they would need to make some changes. <RESIDENT TO RESIDENT ALTERCATION> In an observation on 7/13/2026 at 4:00 PM on the second floor across from the nurse's station Resident 46 was self-propelling in their wheelchair in front of, and right up to Resident 73's wheelchair. Both Residents 46 and 73 were angry, agitated and making hand gestures at each other. Resident 28 was in their wheelchair crying seated within 4 inches from Resident 46. Resident 73 pointed to Resident 46 and 28. Resident 28 then loudly shouted, Shut up, shut up. There were no staff present and the residents were unsupervised in close proximity to each other. An unidentified male resident witnessed the altercation and stated They are just in a spat. This is a common occurrence. In an interview on 07/14/2026 at 12:25 PM, Staff B, DNS, stated the expectation was that staff provide the care and services residents need, including oral care, toileting, showers, and all ADLs, based on their individual preferences and established plan of care. No additional information was provided. Refer to WAC 388-97-1080 (1)

Based on observation and interview, the facility failed to ensure a safe, clean, comfortable environment on 2 of 2 floors. Failure to ensure resident rooms and spaces received routine cleaning placed residents at risk for decreased quality of life. Findings included . In an observation on 07/10/2026 at 9:58 AM, the first-floor hallway had coffee spills and multiple dried soiled areas of various sizes. In an observation on 07/13/2026 at 10:02 AM, the first-floor hallway had multiple black sticky areas on the wood floors of various sizes. The elevator had numerous black marks on the floor. In an observation on 07/14/2026 at 1:53 PM, the first-floor hallway had multiple black sticky areas on the wood floors. The elevator floor continued with multiple black marks all over and no evidence of cleaning or mopping. In an interview on 07/14/2026 at 3:00 PM, Staff A, Administrator was shown the black marks present on the first floor hallway and stated the facility had a floor guy, and they needed to mop the area. In an observation of Resident 3's room on 07/08/2026 at 2:00 PM, there was plant dirt spilled on the carpet below the window. The resident's wheelchair was parked over the top of the spilled dirt pile. A potted plant was observed tipped on its side sitting on the air conditioner box below the window. Observation of the resident's bathroom found feces smeared on the inner rim of the toilet seat at 9 o'clock, the floor of the bathroom was streaked with a light brownish haze. In an observation on 07/09/2026 at 2:10 PM, Resident 3 was up in their chair in the hallway, the spilled plant dirt remained in the same place in the room and the bathroom had smeared feces on the toilet in exactly the same spot, and the same brown hazy floor. In an observation on 07/10/2026 at 8:49 AM, the same spilled plant dirt remained in the same place on the carpet and the bathroom soiled toilet seat and flooring remained unchanged. In an interview on 07/10/2026 at 10:42 AM, Staff FF, Housekeeping Aide, stated there was one housekeeper on each floor and their shift was 6am until 2pm. Staff FF stated their responsibilities included cleaning each room every day, including cleaning bathrooms and vacuuming. Staff FF stated the main hallway floors were done by someone else. Staff FF stated their section included Resident 3's room and Staff FF stated they cleaned that room. In a follow-up observation on 07/10/2026 at 2:26 PM, Resident 3's room still included the same pile of plant dirt, the same smeared feces on the toilet seat and brown hazy bathroom floor. In an observation on 07/13/2026 at 9:00 AM, the pile of plant dirt was no longer on Resident 3's carpet, but the bathroom toilet and floor had still not been cleaned. This is a repeat deficiency from SOD dated 08/20/2025. Reference WAC 388-97-0880

Based on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 4 of 20 residents (Residents 5, 55, 61, and 113) reviewed for comprehensive care planning. This failure placed residents at risk of not receiving needed care, a decline in their condition, and diminished quality of life. Findings included. Review of the facility policy titled, Care Planning – Comprehensive Person-Centered, undated documented a person centered comprehensive care plan should include measurable objectives and timetables to meet the residents medical, nursing, mental and psychosocial needs.the comprehensive care plan will be developed within seven days of completion of the residents comprehensive assessment. the resident will receive the services and/or items included in the care plan. will include problem areas, risk factors, build on strengths, culturally competent, reflect treatment goals, and measurable outcomes, aid in prevention or reduce decline, promote safety, and reflect current standards of practice. <RESIDENT 55> Resident 55 admitted [DATE] with diagnoses to include cerebral infarction (a condition that affects blood flow to the brain) with hemiplegia (paralysis on one side of the body), and dysphagia (difficulty swallowing), requiring enteral feeding (nutrition through a tube into the stomach). Review of Resident 55's care area assessment (CAA) dated 06/29/2026 triggered due to the resident being at high risk for falls due to severe debility, weakness, and cognitive impairment. The CAA documented the residents' bed bound status and safety interventions reduced their fall risk. Review of the Kardex (tool for aides on how to provide care) directed staff to place the bed in the lowest position when the resident was in bed and provide snacks and drinks that the resident preferred if they become upset. The Kardex had conflicting directives that the resident was NPO (nothing by mouth). In observations on 07/09/2026 at 9:18 AM,10:49 AM, and 3:37 PM, Resident 55 was lying in bed and the bed was high. In observations on 07/10/2026 at 9:51 AM,10:19 AM, and 12:38 PM, Resident 55 was lying in bed and the bed was high. In observations on 07/13/2026 at 12:51 PM, Resident 55 was lying in bed and the bed was high. In observations on 07/14/2026 at 8:51 AM and 9:29 AM, Resident 55 was lying in bed restless with their bed in a high position. In an interview on 07/14/2026 at 11:27 AM, Staff G, Licensed Practical Nurse (LPN)/Unit Manager(UM), stated Resident 55 and 61's beds should be in the lowest position. <RESIDENT 61> Resident 61 admitted on [DATE] with muscle weakness and abnormalities of gait and mobility. Review of Resident 61's care plan developed 06/21/2026 documented the resident was at risk for falls and injury related to impaired mobility, muscle weakness and decreased balance. The care plan directed staff to place the bed in the lowest position. In observations on 07/08/2026 at 11:23 AM, 1:32 PM, and 3:04 PM, Resident 61 was lying in bed and the bed was high. In observations on 07/09/2026 at 10:41 AM, 11:34 AM, 1:00 PM and 3:38 PM, Resident 61 was lying in bed and the bed was high. In observations on 07/10/2026 at 8:44 AM, 9:53 AM, 10:19 AM, and 12:34 PM, Resident 61 was lying in bed and the bed was high. In observations on 07/13/2026 at 12:50 PM, Resident 61 was lying in bed and the bed was high. In observations on 07/14/2026 at 8:54 AM, 10:47 AM, and 3:00 PM, Resident 61 was lying in bed and the bed was high. In an interview on 07/13/2026 at 1:19 PM, Staff N, LPN/UM stated they were unaware Resident 55 and 61's beds were not in the lowest position. Staff N stated Resident 61 did adjust the bed at times and they would talk to them about their preference. In an interview on 07/14/2026 at 11:27 AM, Staff C, Director of Nursing (DNS), was informed of Resident 55 and 61's beds observed high. Staff C stated both residents' beds should be in the lowest position. <RESIDENT 113> Resident 113 was admitted to the facility on [DATE] with diagnoses to include hemiplegia following intracranial hemorrhage (bleeding within skull). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 06/08/2026, the resident required total assistance for bed mobility and toilet hygiene (the ability to maintain perineal hygiene). In an observation on 07/08/2026 at 11:34 AM, Collateral Contact 3 (CC3), the resident's mother, came out from the resident's room and loudly called for a nurse, stating that their daughter was vomiting and only one Nursing Assistant Certified (NAC) was in the room performing a brief change. It was observed that Staff W, NAC, was changing the resident alone. In an interview and record review on 07/08/2026 at 11:43 AM, Staff W, stated they were the only staff member performing Resident 113's brief change, and that the resident vomited while being turned in bed. Staff W stated they obtained their clinical care instructions from the Kardex. Review of Resident 113's Kardex with Staff W, verified there were no instructions detailing the required assistance level or staff count for bed mobility or brief changes. In an interview on 07/08/2026 at 11:48 AM, CC3 stated that there was consistently only one NAC assigned to change the resident's brief because it was very difficult to find a second staff member. CC3 stated they were always worried when only one NAC performed care because the resident was unable to move their body and was too large for a single person to turn safely. In an interview on 07/09/2026 at 3:58 PM, Staff X, NAC stated Resident 113 needed two persons for turning and brief changes because the resident was fully dependent. Review of Resident 113's care plan, initiated on 06/10/2026, documented a generalized intervention to provide ADLs(Activities of Daily Living) assistance as needed, but failed to specify the types of ADLs, the level of assistance required, or the number of staff members needed to perform the care. Review of a facility form titled, NURSING COMMUNICATION FROM THERAPY, dated 03/04/2026, instructed the resident required the maximal assistance of two caregivers for bed mobility. In an interview and record review on 07/13/2026 at 10:51AM, Staff K, LPN/UM, stated that Resident 113 required the maximum assistance of two people for bed mobility and brief changes, and confirmed these instructions should have been documented in the care plan. Staff K stated this intervention was included in the old care plan from the resident's initial admission, but was not carried over to the new care plan following the readmission. In an interview on 07/13/2026 at 3:00 PM, Staff C stated that specific ADLs instructions should be included in both the comprehensive care plan and the Kardex, and all interventions must be individualized and person-centered. <RESIDENT 5> Resident 5 was admitted to the facility on [DATE] with diagnoses that included skin infection to lower legs, pressure ulcer to right heel, nutrition deficiency, and limited mobility. The admission MDS dated [DATE], documented the resident had impairment to both lower extremities, and was dependent on staff for toileting, dressing, bed mobility and transfers, with wounds to both lower legs. In an observation and interview on 07/09/2026 at 8:35 AM, Resident 5 was observed lying on their back in the bed. The resident had both of their legs supported by a raised cushion that separated the feet, both feet were also wrapped in green cushion boots. Resident 5 stated they have had chronic wounds to their feet before, this time they became infected. Resident 5 stated they must keep their feet this way to promote healing. Review of Resident 5's comprehensive care plan documented a focus titled skin impairment dated 06/16/2026 for a right heel pressure ulcer and left foot wound. The goal was to have no complications, with interventions listed as: treatment as ordered, and weekly skin observations. The care plan lacked any individualized goals or interventions for prevention and treatment of the resident's wounds and lacked any guidance for staff on how to elevate and support the resident's feet. In an interview on 07/13/2026 at 9:44 AM, Staff D, NAC stated they referred to the Kardex or the care plan for how and what type of care they deliver to each resident. In an interview on 07/13/2026 at 11:05 AM, Staff E, NAC stated the care plan was what they used to know what care to provide to each resident. Staff E stated Resident 5 had wounds to both of their feet. Staff E stated the care plan did not specify how to position their feet, so they relied on the resident to instruct them. In an interview on 07/14/2026 at 8:27 AM, Staff G, stated the UMs and the MDS nurse were usually responsible for updating the care plans, however any nurse could make an adjustment to the care plan if needed. Staff G confirmed that Resident 5 had extensive wound care to both lower legs and should always have their heels in the booties, so they were not resting on the bed. Staff G was asked if that should be reflected in the care plan, and Staff G stated yes, it should. Staff G then reviewed Resident 5's care plan and stated it appeared that they needed to make some improvements to the care plan as the care of the wounds had not been included. In an interview on 07/14/2026 at 10:19 AM, Staff C stated on admission the admission nurse would complete the admission assessment that would trigger areas that would start the base line care plan. Staff C stated from there the MDS nurse would complete the MDS comprehensive assessment and then the comprehensive care plan would develop from that. The UMs and the MDS nurses would update the care plan as needed and quarterly. Staff C stated it was their expectation that Resident 5's wound care treatments and preventions be included in the care plan. This is a repeat deficiency from SOD dated 08/20/2025. WAC reference: 388-97-1020(1)(2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure 5 of 7 Residents (Residents 3, 20, 24, 61 and 70) who were dependent on staff for activities of daily living (ADLs), received the required assistance from staff. Failure to provide assistance with toileting, bathing, oral care and meals placed residents at risk for declines in conditions, diminished dignity and quality of life. Findings included. Review of the facility policy titled Activities of Daily living dated 2021, documented the facility would provide appropriate care and services to residents who were unable to carry out ADLs independently, including support and assistance with hygiene (bathing, dressing, grooming, oral care), mobility, elimination (toileting), dining (meals and snacks), and communication. <TOILETING> <RESIDENT 3>Resident 3 was a long-term resident at the facility since February 2019. Review of Resident 3's Quarterly Minimum Data Set (MDS, a required assessment tool) dated 06/15/2026, documented Resident 3 had significant short term memory impairment and was not oriented to the current month, day or year. The MDS documented no behavior or rejections of care. The MDS also documented the resident was usually understood/understands and participated in all resident centered interviews themselves regarding their preferences for daily care routines, activities and pain. The resident was coded as being dependent on staff for toileting and always incontinent of bowel and bladder. Review of Resident 3's Care Plan dated 01/10/2025 with a revision date of 05/20/2026 included instruction for prompted toileting upon rising, before and after meals, and before bedtime. The care plan revision included dependent with toileting, offer assist, check for incontinence frequently. Review of Resident 3's clinical assessments revealed no bowel and bladder, continence, or toileting related assessments. In an observation and interview on 07/10/2026 at 2:30 PM, Resident 3 was sitting in their wheelchair in the doorway of their room with a furrowed brow and reaching their arm out in an attempt to gain someone's attention. Resident 3 stated I need to go potty really bad; I need to go back to my room. Resident 3's call light was not on. A nursing assistant (NAC) (Staff H) was observed down the hall charting and was notified that Resident 3 was asking to use the bathroom. Staff H stated (Resident 3) just says that. I just remind (them) that (they) have a brief on, and (they) can just go in the brief. Staff H reviewed Resident 3's care plan which included the prompted toileting, then went on to say that they have never taken Resident 3 to the bathroom, and stated Resident 3 would sometimes ask to go to the bathroom when they were lying in bed and sometimes cries. Staff H stated they told Resident 3 they didn't have to worry, because they could just go in their brief and they would clean them up. Staff H stated their shift was over and they were leaving for the day. In a continued observation on 07/10/2026 at 2:35 PM, Staff J, NAC was observed to walk toward Resident 3 and asked the resident if they would like to lie down. Resident 3 was observed to state they needed to go back to their real room. Staff I, NAC arrived and stated Resident 3 was confused and thought they were in a temporary room. Staff I was made aware that Resident 3 had been asking to use the bathroom, and Staff I stated Resident 3 used to be more independent and would take themselves to the bathroom, but after being in the hospital some months ago, now could not transfer themselves. Staff I stated Resident 3 would tell them they needed to go to the bathroom, but they would be already wet, so they would not toilet them. Staff I stated Resident 3 would sometimes tell them to just go because they were already wet. Staff I stated they had not been attempting to toilet Resident 3 when they stated they needed to go because Resident 3 was incontinent. Resident 3 continued with a furrowed brow, verbalizing concern that the room they were in was not the correct room but was no longer stating they needed to go to the bathroom. Staff I asked Resident 3 if they wanted to lie down. Staff J and Staff I were observed to transfer Resident 3 into bed and perform a brief change. Resident 3's brief was soiled. Applying the reasonable person concept, a reasonable person would experience potential shame, humiliation, and diminished dignity if they were dependent on staff for assistance to use the toilet and were not listened to and assisted to the toilet for the potential not to be incontinent. Review of Resident 3's NAC charting on 07/13/2026 at 1:59 PM, documented Resident 3 required totally dependent toilet transfer and was documented as continent of bowel and continent of bladder. Follow- up interviews with Resident 3 were consistent with their MDS documentation of significant short-term memory loss, and Resident 3 was not able to provide further information regarding any past events. In an interview on 07/13/2026 at 2:16 PM, Staff K, Licensed Practical Nurse/Unit Manager, stated Resident 3 had some decline since their hospitalization in April and was mostly charted as incontinent and more dependent. Staff K stated the care plan was updated to include incontinence care but did not know the status of Resident 3's ability to be continent. Staff K stated Resident 3 had a bedside commode and NACs should still be offering the bedside commode or even the bedpan. Staff K was made aware of observation and staff statements that they were not offering Resident 3 toileting and stating they told Resident 3 to eliminate in their brief. Staff K was not aware and stated that should not be occurring. In an interview on 07/14/2026 at 10:02 AM, Staff C, Director of Nursing/DNS, stated continence and mobility were reviewed quarterly and would include bowel and bladder assessments if needed and then care plan updates. Staff C reviewed Resident 3's medical record and stated they did not see any bowel/bladder incontinence assessments and the care plan included some conflicting instruction. Staff C stated the expectation of staff was that any resident asking to be taken to the bathroom would be assisted to the bathroom and staff would never tell any resident to go in their brief. <ORAL CARE> <RESIDENT 70>Resident 70 admitted to the facility on [DATE] with diagnoses to include stroke with right-sided paralysis. Review of Resident 70's communication care plan with a print date of 07/10/2026, documented to ask the resident yes/no questions and to observe non-verbal cues from the resident. In an interview on 07/08/2026 at 11:41 AM, Resident 70 raised one finger when asked how many times the staff assisted them with oral care. In an interview on 07/10/2026 at 1:06 PM Staff H, NAC, stated they did not provide oral care to Resident 70 because of their nothing by mouth (NPO) status. In an observation on 07/10/2026 at 2:08 PM, Resident 70 yawned and observed their tongue had white coating on it and looked like the resident had not received oral care for some time. In an interview on 07/10/2026 at 1:58 PM, Staff R, RN, stated that the NAC's were supposed to provide oral care to residents even if they had NPO status. In an interview on 07/13/2026 at 2:00 PM, Staff K stated that staff should provide oral care to residents even if they were NPO. <BATHING> Findings included . Review of the undated facility policy titled, Shower/Tub Bath, showed the facility would offer residents at a minimum of at least two full baths or showers per week and to the extent possible resident preference for type and frequency of baths would be taken into consideration and honored. If the resident refused the shower/tub, the reason(s) why and interventions taken were to be documented. <RESIDENT 61>Resident 61 admitted [DATE] with diagnoses to include obesity, pressure ulcers and lymphedema (condition where fluid builds up causing swelling and skin thickening). Review of the admission MDS assessment, dated 06/26/2026, showed shower or bath was not attempted in the past six days for Resident 61. Review of the care plan initiated date 06/22/2026, showed the resident required maximum assistance of two staff for bed mobility and they were dependent on staff for bathing. In an observation on 07/09/2026 at 11:50 AM and 1:09 PM, a strong body odor was present for Resident 61. In an observation on 07/10/2026 at 8:44 AM, 9:53 AM, 10:19 AM and 12:34 PM, a strong odor was present when entering the room. Body odor was present for Resident 61. At 12:34 PM, Resident 61 stated they felt stinky and did not get their bed bath yesterday (07/09/2026) and they had asked for one today. In an observation on 07/13/2026 at 12:50 PM, Resident 61 stated they never got their bed bath on Friday (07/10/2026) and they still had not received one. They stated the staff cleaned their wound but that was not the same thing as a bed bath. Review of Resident 61's shower records, dated 06/20/2026 through 07/13/2026, showed the resident received bed baths on 06/30/2026, 07/02/2026, 07/07/2026 and 07/09/2026. In an interview on 07/13/2026 at 1:19 PM, Staff N, LPN/UM was notified Resident 61 stated they did not get a bed bath on 07/09/2026 and staff documented they provided a bed bath that day. Resident 61 was still awaiting a bed bath. Staff N stated there was an odor in the room, and they were not aware of missed bed baths. <RESIDENT 24> Resident 24 was admitted to the facility on [DATE] with diagnoses to include monoplegia of lower limb (partial or complete paralysis of a single leg). According to the admission MDS, dated [DATE], the resident was cognitively intact and dependent on showers. In an interview on 07/08/2026 at 1:56 PM, Resident 24 stated they preferred to have a shower twice a week, but the facility only offered one shower a week or no shower at all for the entire week. Resident 24 stated they could not remember when their last shower was. Review of Resident 24's shower record from 06/13/2026 to 07/08/2026, documented Resident 24 preferred to have showers on Wednesday and Saturday mornings. The record revealed the resident received only two showers during the last 30 days. The shower record also documented that the resident was given three bed baths and refused a shower on two occasions. Review of Resident 24's care plan, initiated on 04/15/2026, showed no focus area, intervention or directives regarding the resident's bathing preferences, required assistance, or preferred frequency. Review of a facility form titled, Resident preference Sheet, dated 04/23/2026, documented Resident 24 preferred showers instead of bed baths. Review progress notes from 06/13/2026 to 07/08/2026, there was no documentation about why Resident 24 was given bed baths instead of their preferred showers, why the resident refused showers, or whether a shower was reoffered on subsequent shifts or days. In an interview on 07/09/2026 at 10:21AM, Resident 24 stated they had never refused a shower and emphasis that they preferred showers, but staff did not provide the necessary assistance. In an interview and record review on 07/10/2026 at 11:43 AM, Staff BB, NAC, stated Resident 24 required total assistance for showers. Staff BB stated they provided the resident with bed baths on two occasions because they did not have enough time to provide a shower. In an interview and record review on 07/10/2026 at 11:54 AM, Staff W, NAC, stated they documented Resident Refused on 06/17/2026 because the resident wanted to attend an activity when the shower was offered. Staff W stated they became too busy and failed to offer the resident a shower again during the remainder of their shift. In an interview and record review on 07/10/2026 at 4:25 PM, Staff K stated that NAC staff must provide showers instead of bed baths when a resident preferred showers. Staff K stated that if a resident refuses a scheduled shower, staff must reoffer the shower on the next shift or the following day and notify the nurse. Staff K verified there was no documentation indicating a shower was ever reoffered to Resident 24 following a documented refusal. In an interview on 07/14/2026 at 12:25 PM, Staff B, DNS, stated the expectation was that staff provide the care and services residents need, including oral care, toileting, showers, and all ADLs, based on their individual preferences and established plan of care. <MEAL ASSISTANCE><RESIDENT 20>Resident 20 admitted to the facility on [DATE] with diagnoses to include Alzheimer's, malnutrition, and cognition impairment. The admission MDS dated [DATE] documented they had severe impaired cognition and required substantial to maximum assistance with meals. In a continuous observation on 07/08/2026 at 12:24 PM, the first-floor lunch trays were delivered to the floor in a cart. At 12:26 PM, an unnamed staff member entered Resident 20's room with a lunch tray and stated to the resident they had their tray and stated they were going to alert another staff member to come assist the resident to eat and then exited the room. At 1:11 PM, 45 minutes after the resident had been served their food another staff entered the room to assist the resident to eat. In an observation on 07/09/2026 at 8:15 AM, unnamed staff delivered breakfast tray to Resident 20 and placed the tray on the over the bed table. The resident was observed to be asleep in bed. At 8:59 AM, staff entered Resident 20's room and closed the door, 44 minutes after the tray was delivered. In an observation on 07/09/2026 at 12:20 PM, unnamed staff were observed to deliver Resident 20's lunch tray to their room, the tray was sat on the sink in their room. At 1:09 PM staff were observed to enter the room to assist Resident 20 to eat lunch, the resident's food sat for 49 minutes. In an observation on 07/10/2026 at 7:59 AM, the resident was observed to be asleep in bed, an unnamed staff were observed to enter the room and place their breakfast tray on the sink. At 8:38 AM, the resident was observed to have sat on the side of the bed, call light was on. At 8:41 AM, Staff E, NAC, entered the room to assist the resident with personal care and breakfast, 52 minutes after their breakfast was delivered. In an interview on 07/10/2026 at 9:24 AM, Staff E stated that there were two carts that were delivered to the first floor. The NACs were responsible for passing the meal trays out before they could assist any residents that needed assistance with meals. Staff E stated that Resident 20's tray was one of the first trays that was delivered on the floor, so they just set it on the sink or table next to their bed until they were done passing all the trays. Staff E stated Resident 20 required one-to-one assistance with meals as they had severe cognitive impairment and needed someone to help them. Staff E stated unfortunately, the food just sits there until we have the time to feed them. In a joint interview on 07/14/2026 at 10:12 AM, Staff N, LPN/UM, and Staff G, LPN/UM, Staff G stated the NACs were the primary staff that passed out meal trays to the residents. Staff N was told of the observations for Resident 20 having to wait at least 45 minutes for meals due to staff not being able to assist until all the trays were passed. Staff G stated well, that's not okay. Staff N and Staff G were not aware Resident 20 did not receive adequate and timely assistance with meals. In an interview on 07/14/2026 at 10:19 AM, Staff C, DNS, was made aware of observations and interviews with staff related to Resident 20's lack of timely assistance with meals. Staff C stated that was an issue and they would need to make some changes. Reference WAC 388-97-1060 (2)(c)This is a repeat deficiency from SOD dated 08/20/2025.

Based on observation, interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 2 of 5 residents (Residents 4 and 78) reviewed for medication parameters, 1 of 3 residents (Resident 70) reviewed for tube feeding, and 1 of 1 resident (Resident 15) reviewed for supplemental nutrition. These failures placed the residents at risk for unmet care needs, decreased nutritional intake, and a diminished quality of life. Findings included. <RESIDENT 15> Resident 15 re-admitted on [DATE] with diagnoses to include nutritional deficiency. Review of a progress note written by Collateral Contact 4, Registered Dietician on 06/06/2026 documented Resident 15 had snacks and Prosource (concentrated liquid protein supplement) added daily for increased protein need for healing. In an interview on 07/13/2026 at 9:20 AM, Staff Z, Licensed Practical Nurse(LPN), stated the facility finally got the ProSource in. They stated the facility had been out of it for a while. They stated the process was to notify the doctor if they were out of medications since they could not give it. In an observation on 07/13/2026 at 9:21 AM, Resident 15 drank their ProSource and commented they liked it. Review of Resident 15's June 2026 Medication Administration Record (MAR) had 9 -reviewed progress note documented on 06/22/2026, 06/26/2026 to 06/30/2026. Review of Resident 15's July 2026 MAR had 9 -reviewed progress note documented on 07/01/2026, 07/02/2026 and 07/04/2026 to 07/11/2026. Review of Resident 15's progress notes from 06/02/2026 to 07/13/2026 showed no notation the supplement was not given, or the provider was informed the doses were not administered. In an interview on 07/13/2026 at 1:19 PM, Staff N, LPN/Unit Manager(UM), stated they were not aware of any issues with the ProSource supplement supply. In an interview on 07/14/2026 at 9:34 AM, Staff AA, Central Supply, stated they had been out of Prosource for a while. They stated they were to notify Staff A, Administrator, if they were out of supplies. They stated there was a box of Prosource single sachets (a small single use of packet) available in the first floor unit managers office that could have been utilized by the second floor for Resident 15. They stated Staff N knew they were there and could have stocked them on the second floor. In an interview on 07/14/2026 at 10:30 AM, Staff K, LPN/UM, stated Staff AA, Central Supply ordered the ProSource. Staff K stated when they were down to the last box, they were to inform Staff AA to stock it. They stated they were to notify the doctor if they were out of it and unable to administer it to the resident. In an interview on 07/14/2026 at 11:03 AM, Staff G, LPN/UM, stated they were looking for the usual bottles of ProSource and were unaware they had the sachet form instead. Staff G stated Staff A came and took the box of sachets last week. Staff G and Staff N stated this should have been communicated to them that it was delivered in packets rather than usual bottles. In an interview on 07/14/2026 at 11:45 AM, Staff C, Director of Nursing Services(DNS) stated they were unaware Resident 15 did not receive their Prosource for multiple days. Staff C stated there were communication issues with the availability. <RESIDENT 4> Resident 4 was admitted on [DATE] with diagnoses that included history of heart attack, heart disease, chronic heart failure, and cognition impairment. The admission MDS dated [DATE], showed the resident had severely impaired cognition and was a fall risk. Review of Resident 4's physician orders documented the following: - Metoprolol Tartrate (medication for blood pressure) give one tablet twice a day, hold if the systolic (SBP- top number of blood pressure) was less than 100 and/or the heart rate was less than 60, - Losartan Potassium Tartrate (medication for blood pressure) give one tablet once a day, hold if the SBP was less than 100, - Spironolactone (medication for blood pressure) give one tablet once a day, hold if the SBP was less than 100. Review of Resident 4's MAR for June 2026 showed the resident was administered spironolactone on 06/12/2026 when their SBP was 99. Review of Resident 4's MAR for 07/01/2026 – 07/10/2026 showed the resident was administered Losartan and Spironolactone on 07/07/2026 for a SBP of 95, given Metoprolol on 07/01/2026 for a SBP of 91 and 07/07/2026 for a SBP of 95. <RESIDENT 78> Resident 78 admitted to the facility on [DATE] with diagnoses that included history of a stroke, high blood pressure, diabetes, and cognitive impairment. The quarterly MDS dated [DATE] documented the resident had severe cognitive impairment, was insulin dependent for their diabetes, and was a fall risk. Review of Resident 78's physician orders showed the following: - Furosemide (medication used to remove excess fluid in body to treat high blood pressure) give once a day, hold for a SBP of less than 100 or a diastolic (DBP - lower number on the blood pressure) was less than 60, - Humalog (injectable medication used to treat high blood sugar) sliding scale, if over blood sugar was above 349 repeat blood sugar check, if above 501 notify the provider. Review of Resident 78's MAR for May, June and July of 2026, documented the resident was administered furosemide daily without any documented blood pressure readings to verify if the SBP was above 100 and the DBP was above 60. On the July [DATE]/01/2026 – 07/10/2026 the residents blood sugars were above 349 on 07/05, 07/06 twice, 07/07, 07/08 three times, and 07/09, with no documented rechecks of the blood sugar. On 07/09/2026 the blood sugar was documented to be 562, there was no documentation the provider had been notified. Review of Resident 78's medical record showed no documentation the provider was notified about the abnormal blood sugars. In an interview on 07/13/2026 at 12:51 PM, Staff F, Registered Nurse (RN), stated they had some standing orders for blood sugar parameters, and they should be in the residents MAR when they were used. Staff F stated that any time we were to notify a provider, there should be a progress note they communicated to them, and they were to hold anytime it was outside of the parameters. In an interview on 07/13/2026 at 1:31 PM, Collateral Contact 1 (CC1), Physician Assistant (PA), stated they did not have standing orders for blood sugars as would be determined on a resident-to-resident basis. CC 1 stated it was their expectation the staff would notify them if the order directed them to. In an interview on 07/14/2026 at 8:27 AM, Staff G stated the expectation was if a resident had abnormal blood pressure on the machine, they would expect a recheck with a manual blood pressure reading device, if it remained abnormal they should notify the provider any medications should be held and documented in a progress note. In an interview on 07/14/2026 at 10:19 AM, Staff C stated all the licensed nurses should be following the physician orders for parameters, notify the physician and document in the progress notes. <RESIDENT 70> Resident 70 admitted to the facility on [DATE] with diagnoses to include stroke with right-sided paralysis. Record review of Resident 70's physician orders with a print date of 07/10/2026, documented the resident was receiving gastrostomy tube (G-tube -a flexible device inserted directly into the stomach to deliver nutrition, fluids and medications) feedings 24 hours a day. In an observation on 07/10/2026 at 1:06 PM, Staff H, NAC, pressed the hold button for the tube feeding machine for Resident 70 and provided care to the resident. After Staff H was done, they then pressed the start button to resume the tube feeding. In an interview on 07/10/2026 at 1:20 PM, Staff H stated they were told in training that they could put the tube feeding machine on hold when they provided care for the resident and resumed the tube feeding when they were done with the care. In an interview on 07/10/2026 at 1:58 PM, Staff R, RN, stated only licensed nurses were allowed to touch the tube feeding machine. If a NAC was getting ready to provide care, they were supposed to inform the licensed nurse so they could put the tube feeding on hold. When they were done providing care, the NAC was supposed to inform the licensed nurse so they could turn the tube feeding on. Refer to WAC 388-97-1060 (1)(2)(c)(3)(h)(k)(iii)

Based on observation, interview and record review, the facility failed to assess, monitor and implement nutritional interventions for residents at risk for weight loss for 5 of 9 residents (Residents 3, 6, 8, 55, and 78) reviewed for nutritional needs. The facility failed to consistently obtain weights and re-weighs, notify the Registered Dietician (RD) of potential weight loss, and consistently monitor the residents who were dependent on tube feeding for nutritional intake. These failures placed the residents at risk for delayed identification of weight loss and decreased quality of life. Findings included. Review of facility policy titled, Nutritional Assessment, dated 10/01/2021, documented the dietician would conduct an assessment as indicated by a change in condition that placed the resident at risk for impaired nutrition. Review of facility policy titled, Weight Assessment and Intervention, dated 10/01/2021, documented the interdisciplinary team would strive to prevent, monitor and intervene for undesirable weight loss for the resident. weights would be completed as ordered by physician, recorded in medical records, if inaccurate a re-weigh would be completed.any weight change of 5% or more since the last weight the provider and RD would be notified immediately. <RESIDENT 78> Resident 78 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) with a gastrostomy (artificial feeding tube placed in the abdomen), malnutrition, and failure to survive. The quarterly Minimum Data Set (MDS – an assessment tool) dated 06/25/2026, documented the resident had severe cognitive impairment, the resident had received more than 51% of their calorie intake from a feeding tube. Review of Resident 78's nutritional risk assessment dated [DATE], documented the resident could not take any food by mouth and relied on tube feeding for 100% of their nutritional intake. The RD determined the resident was malnourished. Review of Resident 78's progress notes dated 05/22/2026, the RD documented the resident's weight loss had appeared to be multifactorial and likely driven by underlying disease processes rather than inadequate caloric provision, and given the resident's chronic conditions and metabolic burden, continued weight loss might be unavoidable despite adequate or increased caloric intake. Review of Resident 78's weights documented the following: - 06/10/2026 144.2 pounds (lbs.), - 06/20/2026 138.2 lbs. (4% weight loss in 10 days), - 06/24/2026 134.0 lbs. (7% weight loss in 14 days), - 07/05/2026 123.8 lbs. (14% weight loss in 25 days), - 07/10/2026 121.2 lbs. (16% weight loss in 30 days). Review of Resident 78's medical record from 06/10/2026 to 07/06/2026, showed there was no documentation the RD or provider had been notified of the resident's weight loss. Review of Resident 78's nutritional risk assessment dated [DATE], documented the resident had recent weight loss, had recently been on a medication to remove excess water from the body, and chronic diarrhea could have contributed to the weight loss. The resident had history of difficulty gaining weight, and the plan was to increase the tube feeding caloric intake. The RD noted the facility should monitor tolerance, weights, labs and skin and to notify if there were any changes. Review of Resident 78's medical record 07/07/2026 to 07/10/2026, showed no documentation the resident had been monitored, per the RD orders. In an interview on 07/10/2026 at 2:21 PM, Collateral Contact 2 (CC 2), RD, stated they noticed the weight loss on 07/03/2026 when they reviewed the residents who were currently on tube feed. CC2 stated they requested a re-weigh for Resident 78 after the weight was documented on 07/05/2026. CC2 stated they were aware the assigned RD for the facility had reviewed Resident 78's medical record on 06/05/2026 and could not locate any documentation the facility notified the RD of the weight loss from 06/20/2026 and beyond. CC2 stated they had some concerns with weights not communicated timely from the facility to the RD's and stated the electronic medical record system alerted the facility of weight loss, so the facility should notify the RD. In an interview on 07/13/2026 at 1:39 PM, Staff Z, Licensed Practical Nurse (LPN), stated the facility obtained weights either monthly or per the physician orders. Staff Z stated the aides would obtain the weight and wrote it down for the licensed nurse to enter into the medical record, if there was a discrepancy they were supposed to get a re-weigh by the next day. Staff Z stated if there was a discrepancy of more than 5%, they would probably let the provider know. Staff Z stated they communicated with the RD about residents weight loss if they saw the RD, and most of the time the Resident Care Managers (RCM) would be the one to communicate with the RD. Staff Z stated they recalled when Resident 78 triggered for significant weight loss and stated they spoke with the provider about the weight loss but did not communicate to the RD. Staff Z stated the nurse manager Staff K, LPN/UM had told them (Staff Z) to get a re-weigh, so Staff Z assumed Staff K had communicated to the RD as well. In an interview on 07/13/2026 at 2:23 PM, Staff K stated the facility obtained weights either monthly or for the residents who were on tube feeding they were done weekly or by the physician orders. Staff K stated if there was a discrepancy of weight loss/gain they were to notify the RD, the provider, family, and make a progress note that all were completed. Staff K stated the weight loss was not communicated to the RD or provider. Staff K stated they usually had a weekly nutrition meeting, however that had been cancelled recently, and they could not recall the last meeting. Staff K stated they did not document what they discussed in nutritional meetings and the RD documented. Staff K was not sure of what or where that would be in the medical record. In an interview on 07/14/2026 at 10:19 AM, Staff C, Director of Nursing Services (DNS – outgoing) stated in the nutritional meetings in the past they had been discussing Resident 78's fluctuations in weights. Staff C was not aware the RD had not been notified of Resident 78's weight loss, and stated there should have been documentation, and notification to the RD and the provider immediately. <RESIDENT 55> Resident 55 admitted on [DATE] with diagnoses to include dysphagia with a gastrostomy tube. Review of the physician orders from the hospital on [DATE] directed staff to weigh Resident 55 on admission, weekly times three then monthly. The resident was to be NPO (nothing by mouth) and receive tube feeding for nutrition at 52 milliliters per hour continuously. Review of Resident 55's clinical record showed the resident did not get weighed per physician order and had the following three weights since admission: 06/22/2026: 130.4 pounds 06/25/2026: 130.4 pounds 07/09/2026: 129.0 pounds Review of Resident 55's Kardex (tool that informs aides how to provide care) showed conflicting information. The Kardex showed the resident was NPO and to provide snacks and drinks that the resident preferred if they became upset. Review of the nutrition Care Area Assessment (CAA) dated 06/29/2026 showed the resident had significant weight loss in the last 30 days and the hospital record on 06/17/2026 noted their weight was 152 pounds. The CAA documentation showed the resident was on enteral feedings per dietician recommendations. Review of the clinical record did not contain a note from the Registered Dietician (RD). In an interview on 07/10/2026 at 12:45 PM, Collateral Contact 2 (CC 2), stated there should have been three days of weights after admission, then weekly. CC 2 stated they could only locate Resident 55's weights on 06/22/2026, 06/25/2026 and 07/09/2026. CC 2 stated there should have been an assessment note from the RD prior to their vacation on 06/29/2026. They stated they did not see one. CC 2 stated the residents should have weekly weights after the first week then be seen by the RD monthly related to the enteral feeding. CC 2 stated there should have been at least three more weights. They stated they had just talked to Staff A, Administrator about their concerns about weight monitoring. CC 2 stated they were frustrated that weights were missed, there were no reweighs when there were ten-pound differences. They stated it would seem the staff would know how to reweigh as the weight would not likely be accurate. They stated the staff needed to try to get consistent accurate weights so they could determine the residents' needs. They stated accurate weights were needed to measure the resident's nutritional status. In an interview on 07/14/2026 at 11:42 AM Staff B, DNS, stated Resident 55 should have been weighed weekly. <RESIDENT 8> Resident 8 admitted on [DATE] with diagnoses to include protein-calorie malnutrition, and end stage renal disease dependent on dialysis (life sustaining treatment to filter waste, remove salt and water from the body). In an interview on 07/08/2026 at 12:04 PM, Resident 8 stated the vegetables were overcooked and the pasta needed to be cooked another way. They stated food in general was overcooked and yesterday the quiche was very overcooked, rubbery and they could not eat it at all. The resident stated they went to dialysis at 3 PM and got back at 9:15 PM. They stated when they return the kitchen was closed and the staff could not reheat their meal, so they quit eating dinner here. They stated they were once offered a peanut butter and jelly sandwich, but they hated them. The resident stated the facility had never sent the dinner with them to dialysis. The resident stated their son had to drive to the kidney center and brought them dinner while they were at dialysis. Review of the physician orders from the hospital on [DATE], directed staff to weigh Resident 8 on admission, weekly times three then monthly. The resident was on a renal diet (specialized diet that involves monitoring fluid intake and balancing protein). Review of Resident 8's clinical record showed the resident had significant weight loss of 28 pounds or 13.1% in less than 30 days. The resident did not get weighed per physician order and had the following four weights since admission: 06/05/2026: 213.0 pounds 06/12/2026: 214.0 pounds 07/02/2026: 197.0 pounds 07/10/2026 185.0 pounds Review of the nutrition CAA dated 06/11/2026, showed the resident scored a six on the mini nutritional assessment indicating they were malnourished. Review of the nutritional at risk assessment on 06/19/2026, showed Resident 8 was at risk for malnutrition and had a moderate decrease in food intake. The assessment documented the resident was at dialysis three times a week during dinner hours and needed a late dinner or snack upon return. The resident preferred egg, tuna or chicken salad sandwiches. In an observation on 07/13/2026 at 12:50 PM, Staff O, Dietary Manager (DM) was at Resident 8's bedside. The resident told Staff O they did not like to complain but they did not care for the overcooked vegetables and would like to have a meal go with them to dialysis. The resident told Staff O that they did not want peanut butter and jelly sandwiches for dialysis, so their son brought them dinner at dialysis. In an interview on 07/14/2026 at 8:38 AM, Staff O stated they were unaware that Resident 8 was not taking a dinner meal to dialysis. They stated their staff did not let them know. Staff O stated the resident did not care for peanut butter and jelly sandwiches but would like turkey and ham sandwiches. Staff O stated they would now send turkey sandwiches. Staff O stated the go to for dialysis meals was peanut butter and jelly since they did not require refrigeration. Staff O stated from now on they would personally go meet with dialysis residents for their meal preference when the resident was out of the facility. In an interview on 07/14/2026 at 9:08 AM, CC1, Physician Assistant, stated they were not aware of any weight loss for Resident 8. They stated they should discuss Resident 8 at weight meetings on Friday, and they might add an appetite stimulant. CC1 stated they would see the resident today. CC1 stated they were unaware the kitchen was not sending dinner with them to dialysis. In an interview on 07/14/2026 at 11:27 AM, Staff G, Licensed Practical Nurse (LPN)/Unit Manager(UM) stated residents were to be weighed for three days after admitting, then weekly for three weeks then monthly. They stated the nurses' aides knew to get everyone's weight on the first of the month. Staff G stated Staff C, DNS would request weights. Staff G stated today they had to beg staff to obtain a weight, and the staff would report back the resident refused. In an interview and observation on 07/14/2026 at 11:42 AM, Staff C reviewed Resident 8's weights and stated they had lost weight and they had not been aware of their weight loss. The computer screen showed there was a significant weight loss warning. Nursing documentation did not contain evidence of ongoing assessment, implementation of interventions and re-evaluation of interventions consistent with professional standards for Resident 8 and 55. The nursing documentation also did not reflect a proactive approach to weight monitoring and nutritional management. <RESIDENT 6> Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's weight record, documented a weight of 127 pounds (lbs.) on 04/23/2026 and 113.6 lbs. on 06/18/2026, indicating a significant weight loss of 10.55% within a two-month period. There were no weights documented in the record after 06/18/2026. Review of Resident 6's July 2026 Medication Administration Record (MAR), documented an active order for weekly weights every Thursday effective 12/18/2025, and another order for daily weight for three days, weekly weight for four weeks, and monthly every four weeks effective 01/20/2025. Review of the latest Nutritional at Risk assessment dated [DATE] at 1:00 PM, documented the usual weight was unknown, no significant weight change, and No decrease in food intake. The assessment documented a 65% meal intake and 100% health shake consumption. No subsequent Nutritional at Risk Assessments were completed. Review of a dietitian progress note dated 06/06/2026 at 12:57 PM, documented a 7.5% weight loss, inaccurately stated the resident was on hospice care, and concluded with No new interventions recommended at this time. There were no further dietitian progress notes in the chart. Review of Resident 6's quarterly MDS dated [DATE], coded the resident as requiring total assistance for eating, experiencing a weight loss of 5% or more in the last month or 10% or more in the last six months, and having a newly developed pressure ulcer. Review of Resident 6's care plan, initiated 08/20/2025, documented the nutritional goal was to maintain current weight without significant weight changes. The care plan lacked updated interventions to address the resident's active weight loss or changing oral intake. In an interview and observation on 07/09/2026 at 1:20 PM, Staff W, Nursing Assistant Certified (NAC), stated Resident 6 only drank a small amount of their health shake, took a couple of bites of food, and ate a few pieces of fruit at lunch, totaling less than 25% of the meal. In an interview on 07/09/2026 at 3:58 PM, Staff X, NAC, stated Resident 6 ate approximately 50% of their meals at most. In an interview on 07/10/2026 at 2:43 PM, Staff EE, LPN, stated Resident 6 was discharged from hospice care last year and had been actively losing weight since 04/30/2026. Staff EE stated the resident's average intake was only 25% to 50% and confirmed the resident had an active pressure ulcer on their buttocks. In an interview and record review on 07/10/2026 at 4:25 PM, Staff K, LPN/UM, stated the facility conducted weekly nutritional meetings to review residents experiencing weight loss and decreased oral intake; however, Staff K could not find any documentation verifying these weekly reviews occurred for Resident 6. Staff K reviewed the record and stated the resident had 17 meals with 0% to 25% intake in the last 30 days, frequently refused health shakes, and had refused Prosource (protein supplement) since July. Staff K confirmed that the resident's nutritional interventions required immediate modification. In an interview and record review on 07/13/2026 at 1:24 PM, CC2 reviewed the resident's weight and oral intake report, noting that the resident's average intake had dropped from 49% down to 39.7% since 06/17/2026. CC2 stated that the resident's weight was a major concern, pointing out that the resident had refused their health shake six times and had not taken their Prosource in July. CC2 stated that the resident should be monitored far more frequently than quarterly and confirmed they could not find weekly nutrition meeting notes. In a follow-up interview and record review on 07/14/2026 at 9:38 AM, Staff K stated they could not recall when the last weekly nutrition meeting took place. Staff K verified there was zero documentation showing that nursing staff had informed the dietitian or medical provider regarding the resident's significant weight loss and decreased oral intake. Staff K stated that weights should be monitored weekly and a re-weigh should be offered immediately if a resident refused. In an interview and record review on 07/14/2026 at 9:57 AM, CC1 stated they were not notified about the significant weight loss and decreased oral intake. CC1 stated the resident's weight should be monitored weekly. CC1 stated the resident should have more nutritional monitoring, especially with the facility developed pressure ulcer. In an interview on 07/14/2026 at 12:29 PM, Staff B, Director of Nursing, stated the expectation was to consistently monitor and identify any changes in a resident's weight, follow up promptly within the IDT(Interdisciplinary Team) to analyze the causes, implement clinical interventions and update the comprehensive care plan. <RESIDENT 3> Resident 3 admitted [DATE] with diagnoses which included cognitive impairment. According to the Quarterly MDS assessment dated [DATE], Resident 3 had no weight loss or weight gain and was identified as at risk for impaired nutrition. The resident was coded as requiring set up assistance for meals. Review of Resident 3's weight was documented at 115lbs. on 06/03/2026. On 12/01/2025 Resident 3 was documented at 138lbs. which met the criteria for significant weight loss of 16.67% in six months. Further review of the record showed no follow-up weights or nutritional assessment related to the weight loss. In an interview on 07/10/2026 at 8:13 AM, CC2 stated they believed the 138lbs. weight was not accurate, as it was out of place in relation to some of the resident's other weights. CC2 also stated the 115lbs. weight was a low outlier and needed a reweigh. CC2 noted resident 3's intakes were stable and a nutrition supplement was being accepted. CC2 stated there were several outlier weights noted for Resident 3 and stated there should have been re-weighs done to confirm the accuracy of the outlier weights. CC2 stated Resident 3 triggered for weight loss but stated likely only because of inconsistent weight methods being used and lack of re-weighs that would have cleared a false high weight. CC2 stated there should have been follow up regardless and a note done to address weight triggers. This is a repeat deficiency from SOD dated 08/20/2025. Refer to WAC 388-97-1060(3)(h)

Based on observation, interview and record review, the facility failed to ensure 1 of 5 medication carts was locked (Blue Medication Cart), failed to ensure proper storage and labeling of medications for 5 of 7 residents (Residents 8, 42, 61, 71 and 100), and failed to dispose and replace expired medications and equipment in 2 of 2 crash carts. These failures placed residents at risk for having access to medications not prescribed to them, missing medications, and receiving compromised or ineffective medication/equipment.Findings included. Review of the facility policy titled, Emergency Management, revised 11/2013, documented that crash cart maintenance should include checking emergency care items and equipment stored in the crash cart against the crash cart checklist once a month and whenever the cart was opened to validate contents and expiration dates. The designee was to replace expired items and sign and date the crash cart checklist. Review of the undated facility policy titled, Medication Storage, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinues, outdated, or deteriorated drugs or biologicals. Compartments (drawers, cabinets, rooms, refrigerators, carts) containing drugs and biologicals shall be locked when not in use .items shall not be left unattended .potentially available to others. <CRASH CART> In an observation of the first-floor crash cart, on 07/10/2026 at 2:51 PM, revealed an intravenous (IV) kit with an expiration date of 05/31/2021, saline solution with an expiration date of 10/2021, oxygen tubing with an expiration date of 01/01/2024, and lubricating jelly with an expiration date of 05/2021. In an interview on 07/10/2026 at 2:51 PM, Staff S, Infection Preventionist/Staff Development Coordinator, verified the expired medications on the first-floor crash cart and stated that night shift nurses were to be checking the crash carts and completing the crash cart checklist binders. In an observation of the second-floor crash cart, on 07/10/2026 at 3:01 PM, revealed IV needles that expired 05/31/2026 and IV needles that expired 02/28/2025. In an interview on 07/10/2026 at 3:01 PM, Staff K, Licensed Practical Nurse (LPN)/Unit Manager (UM), stated that the crash cart should be checked and have expired products removed. In an interview on 07/10/2026 at 3:05 PM, Staff G, LPN/UM, stated their expectation would be no expired medications or equipment in the crash carts. Staff G stated crash cart checklist binders should be done nightly by the nurses. Staff G stated the night nurses were to go through the crash carts and replace anything needed and then document in the crash cart checklist. <UNSECURED MEDICATIONS> <RESIDENT 71> In an observation on 07/08/2026 at 9:57 AM, Resident 71 had a clear plastic cup with one white oblong pill and one large round tablet on their overbed table. The resident stated the pills were left by the nurse before breakfast time and they were not sure what they were. They stated they liked to take their pills with food, and they were dropped off before they ate. They confirmed the medications were left for them to take when they wanted. <RESIDENT 42> In an observation on 07/08/2026 at 12:28 PM, Resident 42's Lispro insulin vial and syringe were on top of the medication cart located on a tray to the left of room [ROOM NUMBER]. There was no nurse present. At 12:31 PM, Staff F, Registered Nurse came out of a room, walked by the cart where the insulin was still present and unsecured. At 12:34 PM, Staff F removed the insulin and syringe. At 12:37 PM, Staff F stated they should have secured them, but they were called to a different room. <RESIDENT 61> In an observation on 07/08/2026 at 11:19 AM, 1:32 PM and 3:04 PM, anti-fungal powder was located on resident 61's sink. In an observation on 07/09/2026 at 10:41 AM, 11:34 AM, 1:09 PM, and 3:08 PM, anti-fungal powder was located on the resident's sink. In an observation on 07/10/2026 at 8:44 AM, 9:53 AM, 10:19 AM and 12:34 PM, anti-fungal powder was located on the resident's sink. In an observation on 07/13/2026 at 12:50 PM, anti-fungal powder was located on the resident's sink. <RESIDENT 8> In an observation on 07/08/2026 at 12:04 PM, a bottle of chewable TUMS was located in Resident 8's top nightstand drawer. In an observation on 07/09/2026 at 1:37 PM, the bottle of chewable TUMS was still present in their top nightstand drawer. In an interview on 07/14/2026 at 11:21 AM, Staff G, LPN/Unit Manager stated they had addressed staff leaving medications with Resident 71 several times with several nurses. Staff G stated the nurses knew they were not to leave medications in resident rooms. They stated the resident usually had three to four pills at bedside, and they just took a cup of medications out of their room the other day. Staff G stated they had provided education to Resident 71 about the nurses not leaving their medications and the need to observe them consuming the medications. They were not aware of Resident 42's unsecured insulin and syringe, Resident 61's Anti-fungal powder at the sink or Resident 8's bottle of chewable TUMS in their nightstand. They stated they would make sure they came out of their drawer. Staff G stated Staff F must have gotten pulled away. Staff N, LPN was present and stated the residents yelled at them when they passed meds and told them they were the only nurse who didn't leave them. Staff N stated they would secure the anti-fungal powder. In an interview on 07/14/2026 at 11:43 AM, the unsecured medications were discussed with Staff C, Director of Nursing. Staff C stated their expectation was for no meds left at bedside and they should be secured in the cart. <RESIDENT 100> Resident 100 was a long term care resident who left the facility three times per week for outside medical treatment. In an interview on 07/09/2026 at 2:50 PM, Resident 100 stated they took a communication binder with them to each treatment, and between treatments, the binder was either at the nursing station or in their room. In an observation of Resident 100's communication binder on 07/09/2026 at 3:00 PM, the binder was found in the resident's room. Resident 100 was not in the room. Review of the binder revealed pages with treatment notes dating back to January of 2026. A page dated 01/14/2026 was observed to have a plastic envelope stapled to the corner which contained one pink colored round pill. There was black marker writing on the outside of the envelope with the resident's name, the name of the medication, and parameters instructing when to hold it based on the resident's blood pressure reading. In an interview on 07/09/2026 at 3:44 PM, Staff R, Registered Nurse (RN), stated Resident 100 took the communication binder to each treatment and stated the provider would review the book at the appointment. Staff R stated if a resident had medication sent with them to an appointment or outing, it should be labeled and there should be follow up regarding whether or not it was given. Staff R identified the medication stapled in the binder as Resident 100's blood pressure medication. Staff R stated the binder should be kept at the nursing station and should not include unsecured medications. <MEDICATION CART> During an observation on 07/09/2026 at 5:36 AM, the blue medication cart was outside the second-floor resident TV room/ lounge. The medication cart was noted to be unlocked, and no staff were within the immediate area. During an interview on 07/09/2026 at 5:40 AM, Staff Q, RN, stated they had just unlocked the medication cart as they were passing medications. Staff Q did not respond to the medication cart being unattended while they were away from the immediate area. During an interview on 07/10/2026 at 8:14 AM, Staff C stated they expected the nurses to ensure the medication cart was locked when they were not in direct supervision of the cart. This is a repeat deficiency from SOD dated 08/20/2025. Refer to WAC 388-97-1300 (2)

Based on observation, interview and record review the facility failed to ensure that each resident was treated with respect, dignity and failed to promote and protect the rights of each resident for 2 of 3 residents (Residents 55 and 61) reviewed for dignity. This failure had the potential to result in embarrassment and psychological harm to residents when staff members failed to provide privacy. Findings included . Review of an undated facility policy titled Resident Rights, showed the center would protect and promote each of the following rights, including personal privacy in accommodations and personal care. Residents had the right to receive care from the center in a manner and environment that promotes, maintains, or enhances their dignity and respect. <RESIDENT 55> Resident 55 admitted to the facility on [DATE] with diagnoses to include stroke with hemiplegia (paralysis and weakness on one side of the body) affecting their right dominant side and major depressive disorder. Review of the admission Minimum Data Set (MDS-an assessment tool) dated 06/29/2026, showed the resident had range of motion impairment on both sides and was dependent on staff for all care including dressing and personal hygiene. In observations on 07/09/2026 at 9:18 AM, 10:49 AM, and 3:37 PM, Resident 55 was lying in bed with the privacy curtain open. Their incontinent brief was exposed and visible to those walking past the room. The resident was exposed from their waist down. Resident 55's roommate was present in the room. In observations on 07/10/2026 at 9:51 AM, 10:19 AM, and 12:38 PM, Resident 55 was lying in bed with both legs off the bed with the privacy curtain open. Their incontinent brief was exposed and visible to those walking past the room. The resident was exposed from their waist down. Resident 55's roommate was present in the room. In observations on 07/13/2026 at 12:51 PM, Resident 55 was lying in bed with their ankles crossed, the privacy curtain was open and their incontinent brief was exposed and visible to those walking past the room. At 1:36 PM, the resident had both legs open and their hands in their brief. At 2:45 PM, the resident was exposed from their waist down. In observations on 07/14/2026 at 8:51 AM and 9:29 AM, Resident 55 was lying in bed restless. The privacy curtain was open, and their incontinent brief was exposed and visible to those walking past the room. The resident was exposed from their waist down. In an interview on 07/14/2026 at 11:27 AM, Staff G, Licensed Practical Nurse (LPN)/Unit Manager (UM), stated Resident 55's brief was exposed and the curtain should be closed so they were not exposed. <RESIDENT 61> Resident 61 admitted on [DATE] with diagnoses to include pressure ulcers. Review of the admission MDS dated [DATE], showed the resident had an indwelling urinary catheter (tube to drain urine from the bladder) and they required assistance for personal hygiene. In observations on 07/08/2026 at 11:23 AM, 1:32 PM, and 3:04 PM, Resident 61's catheter bag was exposed showing amber urine and visible to those walking in the hall. In an interview on 07/13/2026 at 1:19 PM, Staff N, LPN/UM, stated they were unaware Resident 61's catheter was exposed on 07/08/2026. Staff N stated the catheter should be in a privacy bag. In an interview on 07/14/2026 at 11:44 AM, Staff C, Director of Nursing was informed of the exposed brief on multiple occasions for Resident 55 and observation of a catheter bag not secured in a privacy bag for Resident 61. Staff C stated the staff could try to cover Resident 55 with a blanket or try pajama pants. Staff C stated catheter bags should be covered. Reference (WAC) 388-97-0180(1-4)

Based on interview and record review, the facility failed to ensure that a court-appointed representative had the necessary authority for the decision-making as determined by the court for 1 of 1 residents (Resident 12) reviewed for Advance Directives. This failure resulted in an unrecognized lapse in guardianship authority and had the potential to impact care and services for residents. Findings included . Resident 12 admitted in 2014 with diagnoses that included serious mental illness and cognitive impairment. Review of Resident 12's medical record on 07/09/2026 included court documents showing a court appointed guardianship was in place dated 2021. The guardianship documents were stated to expire in 2024. The record showed no notes or further documentation regarding the current status of the resident's guardianship. Progress notes indicated that the facility had been placing calls to obtain consents, had been providing notifications and other correspondences to the guardianship company beyond the expiration date of the court documents. In an interview on 07/09/2026 at 2:06 PM, Staff L, Social Services, stated the facility sent messages to the guardianship company requesting updated documents and they had not provided them. Staff L stated the guardianship company was making all required decisions and functioning as the resident's guardian. In an interview on 07/14/2026 at 10:15 AM, Staff C, Director of Nursing, stated they were attempting to obtain the updated guardianship documentation. At 2:00 PM, Staff C provided a copy of Letters of Guardianship which were dated as being filed on May 27, 2025, and would expire on May 13, 2027. There was no documentation provided showing evidence Resident 12's guardianship company had legal decision-making authority between the prior guardianship expiration in 2024 and the filing date of 05/27/2025. Reference WAC 388-97-0420 (1)-(9)

Based on interview and record review, the facility failed to honor bathing preferences for 2 of 3 residents (Residents 19 and 99) reviewed for bathing. The facility's failure to accommodate resident choices/preferences related to bathing and daily schedules placed residents at risk for poor hygiene, feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life. Findings included . Review of the undated facility policy titled, Shower/Tub Bath, showed the facility would offer residents at a minimum of at least two full baths or showers per week and to the extent possible resident preference for type and frequency of baths would be taken into consideration and honored. If the resident refused the shower/tub, the reason(s) why and interventions taken were to be documented. <RESIDENT 99> Resident 99 admitted on [DATE] with diagnoses to include obesity, major depressive disorder, anxiety with a history of physical and sexual assault. Review of Resident 99's quarterly Minimum Data Set (MDS, an assessment tool) dated 06/09/2026, showed the resident had no impaired cognition and they did not reject care. Review of Resident 99's preferences evaluation on admission [DATE] and quarterly on 06/02/2026, showed it was very important to choose between a tub bath, shower, bed bath or sponge bath. The assessment showed the resident preferred showers. Review of Resident 99's care plan updated on 04/03/2026, documented they frequently refused showers. There were no interventions to assist the staff on how to address the refusals or re-offering of showers. The care plan was recently updated on 07/03/2026 to show they preferred evening showers and female care givers for intimate care, toileting and showering. Review of Resident 99's shower/bathing documentation showed they received two showers in April, two showers in May and two showers in June. As of 07/14/2026, the resident had one shower in July on 07/12/2026. In an interview on 07/13/2026 at 2:53 PM, Resident 99 stated their issue with showers was multiple factors. They stated they were never asked when they would like showers or baths and how often. The resident stated they had not been involved in their care plan since admission. The resident stated they were set up for evening showers and most of the evening staff were males. They said as a victim of sexual assault they did not want a man near them. They stated if they wanted a different time or day, the staff did not follow up and ask them the next day and if they (resident) asked the next day or day after that, the staff would say no, it was not your day. They stated the facility as a whole, loved to say no. They stated another issue was they did not trust the staff to do this vulnerable task. They said they did not require much assistance in the shower. They stated the staff had to make sure a shower chair was in the shower room and towels were on the ground, so they did not slip. They stated even though they did not require much help the staff often said no to their requests to shower. The resident confirmed they only had one or two showers a month since admission. The resident stated they would use wipes to try to clean themselves up in their room. They stated the staff would flat out tell you no if you asked outside of your scheduled shower day and time. <RESIDENT 19> Resident 19 admitted on [DATE] with diagnoses to include obesity, anxiety and muscle weakness. Review of Resident 19's quarterly MDS dated [DATE], showed the resident had no impaired cognition and they did not reject care. Review of Resident 19's preferences evaluation on admission [DATE] and quarterly on 05/18/2026 showed it was very important to choose between a tub bath, shower, bed bath or sponge bath. The assessment showed the resident preferred showers. Review of Resident 19's care plan on 07/14/2026, showed no documentation about the resident's preferences for type of bathing, frequency of bathing, assistance required for bathing or scheduled days for bathing. Review of Resident 19's shower/bathing documentation showed they received no showers in April, three showers in May and six showers in June. As of 07/14/2026, the resident had three showers in July. In an interview on 07/13/2026 at 2:31 PM, Resident 19 was sitting on the side of their bed and stated their roommate (Resident 99), and they rarely took showers because they did not feel the staff was caring and competent. The resident stated staff came into the shower room when they were naked with other residents to weigh them. They stated this occurred on all shifts and involved different staff. They stated they refused showers because if the aides could not do simple tasks how could they trust them to do this most private thing. The resident stated they told the staff to leave when they opened the door and wheeled other residents into the shower room and several staff got huffy with them. They stated they would ask the staff to get them towels and they tried to wash up in their bathroom where no one would walk in on them. The resident commented that was not a replacement for a shower. In an interview on 07/14/2026 at 10:28 AM, Staff P, Licensed Practical Nurse (LPN)/ MDS nurse, stated shower preferences were asked on admit. Staff P stated the admission nurse would ask on admission and put their choices on the care plan. They stated the unit managers would then update any changes in preferences thereafter. In an interview on 07/14/2026 at 11:07 AM, Staff G, LPN/unit manager stated Resident 99 had no male caregivers related to a history of sexual assault. Staff G stated Resident 19 accepted showers more often than Resident 99 as they reviewed the report that showed shower refusals. They stated Resident 99 was set up assistance only and they made sure supplies were there and if they needed help, they assisted them. Staff G stated the aides should be able to set them up for showers any day or another female staff member could. They commented Resident 19 and 99 did not require a lot of time in the shower as they bathed themselves. Staff G stated the aides set them up and then the residents called when they needed help. Staff G stated unfortunately, if it was another person's shower time/day the shower aides could not give them a shower another day. Showers have set days and times. The aides had two showers a shift to complete on top of their other duties. They stated the shower days were assigned but they tried to accommodate the time of day, with a choice of days or nights. Staff G stated the rooms had assigned shower dates. Staff G stated Resident 99 needed more than one shower a month. In an interview on 07/14/2026 at 11:42 AM, Staff C, Director of Nursing (DNS), stated the expectation was during the admission assessment, the resident preferences went to the new care plan on day one and revisions were made by the unit managers. Staff C stated they could not alter the shower schedule to accommodate prior refusals as the aides had two other showers to give that day. They stated Sundays were for make-up showers and resident choices should be honored. In an interview on 07/14/2026 at 2:01 PM, Staff B, DNS, was made aware of the lack of honoring bathing choices for Residents 19 and 99. Staff B stated residents should be asked their preferences, and this should be documented on the care plan. Staff B stated they would be looking into the bathing system. No additional information was provided. Reference (WAC) 388-97-0900(1)(3)

Based on record review and interview, the facility failed to obtain Level II Pre-admission Screening and Resident Review (PASRR - an in-depth, federally mandated evaluation triggered when an initial screen (PASRR Level 1) suspects serious mental illness (SMI) or intellectual/developmental disability) for 2 of 6 residents (Residents 13 and 78) reviewed for PASRR. This failure placed residents at risk of not receiving mental health care and services in the most integrated setting appropriate for their needs. Findings included . <RESIDENT 78> Resident 78 admitted to the facility on [DATE] with diagnoses that included major depressive disorder. Review of Resident 78's admission level I PASRR dated 09/18/2025, documented the resident had a serious mental illness of mood disorder, with a positive screen for a level II evaluation. Review of Resident 78's progress note dated 09/25/2025, documented a request for a level II. Further review of the medical record showed no follow up for Residents 78's level II completed until 07/01/2026. In an interview on 07/13/2026 at 10:53 AM, Staff L, Social Worker, was asked if there was any follow up for Resident 78's level II PASRR. Staff L stated they were unsure as they just made notes on a pad of paper. Staff L reviewed Resident 78's medical record and stated they followed up on 07/01/2026. Staff L was asked if they did any follow up in those 8 months since the resident had admitted , and Staff L stated I guess not, I thought we got something back, but we never got anything. <RESIDENT 13> Resident 13 was admitted to the facility with diagnoses to include post-traumatic stress disorder and general anxiety disorder. Review of Resident 13's PASRR Level I dated 09/15/2025 documented PASRR Level II referral was indicated due to SMI. Review of Resident 13's chart did not have PASRR Level II evaluation. Review of Resident 13's progress notes from 09/15/2025 to 07/09/2026 did not have any documentation of follow up regarding PASRR Level II evaluation. In an interview on 07/09/2026 at 1:35 PM, Staff L, stated that residents awaiting PASRR Level II evaluations were followed up via email with the PASRR Coordinator weekly. The follow-ups were to be documented in the resident's progress notes. Staff L was unable to provide documentation they had the PASRR Level II evaluation and that they followed up with the PASRR Coordinator for Resident 13. This is a repeat deficiency from SOD dated 08/20/2025. Refer to WAC 388-97-1975(8), 1915(4)

Based on interview and record review, the facility failed to ensure 2 of 5 residents (Residents 10 and 16) reviewed for Pre-admission Screening and Resident Review (PASRR - a federal requirement which identifies individual with Serious Mental Illness (SMI) or intellectual or developmental disabilities (I/DD) to provide appropriate services), received the required screening for necessary services. This failure placed the residents at risk for unidentified mental health needs. Findings included . <RESIDENT 16> Resident 16 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, and generalized anxiety disorder. Review of Resident 16's PASRR, dated 02/10/2026, documented the PASRR Level II (an in-depth, federally mandated evaluation triggered when an initial screen suspects SMI or I/DD) was not indicated due to 30-day hospital exemption and a PASRR level II must be completed if a scheduled discharge did not occur in 30 days. Review of Resident 16's progress notes from 02/17/2026 through 07/09/2026 showed no documentation related to PASRR Level II follow-up. In an interview on 07/09/2026 at 2:15 PM, Staff M, Social Services (SS), stated for residents with 30-day hospital exemptions, they follow up with the PASRR Coordinator if they had not received Level II evaluation or invalidation 10 days prior to the expiration. Any follow-up regarding the PASRR should be documented in the resident's chart. Staff M reviewed Resident 16's chart and stated there were no Level II evaluation or invalidation for the resident and there were no documentation of any follow-up. <RESIDENT 10> Resident 10 was admitted to the facility on [DATE] with diagnoses to include depression, and generalized anxiety disorder. Review of Resident 10's PASRR, dated 05/22/2026, documented the PASRR Level II was not indicated due to 30-day hospital exemption. Review of Resident 10's progress notes with a print date of 07/09/2026 documented that on 07/01/2026 Staff L, SS, followed up with the PASRR Coordinator regarding Level II evaluation for the resident which was past the 30-day hospital exemption. In an interview on 07/09/2026 at 1:35 PM, Staff L stated residents that had PASRRs with 30-day hospital exemption were followed up with the PASRR Coordinator if they had not received an invalidation or a Level II evaluation prior to the 30 days. Staff L stated any follow-up was documented in the resident's progress note. Staff L reviewed Resident 10's chart and stated they were late in following up with Resident 10's Level II evaluation. This is a repeat deficiency from SOD dated 08/20/2025. Reference WAC 388-97-1915 (1)(2)

Based on interview and record review, the facility failed to provide the baseline care plan to the resident and/or representative within 48 hours for 2 of 6 residents (Residents 24 and 113) reviewed for baseline care plan. These failures placed residents at risk of not being informed of their initial plan for delivering care and services and placed residents at risk for unmet care needs and possible complications. Findings included .Review of an undated facility policy titled, Baseline Care Plans, showed the baseline care plan would be developed within 48 hours of a resident's admission, and a summary would be provided to the residents and their representative that included the initial goals, a summary of medications, and any services and/or treatments to be administered by the facility. <RESIDENT 24>Resident 24 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS-an assessment tool), dated 04/21/2026, the resident was cognitively intact. In an interview on 07/08/2026 at 1:54 PM, Resident 24 stated the facility had not yet communicated with them regarding their goals and/or plan of care.Review of Resident 24's admission Nursing Collection Tool, dated 04/15/2026 at 12:06 PM, revealed that under the Baseline Care Plan section, the parts indicating Baseline care plan has been reviewed with resident and/or responsible party and Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party were left unchecked.Review of Resident 24' s Electric Health Record (EHR), showed no documentation that a written summary of the baseline care plan was provided to and reviewed with the resident or their representative within 48 hours. <RESIDENT 113>Resident 113 was admitted to the facility on [DATE].Review of Resident 113's admission Nursing Collection Tool, dated 03/03/2026 at 5:14 PM, revealed that under the Baseline Care Plan section, the parts indicating Baseline care plan has been reviewed with resident and/or responsible party and Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party were left unchecked.Review of Resident 113' s EHR, showed no documentation that a written summary of the baseline care plan was provided to and reviewed with the resident or their representative within 48 hours.In an interview and record review on 07/13/2026 at 10:28 AM, Staff L, Social Services, stated the initial care plan was completed 48 to 72 hours upon admission and the baseline care plan was reviewed with the resident and/or representative during the initial care conference. Staff L confirmed that they could not find any documentation about the initial care conferences or if the baseline care plan was provided or explained to the resident and/or representative for Resident 24 and 113. In an interview and record review on 07/13/2026 at 10:51 AM, Staff K, Licensed Practical Nurse/Unit Manager, stated the baseline care plan was provided to and reviewed with resident and/representative within 48 to 72 hours after admission during the initial care conference. Staff K showed a sample form titled Care plan/medication list review and stated the resident and/or representative signed this form to acknowledge receipt, which was then uploaded into their EHR. Staff K confirmed they could not find this form uploaded, nor any other documentation verifying the baseline care plan was provided and reviewed with the resident and/or representative for Residents 24 and 113.In an interview and record review on 07/13/2026 at 3:00 PM, Staff C, Director of Nursing, stated the expectation was that the facility provided a copy of their baseline care plan, reviewed and explained it to the resident and/or representative within 48 hours after admission, and obtained a signed acknowledgment form to upload into the EHR. Staff C confirmed they did not see any documentation verifying that Residents 24 and 113 had reviewed their baseline care plans with facility staff. Refer to WAC 388-97-1020(3)(4)(b)

Based on observation, interview and record review, the facility failed to ensure residents received proper assistive devices to maintain vision abilities and failed to accurately assess and care plan vision services for 1 (Resident 24) of 1 residents reviewed for vision services. The facility miscoded the resident's vision status on the Minimum Data Set (MDS) assessment, failed to address the resident's needs for reading glasses, and failed to incorporate vision interventions into the comprehensive care plan. This failure placed the residents at risk for further vision impairment, unmet care needs, and a diminished quality of life.Findings included. Review of the undated facility policy titled, Visually Impaired Resident Care, defined visual impairment was any visual condition that impacted an individual's ability to successfully complete the activities of everyday life and documented it was the facility's responsibility to assist the resident to obtain needed services. <RESIDENT 24> Resident 24 was admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS-an assessment tool), dated 04/21/2026, the resident was cognitively intact. In an interview and observation on 07/08/2026 at 1:54 PM, Resident 24 stated they liked reading newspapers but left their reading glasses in another State prior to moving into the facility. The resident stated they informed multiple nurses that they required reading glasses, but no one had assisted them in obtaining a pair. A daily newspaper was observed on the bedside table directly in front of the resident. The resident demonstrated that they could read the large headlines but were unable to read the standard font size of the articles' content. Reviewed of Resident 24's care plan, initiated on 04/15/2026, showed no focus areas, goals, or interventions regarding vision needs or the provision of reading glasses. Review of Resident 24's admission assessment, dated 04/15/2026, documented the resident had adequate vision. Review of Resident 24's MDS assessment, dated 04/21/2026, coded the resident's vision as adequate. The assessment also coded that it was very important for the resident to read newspapers, magazines, and books. Review of Resident 24's activity initial assessment, dated 04/15/2026 at 2:53 PM, documented the resident enjoyed reading books and magazines, and the newspaper was delivered to the resident daily. In an interview on 07/10/2026 at 2:21 PM, Staff CC, Activity Director, stated Resident 24 loved reading and enjoyed books, newspapers and the daily chronicle. Staff CC stated they were not aware the resident required reading glasses to read the content. In an interview and record review on 07/13/2026 at 9:57 AM, Staff DD, Registered Nurse/MDS Nurse, stated if the resident could only read the newspaper headlines but not the regular content font, their vision was clinically impaired. Staff DD confirmed the MDS was coded incorrectly, which prevented the Care Area Assessment (CAA) and the corresponding vision care plan from triggering.In an interview and record review on 07/13/2026 at 10:51AM, Staff K, Licensed Practical Nurse/Unit Manager, stated that because the resident could not read standard print and required reading glasses, the admission assessment should not have documented their vision as intact. Staff K verified that a vision care plan should have been developed and the resident should have been placed on the eye doctor list for an evaluation. In an interview on 07/13/2026 at 3:00 PM, Staff C, Director of Nursing, stated the expectation was the resident's vision was accurately assessed and coded so that the proper care plan interventions could be triggered and necessary reading glasses were provided to the resident. Refer to WAC 388-97-1060(3)(a)

Based on interview and record review, the facility failed to ensure nursing assistants received the required 12 hours of in-service education per year, and the in-service education included abuse, dementia and infection prevention related training for 3 of 5 staff reviewed (Staff E, X and Y). Failing to ensure nursing assistants received the required in-service education had the potential to result in staff failing to meet their licensing requirements and decreased staff competency to provide safe and compassionate resident care. Findings included . Review of employee records provided for Staff E, Nursing Assistant-Certified (NAC), documented Staff E was hired 08/24/2023. No evidence of completed in-service education was provided for the prior year for Staff E. Review of employee records provided for Staff X, NAC, documented Staff X was hired 01/07/2025. No evidence of completed in-service education was provided for the prior year for Staff X. Review of employee records provided for Staff Y, NAC, documented Staff Y was hired 10/11/2023. In-service education provided showed Staff Y completed less than 12 hours of in-service education for the prior year, and hours completed did not include abuse, dementia or infection prevention in-services. In an interview on 07/13/2026 at 1:44 PM, Staff S, Licensed Practical Nurse/ Staff Development Coordinator, stated the facility changed training software and no longer had access to the old system where some of the staff education may be located. Staff S stated the facility had no evidence of completion of the required trainings for the requested staff. Refer to WAC 388-97-1680 (2)(b)(c)

Based on observation, interview, and record review, the facility failed to ensure that staff followed transmission-based precautions (TBP) for 1 of 2 units (Second floor) reviewed for infection control procedures. This failure placed other residents and staff at risk for transmission of infection.Findings included.According to the Centers for Disease Control website (cdc.gov/infection-control/hcp/basics/transmission-based-precautions) when a resident had Contact Precautions, staff: Clean hands before entering and when leaving room. Wear a gown and gloves for all interactions that may involve contact with the patient or their environment. Limit resident movement outside of the resident's room to medical-necessary purposes.Review of a facility policy titled, Transmission Based Precautions, review date 10/24/2022, documented that all staff and visitors would wear gloves and gowns when entering the room for all interactions that may involve contact with the resident or resident's environment. Review of Resident 1's order summary report documented an order for contact precautions initiated on 02/24/2026.Review of Resident 1's care plan showed a focus area for contact precautions related to wounds, initiated on 02/24/2026.During an observation on 05/20/2026 at 9:25 AM, a Contact Precaution sign was at the doorway of Resident 1's room (room [ROOM NUMBER]). The sign documented: Contact Precautions. Everyone must clean their hands before entering and when leaving the room. The sign also showed providers and staff must put on gloves and a gown before entering room. There was a plastic three drawer rolling cart outside the door that contained gloves and disposable gowns.During an observation of meal pass on 05/20/2026 at 12:13 PM, Staff B, Certified Nurses Aide (CNA), brought Resident 1 their lunch tray. Staff B did not put on gloves or a gown before entering the room. Staff B was observed to touch Resident 1's bedside table and place items on Resident 1's bed, brushing their pants up against the edge of the mattress.During an interview on 05/20/2026 at 12:15 PM, Staff B reported they did not use a gown or gloves because they were just the delivering the meal tray. Staff B reviewed the sign at the doorway and stated they should have put on gloves and a gown before entering the room.During a continuous observations on 05/20/2026 at 3:01 PM- 3:12 PM, Resident 1 was sitting in a wheelchair in the hallway near the nurse's station. Staff C, Licensed Practical Nurse, spoke briefly with Resident 1 and then pushed them into their room. Staff C did not put on a gown or gloves prior to assisting Resident 1. After entering the room, Staff C was observed to push on top of the bed with both hands, kneel on the floor to peer under the resident's bed, and then removed the bedding from the bed, exposing an air mattress. Staff C lifted the air mattress from the bed frame and attempted to disconnect the lower section. At 3:04 PM, Staff D, CNA, entered Resident 1's room without applying a gown or gloves. Staff D put their forearm and hand on Resident 1's shoulder as they talked with them. Staff D also pushed on the air mattress with both hands and then left the room. Resident 1 spoke to Staff C. Staff C exited the room without performing hand hygiene, walked to the medication cart and took a spoon out of the container attached to the left side of the cart, and returned to the room and provided to Resident 1.During an interview on 05/20/2026 at 3:07 PM, Staff D stated they had not worn a gown or glove as they were not doing personal care. Staff D reviewed the sign and reported the sign showed they should have worn a gown and gloves to go into the room and that they did not realize that sign was different from the other signs on the unit [Enhanced Barrier Precaution (EBP) sign].During an interview on 05/20/2026 at 3:12 PM, Staff C reported that Resident 1 can self-propel their wheelchair and came out of their room on their own. Staff C reviewed the sign at the doorway to Resident 1's room and reported that sign was incorrect and they should be on EBP and not Contact Precautions. Staff C was asked about performing hand hygiene when exiting Resident 1's room and before touching the medication cart, but they did not respond.During an observation on 05/21/2026 at 9:40 AM, Resident 1 was observed sitting in their wheelchair near the elevators on the first floor.During an interview on 05/21/2026 at 12:25 PM, Staff A, Director of Nursing, stated residents on contact precautions should remain in their room. Staff A stated staff should read the TBP sign before entering the room and follow the directions. Specifically for contact precautions, staff need to do hand hygiene and apply a gown and gloves before entering room. Staff A stated staff need to remove the gown and gloves before exiting the room and then do hand hygiene when leaving. Refer to WAC 388-97-1320 (1) (a)(c)

Based on observation, interview and record review, the facility failed to revise care plans accurately to reflect the resident's needs for 3 of 4 residents (Residents 1, 2 and 3), reviewed for care planning revision. This failure placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life. Findings included . Review of the facility's undated policy titled, Care Planning - Interdisciplinary Team, documented that the care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident. <RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses to include hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebrovascular disease (conditions affecting blood flow to the brain, including stroke or bleeding) and mononeuropathy (the damage of a single peripheral never which leads to localized numbness, tingling and pain) of upper limb. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 01/27/2026, the resident had intact short and long memory and had impairment to one-sided upper extremity. In an interview on 03/24/2026 at 11:23 AM, Resident 1 stated they had bilateral shoulders surgery and could not tolerate blood pressure (BP) taking on the upper arms due to pain. Resident 1 stated they preferred the BP cuff to be placed on the forearm and had informed multiple nursing staff of this preference, yet staff continued to apply the cuff to the upper arms. In an interview on 03/30/2026 at 11:01 AM, Resident 1 expressed frustration, stated they were tired of repeating the request to nursing staff and asked, why cannot they document it? Review of Resident 1's care plan, initiated 01/21/2026, showed no intervention or instruction regarding taking BP on the forearms. Review of Resident 1's Kardex (a tool used to provide directions on how to care for a resident), as of 03/25/2026, there was no care instruction regarding forearm BP cuff placement. In an interview on 03/30/2026 at 11:30 AM, Staff F, Nursing Assistant Certified (NAC), stated they were not aware of the resident's preference for forearm BP readings until the resident told them directly. Staff F confirmed this care instruction was not documented in the residents' Kardex. In an interview on 03/30/2026 at 11:38 AM, Staff G, Registered Nurse/Unit Manager (UM), stated they were responsible for revising and reviewing the comprehensive care plan whenever there were changes to residents. Staff G stated the nursing staff obtains care instructions from the care plan and Kardex. Staff G confirmed they were not aware Resident 1 wanted BP taken on the forearms and stated this information should have been updated in the care plan. <RESIDENT 2>Resident 2 readmitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage (sudden bleeding into the space surrounding the brain), contracture of left hand, and weakness. According to the quarterly MDS assessment, dated 01/29/2026, the resident was cognitive intact and required maximum assistance for bed mobility. <GET OUT OF BED>In an interview on 03/24/2026 at 10:22 AM, Resident 2 stated they were supposed to get out of bed for two hours every day, but some NACs were not aware of this care.Review of Resident 2's March 2026 Medication Administration Record/Treatment Administration Record (MAR/TAR), showed an order to document the time the resident got up and the time resident returned to bed daily, initiated on 01/08/2026. Review of Resident 2's care plan, initiated 06/09/2025, showed no intervention regarding getting the resident up or out of bed. Review of Resident 2's Kardex, as of 03/25/2026, showed no care instruction for getting the resident up or out of bed. In an interview and record review on 03/30/2026 at 11:48 AM, Staff H, NAC, stated the NACs obtained care instruction from Kardex, but confirmed there was no instruction for getting the resident out of bed. in their Kardex. In an interview and record review on 03/30/2026 at 11:54 AM, Staff I, Licensed Practical Nurse (LPN)/UM stated the NAC obtained care instruction from Kardex before their work. Staff I confirmed that the care instruction for getting the resident up/out of bed was not in their care plan and Kardex and could be updated in the care plan. <PRECAUTION>In observations on 03/24/2026 at 10:22 AM and 03/30/2026 at 10:02 AM, observed a contact precaution signage posted outside of Resident 2's door. Review of a progress note dated 03/10/2026 at 9:01 AM, documented Resident 2 was placed on contact precaution. Review of Resident 2's care plan, initiated 01/05/2025, documented Resident 2 required Enhanced Barrier precautions for isolation. Review of Resident 2's Kardex, as of 03/25/2026, there was no care instruction of contact precaution. In an interview and record review on 03/30/2026 at 11:54 AM, Staff I confirmed that Resident 2 was on contact precautions and the care plan was not updated. In an interview and record review on 03/30/2026 at 1:08 PM, Staff J, LPN/Infection Preventionist, stated Resident 2 was placed on contact precautions and the care plan and Kardex should be updated. <RESIDENT 3>Resident 3 was admitted to the facility on [DATE] and discharged on 03/02/2026. Review of a progress note dated 02/23/2026 at 4:53 PM, documented Resident 3 had a pressure ulcer and repositioning the resident as tolerated. Review of Resident 3' s March MAR/TAR, documented an order for reposition every two hours to maintain skin integrity and relieve pressure off at coccyx area, initiated on 02/19/2026. Review of Resident 3's care plan, initiated on 02/23/2026, the focus under skin impairment documented the resident had moisture associated skin damage at coccyx. However, there was no intervention of repositioning the resident every two hours. In an interview and record review on 03/30/2026 at 1:08 PM, Staff J, stated there was an order of repositioning the resident every two hours which was not updated in the care plan and Kardex. In a joint interview on 03/30/2026 at 4:10 PM, Staff A, Interim Administrator, and Staff B, Director of Nursing, stated the expectation was for the interdisciplinary team to update care plans timely to ensure all residents' needs and physician orders were accurately reflected. Reference WAC 388-97-1020 (2)(a)(5)(b)

Based on observation, interview and record review, the facility failed to ensure residents received restorative services (movement of joints to maintain range of motion and/or splint brace assistance) to maintain and/or prevent declines in mobility and contracture for 2 of 2 sampled resident (Residents 1 and 2) reviewed for range of motion (ROM)/mobility. This failure placed residents at risk for development of contractures (joints become fixed in place), further decline in ROM, decreased mobility and a diminished quality of life. Findings included . Review of the facility undated policy titled, Restorative Nursing Services, documented residents would receive restorative nursing care as needed to achieve and maintain optimal physical, mental and psychosocial functioning. The policy specified that residents may initiate a restorative nursing program upon discharge from rehabilitative care. <RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses to include hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebrovascular disease (conditions affecting blood flow to the brain, including stroke or bleeding), left lower leg fracture, and weakness. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 01/27/2026, the resident had intact short and long memory, required moderate assistance for bed mobility and transfers, and had impairment to one-sided upper and lower extremities.In an observation and interview on 03/24/2026 at 11:23 AM, observed resident 1 was lying in bed with a bent inward left forearm and hand. Resident 1 stated they were no longer receiving services from therapists, and no nursing staff was assisting with exercise either. In an interview on 03/25/2026 at 10:27 AM, Collateral Contact 1 (CC1), family member of Resident 1, stated the resident had not received any therapy exercises or restorative service since February. Review of Resident 1's care plan, initiated 01/21/2026, showed Resident 1 was not receiving restorative services.Review of the care plan history showed Resident 1 had never received any restorative services. Review of Resident 1's electronic health record (EHR), there was no documentation that the resident received any restorative nursing interventions. Review of Physical Therapy PT Discharge Summary, dated and signed on 02/21/2026 at 7:01 PM, documented Restorative Programs Established/Trained=Restorative Range of Motion Programs, Restorative Transfer Program, Range of Motion Program Established/Trained: PROM (Passive Range of Motion) to L UE (Upper Extremities) and L LE (Left Extremities), Transfer Program Established/Trained and Restorative Nursing interventions: providing stand-by assist with transfer.Review of Occupational Therapy OT Discharge Summary, dated and signed on 02/12/2026 at 4:38 PM, documented recommendations for a splint/brace.In a joint interview and record review on 03/25/2026 at 11:44 AM, Staff D, Occupation Therapist (OT), stated that the OT discharge summary recommended splint and brace for Resident 1 to prevent contracture because the resident's left upper extremity had impaired range of motion and strength. Staff D stated, however, they did not have the time or opportunity to try the splint or brace on the resident before the insurance was discontinued. Staff C, Director of Rehab, stated they were not aware the resident still required therapy service for splint measurement and fit testing and they should continue the therapy under Medicaid Part B. Staff C stated that the expectation was for therapists to fill out referral forms in the EHR to initiate restorative programs for the MDS Coordinator to implement. In a follow-up interview on 03/25/2026 at 12:13 PM, Staff D stated they could not find any initial referral documentation in EHR.In an interview and record review on 03/25/2026 at 12:32 PM, Staff E, Licensed Practical Nurse/MDS coordinator, stated Resident 1 had not received restorative services and they were unaware of the recommendations because no referral was ever placed in the EHR by the therapy department. <RESIDENT 2>Resident 2 readmitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage (sudden bleeding into the space surrounding the brain), contracture of left hand, and weakness. According to the quarterly MDS assessment, dated 01/29/2026, the resident was cognitive intact, required maximum assistance for bed mobility, and total assistance for transfers. The assessment showed the residents had bilateral upper and lower extremities impairment and no therapy or restorative nursing programs.In an interview on 03/24/2026 at 10:22 AM, Resident 2 stated their therapy service was discontinued since last October and there was no restorative nursing staff who were assisting with exercise. Review of Resident 2's care plan, initiated 06/09/2025, showed Resident 1 was not receiving restorative services.Review of Resident 2's EHR, there was no documentation of the resident receiving any restorative services. Review of Occupational Therapy OT Evaluation and Plan of Treatment, dated and signed on 10/27/2025 at 5:22 PM, documented Resident 1 had left upper extremity range of motion impairment and a left-hand contracture, and the resident was wearing left orthotic to manage flexion tone prior to admission.Review of Occupational Therapy OT Discharge Summary, dated and signed on 11/26/2025 at 9:29 AM, documented a discharge recommendation for Restorative care and assistance with donning/doffing orthotic wear.Review of Physical Therapy PT Discharge Summary, dated and cosigned on 11/25/2025 at 4:37 PM, documented showed a recommendation for restorative programs if the resident did not continue with Medicaid Part B services.In an interview on 03/25/2026 at 11:01 AM, Staff C confirmed Resident 2 discontinued therapy services on 11/26/2025 and did not continue with Medicaid Part B services. Staff C stated they recommended the resident be on restorative nursing programs after their therapy services were discontinued. In an interview and record review on 03/25/2026 at 12:02 PM, Staff E stated that Resident 2 had no restorative nursing programs since readmission in October. Staff E stated the therapists needed to re-evaluate the resident after hospitalization and initiate new restorative programs recommendations into EHR. Staff E confirmed that they were not aware of the recommendations and there was no referral documentation in the system.In an interview on 03/25/2026 at 12:13 PM, Staff C stated they could not find any restorative program referrals from the therapists in the EHR after readmission in October.In a joint interview 03/30/2026 at 4:10 PM, Staff A, Interim Administrator and Staff B, Director of Nursing, stated they the expectation was for all residents to receive recommended restorative nursing programs. Staff B stated that once therapists discharged a resident, they should initiate the recommended restorative programs in the EHR for MDS Coordinator to follow up and implement. Reference WAC 388-97-1060(3)(d)(j)(ix) .

Based on interview and record review, the facility failed to ensure preparations were made for a safe discharge for 1 of 3 residents (Resident 1) reviewed for discharges. The facility failed to provide instructions upon discharge, provide wound care training and ensure medications and wound care supplies were provided at discharge. This failure placed residents at risk of an unsafe discharge and risk for medical complications. Findings included .<RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses including diabetes, wound to right foot, and depression. Review of the residents' Minimum Data Set (an assessment tool) showed the resident had moderate cognitive impairment.Review of a progress note dated 02/20/2026, documented Resident 1 discharged home with family.Review of Resident 1's electronic health record (EHR), showed discharge instructions and discharge summary was incomplete.Review of Resident 1's EHR did not show documentation of wound care training.Review of a document titled Medications discharged with Resident did not include a blood pressure, antidepressant, and insulin medications.Review of Resident 1's discharge packet document did not show discharge instructions, discharge summary, physician orders for wound care to the resident's right foot, did not show documentation of wound care training, no documentation of wound care supplies, blood pressure, antidepressant, and insulin medications sent with the resident upon discharge from the facility. In an interview on 03/05/2026 at 1:13 PM, CC1 stated they were not educated for wound care, and did not receive wound care supplies or insulin for Resident 1 prior to the resident discharging from the facility.In an interview and record review on 03/05/2026 at 11:57 AM, Staff C, Social Services, reviewed Resident 1's electronic medical record and acknowledged the discharge instructions and discharge summary were incomplete. In an interview and record review on 03/05/2026 at 12:19 PM, Staff D, Licensed Practical Nurse, Nurse Manager, acknowledged Resident 1's discharge instructions and discharge summary were incomplete. Staff D acknowledged the discharge packet showed no orders for wound care to the resident's right foot wound, no documentation of wound care training, no documentation of medications for blood pressure, antidepressants, and insulin provided at discharge. Staff D stated wound care supplies and insulin would not be sent with the resident upon discharge from the facility.In an interview and record review on 03/05/2026 at 1:42 PM, Staff B, Registered Nurse, Director of Nursing, stated discharged residents would sign and receive a discharge packet containing a discharge summary, discharge instructions, physician orders, prescribed medications, and wound care training and supplies. Staff B reviewed Resident 1's discharge packet and acknowledged the discharge summary and discharge instructions were not included, the form titled Medications discharged With Resident did not include blood pressure, antidepressant, and insulin medications and was not signed by the resident and did not show wound care orders for the resident's right foot wound or documentation of wound care supplies. Staff B stated there was no documentation of wound care training provided prior to discharge. Reference WAC 388-97-0120 (3)(a)

Based on interview and record review, the facility failed to ensure residents received scheduled hemodialysis (HD- a form of dialysis - an artificial filtration of waste products and excess fluid of the body from the blood using a machine with a special filter) treatment as ordered for 1 of 2 residents (Resident 1) reviewed for HD. Resident 1 experienced harm when they had volume overload (a condition where the body holds too much fluid) requiring hospitalization to intensive care unit due to missed HD treatments. This failure placed other residents that required HD at risk for unmet care needs, decline in medical condition and related complications.Findings included.Resident 1 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include end stage renal (kidney) failure and dependence on renal dialysis. In a telephone interview on 12/02/2025 and 11:30 AM, Collateral Contact 1 (CC1), stated the facility had not notified them that Resident 1 missed all scheduled HD treatment since admission. CC1 stated Resident 1 was unable to tolerate sitting in a wheelchair due to weakness and declining condition. CC1stated Resident 1 needed a closer HD center that provides a stretcher or bed during HD treatment. CC1 stated the facility did not do anything to accommodate Resident 1's needs and preferences to change transportation time or arrange a closer HD center. CC1 stated Resident 1 was admitted to intensive care unit on 11/27/2025 due to fluid retention from missed HD. In a telephone interview on 12/03/2025 at 2:36 PM, Resident 1 stated they canceled the scheduled HD while at the facility because they could not sit for five to six hours, and they needed a closer HD center that could provide a bed during HD treatment. Resident 1 stated they told [an unknown] facility nurse many times that they could not sit for more than two hours and needed to change to a closer HD center. Resident 1 stated the facility did not attempt to change the center or the transportation time. Resident 1 stated they were very upset they could not go to HD and ended up in the hospital in the intensive care unit. Resident 1 was still in the hospital at the time of this interview and stated they would not be returning to this facility. In a telephone interview on 12/02/2025 at 2:14 PM, CC2 stated Resident 1 was scheduled for HD on Tuesday, Thursday and Saturday every week had not attended the HD center since the end of October 2025. CC2 stated Resident 1 expressed they preferred a later transportation time and a closer dialysis center that could provide a bed during HD treatment. CC2 stated the facility never notified them when Resident 1 canceled or postponed their appointment and the facility never communicated with them about Resident 1's preferences or arrangement of a different time or location. CC2 stated they called the facility on 11/26/2025 and informed them that Resident 1 had not attended any HD treatment since the end of October [2025] and Resident 1 would lose their appointment spot. CC2 stated they had to reach out to the facility many times to identify where the resident was or if the resident was coming for dialysis.In an interview on 12/02/2025 at 2:29 PM, Staff E, Physician Assistant, stated they were not aware Resident 1 had not gone to any HD treatment since they readmitted to the facility until they were notified by the Social Worker [Staff B] on 11/27/2025. In an interview on 12/02/2025 at 3:09 PM, Staff B stated they were not aware that Resident 1 had missed all their HD treatment until the dialysis center called them. Staff B stated they were not aware of which staff member handled transportation arrangements or how to coordinate another HD center. Staff B further stated that they thought the HD center would find Resident 1 a closer HD center where a bed was provided. In an interview on 12/03/2025 at 1:17 PM, Staff D, Business Office Manager, stated they arranged Resident 1's HD transportation and they were not aware that Resident 1 preferred a different transportation time and center. Staff D stated they were not aware Resident 1 preferred a stretcher until the HD center notified Staff B on 11/26/2025. In an interview on 12/02/2025 at 3:31 PM, Staff C, Unit Manager, stated they were not aware that Resident 1 canceled their HD appointment. Staff C stated they were not aware Resident 1 had missed all the scheduled dialysis treatment until the HD center talked with Staff B. A joint record review with Staff C showed no documentation to show why Resident 1 had canceled their HD and no documentation of risk and benefit discussed with the resident, nor was there any notification to the provider and resident representative about missed HD treatment. Staff C stated they could not find documentation to show Resident 1's condition was monitored due to missed HD. Staff C stated they expected the nurse to document every time a resident missed their HD treatment and to notify the provider, resident representative, and facility management. Staff C further stated the nurse was to document the monitoring of edema (swelling caused by excess fluid trapped in the body's tissues), shortness of breath, change of blood pressure, and blood sugar, and discuss and document the risk and benefit with the resident and their representative. In a phone interview on 12/03/2025 at 2:49 PM with Staff A, Administrator, stated they expected staff to notify the HD center and the provider when residents missed their HD treatment, and to discuss the risk and benefit to the residents and/or their representative. Staff A stated they expected the staff to provide ongoing monitoring and medical management when residents missed their HD treatment and to coordinate rescheduling missed appointments.Review of Resident 1's November 2025 Medication Administration Record, showed Resident 1 had dialysis every Tuesday, Thursday and Saturday since 11/04/2025. Nurse documented 9 (refer to progress notes) on 11/04/2025, 11/08/2025, 11/11/2025 and 11/27/2025. Review of the progress notes on the above identified dates showed no documentation that HD was provided. Review of Resident 1's care plan revised on 11/10/2025, showed a focus care area of HD but there were no interventions regarding Resident 1's preferences on schedule and location, coordination between facility and HD center, and follow-up for missed HD treatment. In an interview on 12/02/2025 at 3:31 PM, Staff C stated there was no focus area for missing HD treatment in the care plan. Review of Resident 1's progress notes on 11/22/2025 at 3:23 PM, documented the resident missed HD treatment and was rescheduled for 11/24/2025. There was no documentation about arrangements being made or whether the resident had attended that session. Review of a progress note dated 11/11/2025 at 10:13 AM, documented that Resident 1 refused HD treatment. There was no documentation whether the HD center, resident or their representative or provider were notified, or if treatment was rescheduled. Further review of the progress notes from 11/01/2025 to 11/26/2025, showed no documentation about Resident 1's preferences on time or location, reasons for missed HD appointments, whether notifications were made to HD center, provider, the residents and their representative, and/or obtain ongoing monitoring and medical management for changes and any complications occurred for the resident. There was no documentation about what risks and benefits explained to the resident. Review of a hospital emergency room record dated 11/27/2025 at 11:40 PM, documented Resident 1 was lethargic (decreased consciousness), short of breath, and had low blood pressure and that Resident 1 had imminent deterioration and life-threatening condition, which required them to be admitted to intensive care unit for immediate medical intervention. Review of hospital physician's notes dated 11/28/2025 at 2:31 AM, documented that Resident 1's primary medical problems were volume overload likely due to missed HD. Review of a hospital physicians record dated 11/28/2025 at 2:51 PM, documented that Resident 1 had heart failure (the heart can't pump enough blood to meet the body's needs) likely due to missing HD. Reference WAC 388-97-1900 (1)

Based on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of range of motion (ROM) for 1 of 4 sampled residents (Resident 4) reviewed for ROM. Resident 4 experienced harm as evidenced by moderate pain and decreased functional ability due to the formation of a hand contracture (joint becomes fixed in place) which was not present on admit. The failure to not provide appropriate services/interventions for ROM placed other residents at risk of developing new contractures and/or worsening of existing contractures. Findings included.Review of the undated facility policy titled, Resident Mobility and Range of Motion, documented: During resident's comprehensive assessment, the licensed nurse identifies the resident's current joints ROM, limitation of movement, contractures, pain or other complications could cause or contribute to impaired ROM, underlying contributing factors to ROM such as neurological conditions, e.g. cerebral-vascular accident. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline and/or improve ROM. Interventions include therapies, the provision of necessary equipment, and/or exercises. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Resident 4 readmitted to the facility on [DATE] with diagnoses to include right hemiplegia and hemiparesis (one side weakness or inability to move) following stroke (damage to brain tissue). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 06/06/2025, the resident was cognitively intact, had no diagnosis of contracture or impaired joints, and received no restorative programs or therapies services. In an observation and interview on 08/13/2025 at 11:15 AM, Resident 4 stated they could not straighten out their fingers on their right hand. Resident 4 stated the facility had not provided any exercise or service for their hand and arm. Resident 4 attempted to open their right hand with their left but could not get the hand flat. The second, third and fourth fingers were bent in a fixed position. Resident 4 was observed to have their right elbow bent in a rigid position and held closely to their body and their right hand closed tightly in a fist. Resident 4 stated they could not use their right hand to press the buttons on the TV remote and the call light in the past but no longer was able to. Resident 4 stated it hurt when they tried to open their right hand or move their right elbow and shoulder. In an interview on 08/18/2025 at 9:25 AM, Resident 4 stated they had never had any restorative program or services on their right upper extremity (hand, wrist, elbow and shoulder). In an interview on 08/19/2025 at 9:17 AM, Resident 4 stated they asked to see therapist because they felt their “right hand and arm had more pain and was getting worse than half a year ago.” Resident 4 rated their right upper extremity pain was five on the scale of zero to ten. Review of Resident 4's physician note, dated 08/10/2025 at 1:49 PM, documented the resident had moderate risk for developing contractures if not receiving adequate therapy. Review of Resident 4's physician note, dated 08/13/2025 at 8:39 PM, documented the resident had moderate risk for developing contractures if not receiving adequate therapy. Review of Resident 4's care task list, print date 08/14/2025, showed Resident 4 had no restorative programs for upper body ROM or contracture. Review of Resident 4's care plan, print date 08/14/2025, showed no focus care area about limitation ROM or contracture management. Review of Resident 4's functional abilities and mobility care area assessment, dated 03/11/2025, showed no documentation about Resident 4's limitation of movement, pain or any other risks for complications and/or contributing factors to maintain or prevent a decrease in ROM and mobility. Review of Resident 4's Occupational Therapy (OT) evaluation, dated 03/02/2025, documented Resident 4 had no functional limitations present, no contracture and right upper extremity ROM and strength were WFL (within functional limits-indicate that range of motion is sufficient to perform the daily activities). Review of Resident 4's OT evaluation, dated 08/15/2025, documented Resident 4 was seen due to exacerbation of limited and painful movement and decrease in range of motion. The evaluation documented that the resident had right hand and elbow contractures, and right upper extremity ROM and strength were impaired. In an interview on 08/15/2025 at 12:51 PM, Staff GG, Nursing Assistant Certified (NAC), stated Resident 4 had contracture at right upper arm and could not open their right hand. Staff GG stated Resident 4 complained about pain in their right hand and arm during upper body dressing and repositioning. Staff GG stated the resident had no restorative programs for the contracture and ROM. In an interview on 08/18/2025 at 9:22 AM, Staff N, Licensed Practical Nurse (LPN), stated Resident 4 had a right upper extremity contracture but no restorative program for the right upper extremity. In an interview on 08/18/2025 at 9:30 AM. Staff II, Restorative aide/NAC, stated they did not have a restorative program for right upper arm for Resident 4, and they were not sure if the resident had contractures. In an interview on 08/18/2025 at 9:50 AM, Staff NN, Rehab Director, stated Resident 4 was never seen by therapy for their right upper extremity ROM or contracture prior to 08/15/2025. In an interview on 08/18/2025 at 9:55 AM, Staff RR, OT, stated they just started to see Resident 4 on 08/15/2025 for right hand pain, contracture, and decrease in ROM. Staff RR reviewed all the past therapy records and stated Resident 4 did not have documentation of having a right upper extremity contracture. In an interview on 08/18/2025 at 10:30 AM, Staff L, LPN/second floor Unit Manager, stated Resident 4 had the right upper extremity contracture. Staff L stated Resident 4 had no restorative program for the contracture. Staff L stated there was no care plan about the contracture and ROM. In an interview on 08/19/2025 at 2:53 PM, Staff B, Director of Nursing Services, stated they expected a resident with ROM limitation or contracture to be identified early, evaluated, treated and followed with restorative programs to maintain, improve or prevent further functional decline. Reference WAC 388-97-1060 (3) (d)

Based on observation, interview and record review, the facility failed to provide adequate supervision and/or failed to follow the resident's care plan to prevent accidents/falls for 2 of 3 residents (Resident 1 and 2) reviewed for injuries and accident hazards. Resident 1 experience harm when they received care while in bed without two staff assistance which resulted in a fall and the resident sustained a pelvic fracture, and Resident 2 experienced harm when they exited the facility unsupervised, was subsequently found by an Emergency Medical Technician (EMT) lying on the sidewalk next to the road and sustained a significant injury requiring a hospital admission. This failed practice placed residents at risk for elopement, falls, and injury. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include left hemiparesis (partial paralysis of left side of the body) and amputation (removal of body part) of the right leg above the knee (AKA). Review of Resident 1's care plan showed a focus area for assistance needed for activities of daily living (ADL- activities such as dressing, bed mobility, personal hygiene, and toileting) and mobility due to hemiparesis and AKA, initiated on 10/14/2022. The care plan showed a care approach for staff to use two persons assist for bed mobility, initiated on 08/15/2023. The care plan showed a focus area for bladder incontinence initiated on 01/30/2024, with an intervention the resident required for two staff assistance for toileting and incontinent care, initiated on 01/30/2024. Review of Resident 1's Kardex (list of resident's care needs), dated 05/10/2024, showed the resident required two persons assist with bed mobility and incontinent care. Review of a facility risk management system (incident report) document, titled fall, dated 05/10/2024, showed Resident 1 rolled off the bed while care was being provided and sustained a pelvic fracture. The summary showed the cause of the fall was due to Staff C, Nursing Assistant Certified (NAC), provided incontinent care with one staff assist, but Resident 1 required two staff to provide bed mobility and incontinent care. During an interview on 05/23/2024 at 1:40 PM, Staff C stated Resident 1 was laying on their side, facing away from them, while they provided incontinent care. Staff C stated the resident was lying still when they slid off the mattress and onto the floor. Staff C stated they had been performing incontinent care and bed mobility on Resident 1 by themselves for the prior three months and had not had any problems. Staff C stated the resident Kardex was where they checked for resident's care needs but stated they had not reviewed Resident 1's Kardex to see if any changed had been made. During an interview on 05/31/2024 at 1:25 PM, Staff G, Physical Therapist, stated Resident 1's physical abilities fluctuate. Resident 1 required one staff assist on their good days, but required two staff assist on their bad days. Staff G stated Resident 1's abilities varied when they were tired or more fatigued due to their medical condition. During an interview on 05/31/2024 at 1:40 PM, Staff B, Registered Nurse (RN)/Director of Nursing Services (DNS), stated Resident 1 would not have fallen off the bed if Staff C had been providing care with a second staff member. During an interview on 05/31/2024 at 2:29 PM, Resident 1 stated they required one staff assist at times and other times required two staff assist. Resident 1 stated they did not know what happened to cause them to roll off the bed, they stated I was just lying there and the next thing I knew I was on the floor. <RESIDENT 2> Resident 2 admitted to the facility on [DATE]. Review of the Minimum Data Set assessment (lists resident's abilities/deficits), dated 05/17/2024, showed Resident 2 had severe cognitive deficits. Review of the care plan showed Resident 2 was at risk for elopement and wandering, initiated on 05/13/2024. The goal statement was that the resident would not leave the building unattended through the next review date of 08/20/2024. The care plan showed Resident 2 had limited physical ability due to vision difficulties. The care plan showed staff were to supervise Resident 2 when walking in the facility, initiated on 05/12/2024. Review of Resident 2's Elopement Risk Assessment, dated 05/16/2024, showed the resident was at risk for elopement. A wander guard (alarm system that sounds if resident gets near an exit door) device was placed on the resident's ankle. Review of a facility risk management system document, titled Elopement, dated 05/28/2024, showed Resident 2 had been found outside of the facility, had a fall with major injury and was brought back to the facility by an EMT. The document showed Resident 2 thought they were on a boat and asked the staff when the boat would dock so they could go home. The document showed Resident 2 had severe cognitive deficits and a desire to exit seek. The root cause of the elopement showed Resident 2's room was close to the front door. The family had visited that day, and this could have triggered Resident 2 into wanting to go home. The resident may have left the facility behind a visitor as the automatic door did not close for 30 seconds after opening and the staff did not identify the wander guard alarm from the front door alarm. Review of Resident 2's hospital admission History & Physical, dated 05/29/2024, showed Resident 2 complained of right sided chest wall pain. The hospital records showed Resident 2 had six broken ribs and a collapsed lung on the right side. During an interview on 06/07/2024 at 9:47 AM, Staff D, RN/Unit Manager, stated Resident 2 was identified early in their stay that they were at risk of elopement, and a wander guard device was placed on them. Staff D stated Resident 2 was confused and thought they were in another state waiting to get on a boat. Staff D stated Resident 2 frequently wandered in the hallways and up to the front door. During an interview on 06/07/2024 at 11:20 AM, Staff B stated the facility found out about the elopement because an EMT had notified the facility that Resident 2 had fallen on the sidewalk. Staff B stated the facility was able to determine that Resident 2 left the facility through the front lobby door. Staff B stated they were not able to determine if the wander guard system did not alarm and the resident followed a staff person out the door, or if the wander guard did alarm and the staff silenced the alarm without checking for residents as it was change of shift and staff were leaving/entering the facility. Refer to WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer (PU) (bedsore)/pressure injury (PI), (localized damage to the skin and underlying soft tissue usually over a bony prominence) for 2 of 2 sampled residents (Resident 28 and 74) reviewed for PU's. The facility did not consistently complete comprehensive and accurate assessments, develop/update and implement person centered care plans to address the residents' risk factors for developing and deteriorating PUs, or monitor to ensure the implementation of care plan interventions. Residents 28 experienced harm when they were admitted without a PU and developed an unstageable (is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough, nonviable tissue, or eschar, dead tissue, obscures the wound bed) PU on their heel and placed all residents at risk for developing PUs/PIs and a decreased quality of life. Findings included . Review of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facility's, revised 02/02/2023, showed: -An avoidable PU is defined as a PU that developed in the facility and the facility failed to do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident's needs, goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. -A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. - A Stage III PU is a full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough (nonviable tissue) and/or eschar (dead of devitalized tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity (body fat) can develop deep wounds. Undermining (destruction of tissue or ulceration extending under the skin edges) and tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) may occur. <RESIDENT 28> Resident 28 was admitted to the facility on [DATE] with diagnoses that included a right periprosthetic knee fracture (a fracture above or around a total knee replacement) with an external fixation device in place (a metal frame with pins or wires inserted in bones to hold them together while healing,) Diabetes Mellitus (alteration in how the body uses sugar), neuropathy (numbness and pain from nerve damage) in their legs and feet, and Parkinson's disease (a disorder of the central nervous system that affects movement). Review of Resident 28's Admission Minimum Data Set (MDS- an assessment tool) assessment, dated 09/19/2023, showed the resident was cognitively intact, received extensive assistance of two staff members with bed mobility, required extensive two-person assistance with a mechanical lift for transfers, identified at risk for developing PU's, and currently had no PU's present. The Care Area Assessment (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned), dated 09/26/2023, showed the resident was at risk for developing PU's related to right knee fracture and required extensive assistance of two staff for bed mobility, and did not walk. Review of Resident 28's Care Plan focus/problem Alteration in Skin Integrity, dated 09/13/2023, showed Resident 28 was at risk for PU development related to (but not limited to) their right periprosthetic knee fracture with pain, and weakness. Interventions included to monitor nutrition and reposition the resident in bed with a draw sheet. Updated interventions, dated 9/26/2023, included use of a pressure reducing mattress and floating the resident's heels while in bed. Review of Resident 28's weekly skin observation assessment tools, dated 09/14/2023 to 10/05/2023, showed no new skin conditions or documentation of a current PU/PI. There was no weekly skin assessment tool found for 10/12/2023. Review of Resident 28's weekly skin observation assessment, dated 10/17/2023, showed the resident had a PU on the resident's left heel measured 4 centimeters (cm) by 2.8 cm. The wound was unstageable due to the presence of eschar. Review of a physician order, dated 10/17/2023, showed to ensure offloading (a way to redistribute pressure) device was placed to both of Resident 28's heels, a specific treatment to the left heel wound on Monday, Wednesday, and Friday and a referral to a contracted wound consultant company. Review of the facility incident investigation, dated 10/23/2023, showed Resident 28 had a left heel wound that was found on 10/16/2023 (date identified on the investigation). Review of Resident 28's Treatment Administration Record (TAR), initiated 10/29/2023, showed the nurse was to document every shift to ensure pressure offloading boots were in place to both heels. Review of the contracted wound consultant company initial assessment, dated 10/23/2023, showed Resident 28's left heel wound measured 5 cm by 3 cm and was covered with slough. Review of the contracted wound consultant company weekly assessment, dated 10/30/2023, showed Resident 28's left heel wound measured 4.5 cm by 3 cm in size and was covered with slough. Review of the contracted wound consultant company weekly assessment, dated 11/20/2023, showed Resident 28's left heel wound measured 4.5 by 3 cm with depth of 0.2 cm following debridement (removal of slough) of the wound. Records showed PU was a Stage 3 after the debridement. Review of the contracted wound consultant company weekly assessments from 11/20/2023 through 12/11/2023 showed no change in left heel wound size. During an interview on 12/07/2023 at 08:59 AM with Resident 28, stated they developed a sore on their left heel about a month ago from rubbing their heel on the bed when repositioning self while in bed. In an observation and interview on 12/11/2023 at 08:20 AM, Resident 28's left heel wound was observed with an adhesive bordered dressing in place. CC5 stated had just completed wound care and found left foot wound healing had stalled and would make recommendations for further diagnostic measures to promote wound healing. During a joint review of the incident investigation and interview on 12/13/2023 at 11:40 AM, with Staff A, Administrator, and Staff B, Director of Nursing Services, Staff B stated Resident 28's left heel PU was not present on admission and developed at the facility. Staff B stated the incident report did not show the PU was unavoidable. Staff B stated they did not offer use of offloading boot to Resident 28's left foot until after wound was found. 47104 <RESIDENT 74> Resident 74 was admitted to the facility on [DATE] with diagnoses to include severe protein calorie malnutrition (weight loss from not enough protein and calorie intake), adult failure to thrive (weight loss, poor appetite, nutrition, and inactivity), muscle wasting and atrophy (decrease in the size of the muscle), and anorexia (an eating disorder characterized by an abnormally low body weight). Review of Resident 74's Admission MDS assessment, dated 10/25/2023, showed Resident 74 was frequently incontinent of bowel and bladder, and there was no documented no PU's present upon admission to the facility. Review of the hospital discharge summary, dated 10/19/2023, showed Resident 74 admitted to the hospital with a coccyx wound, directions to the nursing home to follow standard nursing protocols for wound care to the coccyx wound, and a supplement twice daily to assist with wound healing. Review of Resident 74's facility admission orders, dated 10/19/2023, did not show wound care orders to the coccyx or a supplement, that were identified on the hospital discharge orders. Review of Resident 74's Admission Evaluation assessment, dated 10/19/2023, showed the resident had no skin issues. Review of Resident 74's Braden Scale for Predicting Pressure Ulcer Risk (a standardized, evidence-based tool to identify resident's risk for developing PU's), dated 10/19/2023, showed a score of 17, indicated the resident was at risk for developing a PU. Review of the skin at risk care plan, dated 10/19/2023, showed Resident 74 was at risk for skin breakdown. Interventions included education to the resident and caregiver on the importance of repositioning and nutrition. Review of the activities of daily living care plan, dated 10/19/2023, showed Resident 74 required one-person limited assistance for bed mobility and transfers, and one-person extensive assistance for toileting. Review of a provider note, dated 10/20/2023 at 8:23 PM, showed Resident 74 had an unstageable coccyx wound and was being seen by the in house wound care team. Review of a nursing progress note, dated 10/21/2023 at 1:59 PM, showed Resident 74 had blanchable (when there is a red ulcer that is pressed down and released, the redness goes away and then comes back) redness to their sacrum (bottom) and the nursing staff applied barrier cream. Review of a physician order dated, 10/22/2023, showed barrier cream applied every shift to blanchable redness to Resident 74's sacral (bottom) area. Review of a nursing progress note, dated 10/25/2023 at 9:36 PM, showed Resident 74 had an open area to their coccyx with a dressing in place. Review of Resident 74's TAR, dated 10/19/2023 through 10/25/2023, showed no wound care orders to the resident's unstageable coccyx wound. Review of a physician order, dated 10/26/2023, showed a referral to contracted wound consultant company to evaluate and treat Resident 74's wound if indicated. Review of the faxed referral to the contracted wound consultant company, dated 10/26/2023, showed Resident 74 had a wound to their coccyx and the acquired date was 10/25/2023 ?. Review of a physician order, dated 10/26/2023, showed an order for Resident 74 to have a low air loss mattress, a supplement daily, and wound care treatment daily was implemented. Review of a focus care plan interventions of an actual unstageable PU to Resident 74's coccyx, dated 10/27/2023, included to assess and document the coccyx wound, treatment per the physician orders, monitor nutrition, and monitor and report changes in the coccyx wound to the physician. Review of Resident 74's Braden Scale Risk assessment, dated 10/26/2023, showed a score of 13 which indicated the resident was at moderate risk for developing PU's. Review of Resident 74's weekly wound evaluation, dated 10/27/2023, showed the resident had a 1.5 centimeter (cm) by 1.0 cm unstageable skin tear to their coccyx (tailbone). Review of nursing note dated 10/31/2023 at 12:18 PM, Staff W, Registered Nurse (RN)/Unit Manager, documented Resident 74's was seen by the contracted wound care company evaluated Resident 74's coccyx. A new coccyx wound care order was implemented. Review of Resident 74's Braden Scale Risk assessment, dated 11/02/2023, showed a score of 12, indicating the resident was at high risk for PU development. Review of a risk review progress note, dated 11/02/2023 at 5:56 PM (eleven days after the wound was identified), Staff B documented Resident 74 had an unstageable coccyx wound which was identified on 10/21/2023 as blanchable redness to the resident's coccyx. Staff B documented through a review the resident was noted to have an unstageable coccyx wound when admitted to the facility. Review of a nursing progress noted dated 11/06/2023 at 7:30 AM, Staff W documented Resident 74 was evaluated and treated by Collateral Contact 5 (CC5), Advanced Registered Nurse Practitioner, from the wound care company. Review of a late entry nursing note, dated 11/07/2023 at 12:37 PM, Staff W, documented Resident 74's wound base had slough versus fibrinous (a protein found in plasma) tissue, no changes to wound care. Review of a late entry progress note, dated 11/14/2023, Staff W documented Resident 74's coccyx PU measured 1.6 cm by 0.5 cm by 0.1 cm. The wound base had slough versus fibrinous tissue and re-staged the PU to a Stage III. Review of a nursing progress noted, dated 11/20/2023 at 9:01 PM and 11/27/2023 at 10:59 AM, Staff W documented the resident was evaluated and treated by CC5, no changes to wound care. In an interview on 12/07/2023 at 11:03 AM, Resident 74 stated they had a wound on their bottom. Resident 74 stated the facility found the wound and have been providing treatments. observed lying on right side in bed. The resident stated they ensure they do not lie on their back, so the wound does not worsen. In an interview on 12/08/2023 at 9:30 AM, Staff HH, Nursing Assistant Certified (NAC), stated the resident had sore by her tailbone but was not sure if it was still there. Staff HH stated the resident was able to turn and reposition herself. In an observation and interview on 12/11/2023 at 7:45 AM, Resident 74's wound was observed with CC5, stated the coccyx wound was closed and blanchable. In an interview on 12/12/2023 02:26 PM, Staff B, stated the admission Braden was incorrect, and the resident was more at risk than the assessment showed. Staff B stated had the assessment, dated 10/19/2023, been accurate, the facility would have initiated more preventative measures. Staff B stated the resident had a PU prior to admission but had no treatment orders from the hospital. When asked about expectation for a new admission who is at risk for developing skin issues, Staff B, stated Resident 74 should have had an accurate skin assessment and an air mattress and other preventable measures should have been initiated. Staff B stated once the wound was identified the resident was referred to wound care company. Staff B stated the investigation did not show the PU was clinically unavoidable. This is a repeat deficiency from the Statements of Deficiencies, dated 06/10/2022 and 12/23/2022. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to ensure there was a system that provided pharmaceutical services (including procedures that effectively dealt with serious prescription discrepancies) that assured the accurate administration of all drugs and biologicals for four of five residents (4, 14, 1, 5) reviewed for safe and accurate medication practices. Resident 4 was harmed when they were administered 20x the intended dose of Oxycodone (a strong pain medication that affects mood/behavior and can be lethal in high doses) and had to be hospitalized . Several licensed nurses (LN), to include the only nurse manager, failed to verify the correct dose of the medication. LNs failed to correctly interpret physician orders and drug concentrations and failed to identify discrepancies in drug records. There was inaccurate documentation or missing documentation between the controlled substances records and the Medication Administration Records for the affected resident. Immediate Jeopardy (IJ) was called on 12/02/2022 at 2:35 PM, at F755 - Pharmacy Services/Procedures/Pharmacist/Records, when the facility was found to have inadequate pharmaceuticals procedures and record-keeping procedures in place and a resident had to be hospitalized when the facility administered the resident a single dose 20x the intended dose of Oxycodone (a potent opioid medication used for pain management). They removed the immediacy on 12/07/2022, by auditing medication records and educating licensed nurses on correct procedures for ordering and documenting medications, accounting for controlled substances, and ensuring licensed nurses were competent in performing medication dose calculations. Findings included . Review of the facility General Dose Preparation and Administration policy, dated August 2018, showed that, Prior to Medication Administration: Nursing Center staff should verify each time a medication is administered that it was the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. The Nursing Center staff should confirm that the Medication Administration Record (MAR) reflects the most recent medication order. Nursing Center staff should document the administration of controlled substances in accordance with applicable law. Record review of the policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, dated January 2022, showed when providing a written or verbal prescription to the pharmacy, the physician/prescriber should provide a verbal telephone order to the facility nurse or enter the order in the resident's electronic medical record. When submitting an E-prescription (electronic prescription) to the pharmacy, the physician/prescriber must also provide identical written or verbal chart orders to facility staff. Facility staff should immediately record the new orders in the resident's medical record and medication administration record. Upon receipt of medications from the pharmacy that have been electronically prescribed, facility staff should reconcile the medications received to the orders entered in the resident's medical record. Facility staff should notify the physician/prescriber of any identified discrepancies in electronically prescribed orders from the pharmacy and orders entered into the resident's medical record for resolution. RESIDENT 4 The resident admitted to the facility 11/18/2022 with diagnoses to include pancreatic cancer, secondary cancer to the liver, lungs and bile duct, abdominal pain, malnutrition, generalized weakness, and a need for assistance with personal care. In a phone interview on 12/01/2022 at 3:20 PM, Collateral Contact 1 (CC1), a family member of the resident, stated the nursing home had overdosed the resident on Oxycodone when staff gave them 200 milligrams (mg) instead of the 10-20 mg they were supposed to get. CC1 stated since the resident had terminal cancer and the overdose, they were probably never going to leave the hospital because their condition had deteriorated after the overdose. Review of Emergency Medical Service (EMS) records, dated 11/28/2022, showed when the medics arrived the resident had altered mental status and ineffective breathing. The medics administered Narcan (a lifesaving medication used to help reverse the effects of an opioid overdose), and the resident became responsive, and was transported to the hospital. The medics documentation showed their Primary Impression was Overdose - other opioids. Review of the resident's Skilled/Intermediate Nursing Facility Transfer Orders, dated 11/18/2022, showed the resident was ordered to receive Oxycodone 1mg/ml (milliliter) take 10 mls via J-tube (feeding tube) every 4 hours for abdominal pain (which equaled 10 mg per dose). Review of the resident's November 2022 Medication Administration Records (MARs) showed the admission order for Oxycodone that was to be scheduled, and not as needed, was transcribed and put on the MARs to be given every 4 hours, as needed. The order was transcribed and placed on the MARS to administer Oxycodone 100mg/5ml give 10ml via J-tube every 4 hours, which was a dose of 200mg. In an interview on 12/02/2022 at 4:01 PM, Staff K, Registered Nurse (RN)/Assistant Director of Nursing/Staff Development Coordinator/Infection Preventionist, stated when they had initially entered the resident's Oxycodone orders into the electronic health record, they may have clicked on the wrong line and may have pre-populated the wrong Oxycodone concentration. Review of an Order Audit Report for Oxycodone, dated 11/18/2022, showed Staff K, had initially entered the Oxycodone order into the electronic health record, then Staff CC, Agency Licensed Practical Nurse (LPN), confirmed the incorrect order, they confirmed Oxycodone Oral Concentrate 100mg/5ml give 10ml every 4 hours as needed, not the correct order from the hospital, which was for Oxycodone 1mg/ml take 10 mls scheduled every 4 hours. In a phone interview on 12/14/2022 at 10:10 AM, Staff CC, stated that a member of administration either Staff K, or the Director of Nursing, would enter admission orders into the electronic health record, then another nurse would confirm the admission orders with the prescriber and activate those orders. Staff CC stated the orders they confirmed were the paper orders, but they ended up being different than the ones entered into the electronic health record by a member of administration. In an interview on 12/02/2022 at 11:47 AM, the administrator stated Staff CC should have confirmed the orders the resident came with, not the orders staff had entered into the electronic health record. Review of an Order Audit Report for Oxycodone, dated 11/23/2022, showed Staff GG, Agency RN, revised the previous Oxycodone order, to change from every 4 hours as needed, to every 4 hours scheduled. In a phone interview on 12/14/2022 at 2:25 PM Staff G, Advanced Registered Nurse Practitioner, stated they gave Staff GG a verbal order to change the resident's as needed Oxycodone order to routine (11/23/2022). Review of the resident's orders on/about 11/23/2022, showed no documentation Staff GG had documented the verbal order from Staff G to change the resident's treatment with Oxycodone from as needed, to scheduled every 4 hours. In a phone interview on 12/13/2022 at 4:14 PM, Staff GG stated on 11/23/2022 they received a verbal order from Staff G to change the resident's order for Oxycodone from every 4 hours as needed, to every 4 hours scheduled. Staff GG stated there was no conversation at all about the medication concentration, that they kept everything the same except now it was a routine order, not as needed. Staff GG stated the facility policy was that verbal orders should be written down, then read back to the provider, which they didn't do, Staff GG stated it was their mistake. Review of a pharmacy bottle label dated 11/18/2022, showed the pharmacy supplied the nursing home with a 473 ml bottle of Oxycodone 5mg/5ml. In an observation and interview on 12/01/2022 at 11:21 AM, Staff GG, stated this was the bottle of Oxycodone the pharmacy initially supplied after the resident admitted to the facility. This was also the bottle the nurses used to administer the resident 50 doses of Oxycodone at 10 mg each, this was also what the nurses documented on the correlating controlled substances records, but these records did not contain all entries because multiple nurses failed to document on both the MARs and controlled substances records. Between 11/19/2022 - 11/28/2022, eight licensed nurses, including Staff Q, LPN, documented on the resident's MARs that they administered 200mg doses of Oxycodone on 50 occasions. In an interview on 12/06/2022 at 10:00 AM, Staff Q, LPN, stated they did not know they had documented on the resident's MARs they gave 200 mg doses, and then documented 10 mg doses on the controlled substances records. Staff Q stated they had not compared the orders on the MARs to the controlled substances records. Review of November 2022 MARS and controlled substances records showed three nurses on six occasions didn't document controlled substances on both the MARs and controlled substances records. In a phone interview on 12/12/2022 at 12:51 PM, when asked about the two doses of Oxycodone they had documented on the MARs, but not on the controlled substances records on 11/25/2022 at 4:00 PM and 9:00 PM, Staff FF, Agency LPN, stated they had not realized they forgot that. When asked if they realized the doses nurses had documented on the MARS at 200 mg was different than the 10mg doses they documented on the controlled substances records and was on the medication bottles, Staff FF stated they had not realized that, but thinking about it now, they thought that was where they all messed up. In an interview on 12/02/2022 at 11:47 AM, the Administrator stated that up until that last dose that sent the resident to the hospital, the staff had given the resident the right dose, except for their documentation in the MARs was not correct. Review of the resident's Oxycodone controlled substances records for November 2022, showed on 11/23/2022, the math regarding the on-hand quantity of Oxycodone was lacking, it went from 303 mls to 2903 mls, then 2803 mls, then 2703 mls. The last entry on the page showed an on-hand quantity of 173 mls, but then review of the next page showed staff started that page with 153 mls. Accountability and documentation of the resident's Oxycodone was inaccurate. In a phone interview on 12/12/2022 at 12:51 PM, when asked about the missing 20 mls of Oxycodone on 11/25/2022 when a new page was started on the controlled substances records, the new page started at a quantity of 153 mls, when the last page on the controlled substances records had 173 mls, Staff FF stated they hadn't been aware of that. Review of an incident investigation, dated 11/28/2022, showed Staff G, wrote a prescription dated 11/26/2022 for Oxycodone Oral Concentrate 100mg/5ml, give 10ml via J-tube every 4 hours for pain (this new prescription was for 200 mg doses). This order did not get filled by the pharmacy, but it did add to the confusion from the multiple orders. In a phone interview on 12/14/2022 at 2:25 PM, Staff G stated the problem was they had signed the Oxycodone order for 200 mg, but they had not read the whole thing. Staff G stated it was their mistake, that they should have caught that. Staff G stated they had given a copy of the order to a nurse, but they did not remember who they gave it to. Staff G stated the pharmacy did not fill that order for Oxycodone, that they thought an on-call provider had actually given the order for the Oxycodone that the resident had been overdosed on. Staff G stated the pharmacy had not contacted them for clarification regarding their 200 mg Oxycodone order. Review of a prescription, dated 11/27/2022, that the facility did not have in the resident's clinical record on 11/28/2022, showed Staff F, Physician's Assistant, wrote an order for Oxycodone Oral Concentrate 20mg/ml, take 1/2 ml every 4 hours (dose of 10mg). In a phone interview on 12/15/2022 at 1:00 PM, Staff F stated they didn't know which nursing home nurse called them for the order, but they assumed a nurse called for an Oxycodone refill and they gave them an order for the refill. Staff F stated they had been covering call duty and they got a call regarding a refill, and they had not treated that resident before. Staff F stated they gave an ePrescription that went directly to the pharmacy, and that no orders went back to the nursing home. Staff F stated No, when asked if they provided the nursing home with an identical written or verbal chart order to facility staff. Review of the resident's nursing home orders revealed no documentation of a verbal order from Staff F on/about 11/27/2022. Review of the resident's progress notes on/about 11/27/2022, showed no documentation a nurse had called Staff F for an Oxycodone refill. Review of an Oxycodone medication bottle/label showed the pharmacy did fill Staff F's Oxycodone order, dated 11/27/2022, it had 30 mls, or enough for 60 doses at 10mg/each. Review of a facility incident investigation, dated 11/28/2022, showed Staff FF questioned the situation with the new bottle of Oxycodone that indicated to give only 10mg (and not the 200mg that nurses had documented for 50 doses). Staff FF went to the Staff E, Director of Nursing (DON), who told them to contact the pharmacy for verification and for them to send additional doses since they only sent 30ml (enough for 3 doses at 10ml/dose). The investigation documentation indicated Staff FF did call the pharmacy and questioned as to why they only sent 30 mls if the order was to give 10 mls and asked why the order on the bottle was different from the order in the system. Staff FF stated the pharmacist/rep stated she was unsure but could send a larger supply on the night run. At 4:20 PM on 11/28/2022 Staff FF administered the resident a dose of Oxycodone at 200mg. At 5:00 PM the resident was found unresponsive and EMS was summoned who eventually gave the resident Narcan which was immediately effective, and the resident was then hospitalized . In a phone interview on 12/12/2022 at 12:51 PM, Staff FF stated the resident had been getting 200mg for over a week, so they questioned the new bottle that was labeled they were only to get 10mg, so they went to the DON because there was now only enough Oxycodone left for 3 doses and the resident was to get it every 4 hours. Staff FF stated the DON had not instructed them to clarify the order with the resident's physician/provider. Staff FF said when they called the pharmacy the pharmacist didn't raise any red flags, that they said that was strange, and that they had put them on hold to look into it, when they came back they said they would go ahead and send more and it would be on the night run. Staff FF said they told the pharmacy to be safe, to go ahead and fax them a copy of the signed order from the physician. Staff FF stated the pharmacy did fax the Oxycodone order from Staff G, ARNP, twice, because the first one didn't have the doctor's signature, so Staff FF called them again. Staff FF stated they were not sure who they talked to at the pharmacy, that it may not have been a pharmacist, but may have been just a pharmacist representative. Staff FF stated they did not document a progress note when they called the pharmacy. Review of email interview answers from Staff I, Consultant Pharmacist, dated 12/06/2022 showed: the pharmacy received a call from a nurse at 11/28/2022 at 4:09 PM. Nurse called insisting the dose was for Oxycodone 100mg/5ml: give 10ml or 200mg po q4h not 10mg po (by mouth) q4h. The pharmacy faxed clarification to the nursing home on 11/28/2022 at 4:31 PM to clarify order pharmacy fax cover sheet message: Doctor, please clarify: 10ml dose would be 200mg per dose. Review of the controlled substances records for November 2022 showed the nurse gave the resident Oxycodone 200mg on 11/28/2022 at 4:20 PM. In a phone interview on 12/12/2022 at 12:51 PM, Staff FF stated they did receive the fax and it was the order from Staff G, ARNP, to give 200mg doses, which was the same amount nurses had documented they had been giving the resident all week. Staff FF stated that was all the verification they needed, so they gave the resident 200mg as ordered. Then 30 minutes later when they checked on the resident, they found the resident semi-unconscious, and was still breathing, but barely. The medics arrived and gave Narcan and took the resident to the hospital. In a phone interview on 12/12/2022 at 11:28 AM, Collateral Contact 1, family member of Resident 4, stated Resident 4 had passed away the day prior (12/11/2022). In an email communication on 12/15/2022, Staff H, Executive Director of the pharmacy supplier/pharmacist when asked if there was a pharmacy protocol for immediate person to person notification for provider prescriptions that were so irregular they could result in a resident receiving a lethal dose of a medication, they answered they held the order for 100mg/5ml with a 10ml dose every 4 hours, and they reached out to the prescriber and followed appropriate protocol and no additional outreach was needed. Staff H stated there was a failure by the facility to reconcile new admission orders entered into the electronic health record to hospital discharge orders by two separate nursing staff, and they had recommended training on this topic for the nursing staff. In an interview on 12/02/2022 at 11:47 AM, the Administrator was asked about the Director of Nursing's (DON) involvement in the matter, they stated they believed the DON was asked about the issue as they were leaving the building, and per the nurse, the DON had instructed the nurse to call the pharmacy, but the nurse should have contacted the provider. The Administrator stated if there was an issue with an order, or if they were questioning the order, they need to contact the provider. Similar findings were noted for Resident 14 who experienced nine medication errors about 10 days earlier, when facility staff failed to reconcile the admission orders with the hospital discharge orders. RESIDENT 14 The resident admitted to the facility 11/08/2022 with diagnoses to include coronary artery bypass and grafting (surgical revascularization of blood vessels in the heart), diabetes, history of a stroke, heart failure, kidney disease, gastroesophageal reflux (acid reflux), and high blood pressure. Review of an incident investigation, initiated 11/09/2022, and not signed it was reviewed by any facility staff, showed there were multiple medication errors that occurred when the facility and pharmacy failed to ensure the resident only received medications as ordered on admission. On 11/09/2022 and 11/10/2022, the resident received doses of medications that had been discontinued on the admission orders, they received the wrong dose of another medication, and they did not receive another medication that had been ordered. Review of Staff H's email interview answers, received 12/20/2022 showed the pharmacy had supplied the nursing home with five medications that had been discontinued. The pharmacy was asked to provide a copy of the physician/prescriber orders the pharmacy used to justify supplying the nursing home with the discontinued medications and none was provided. Review of the resident's progress notes showed a progress note by Staff I, Consultant Pharmacist, dated 11/17/2022, that they had done a Medication Regimen Review (MRR), and irregularities were noted, but the only irregularity identified by Staff I was that the provider needed to clarify the indications for use of the Metoclopramide (a medication used to treat acid reflux), none of the multiple medication errors were identified. Review of Staff H's email interview answers (the ones requested of the consultant pharmacist on 12/10/1022), received 12/15/2022 showed they were asked about only identifying one medication irregularity on the MRR done 11/17/2022, and not the other nine, and whether they had identified those medication errors, they answered the MRR was a review of current orders at the time of review, and it was not a retrospective review of past orders, they didn't answer the question whether the consultant pharmacist had identified the multiple medication errors, this question remains unanswered. Further review of the facility incident investigation, dated 11/09/2022, showed Staff CC, Agency LPN, failed to correctly confirm admission orders with the prescriber, and the errors occurred, which was the same failure that occurred with Resident 4. In a phone interview on 12/14/2022 at 10:10 AM, Staff CC stated that the nurse (Staff GG, Agency RN) that entered the wrong orders in the electronic health record entered the home medication orders, not the admission orders that came with the resident to the nursing home when they admitted to the facility. Staff CC stated they had missed a step when confirming the admission orders because they went out of order. When they confirmed the resident's paper admission orders, they were different than the ones that another nurse had already entered into the electronic health record which they stated were home orders, so the wrong orders got activated. Staff CC stated that they remembered that there were quite a bit of errors. In a phone interview on 12/16/2022 at 8:58 AM, Staff D, Medical Director, stated that they thought nine medication errors was significant. RESIDENT 1 The resident admitted to the facility 08/18/2020 and had diagnoses to include Parkinson's disease. Review of the November 2022 MARs showed the resident had an order for morphine (medication used to treat pain) for pain. Comparison of the documentation of medication administration on the MAR and the controlled substances records showed documentation irregularities as follows: According to the MAR the resident was administered morphine on 11/19/2022 at 12:00 PM, but there was no corresponding entry in the controlled substances records. Similar findings were noted for the dose administered 11/21/2022 at 12-midinght and another dose at 4:00 AM. In addition, a dose administered on 11/20/2022 at 8:00 AM, was not given within the facility's accepted guidelines of 1 hour before/after the scheduled dose. The controlled substances records showed it was given at 10:13 AM, then, per the controlled substances records, the next dose was given at 12:36 PM (2 hours and 23 minutes later), though the order was for it to be given every 4 hours. Review of documentation provided by the Administrator on 12/22/2022 regarding these morphine administration irregularities, showed these irregularities did in fact occur. RESIDENT 5 The resident admitted to the facility 09/22/2022 and had diagnoses to include nasopharyngeal cancer status-post chemoradiation (treatment for cancer) and chronic pain. Review of the resident's Lorazepam (controlled substance sedative medication being given to the resident for anxiety and nausea) documentation from 11/01/2022 - 12/04/2022, showed there were nine irregularities. The controlled substances records indicated one tablet of Lorazepam was administered on 11/02/2022 at 6:35 AM, but the dose was not documented on the MARs. Similar findings were noted on 11/06/2022 at 7:30 AM, 11/12/2022 at 12:00 PM, and 11/14/2022 at 8:00 AM. On 11/27/2022, controlled substances records indicated four doses administered, but the MARs indicated only three doses for that day. Review of the controlled substances records showed one tablet was administered on 11/19/2022 at 6:00 AM or 7:00 AM (the documentation time was illegible), and this dose was not documented on the MARs. A 11/27/2022 entry on the controlled substances record had no time listed, it was blank. The MARs did have a documented time of 11:38 PM. The controlled substances records indicated one tablet of Lorazepam was removed on 11/07/2022 at 6:50 AM, another entry reflected another tablet taken out at 6:00 AM. The 6:00 AM dose did not get documented on the MARs. Documentation regarding this dose was provided by the Administrator on 12/23/2022 showed the 11/07/2022 6:00 AM dose actually had an incorrect date documented; it should have been 11/08/2022. Similar findings were noted on 11/28/2022, where the MARs indicated dose given at 9:54 PM, but the date on the controlled substances records indicated 11/27/2022. Review of documentation provided by the Administrator on 12/23/2022 indicated these discrepancies did exist, and the Administrator provided the names of the nurses that failed to document controlled substances and medication administration properly. FACILITY PHARMACY/PHARMACEUTICALS RECORDS Review of Controlled Substances Record Book, for the 1st floor Schedule III Green Book number 1, on 12/01/2022 at 1:00 PM showed from April 2022 - 12/01/2022, there were well over 100 shifts in that one controlled substances book where nurses that failed to document they conducted joint nurse controlled substances inventories as required. Review of the 1st floor controlled substances record book schedule II, yellow book, on 12/06/2022 at 7:30 AM, showed Staff L, RN, had not yet signed the book that they had conducted a joint controlled substances inventory that shift. In an interview at 7:30 AM, Staff L stated they forgot to sign the book. Review of the 2nd floor controlled substances record book schedule III, book III, on 12/07/2022 at 8:45 AM, showed no nurse had yet signed they did a joint controlled substances inventory with the other nurse who made a scribble mark for their Signature 1 that shift. Investigation revealed the staff member that had not yet signed was Staff R, LPN. The same issue was found with controlled substances record book II, Blue 2nd floor, schedule II, as Staff R also failed to sign that book that they had done a joint controlled substances inventory at the beginning of their shift that day. Review of the 2nd floor schedule III, Book number 8, green book, on 12/02/2022 at 8:10 AM, showed that Staff N, LPN, had already pre-signed the 3 PM-11 PM shift documentation that they had already conducted an evening shift joint nurse controlled substances inventory. Review of the consultant pharmacist's, Staff I, Physician Order Transcription Audit for active residents' irregularities, dated 12/05/2022, showed they identified 13 occasions where the narcotic order was not transcribed accurately in PCC (PointClickCare - electronic health record), 22 times the narcotic order in PCC did not match the controlled substances record, 21 times the PCC narcotic order did not match the medication card or the narcotic bottle. There were many notes that indicated follow-up was necessary. Review of Quality Improvement: Consultant Pharmacist Summary report for June 2022 showed: -Controlled substances documentation: 06/16/2022 pink cart 2nd floor - narcotic ledger entry not always cross match with MAR, 05/19/2022: green cart 2nd floor - a few ledger book pages not complete with missing Rx (prescription) number and missing full directions, 04/29/2022: green cart first floor - narcotic ledger book not cross matched with MARs, 03/17/2022: 2nd floor blue cart - missing Rx # on count sheet and please write out full directions (avoid using see MAR,) narcotic ledger entries not always cross matched with MAR. Routine and PRN (as needed) dose given less than 10 minutes after routine dose administered-please review with nursing to wait 4 hours before giving additional Oxycodone. 02/24/2022: 1st floor yellow cart and green carts - missing full directions, Rx number, two sets of signatures (nurse/POA or resident) when narcotics sent home. Narcotic ledger entries not cross-matched with MAR. The time signed out in MAR not always after signing out in ledger book. Observed times in MAR before signing out ledger book. Wasted narcotics need to be witnessed by a second nurse, on 02/13/2022 a residents Norco was wasted without a 2nd witness. Review of Quality Improvement: Consultant Pharmacist Summary report for July 2022 showed: -Controlled substances inventory was reconciled according to facility procedures: -03/17/2022: 2nd floor blue cart book - missing signatures on 2/17, 2/25, 2/12 on C2 book, and 3/3 on C3 book; Green cart book -missing signatures on 3/10, 3/4 C2 book, and 3/15, 3/16, 3/5, 3/4, 3/3, 3/1 on C3 book, -02/24/2022: 1st floor yellow cart and green carts - missing set of signatures (yellow - missing 2/1, 2/2, 2/7, 2/11, 2/15; and green - missing 2/6, 2/11, 2/12, 2/20, -01/28/2022: 2nd floor green cart; missing set of signatures on 1/26, 1/25, 1/21, 1/15, 1/14, 1/13, 1/12, 1/10, 1/5, 1/3 - C2 book. -similar other findings as with June 2022 report. Review of Quality Improvement: Consultant Pharmacist Summary Reports for August, September, October, and November 2022 had similar findings as with June and July 2022. Reference: (WAC) 388-97-1300 (1)(b)(i, ii)(c )(i-iv)(3)(a)(4)(a)(i)(d) See related citations: F835 - Administration

Based on interview and record review, the facility failed to ensure the facility was administered in a manner that used its resources effectively and efficiently so residents could attain or maintain their highest practicable physical, mental and psychosocial well-being and to ensure the facility maintained substantial compliance with state and federal regulations. The Administration failed to ensure there was active and engaged oversight and monitoring of systems related to Abuse/Neglect, Pressure Ulcers, Pharmacy Services, Hospice Services and Resident Records. These failures caused residents to have unmet care needs and caused harm to residents. Immediate Jeopardy (IJ) was called on [DATE] at 6:10 PM, at F835 - Administration, when the facility failed to ensure the nursing home was staffed and managed to address the significant clinical needs and quality of life and quality of care needs for residents. Residents had unmet needs in multiple care areas to include pressure injury/ulcer care/prevention, urinary catheterization, dressing changes, hospice care, pharmaceuticals processes, skilled nursing staff supervision/administration, inaccurate/incomplete/altered clinical records, and failures in investigating allegations of abuse. They removed the immediacy on [DATE] by establishing procedures for Director of Nursing coverage, updating hospice resident care plans and designating Facility hospice representatives, auditing narcotics medications and orders for accuracy, reviewing grievances and facility patient protection practices, reviewing the facility's operational systems, auditing residents with catheters and pressure ulcers, educating nurses and nursing assistants, and reviewing medication errors. Facility administration failed to ensure and provide administrative oversight and consistent nursing supervisory oversight of facility personnel, practices and policies regarding pharmaceuticals. The failure to provide oversight resulted in an Immediate Jeopardy (IJ) for CFR 483.45, F755 - Pharmacy Services/Procedures/Pharmacist/Records when the facility was found to have inadequate pharmaceuticals procedures and record-keeping procedures in place and a resident had to be hospitalized when the facility administered the resident a single dose 20x the intended doses of Oxycodone (a potent opioid medication used for pain management). Findings included . In an interview on [DATE] at 9:20 AM, the Administrator was asked who was in charge of the nursing department while the Director of Nursing (DON) was out of state, they answered they were, and they would get hold of Staff J, Agency Registered Nurse (RN)/Nurse Manager, or Staff K, RN/Staff Development Coordinator (SDC)/Infection Preventionist (IP) if necessary, as both staff were also assistant DONs. The Administrator did not ensure that a qualified nurse was in charge (overseeing) of the nursing department. In an interview on [DATE] at 11:38 AM, Staff K, RN/SDC/IP, stated there was no established facility procedures for how licensed nurses would know who to contact for urgent nursing matters after hours, but staff could call them. Staff K stated they did not know who was on-call after hours for nurses who needed a DON for urgent nursing matters while the DON was currently out of state. Staff K denied they were ever told they were a DON designee, that they were on-call for the facility, or they were ever told they had on-call duties at all. Staff K stated staff could call the Administrator if they needed to speak with a DON for urgent nursing matters. Staff K stated they also had another job working for an agency as a floor nurse, and just that weekend they worked Saturday and Sunday nights at another nursing home for the agency while the DON was out of state, and they had worked the past Tuesday night for an agency as well. Staff K stated they could ask the Administrator who was on-call the previous weekend. In an observation on [DATE] at 12:10 PM, Staff K was standing outside the Administrator's office and was observed to tell the Administrator the surveyor wanted to know who was the on-call for licensed nurses to contact over the weekend for nursing matters. The Administrator was overheard to tell Staff K to tell the surveyor that they had been on-call this past weekend. The Administrator was asked about their DON designee working at another facility while on-call for this facility, and while the facility was currently in a COVID outbreak, and while the facility residents were still in immediate jeopardy for inadequate pharmaceuticals procedures, the Administrator did not respond. Review of a Controlled Substances Record Book, for the 1st floor Schedule III Green Book number 1, on [DATE] at 1:00 PM showed from [DATE] - [DATE], there were well over 100 shifts in that one controlled substances book where nurses had failed to document they conducted joint nurse controlled substances inventories as required at the beginning of each shift. Review of an incident investigation, dated [DATE], showed the facility had caused multiple medication errors for Resident 14 when staff failed to accurately confirm physician orders on admission. Facility nurses administered five medications that had been discontinued on the admission orders, and they didn't administer a medication that had been ordered, and they administered an incorrect dose of another medication. The investigation was not thorough, and it lacked witness statements from involved staff, there was no reporting done, and the incident was not logged on the incident reporting log, and the incident was not documented in the resident's clinical record. There was also no documented review of this incident, as no staff had signed they reviewed the incident investigation. The facility failed to monitor the staff/failed pharmaceuticals processes that had caused the multiple medication errors, and they failed to protect other residents from their staff and the failed facility processes. The same staff member that failed to accurately confirm the resident's medication orders on admit, then also failed to accurately confirm Resident 4's admission orders on [DATE], when that resident admitted to the facility. Review of an incident investigation, dated [DATE], showed Resident 4 was harmed when the facility administered them a dose of Oxycodone that was 20x the intended dose, and they had to be hospitalized and later expired. The same nurse that failed to properly process Resident 14's admission orders also failed to accurately confirm Resident 4's admission medication orders. The administration's failure to address Resident 14's medication errors and to monitor staff/processes to ensure the incident wasn't repeated resulted in harm to Resident 4. This investigation was also not thoroughly investigated, and it was also not reported as required. Review of an incident investigation, dated [DATE], showed Resident 2 had new skin issues on their feet. The investigation was incomplete as it lacked witness statements, it failed to document what the facility was going to do to correct the matter to ensure it did not happen again, and it lacked review by the Administrator and Medical Director. Review of an incident investigation, dated [DATE], showed Resident 2 had additional new skin issues on the back of their legs. The investigation was incomplete as it lacked witness statements, it failed to document what the facility was going to do to correct the matter and to ensure it did not happen again, and it lacked review by the Administrator and Medical Director. In a phone interview on [DATE] at 12:20 PM, Staff B, Regional Director of Operations Senior Care/Governing Body, stated the primary responsibility for reviewing incidents/investigations was with the Administrator, Director of Nursing, and the Medical Director. In an observation on [DATE] at 10:30 AM, Resident 2 was observed to have six skin injuries to include a sacral pressure injury, a pressure injury on the left posterior hip, a pressure injury on the lateral side of the left ankle, a pressure injury on the left heel, a pressure injury on the right heel, and a pressure injury on the posterior, midpoint aspect of the right lower leg. In observations and interview on [DATE] and [DATE], the resident was observed to not be repositioned, had no pressure relief interventions in place for their heels, and no Prevalon boots were being put on the resident. In interview, staff stated they didn't know if the resident had Prevalon boots or if they were care planned to wear them, staff stated they didn't know the resident because they had been moved to this new room recently. Review of Resident 2's census information showed the resident had moved to their new room on [DATE]. Review of an incident investigation, dated [DATE], showed Resident 1 had a new sore to their right heel. The investigation was not thorough, and it lacked review by the Administrator and Medical Director. Review of a Concern Form, dated [DATE], showed a hospice provider had reported to the DON that Resident 1's spouse was concerned the resident was always laying on their back, and that a urinary catheter had not been inserted as coordinated with staff, and a wound dressing change order had not been followed by staff. The facility failed to identify the allegation as potential abuse/neglect and investigated those allegations as a concern, or as a grievance. The concern/grievance did not get thoroughly investigated, reported properly, or logged properly. Review of Resident 1's Skilled Nursing Facility and Hospice Service Agreement, dated [DATE], and signed by the Administrator, did not get implemented, as the agreement called for the facility to designate a facility representative to coordinate care with hospice staff. Review of two other hospice resident's Skilled Nursing Facility and Hospice Service Agreements, Residents 2 (dated [DATE]) and 5 (dated [DATE]), both of which were signed by the administrator, did not get implemented either as the facility had failed to designate facility representatives to coordinate care with hospice staff. In an interview on [DATE] at 11:52 PM, Staff J, Agency RN/Nurse Manager, stated there were currently three residents in the facility (1, 2, 5) that were on hospice, and none of them had a designated Facility representative to coordinate hospice cares. RESIDENT 3 On [DATE], a review of the resident's [DATE] Treatment Administration Records (TARS), showed documentation starting on [DATE] for a treatment: Sacrum, one time a day every Mon, Wed, Fri for PI (pressure injury) NS (normal saline) cleanse, skin prep to periwound (around the wound) and allow to dry, protect with bordered foam dressing. There was documentation this was done on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] a review of the resident's [DATE] TARs showed someone had changed the sacral treatment documentation retroactively back to [DATE] and all of the dates following to include [DATE], [DATE], [DATE], [DATE], and [DATE], they now reflected: Sacrum, one time a day every Mon, Wed, Fri for PI, NS cleanse, skin prep to periwound and allow to dry, Medi-honey to wound base, protect with bordered foam dressing. In an interview on [DATE] at 3:34 PM, Staff J stated that yesterday they called and got a verbal order to add Medi-honey, and they updated the previous order instead of cancelling it and entering a new one. Staff J was asked where they documented the verbal order, they stated they didn't specifically document the verbal order, that they went into the electronic health record and revised the previous order. Staff J was asked where they had documented the verbal order and the identity of the prescriber for that verbal order, they stated they hadn't documented that information. Joint review of the TARs showed that Staff J had retroactively changed the previous order to [DATE], Staff J was unable to provide any information about that. Joint review of the resident's progress notes from the day prior showed there was no documentation Staff J had called the provider to get the new order. The new order showed up in the electronic health record that it was given by Staff NN, Physician, but Staff J stated Staff OO, ARNP, gave that new verbal order. In a phone interview on [DATE] at 9:00 AM, Staff D, Medical Director, was unable to speak to how they had helped the facility with implementation of resident care policies or ensuring physicians/providers were knowledgeable and compliant with pharmacy prescribing policies. The Medical Director was also unable to state how they had reviewed incident investigations or how they had helped protect residents from staff that didn't follow facility policies and had committed the same medication errors with different residents. The Medical Director was also unable to state how they had provided medical direction to the facility regarding what types of incidents they wanted to be made aware of, except the medical director did state they had told the facility they wanted to be made aware of medical errors. Resident 14's medication errors were discussed with the Medical Director, the Medical Director stated they had not provided medical direction on that one. The Medical Director stated the facility had not notified them of the significant medication error for Resident 4 until four days after the resident was hospitalized . The Medical Director was not aware of the pharmacy policy for ePrescriptions that indicated prescribers were to also send identical hard copy or verbal orders back to the facility after they had submitted ePrescriptions directly to the pharmacy. Reference: (WAC) [DATE] (1)(2)(b)(i, ii)(7)(b) See related citations: F607 - Develop/implement abuse/neglect Policies F684 - Quality of care F755 - Pharmacy services/procedures/pharmacist/ records

Based on observation, interview and record review, the facility failed to ensure two of three residents (2, 1) reviewed for pressure injuries, received care planned interventions including applying pressure-relieving boots, offloading their heels, and repositioning, and staff failed to use careful and gentle resident-handling techniques, and to ensure uninterrrupted care and services after a room move, and to perform dressing changes as ordered and to insert a urinary catheter as ordered. Resident 2 was harmed when they experienced pressure injuries that didn't heal, and which resulted in them developing new pressure injuries, and Resident 1 was harmed when they developed a pressure injury and worsening of the pressure injury due to staff failing to implement their plan of care. Findings included . RESIDENT 2 The resident admitted to the facility on [DATE] and had diagnoses to include dementia, osteomyelitis (inflammation of bone caused by infection) of a sacrum (shield-shaped bony structure that is located at the base of the back and is connected to the pelvis) pressure injury, a Stage IV (Stage IV = full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) sacral pressure injury, uropathy (blockage in the urinary tract), a communication deficit, and aphasia (a disorder that affects how a person communicates). According to the quarterly Minimum Data Set assessment, dated 08/25/2022, the resident had no cognitive impairment, required 2-person assist with bed mobility and toileting, no transfers had occurred, and was totally dependent on staff for bathing. Review of Resident 2's wound healing progress notes, dated 10/03/2022, showed the resident had one wound, a Stage IV sacral pressure injury. Review of an incident investigation, dated 10/13/2022, showed Resident 2 had new pressure injuries on their feet, and that staff were using Prevalon (pressure-reducing boots) boots for pressure relief. Review of an incident investigation, dated 10/21/2022, showed Resident 2 had developed new skin issues on the back of their legs. Review of the resident's KARDEX (care directives for nursing assistants), copy date 11/28/2022, showed there were multiple interventions listed for encouraging and assisting the resident to reposition to offload pressure, and to apply the pressure-relieving boots. In an observation on 11/28/2022 at 10:30 AM, Resident 2 was observed to have six skin injuries to include a sacral pressure injury, a pressure injury on the left posterior hip, a pressure injury on the lateral side of the left ankle, a pressure injury on the left heel, a pressure injury on the right heel, and a pressure injury on the posterior, midpoint aspect of the right lower leg. In an observation on 11/28/2022 at 12:15 PM, the resident had no pressure-relieving boots on their feet. In an observation on 11/28/2022 at 1:42 PM, the resident was laying on their back in bed, their heels were directly on the bed, and they had no pressure-relieving boots on their feet. In an interview on 11/28/2022 at 2:05 PM, Staff U, Nursing Assistant, stated the resident didn't tolerate being positioned on their sides. Staff U stated they did not know if the resident had any pressure-relieving boots, and they didn't know if the resident was on any turning/repositioning program. In an observation on 11/29/2022 at 7:15 AM, the resident was observed laying on their back in bed, they had a pillow under their knees, their heels were directly on the bed, and they were not wearing pressure-relieving boots. The resident stated they needed help because their back hurt. In an interview on 11/29/2022 at 7:18 AM, Staff V, Nursing Assistant, stated they did not know if the resident had pressure-relieving boots because the resident had recently moved to their current room from another room and they didn't know them yet. Staff V looked in the resident's closet, and they pulled out a large blue padded pressure-relieving boot, they stated they would put it on the resident. Staff V was asked about the resident being positioned on their back; Staff V was unable to provide any information. In an observation on 11/29/2022 at 7:54 AM, the resident was still positioned on their back and was not wearing any pressure-relieving boots. In an observation/interview on 11/29/2022 at 7:58 AM, Staff V stated the resident rarely got out of bed because their bottom was sore. The resident stated they didn't get out of bed because of their back. The resident was asked if they were going to get out of bed that day, they stated they didn't know. In an observation on 11/29/2022 at 8:50 AM, Staff V and Staff W, Nursing Assistant, did incontinent cares for the resident, and they changed the resident's bed linen. After changing the resident's bed linen, Staff W was observed to give several strong yanks and pulls on the bottom sheet to straighten it out while the resident was on their back. Staff W was asked if they had any concerns of the resident's skin shearing, they did not provide any information. Staff V and Staff W put a pressure-relieving boot on the resident's right foot, then they started covering the resident with blankets. They were asked if the resident had a pressure-relieving boot for the left foot, they looked and found another pressure-relieving boot in a plastic bag that was in another large plastic bag and laying on the floor in the corner of the room, and they placed it on the resident's other foot. The staff were observed to turn the resident slightly to their left with a pillow behind their back. The staff stated they didn't know the resident because they were new to them because of the recent room change. In an observation on 11/29/2022 at 11:05 AM, the resident was observed to be still in bed and still laying on their left side, and they were still wearing the pressure-relieving boots. In an observation on 11/29/2022 at 1:45 PM, the resident was observed laying on their back in bed, and was still wearing the pressure-relieving boots. In an interview on 11/29/2022 at 1:59 PM, Staff J, Agency Registered Nurse (RN)/Nurse Manager, stated the resident had refused to wear the pressure-relieving boots in the past. Staff J was asked for documentation regarding the resident's refusal to wear their boots, Staff J looked in the computer and stated they couldn't find any. Staff J then stated the facility had recently run out of pressure-relieving boots. Staff J was asked how they ensured uninterrupted resident cares when residents had room moves, they were unable to provide any information. Review of the resident's census information showed they had moved to their current room on 11/22/2022, and they had previously been in a room down a different hall on the same floor. In an observation on 11/30/2022 at 7:40 AM, the resident was observed lying in bed on their right side and they were wearing their pressure-relieving boots. In an observation on 12/01/2022 at 9:05 AM, the resident observed in bed and wearing their pressure-relieving boots. RESIDENT 1 The resident admitted to the facility on [DATE] and had diagnoses to include dementia, history of a stroke, and Parkinson's disease (a disorder of the nervous system that affects movement, often including tremors). According to the quarterly Minimum Data Set (MDS) assessment, dated 05/24/2022, the resident had moderate cognitive impairment, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers, had no unhealed pressure ulcers, and required 2-person assist with bed mobility, transfers and toilet use. Review of a Concern Form, dated 11/18/2022, showed Staff XX, Hospice RN Case Manager, made an allegation to the Director of Nursing (DON) that the facility had failed to follow the Hospice Plan of Care as coordinated with facility staff, regarding a urinary catheter had not been placed as coordinated, a wound dressing change order had not been followed, and that the resident's spouse had voiced concerns that when they visited, the resident was always laying on their back. Review of Hospice RN Visit Provider Notes, dated 11/14/2022, showed the resident had a decubitus ulcer (pressure injury) on their sacrum that the Facility nurse manager reported had happened over the weekend, Review of Hospice RN Case Manager visit notes, dated 11/18/2022, showed: Upon arrival, the patient did not have a urinary catheter inserted per the Plan of Care, so the Hospice RN Case Manager inserted it and they had a discussion with the DON (Director of Nursing) as to why the urinary catheter wasn't inserted on Monday (11/14/2022) when the Facility received orders and when the Facility Nurse Manager, Staff J, Agency RN/Nurse Manager, had stated their staff would insert the catheter. Upon arrival the patient was found on their back in bed, the pressure ulcer on the resident's sacrum had significantly increased in size, it had eschar (dead tissue that eventually sloughs off healthy skin after an injury) with drainage that was brownish in color and had a foul odor. The patient still had a Mepiplex bordered dressing in place (even though orders were changed to betadine and cover with ABD (a type of dressing). Review of a progress note, dated 11/21/2022, showed: the resident's wound to the sacrum measured approximately 5.5 x 4.6 centimeters with 100% eschar, and had no drainage. In a phone interview on 11/29/2022 at 12:05 PM, Staff XX, Hospice RN Case Manager, stated they had given the Facility Hospice orders for wound care, but they (Facility staff) did not want to follow them because they were concerned the resident would be wet from urine, so they got a Hospice order for a urinary catheter to be inserted, and they faxed it to the Facility, and even offered to come in and insert the urinary catheter, but they (Facility staff) stated all they needed was the order. Staff XX stated then when they returned to the Facility at the end of the week, the urinary catheter had not been inserted and the Facility had not notified Hospice that the catheter had not been inserted or that the Facility had not followed the Hospice wound care orders either. In a phone interview on 11/29/2022 at 1:15 PM, Staff XX stated they knew the order for dressing changes did not get implemented timely because when they came into the facility on [DATE] they saw a dirty foam dressing on the resident's bottom. Staff XX stated earlier that week they had talked to Staff J about the dressing change and catheter being inserted, and during the week had also talked to Staff R, Licensed Practical Nurse (LPN), who had told them they didn't have the correct size of catheter, and that Staff XX offered to bring one in. Staff XX stated had Hospice been notified the Facility did not obtain and insert the catheter, they could have brought the correct-sized catheter in. In an interview on 11/30/2022 at 11:29 AM, Staff R, LPN, stated the resident's wound was not getting better which is why the Hospice wanted a catheter. Review of the resident's Treatment Administration Records, for November 2022, showed an order: Non-stageable Pressure Ulcer to Sacrum: pain with betadine, allow to air dry, cover with ABD pad and secure with minimal tape every other day, Use skin protectant under tape and around the wound. If intact necrotic tissue sloughs (was removed) off or for any other changes, contact Hospice 24-hr nurse one time a day every other day for Sacrum wound. This order was signed off as done by Staff M, RN, on 11/15/2022 and 11/16/2022. In a phone interview on 11/30/2022 at 2:12 PM, Staff M, RN, stated they didn't want to use the ABD dressing because the resident was incontinent and it would get saturated and they didn't want it to get wet. Staff M stated they didn't want to put plastic tape on because they've seen people blister, so they didn't use the ABD dressing, they used an Optifoam dressing instead (on 11/15/2022 and 11/16/2022). In a phone interview on 11/30/2022 at 2:22 PM, Staff O, LPN, stated they had applied an Optifoam dressing on the resident that week because the other dressing had come off. Staff O stated they had not checked the current dressing order and didn't call Hospice for an order, they just covered the wound with a foam dressing. In a phone interview on 12/01/2022 at 9:20 AM, Staff XX, Hospice RN Case Manager, stated the Facility never called them back and they never implemented the dressing change orders and they never implemented the catheter orders, and they never contacted them that they never implemented the orders. Staff XX stated they didn't want to get anyone in trouble, but there needed to be better care. Staff XX stated the dressing that was on the resident when they returned to the facility had been very soiled and the wound was significantly worse, it was bigger, it was filthy with foul odors and it was very soiled, and it was not the dressing that was ordered. Reference: (WAC) 388-97-1060 (3)(b)

Based on interview and record review the facility failed to provide necessary care and services, consistent with professional standards of practice, to one of four residents (#146) reviewed for pressure ulcers (PUs). Failure to thoroughly assess, consistently monitor, and aggressively provide care and treatment caused harm to Resident #146 when she acquired, in the facility, a Stage IV pressure ulcer to the coccyx, infection of the wound and osteo[DIAGNOSES REDACTED] (infection of the bone). Findings included . According to the National Pressure Ulcer Advisory Panel a pressure ulcer (also known as a pressure injury) was a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A stage I PU was defined as intact skin with non-blanchable redness (reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device) of a localized area usually over a bony prominence. A stage IV PU was defined as a full thickness tissue loss with exposed bone, tendon or muscle. Slough (non-viable tissue) or eschar (dead tissue) may be present on some parts of the wound bed. Often included undermining and tunneling (undermining was the destruction of tissue or ulceration extending under the skin edges so that the PU was larger at its base than at the skin surface. Tunneling was a passage way of tissue destruction under the skin surface that had an opening at the skin level from the edge of the wound). Resident #146 was admitted [DATE] for post acute care, rehabilitation and strengthening after hospitalization [MEDICAL CONDITION] (potentially life threatening condition caused by the body's response to an infection) due to infectious [MEDICAL CONDITION] (inflammation of the colon). She had multiple diagnoses, including polymyalgia rheumatica (disorder of tissue causing pain and stiffness of the muscles). Review of the admission skin assessment dated [DATE], the resident had blanchable redness (when area pressed firmly with finger turns pale or white) to both of her heels. There was blanchable redness to her coccyx and left upper buttocks, measuring 1.5 centimeters (cm) by 1.5 cm with mild tenderness. Excoriation (abrasion) to the buttocks was also observed. According to the Physician's Assessment and Plan dated 04/25/19, showed Resident #146 was at risk for pressure ulcerations due to weakened condition and/or injury, decreased ability for self-positioning: Nursing to assist in repositioning and to monitor for signs of pressure ulcers. According to the Admission Minimum Data Set (MDS) assessment, dated 05/01/19, the resident was cognitively intact, required extensive assistance of two staff members for bed mobility and did not exhibit any behaviors indicating rejection of care. She was assessed to be at risk of developing pressure ulcers. There were no unhealed pressure ulcers present. The resident had an indwelling Foley catheter (tube inserted into the bladder to drain urine). Review of the care plan showed a focus area of redness at left buttocks related to immobility, initiated 04/24/19, showed interventions to include encourage and assist as needed to turn and reposition. Review of interdisciplinary progress notes from the time of admission on 04/24/19 showed the following: - On 04/24/19: Requested an air mattress for patient for PU [MEDICATION NAME]. She had a foam dressing on her coccyx and received oxygen via nasal cannula continuously. Her Foley was draining yellow urine; - On 04/29/19: The Foley catheter was removed and had to be reinserted on 05/01/19 related to urine retention; - On 05/01/19: The Registered Dietician (RD) recommended Ensure Plus three times a day (237 milliliters each). The resident was having multiple loose stools for the past few days; - 05/02/19: The resident was diagnosed with [REDACTED]. - On 05/09/19: Wound care on the sacral area was done and new dressing was applied (this was the first documentation in reference to the coccyx/sacral area from the time of admission, for 15 days, and there was no assessment information). There had been almost daily documentation that the resident's position was changed frequently without any specifics of how the resident was positioned, whether the position changes provided the necessary offloading of pressure over the bony prominence of the back/sacrum (i.e. - was she positioned at any time off of her back side?). There was a referral made to the facility's contracted wound healing company on 05/14/19. Information on the referral indicated the wound on the coccyx was unstageable (due to presence of slough and/or eschar) and was present on admission, which documentation in the medical record showed the resident had no PUs at the time of admission to the facility. Review of the alteration in skin integrity focus area, initiated 05/14/19, had interventions which included a pressure redistributing device on bed and chair, to encourage to reposition as needed, report abnormalities, use assistive devices as needed and observe skin condition with ADL (activity of daily living) care daily. The next facility documentation related to wound care was dated 05/21/19, and stated the resident complained of lower back pain after treatment by the wound care team. The resident's wound was evaluated by the facility's contracted wound healing company on 05/21/19 and showed the PU to the coccyx was an unstageable pressure injury obscured full-thickness skin and tissue loss. The wound measured 5 cm length by 4 cm width and 0 cm depth. The wound care consultant surgically debrided the PU. The post debridement measurements were 5 cm length by 4 cm width by 2.5 cm depth. The area around the wound was reddened. Review of the facility's contracted wound healing company orders dated 05/21/19, directed the nursing staff to change the coccyx wound dressing twice daily and as needed, encourage repositioning every 2-3 hours, alternating pressure mattress per the residents primary care physician (PCP) orders (which had been requested on 04/24/19), encourage offloading of heels and bony prominence's, supportive wheelchair (w/c) cushion for offloading and repositioning the resident when up in the w/c 2-3 hours for pressure relief. Other recommendations were to please notify PCP of stage 4 PU to the resident's coccyx. The assessment showed the bone was palpable (able to be touched) to the base of the wound and recommend a MRI (a medical exam using magnetic resonance imaging) and ID (infectious disease) follow up. Review of the medical record, showed the first documentation regarding the presence of an alternating pressure mattress was dated 05/28/19, 14 days after the PU was identified. Review of the physician orders [REDACTED]. Review of the MRI exam dated 05/30/19, showed a large sacral ulcer with [MEDICAL CONDITION] (infection) and a small focus of osteo[DIAGNOSES REDACTED] at the mid sacrum. On 06/03/19 Resident #146 was evaluated by her PCP. The PCP documented Patient is being evaluated today for follow-up sacral ulceration pressure wound drainage and complaints of sacrococcygeal pain. Patient indicates that she has been taking current medication regimen however states that her pain has been inadequately managed and she has been avoiding movement due to increased pain. Review of a facility skin note dated 06/04/19, showed the resident had been assessed during wound rounds and showed the stage IV PU to the coccyx measured 6 cm (length) by 4 cm (width) by 2.2 cm (depth) with undermining (occurred when the tissue under the wound edges became eroded, resulting in a pocket beneath the skin at the wound's edges) starting from 7 o'clock to 12 o'clock with maximum depth of 3.5 cm. Review of the medical record showed on 06/22/19 Resident #146 medical status drastically declined. The physician was notified and the resident was sent to the emergency department. She did not return to the facility. During an interview on 10/18/19 at 3:25 PM, the above information was shared with the Director of Nursing Services (DNS). Information was requested regarding facility assessments of the residents skin, from the time of her admission until discharge, as there was no information located in the resident's electronic or hard copy record. Further information was requested related to initiation of preventive treatments, such as the alternating pressure mattress requested at the time of admit, on 04/24/19, and documentation of amount of Ensure Plus consumed, as ordered three times per day by the RD on 05/01/19, and any other information to show that necessary care and services were provided to Resident #146. During an interview on 10/19/19 at 12:25 PM, with the DNS and Staff F, Registered Nurse/Unit Manager, showed the following information was provided: - The dressing was changed on 04/27/19 without an assessment; - The DNS stated if a resident was admitted with an issue, such as a skin alteration or PU, they should have weekly assessments; - Staff F stated he had completed a body audit/skin check with another Licensed Nurse (LN) on 04/30/19. He remembered the resident's coccyx was darkened, non-blanchable, the skin was intact and a foam dressing was in place for protection (neither LN had documented an assessment); - The alternating pressure mattress was initiated on 05/15/19, 21 days after it was recommended by the LN; - When a nutritional supplement, such as Ensure plus was ordered, LN's or staff documented it was offered/given to the resident but the amount actually consumed was not documented (this indicated it was not known how much a resident had actually taken to enable evaluation of quality of intake); and - Both the DNS and Staff F confirmed there were no assessment done of Resident #146's coccyx wound from the day of admission until it was evaluated by United Wound Clinic on 05/21/19, when it was identified as a Stage IV PU. WAC Reference: 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure residents who engaged in smoking were assessed, provided a safe environment, necessary devices, supplies, and adequate supervision to prevent injury from burns; as well as protect other residents from potential fire hazard. This failure affected one of one residents (51) who smoked and potentially placed all residents at risk for injury related to unsafe smoking. The failed practice also affected two of three residents (19 and 162) related to resident to resident altercations and falls. The failed practice resulted in Immediate Jeopardy (IJ) on 08/23/18 at 2:58 PM when the facility failed to ensure residents and the resident environment were as safe as practicable from injury [MEDICAL CONDITION] fire. The Immediate Jeopardy was removed on 08/27/18 at 3:00 PM after the facility initiated reassessments of all residents who were at risk for smoking, provided at risk residents and visitors notification that the facility was a non-smoking property and communication and training for improved response when resident's were suspected of, or found smoking. Findings included . SMOKING Record review of the facility's guideline titled, Smoking Guidelines, revised date of 07/2017, showed the purpose was to determine if a resident was an independent smoker or an at risk smoker before the resident exercised the privilege to smoke while residing within the facility and to establish guidelines for all residents that desire to smoke. - Guidelines . Provide interdisciplinary team (IDT) members and center staff education on the Smoking Guidelines and Smoking Evaluation during general orientation and as the center deems necessary . - Evaluate patients that smoke utilizing the Smoking Evaluation tool either: a) upon admission; b). when a previous non-smoking patient takes up smoking c). if unsafe smoking practices are observed in a current smoker, d) when a patient that smokes has a significant change in medical condition. - Education is provided when: (a) a new patient is identified as a smoker .Upon completion of the evaluation, the interdisciplinary including team, including the attending physician, will make a decision whether the patient is an independent or an At Risk Smoker . - The IDT completes a comprehensive patient care plan that reflects the resident's smoking evaluation outcome, smoking supervision that was necessary, type of protective smoking equipment that was needed, education on the Smoking Guidelines and options for smoking cessation, instruct residents/family members/visitors not to share lighted cigarettes, lighters or other smoking accessories with other residents. During the entrance conference on 08/20/18 at 9:28 AM, the Mobile Administrator (acting Administrator) and Director of Nursing Services (DNS) stated they did not have any residents who smoked in the facility. They both stated, We have no smokers, we are a non-smoking campus. A single sheet of paper was included in the survey readiness book, provided by the facility, which read: WE ARE A NO SMOKING FACILITY. WE HAVE NO RESIDENTS WHO SMOKE AT THE FACILITY. RESIDENT 51 Resident 51 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his discharge Minimum Data Set (MDS) assessment dated [DATE] he had severe cognitive impairment. He discharged from the facility on 02/16/18 and readmitted to the facility on [DATE]. The 03/09/18 MDS showed he had no cognitive impairment on readmission. Resident 51's facility admission assessments on 02/09/18 and 03/05/18 both indicated he was a non-smoker. He was not assessed for smoking safety and no care plan was developed despite his longstanding smoking history. The resident was at high risk to smoke given his current stressors of recent loss of both lower extremities and his sudden impaired mobility. Review of a progress note dated 07/15/18 at 1:26 PM, showed Resident 51 asked if he could smoke on the patio, Resident 51 was told that Manor Care was a no smoking facility. Resident 51's two packs of unopened cigarettes and matches would be kept in the Unit Manager's office and would be available to him upon discharge, Resident 51 verbalized the idea of crossing the street to smoke, the resident was re-educated that it was very unsafe to do so. Review of the care plan showed a smoking care plan was developed on 07/16/18, the next day. The care plan interventions directed staff to educate/review the non-smoking status of the center, educate/review, and offer the resident smoking cessation options. The care plan did not address his desire to smoke across the street. Review of an admission note dated 02/10/18 at 9:35 PM, from the resident's physician and facility medical director showed current every day smoker. A social service history dated 02/12/18 at 9:14 AM showed prior to hospitalization he was an active smoker . Review of a fax from the hospital admissions to the facility on [DATE], included the hospital's History and Physical Admission Notification .He has smoked for forty years; was able to cut down to < 10 cigarettes a day. Tobacco abuse-has not smoked since March, Resident stated, I am dying for a cigarette. Review of Resident 51's Occupational Therapy (OT) Evaluation & Plan of Treatment dated 08/08/18 showed the resident had a recent fall out of chair. The OT's background assessment showed the resident was known to fall forward and backwards in chair, sideways and slide out of his chair. The resident had poor sitting balance noted with impaired left upper and right upper extremity strength impairment. In an observation on 08/23/18 at 12:39 PM, Resident 51 was seated in a wheelchair about 25 feet from the facility door smoking a cigarette in his right hand. He took another puff and threw the lit cigarette into dry, thick ivy brush. Smoke was visible from the ivy for approximately one minute. Resident 51 was asked his name and if this was, where he usually smoked. He stated his name and I am not going to say that. He was asked where he usually extinguishes his cigarettes and he pointed to a light colored rock. The rock did not have any visible burn marks indicative of extinguishing a cigarette. The resident stated, You work for DSHS. See no evil; hear no evil, please, please. He then commented, They water this area every night. The resident had wheeled past a large white and blue sign that stated No smoking campus. During an interview on 08/23/18 at 12:42 PM, the Administrator, Mobile Administrator, and the Staff JJ, Quality Assurance (QA) Nurse were alerted to the imminent concern regarding Resident 51 smoking out front and disposing a lit cigarette into the ivy bush with no appropriate place to extinguish or dispose of extinguished cigarettes. The facility Administrator got up and stated, Is he still out there? He is not supposed to smoke, he signed an agreement. They each confirmed they had no knowledge of any resident smoking. Upon leaving the front office, Resident 51 was seated by the receptionist. He looked up with an uneasy look and stated, I don't know how I am? .see no evil, hear no evil? On 08/23/18 at 1:23 PM, Resident 51 stated he bums the cigarettes from visitors who smoke. He throws the cigarettes into the bushes, which is ok because they have a watering system. He said he can tell which visitors smoke by their brown teeth or they have gaps in their teeth or stains. He hoped he didn't get anyone into trouble. He stated that the nurse (Staff P) knows he smokes and one nurse took two of his packs from him and has them in her office. He stated he only tossed the cigarette yesterday and today. During an interview on 08/23/18 at 1:26 PM, Staff P, Nurse Supervisor RN stated Resident 51 smoked and was not on a nicotine patch. In a joint interview with the DNS and QA nurse on 08/23/18 at 1:57 PM, Staff JJ, QA nurse stated, We are a non-smoking facility. They sign a non-smoking agreement and we would work with them. The Administrator is talking to him now. He got a match and cigarette from a visitor. We would do a smoking assessment, update the care plan and work with the resident on cessation and offer (nicotine) patches. The DNS and Staff JJ, QA Nurse were informed Resident 51 as well as the medical record indicated staff were aware of his desire to smoke and cigarettes were previously found on the resident. At 2:02 PM, Staff R, RN Supervisor, was asked about completing Resident 51's smoking assessments. Staff R stated He was here a while and the first time he was here he was out of it. He is aware it is a nonsmoking facility. Staff R provided no information as to why she did not proceed with the smoking assessment or care plan. She provided no information as to where his cigarettes were kept nor why she did not proceed with the smoking assessment or care plan. Record review showed Resident 51 admitted with a known 40 + year smoking history prior to admission. The facility medical director/resident's physician documented he was a current every day smoker on 02/10/18, the following day after admission. A facility social service note dated 02/12/18 described the resident as an active smoker. There were no smoking assessments completed on both admissions to the facility as the admission nurse documented non-smoker. The smoking care plan was not developed until 07/16/18, one day after the match and two packs of cigarettes were found in the resident's possession. Furthermore, Resident 51 had liver disease with elevated ammonia levels, which could cause a decrease in cognition. He was also a bilateral above the knee amputation with impaired sitting balance, had a history of [REDACTED]. On 08/24/18 at 10:16 AM, The Administrator and QA nurse stated,We have assessed all residents and identified 14 residents at risk for smoking. The residents had new assessments and their care plans were revised. Review of the SBAR (Situation, Background, Assessment, Recommendation), a physician communication tool revealed 8/25/18 entry (Resident 51) was observed smoking outside the facility by a nursing staff. Review of a progress note 08/25/18 11:48 PM, by Staff M, LPN Nurse Supervisor revealed This LN and other nurse was notified by CNA that she found (Resident 51) smoking cigarette out side, by the entrance of the building after he put the cigarette out she escorted him back to the room. This LN and other asked him what happened and he stated that he snuck out of the building, went outside without without telling staff and asked someone's family member for a cigarette and a lighter, then he smoked. He said he knew that he was wrong and he was not supposed to do it but he was not sure why he did it. The LN assessed the resident's skin, the fingers and in his body and no burn or skin issue were noted. The Resident agreed and allowed for a room search for other cigarettes, no cigarettes, lighter or matches were found in the room. The resident was placed on alert charting for observation and the resident agreed to have a wonder guard placed on his wheelchair. The M.D. and family were notified. Review of the care plan on 08/27/18 did not include Wanderguard as an intervention. In an interview on 08/27/18 at 09:02 AM, The DNS was asked about Resident 51 smoking on 08/25/18. She stated, I know he smoked. When asked how they were assuring resident safety as he smoked again. The DNS staed I don't know, we didn't assess him because he didn't have anything on him. I will have to look. When asked if she felt he was safe to smoke with a high ammonia level and recent bilateral AKA (unable to lean over to safely extinguish a cigarette and no ashtray on premises). The DNS stated we are a non-smoking facility and would not accommodate his desire to smoke. She stated, He has not smoked for months. I understand the stress is causing him .We will put him on 1 on 1. The DNS was asked how the cigarette was disposed of on 08/25/18, as it was not documented in the progress note; she stated, He threw it into the bushes again . lit. I know I know He snuck out . he is independent. I have to see when it was . he eats on the first floor maybe he snuck out then. I don't know I really need to check. She confirmed he had not been assessed for smoking safety outside of his room. When asked why his ability to safely extinguish a lit cigarette as part of the assessment, she would not answer. The DNS was asked why the care plan was not revised after the most recent smoking incident to include the Wanderguard. She stated, We decided against the Wanderguard but didn't note that so it didn't go onto the care plan as an intervention. No additional information was provided for the delay in assessment and care plan revision. Review of the smoking facility smoking evaluation was not completed by the facility until 08/27/18 at 12:34 PM , two days after he smoked again. The assessment summarized Pt (patient) is bilateral leg above knee [MEDICAL CONDITION], pt does not make safe decisions, is not able to put out cigarettes safely as evidenced by pt seen flicking cigarette butts into bushes. In an interview on 08/27/18 at 10:49 AM, Resident 51 was up in his wheelchair at foot of his bed. Resident 51 stated, I got in trouble big time and laughed. Somebody else gave me this cigarette. Usually what I do is . if I see someone coming up, I ask them. I grab one, they usually light it for me, or they give me a match. Different people . different times. It is easy . Believe it or not, smoking is still a big thing. I only get one at a time so I don't have to pay for them (cigarettes). The resident discussed local news and indicated he was aware of the fires, poor air quality and the statewide burn ban in effect. He stated, I am never gonna live that smoking down. I was a basket case when I first lost my legs. It is very traumatic to cope with. It's tough. Still is. I have a lot to deal with. The resident confirmed smoking is his way of coping. The facility staff and Resident's physician were aware of the resident's smoking at the time of the entrance conference. The facility inconsistently completed smoking assessments and care plans on residents who were current smokers or had a recent history of smoking. The facility did not provide supervision to resident 51 after he smoked out in front of the facility on two occasions. On both occasions, he threw a lit cigarette into dry shrubbery without extinguishing them, a clear disregard for safety. The facility lacked timely measures to assess and ensure residents at risk for smoking were assessed. The facility did not address Resident 51's verbalization he would cross the street to smoke. There was no measures in place for residents to navigate on the driveways and provided no safe way to extinguish and dispose of burning smoking materials. SUPERVISION TO PREVENT ACCIDENTS: RESIDENT 19 Resident 19 admitted [DATE] with [DIAGNOSES REDACTED]. Record Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had short and long term memory loss, was non-English speaking and used a wanderguard bracelet (an electronic monitoring bracelet which alerted staff if a confused resident neared an exit) due to a history of wandering in the facility. There were no physical behaviors directed at others documented during the reference period. Review of Resident 19's care plan showed an intervention had been in place since 02/19/18 which stated keep resident at arm's length away from other residents. This was put in place after a resident to resident altercation where Resident 19 hit another resident on the arm. At the time the facility reported that this behavior was new. The goal was that the resident would not have unwanted contact with patients or staff. The care plan further showed the resident was impulsive, had impaired judgement and was at risk for falls and elopement. Interventions included: frequent visual checks, provide assist to transfer and ambulate as needed, offer/assist to walk when safe walk to dine to and from meals. A review of a resident to resident incident dated 07/12/18 showed that the facility failed to ensure arm's length distance away from other residents. Resident 19 had willfully reached out and pinched another resident in the hallway, causing injury. The facility investigation determined the incident to be isolated with no mention of the prior known behaviors of Resident 19 or the failure to follow current care planned interventions to keep Resident 19 at arm's length away from other residents. Resident 19's care plan was further updated on 07/12/18 to include: Approach slowly and slightly to the side, Be cognizant of invading the resident's personal space, Close supervision by staff, staff to monitor for aggressive behavior, (and continued to state) keep residents at arm's length away from other residents A review of a second resident to resident incident dated 08/03/18 showed that Resident 19 had an agitated episode in the dining room and willfully threw a cup of coffee across the room which landed in the middle of a table where five other residents were sitting. Several residents were splashed with coffee. There were no reported injuries other than residents stating it startled them. When interviewed using interpreter service, Resident 19 could not recall the incident. There were no new care plan interventions implemented. Resident 19 was then noted to have 2 non injury falls in 2 days on 08/05/18 and 08/06/18 while attempting to ambulate independently. The investigations determined his impulsive behaviors were due to progressing dementia. A review of a third resident to resident incident dated 08/07/18 at 1:30 PM showed the facility again failed to adequately supervise Resident 19 who was observed up independently propelling in the hallway and to willfully punch another resident a couple of times while passing in the hallway. Witness statements showed that several staff observed the incident but did not address what supervision or interventions had been attempted to keep Resident 19 from coming within arm's length of other residents. A nurse practitioner progress note dated 08/07/18 at 3:30 PM showed the nurses had reported increasingly aggressive behavior toward staff and other residents .concern for harm to other residents. The care plan was then updated on 08/07/18 to include 1:1 (one to one assigned staff) during waking hours. In an interview on 08/27/18 at 10:46 AM, Staff D, clerk, was the assigned 1:1 staff member to monitor Resident 19. Staff D stated she did not know anything about the resident's care plan, I don't know, you would have to ask the nurses; I am just the visual 1:1. She stated when Resident 19 got upset like he did this morning and he tried to stand up, she said she just pointed down at the wheelchair and he would sit down. Then she said if he got agitated she would call for one of the nursing assistants. She stated she was not made aware of specific interventions related to behaviors. On 08/27/18 at 12:55 PM, Resident 19 was up in the hallway sitting in his wheelchair with Staff D and he was talking loudly in Korean, had a furrowed brow and was moving his arms up and down. Staff D started to wheel him down the hall saying, let's go get some coffee. Staff D stopped in the hall near the nurse's station and right next to (within arm's length) of Resident 18. Resident 19 was attempting to stand up. Staff D stated sit down, sit down, sit down! let's go get some coffee. Staff X, Human Resources and Staff G, Unit Manager were at the nurse's station. An incoming stretcher caused Staff D to move Resident 19 further down the hall. No other staff members in the area attempted to assist Staff D with Resident 19, to attempt to determine what needs he was communicating or to assist him to walk per the care plan. At 2:07 PM, Resident 19 was observed lying on his bed. Resident 18 observed sitting in his wheelchair in the hall near the doorway. There were no staff members within sight of Resident 19. In an observation on 08/27/18 at 2:22 PM, there remained no facility staff observed within view of Resident 19's room. Resident 19 was lying in his bed, Resident 18 remained in the hall. In an interview on 08/29/18 at 12:47 PM, Staff E, central supply clerk was the assigned 1:1 staff member to monitor Resident 19. Staff E stated she was also not aware of any behaviors for Resident 19 stating, I guess I am just here in case he tries to leave, I asked if it was okay if he gets up because he gets up and goes into the bathroom and moves around, I guess he could fall. Staff E stated she was not aware of any care planned safety interventions for behaviors. In an interview with a family member of Resident 19 on 08/29/18 on or about 1:00 PM, the family stated that the resident does not remember, but he talked about things that occurred a long time ago. The family stated they were aware that the resident had been aggressive with staff, residents and they were worried about wandering and falls. The family member stated we do not want him to get hurt or to hurt anyone. They stated they were not sure if he could walk but he frequently tried. They stated they have not seen any staff attempt to help him walk, but thought maybe he should practice. In an interview on 08/30/18 at 12:47 PM, the DNS (Director of Nursing Services) stated that after the incident where Resident 18 was pinched on 7/12/18, the plan was to keep him at arm's length of other residents. She stated Resident 19 was impulsive and fast. When asked regarding the incident which involved Resident 18 being punched by Resident 19 on 08/07/18 she stated, he (Resident 19) moved so fast; he was passing the other resident and he had moved so fast they couldn't stop him. She stated that was when they initiated the 1:1 only during waking hours because he never does anything in his room. The DNS did not have further information regarding why care planned interventions had not been followed allowing Resident 19 to be within arm's length to pinch and punch Resident 18. There were also observations that the 1:1 was not consistently in place and interviews from the 1:1 staff members who did not demonstrate or verbalize thorough education and training regarding their 1:1 job duties involving how to supervise Resident 19 effectively to protect and prevent harm to the other residents. The DNS stated the 1:1 staff should have training and felt they had received it but must not have retained it. FALLS RESIDENT 162 Resident 162 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was Spanish speaking and often confused. The resident discharged on [DATE]. Record review revealed the resident sustained [REDACTED]. Review of the resident's fall dated 06/26/18, documented the resident was found on the floor in her room, next to her wheelchair by the bed. The nurse was in the resident's room three minutes prior administering medications. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. Review of the resident's fall dated 06/28/18, documented, at 4:30 PM, the resident was found sitting on the floor facing the door way. She was speaking Spanish and pointing to her bag. Head to toe assessment was completed, no injuries found. Resident denied pain, neuros and vitals taken. Resident was last toileted at 4:00 PM and last seen at 4:25 PM lying in bed, call light within reach but not on. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. The resident's care plan was updated to include engaging resident in activities and routine Tylenol for pain management. Review of the resident's third fall on the same date, 06/28/18, documented, around 11 PM, the resident was found lying on her back on the floor by the bathroom, facing the doorway. Resident was speaking Spanish and pointing to the toilet. Head to toe assessment completed, no injuries found. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. The resident's care plan was updated to include encouraging resident to use the bathroom upon rising, after meals and at bedtime and as needed to encourage continence and anticipate needs. Review of the resident's fall dated 06/29/18, documented, around 9:21 PM, the NA found the resident on the floor in her room, the resident was laying on the floor on her left side by the sink. Head to toe assessment completed, no injury found. Resident was speaking Spanish and pointing at her head, the resident was assisted back to bed, neuro checks were done per protocol. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. The residents care plan was updated to include a new order to change [MEDICATION NAME] from as needed to routine at bedtime to facilitate regular sleeping patterns due to resident noted with increased restlessness later in the evening. Review of the resident's fall dated 07/02/18, documented, the resident had a witnessed fall around 8:15 PM, the LN was walking into residents room with medications and saw the resident standing by the bedside table and starting to fall, the LN was unable to prevent the fall. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. The resident's care plan was updated to include calling and eliciting family assistance when resident is restless in the evening. Review of the resident's fall dated 07/04/18, documented, the resident fell around 10 or 11 AM, the resident stated, she fell , got herself up off the floor and nobody helped her. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. Review of the resident's fall dated 07/19/18, documented, the resident had a non- injury fall around 7: 45 AM, the resident was found sitting on the floor beside the bed, facing her dresser. The top drawer was pulled out, sitting in front of resident with contents spilled over. The fall was attributed to the resident's impaired cognition, poor safety awareness and impulsivity. The resident's care plan was updated to include offering snacks with coffee in the morning before breakfast and to encourage resident to sit at nursing station when resident is awake. Review of the resident's fall dated 07/21/18, documented, around 5:50 PM, the resident was found sitting on her bottom, next to her wheelchair in the hallway, between her room and the nursing station. Review of the resident's fall dated 07/30/18, documented at 8:00 AM, the resident was found sitting on the side of her bed, the resident was placed in the television room and was provided with a busy box and coloring book. The staff found resident on the floor in the television room, laying on her back, next to her wheelchair trying to get up. The resident stated, she was reaching for the book and slipped out of her chair. Review of the residents multiple falls, revealed the facility did not have an interdisciplinary systematic approach to proactively identify environmental hazards, the resident's risk for an avoidable accident and evaluation of the resident's need for supervision. Furthermore, the facility failed to monitor if interventions where being followed, failed to monitor for effectiveness and modification of interventions as necessary. In an interview with the DNS on 08/31/18 at 8:51 AM, when asked about Resident 162 multiple falls, the DNS attributed the falls to the resident's Dementia and impulsivity. No further information, such as an interdisciplinary evaluation of the falls, analysis to identify the root cause of each fall, trends, and plan to prevent re-occurrence was provided. Reference (WAC): 388-97-1060 (3) (g)

Based on observation, interview and record review the facility failed to ensure each resident was free from abuse for one of four residents (18) reviewed for abuse. This failure resulted in harm to Resident 18 who experienced physical abuse from another resident during two separate resident to resident altercations. Findings included . A review of the facility policy titled, Patient Protection Practice Guide, dated 11/03/16, showed that the resident had a right to be free from abuse, neglect, misappropriation of resident property and exploitation. RESIDENT 18 Resident 18 admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition, comprehension, and disorganized thinking. The MDS also showed Resident 18 required extensive assistance for his activities of daily living and utilized a wheelchair for mobility. A review of the care plan showed Resident 18 may exhibit verbal or physical agitation such as calling out, and had the potential for sensory overload, it warned caregivers to be cognizant of invading his personal space. A review of a resident to resident incident dated 07/12/18 at 11:15 AM, showed that another resident (Resident 19) had willfully pinched Resident 18 on the upper arm in the hallway. The facility investigation identified the incident as a patient to patient altercation resulting in harm. Resident 18 was assessed and found to have three reddened areas approximately two centimeters by two centimeters each on the right upper arm. Resident 18 was cognitively impaired and was documented at the time to have no recollection of the event. On 08/03/18, Resident 18 was among a group of residents who were splashed with coffee in the dining room when Resident 19 threw a cup of coffee across the room. The residents reported being startled. Resident 18 was placed on alert. A review of a resident to resident incident dated 08/07/18 at 1:30 PM, showed Resident 19 willfully punched Resident 18 in the arm while passing him in the hallway. Resident 19 was observed by facility staff to pass by Resident 18 in the hallway and punch Resident 18 in the upper arm a couple of times. A witness statement signed by Staff X, Human Resources, stated that Resident 18 had swung back in response to Resident 19. The facility investigation identified the incident as a patient to patient altercation resulting in harm. The investigation stated that the residents were interviewed and that the residents did not recall the incident. In an interview with Resident 18 on 08/21/18 at 9:08 AM, Resident 18 was asked regarding the protective sleeves he wore over his arms. He stated, someone cut up my arms .but they got the guy. He could not recall specific details due to cognitive impairment. On observations throughout the survey, Resident 18 was observed to self propel slowly in the halls and was often observed sitting in his wheelchair by the nurse's station, eating meals in the dining room, or attending group activities. His room was directly across the hall from Resident 19. Record Review of Resident 19's care plan showed an intervention had been in place since 02/09/18 to keep the resident at arm's length of other residents related to a history of aggressive behaviors. The facility had established a pattern of behavior by Resident 19 which placed residents at risk of being the victim of his aggressive behaviors. The facility repeatedly failed to implement care planned interventions to protect other residents from physical abuse resulting in Resident 18 experiencing abuse by Resident 19. During an interview on 08/30/18 at 12:47 PM, the Director of Nursing Services (DNS) stated that after the incident where Resident 18 was pinched on 07/12/18 that the plan was to keep him (Resident 19) at arm's length of other residents, which had already been in place but not followed; the DNS acknowledged this did not occur. The DNS stated Resident 19 was impulsive and fast. When asked regarding the incident which involved Resident 18 being punched by Resident 19 on 08/07/18, she stated He (Resident 19) moved so fast; he was passing the other resident and he had moved so fast they couldn't stop him. When asked what was being done to protect the other residents from Resident 19 she stated that after the incident on 08/07/18, the facility placed Resident 19 with a one to one staff member during waking hours. The DNS did not have further information regarding why care planned interventions had repeatedly not been followed for Resident 19 allowing him to be within arm's length of other residents including Resident 18 who experienced abuse by being pinched and punched, causing physical injury to his arm and causing an avoidable psychological and physical reaction of striking out in response to being punched. Refer to: F 689 Free of Accident Hazards/Supervision/Devices Reference (WAC): 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to ensure three of six residents (59, 83, & 27) reviewed received the necessary care and services in accordance with professional standards of practice. The facility failed to comprehensively assess, evaluate and timely treat a resident (59) with a urinary tract infection. The failed to ensure 1 of 3 residents (83) received adequate positioning. Additionally, The facility failed to ensure bowel management protocols were followed for 1 of 3 residents (27). These failures placed residents at risk for discomfort, experiencing health complications and diminished quality of life. These failures resulted in harm for Resident 59 who experienced a delay in lab services, treatment and unresolved urinary pain. Findings included . URINARY TRACT INFECTION RESIDENT 59 Resident 59 admitted [DATE]. She was able to make her needs known. Review of a progress note, dated 08/18/18 at 4: 08 AM, showed c/o (complained of) burning sensation and difficulty with urination .MD (Medical Doctor) notified, ordered UA/CS (urine analysis/culture and sensitivity) and to start [MEDICATION NAME] (pain reliver for urinary symptoms) .UA collected and picked up at 0630. Review of a progress note, dated 08/18/18 at 3:10 PM, showed, Resident still complaining of bladder discomfort, offered plenty of water and residents is on [MEDICATION NAME] .awaiting UA result . Review of a progress note, dated 08/19/18 at 10:41 PM, showed Resident still complained of pain and discomfort with urination. Review of a progress note, dated 08/20/18 at 2:27 PM, showed the the resident c/o dysuria (painful or difficult urination) prior to leaving for her appt (appointment). Review of a progress note, dated 08/21/18 at 12:25 AM, showed Resident on and off complaining of bladder discomfort .resident is on [MEDICATION NAME] . Review of the Medication Administration Record [REDACTED]. There was no follow up on the new order of [MEDICATION NAME]. Resident 59 did not have a new order for [MEDICATION NAME] as of 08/30/18. Review of a progress note, dated 08/22/18 at 12:53 AM, showed Resident complained of bladder discomfort .also resident urine result is back and faxed to MD awaiting for respond. Review of a progress note, dated 08/23/18 at 10:18 PM, showed, Resident is on ABX (antibiotics) first dose given burning sensation when urinating. In an interview on 08/24/18 at 9:41 AM, Resident 59 stated, So they finally woke me up last night to give me my [MEDICATION NAME] (antibiotic). I was in pain over a week now. What a mess. I had severe burning during peeing over a week ago. First they took a urine sample from a dirty bed pan. I told them they needed to do a clean catch and he didn't understand. So .the UA comes back dirty. Go figure . So they get another UA and of course it takes 24 hours for preliminary (results) and then 48 (hours) for the culture and sensitivity .I finally got the first dose of antibiotic just last night. All the while I had terrible pain for over a week they did give me some [MEDICATION NAME] (pain reliever for urinary infections), it helped a bit. Review of a progress note, dated 08/25/18 at 5:57 AM, showed, c/o urinary frequency and urgency. Requests pyridum. Advised pt (patient) she does not have an order for [REDACTED]. Review of the medical record showed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. In an interview on 08/31/18 at 10:33 AM, the Director of Nursing Services (DNS) was alerted to Resident 59's concerns with the manner of urine specimen collection, delay in lab results thus delay in antibiotic use. She indicated she would look into this. In a phone interview on 09/10/18 at 9:45 AM, Client Services at Swedish Laboratory Services was asked what occurred in regards to Order # N 80. Client Services indicated the facility sent the urine to the lab in the incorrect container. The facility failed to address her frequent urinary symptoms of pain resulting in continued pain. POSITIONING RESIDENT 83 Resident 83 admitted [DATE] with [DIAGNOSES REDACTED]. She required extensive assist for positioning. Review of her At risk for complications due to musculoskeletal problems r/t scoliosis care plan included a goal for the resident to remain free of complications related to scoliosis with inability to sit straight up. The care plan showed Has long history of bend to right side The care plan interventions directed staff to assist with bed mobility, provide assist of 1 to transfer and reposition in bed, refer to therapy plan of treatment in the medical record for more detail, report increasing changed in back pain intensity/level. The care plan did not address positioning in her wheelchair to enable more upright support. Review of her Occupational Therapy discharge summary, dated 05/11/17, showed Pt has severe kyphosis and scoliosis with R (right) tilt that makes positioning difficult . family shared how they position pillows at home on right side to support UE (upper extremity) in order to promote UE use when self feeding. On 08/20/18 at 12:18 PM, Resident 89 was observed in the dining room. Resident 89 was leaning very far to the right and the table was at her chin level. The resident had to extend her arm all the way out to reach her plate of food. Resident 89 dropped food off her utensil frequently when bringing the food back toward her mouth. The resident was observed to have food in her lap. At no time did staff offer assistance or repositioning. During multiple frequent observations all days of survey, Resident 89 was observed leaning to the right in her wheelchair without any positioning pillows. On two occasions (08/24/18 at 11:32 AM and 08/29/18 at 4:04 PM), she was observed to have a pillow. Her position was improved when the pillow was in place. In an interview on 08/30/18 at 8:39 AM, Staff G, Registered Nurse (RN)/Unit Manager, confirmed special positioning directives or positioning with pillows should be on the Kardex and Care plan. There were no positioning directives on the Kardex or Care plan. In an interview on 08/30/18 at 2:48 PM, Staff DD, Nurse Aide (NA), was asked about care and positioning for Resident 83, she stated She love pillows on her right side . She is better in wheelchair with pillows or her right shoulder comes down. We offer her to lie down. Family .brought in her pillow. In an observation and interview on 08/31/18 at 8:40 AM, Resident 83 was being wheeled in her wheelchair by Staff KK, NA, there were no pillows present and resident right arm was almost on the floor. Staff KK was asked about the residents' positioning, she stated, Yeah we usually put pillows here and here (indicated behind her back and on her left side. The facility failed to ensure Resident 89 maintained an adequate position in the wheelchair to promote self-feeding and comfort. This failure place Resident 89 at risk for not attaining or maintaining her highest practicable level of well-being. BOWEL MANAGEMENT RESIDENT 27 Resident 27 was a long-term resident of the facility with [DIAGNOSES REDACTED]. The resident had a care plan related to his gastrointestinal distress. There was no care plan adressing constipation. In an interview on 08/21/18 at 12:56 PM, the resident stated, I have a little problem with constipation. He said he was able to go to the bathroom himself. Record review of the resident's last 30 days of daily toileting bowel documentation and the resident's progress notes showed the resident did not have a bowel movement (BM) for the following dates: · 08/06/18 through 08/10/18, for five days, · 08/15/18 through 08/18/18, for four days, · 08/21/18 through 08/25/18, for five days. Review of the resident's Medication Administration Record [REDACTED]. In an interview on 08/29/18 at 10:01 AM, Staff C, LPN, stated that sometimes we ask him and he would state he has had a BM which would be documented in the progress notes. Review of the progress notes showed no abdominal assessments nor bowel documentation. In an interview on 08/29/18 at 10:56 AM, Staff B, RN/Unit Manager, stated that they had a system which alerted the staff when a resident had not had a BM for the past three days. Staff B continued to state that they would then take action, depending on each resident, would assess the resident's bowel sounds, review medication available, and would let the provider know. In an interview on 08/31/18 at 10:18 AM, the DNS stated that the nurses look at the bowel report every morning and place on the 24 hour sheet so the residents will get their bowel medications. I think (Resident 27) was an issue. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure appropriate services were provided to maintain, increase and/or prevent a decrease in range of motion for seven of nine residents (39, 84, 30, 36, 83, 72 and 2) reviewed for range of motion. This resulted in harm for Resident 39 who developed limited range of motion (ROM) to his left upper and lower extremities, a left foot and right finger contractures (shortening and hardening of muscles and joints). Further, Residents 30, 72, 36 and 83 were assessed to have declines in their ability to perform activities of daily living (ADL). These failures placed residents at risk for developing pain, new contractures and/or worsening of existing contractures and loss of self worth when they required more staff assistance. Findings included . RESTORATIVE PROGRAMS RESIDENT 39 Resident 39 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Occupational (OT) and Physical Therapy (PT) evaluations dated 10/01/12, showed no impairment in joint motion. The Minimum Data Set (MDS) assessment, dated 07/03/18, documented the resident had impaired functional range of motion on one side of upper and lower extremities and required extensive assistance for activities of daily living. In an interview on 08/20/18 at 11:18 AM, Resident 39 stated, I have a big problem. I don't get restorative .An aide used to do restorative but I haven't seen her in a long time. I have asked my aides and they say they aren't trained. No one does range of motion. They moved a bunch of equipment from the basement in there (restorative gym). They absolutely are not doing my range of motion. The care plan and Kardex (directs nursing assistants how to care for resident) initiated 01/22/13, directed staff to encourage and provide active-assisted ROM of left upper extremity and active ROM to the right upper extremity twice daily (see exercise chart in pt room or in pt chart). There were no exercise approaches to address his lower extremities. Review of the clinical record revealed his last therapy eval was on 07/07/17 for a new wheelchair request. Review of a nursing progress note dated 08/15/18 at 5:21 PM, showed the resident's left leg .started to have contraction with limited dorsiflexion of the foot at the ankle joint moving the top of the foot toward the leg, and staying on plantar flexion. Left arms express limited ROM and express pain to certain angle, hands also express stiffness on dexterity .This was reported to the physician. Review of a physician communication form dated 08/15/18, showed foot drop on L (left) LE (lower extremity) Please write a T.O. (telephone order) for PT (physical therapy). Review of an Advanced Registered Nurse Practitioner (ARNP) note dated 08/15/18, showed the staff reported worsening contractures of the left upper and lower extremity joints. An order was written for PT and to develop a restorative program. The resident already had orders for staff to complete a restorative program. Review of the medical record showed Resident 39 was not assessed by PT or OT until 08/29/18; 14 days after the orders were received. Review of the PT evaluation on 08/29/18, showed the resident was referred to PT following development of a left LE contracture. The resident presented with limited left upper and lower extremity ROM, a left plantar flexion contracture, an increase dependence with basic ADL's due to the documented physical impairments and associated functional deficits. A foot brace was recommended to keep L foot in neutral and minimize worsening of foot drop. Review of the OT evaluation on 08/29/18 showed the resident was evaluated to address the left upper extremity contracture. A restorative program will be established for him with recommendations for a soft hand splint. On all days of survey, Resident 39 was observed frequently. There were no observations of range of motion for Resident 39. At no time was a splint in place. During an interview on 08/27/18 at 2:04 PM, Staff Q, Staff Development /Restorative Coordinator stated We do not have a restorative team with aides per say. The aides are to do the programs. Staff Q stated there were no reassessments of current restorative programs. Staff Q was informed of Resident 39's concern of not receiving restorative and his new left foot drop. He stated he was unaware of his concern and the development of foot drop. He stated he had heard other residents complain about lack of restorative several months ago. During an interview on 08/29/18 at 1:49 PM, Staff AA, Licensed Practical Nurse (LPN), stated the facility had no restorative aids. Staff AA stated she had only seen PT and OT at the facility. Staff AA stated she had not seen the Nursing Assistants (NA) doing any ROM exercises to the residents. RESIDENT 84 Resident 84 was admitted to the facility on [DATE] following a hospitalization for confusion and falls. The resident had [DIAGNOSES REDACTED]. During an interview on 08/20/18 at 12:16 PM, Resident 84 stated that he was not getting any exercise and would like therapy. Review of the Therapy Discharge Communication form and Exercise Program form both dated 07/09/18 showed an exercise program for active range of motion (ROM) of the lower extremities with the following specific exercises to be completed for two sets of 10 repetitions: Supine (lying straight face up on the back) side leg, Leg raises, Elevated ankle pumps, Heel slides. Review of the resident's care plan and Kardex showed the resident was at risk for loss of ROM related to impaired mobility and weakness with a goal for no decline in ROM and interventions for active assisted ROM exercises of the lower extremities twice a day and passive ROM of lower extremities during activity of daily living (such as bathing, dressing or grooming). Review of the last 30 days of the NA's electronic documentation showed the resident refused active assist ROM of the lower extremities 25 out of 60 times. In mulitple frequent observations on 08/20/18, 08/24/18, 08/27/18, 08/29/18 and 8/30/18, the resident was lying in bed with no noted active exercise program. During an interview on 08/27/18 at 10:41 AM, the resident was asked if he had been receiving any exercise. The resident stated, No, nothing. Before I would go to therapy for exercises that was good. At 11:45 AM, Staff F, Director of Rehab, stated the facility did not have a traditional restorative program but the direct care staff, the NA's, performed the resident's functional maintenance programs (FMP). A copy of the FMP was placed in the resident's room on their bulletin board and in the resident's chart. At 11:54 AM, Staff H, NA, stated that the resident's FMP can be viewed on the computer. Staff H stated Resident 84's exercises were only a one person assist. At 11:57 AM, Staff I, NA, stated that the FMP was incorporated when providing ADL's for Resident 84, that way we make him do his own movements and he does it with his cares (ADL's). Staff I stated if Resident 84 was on a FMP, then the NA would document the number of minutes it took him to perform the FMP in the electronic medical record. At 12:06 PM, Staff J, NA, stated that Resident 84 refused a lot due to pain. Staff J stated they let the nurse know that sometimes he would be in so much pain. Anytime I have him, I do not want to neglect him. He will yell out to not touch or to get out, but it is because of the pain. If he is not in pain he will let me straighten him out. He has only let me do the reps once or twice only on a good day when his pain is under control. At 1:15 PM, Staff K, Assistant Director of Nursing, stated that if a resident would refuse the FMP exercises the nurse would be informed along with the doctor or myself. The therapy department would need to be informed and would need to re-evaluate to see if further recommendations were needed. Staff K stated I do not think this has occurred for (Resident 84). At 1:28 PM, Resident 84 stated, I want to do stuff but cannot find the right people to talk to. I used to go down to therapy, they were great people. But now no one comes in to exercise my legs. At 1:38 PM, Staff L, NA, stated, If a resident is on FMP it would be on the resident's bulletin board. If (Resident 84) is on one he would have a paper. Staff M, Licensed Practical Nurse, looked throughout Resident 84's room and was unable to locate a FMP exercise form in Resident 84's room. At 1:58 PM, Staff L, stated that the resident had pain to his left leg and his ROM was done with his ADL's. In an observation and interview on 08/27/18 at 2:04 PM, the resident had the FMP exercise program posted on his bulletin board. The resident stated, They just put it up, but the staff have not done those exercises for me before. At 2:09 PM, Staff O, NA, stated that she only does Resident 84's ADL's and tries to do his leg exercises but the resident complained of pain to his left leg a lot. Staff O stated they let the nurse know. In a follow up interview on 08/29/18 at 9:44 AM, Resident 84 stated he had no received any ROM exercises. At 1:20 PM, the resident stated No one had been in to offer any exercises. During an interview on 08/29/18 at 1:31 PM, Staff Q stated that the therapy department referred the resident for a FMP, then the nursing department would complete the program and chart like every other nursing charting. Staff Q clarified the nursing department was the restorative team. Staff Q stated the MDS assessment would identify if a resident had a decline or refused care. Staff Q stated the FMP's were not reviewed unless there was a concern and would refer the resident back to the therapy department for re-evaluation. Staff Q was then informed of Resident 84's refusals and report of not receiving the FMP exercise program. During an interview on 08/30/18 at 8:54 AM, the resident denied having any lower extremity exercises as of yet. RESIDENT 2 Resident 2 admitted [DATE] with [DIAGNOSES REDACTED]. He was able to make his needs known. Review of the annual MDS dated [DATE] showed the resident required extensive assist for activities of daily living. In an interview on 08/21/18 at 8:37 AM, Resident 2 was observed with his left hand clenched. The resident said he did not receive any restorative exercises or therapy. Review of his care plan on 04/23/18, directed staff to perform restorative active-assisted range of motion of lower extremities during ADL's daily. Passive range of motion of lower extremities during ADL's, RUE Supine and seated LE ROM (lower extremity range of motion) 2 X 10 reps once a day. The type of assistance (active or passive) was conflicting. There was no evaluation of the program to assess if the resident continued to benefit from the current program or needed to be evaluated by a therapist. On all days of the survey, Resident 2 was observed in his bed. There was no observations of range of motion occurring. RESIDENT 30 Resident 30 admitted [DATE] with [MEDICAL CONDITIONS] and difficulty walking. She was not interviewable. Review of the quarterly MDS assessment dated [DATE], showed Resident 30 was independent with walking and required supervision to complete her personal hygiene. Review of the MDS assessment dated [DATE], showed the resident required extensive assistance for ambulation and personal hygiene, which was a decline. Review of the care plan dated 04/17/18, directed staff to encourage and assist the resident to do active ROM exercises of lower extremities twice a day X 10 reps once a day. Review of the tasks showed Resident 30 did not receive range of motion per the care plan. On all days of the survey, Resident 30 was not observed receiving restorative services. Review of the medical record showed no evidence the facility acknowledged/recognized the residents decline in ambulation and personal hygiene. RESIDENT 36 Resident 36 admitted [DATE] with multiple cardiac issues. Review of the quarterly MDS assessment dated [DATE] showed the resident required one person assist for transfers, dressing and personal hygiene. Review of the quarterly MDS assessment dated [DATE], showed the resident required two person extensive assist with these tasks, which was a decline. Review of her care plan on 08/04/15, directed staff to encourage and assist with active ROM exercises and passive ROM exercises of lower extremities once a day. Resident 36 was observed lying in her bed on multiple occasions all days of survey. She was not observed out of bed during survey. During an interview on 08/21/18 at 10:12 AM, Resident 36 stated, One of my legs doesn't work very well. They said they were going to (do restorative) but never did. During an interview on 08/29/18 at 1:46 PM, Resident 36 was asked if she received exercises in bed or range of motion. She said No why? I used to a long time ago. I wonder where those bands even are. There were no Thera bands (resistive exercise bands) visible in her room. There were no observations of range of motion during survey. RESIDENT 83 Resident 83 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 83 was not interviewable. Review of the annual MDS assessment dated [DATE] showed the resident was independent with eating and one person limited assistance for ambulation. Review of the quarterly MDS assessment 07/26/18, showed the resident required one person assistance for eating, and extensive assistance while ambulating, which was a decline. Review of her activities of daily living care plan directed staff to encourage the resident with ambulate (walk) with a front wheeled walker and contact guard assist around the facility twice daily. Review of her care plan for at risk for loss of range of motion r/t physical limitations directed staff to perform active-assisted range of motion of lower extremities during ADL's. She was at high risk for upper extremity decline with [MEDICAL CONDITION] and right tibia fracture. Her care plan did not address upper extremity range of motion. Resident 83 was observed on multiple observations all days of survey in her wheelchair with poor posture. At no time was she observed ambulating or receiving range of motion. RESIDENT 72 Resident 72 admitted [DATE] with arthritis and weakness. Review of the significant change MDS assessments dated 04/24/18, showed the resident required limited one person assist with eating. Review of the quarterly MDS assessment dated [DATE], showed the resident required extensive assist to eat, which was a decline. in an observation on 08/23/18 at 8:04 AM, Resident 72 was observed in the dining room eating breakfast without any staff assistance. The resident pointed to her milk carton and asked me, Can you see if I have any more milk in there? Review of her Kardex and Care plan directed staff to encourage and assist the resident to complete upper extremity yellow T-band (Thera band) and lower extremity ROM exercise twice daily, encourage and assist the resident to do passive ROM exercises of lower extremities twice a daily and to perform lying and seated LE ROM once a day (see exercise sheet in pt room or in chart). There was no exercise sheet observed in the resident's room. There were no reevaluations of the restorative programs or referrals to Physical, Speech or Occupational therapy with her decline in function. Reference: (WAC) 388-97-1060 (3)(d)

Based on interview and record review, the facility failed to timely identify, thoroughly monitor, assess, and take timely actions on all changes in the resident's condition for 1 of 3 sample residents (1). Failure to provide necessary care resulted in Resident 1 being hospitalized for [REDACTED]. Findings Included . Skin Resident 1 admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident required 2-person assist with bed mobility, toileting, and personal hygiene, and rarely transferred out of bed by choice. The resident displayed some refusals of care and verbal behavior symptoms. Evaluation(s) for predicting pressure ulcer risk showed the resident was at risk for pressure-related skin issues. Resident 1's admission skin screen showed some bruises, and redness/rash in the groin perirectal area. Review of the (MONTH) and (MONTH) (YEAR) electronic Treatment Administration Record (eTAR) had an ongoing order for a weekly skin observation (checking for any skin alterations/problems) and to update the skin alteration sheet. Directions on a skin alteration record (sheet) indicated it was to be completed weekly and as needed and one form was to be used for each skin alteration site. The record was to document ongoing assessments of each identified skin alteration, as marked on a body diagram, to include an in-depth description with measurements, drainage, and appearance of skin surrounding each site. This ongoing assessment documentation assisted with the identification of improvement or decline in the skin alteration over time. The documentation continued until the resolution of each skin alteration. Review of a skin alteration record from (MONTH) (YEAR) through (MONTH) 20, (YEAR) showed Resident 1 had a pink rash on the groin and showed no notable changes. Review of the (MONTH) (YEAR) eTAR also revealed a long-standing order to monitor rashes on Resident 1's bilateral groin and peri-rectal area twice a day with an application of an antifungal powder to those areas until resolved. Associated nursing progress notes occasionally mentioned a pink groin rash, but did not indicate if there had been any improvement or decline with use of the antifungal powder. Skin (body) audit progress notes for 2/17/18 and 2/25/18 showed Resident 1 had pink groin rash, and was treated with [MEDICATION NAME] powder. No other skin alteration(s) were noted. On 2/13/18, a physician assistant (PA) documented that Resident 1 had an itchy, red rash on her upper back. The PA ordered cortisone cream and anti-itch medication. The cream was to be applied to the resident's back every shift until resolved, and staff were to monitor for ADS (adverse symptoms) and effectiveness. The note did not indicate the size of the rash. The clinical record did not show any nursing notes or skin alteration records for (MONTH) (YEAR) that described Resident 1's rash on the back nor documentation regarding the effectiveness of the cream application to the back rash until 2/28/18. On 2/28/18, a nurse progress note documented Resident 1 was yelling out in pain, multiple open pustules were found on the back, buttocks, and shoulders with greenish, sero-sanguinous (thin, red) drainage and the physician was notified. An associated skin alteration sheet was initiated for the multiple open area. Three skin alteration sites were circled on the body diagram on the left side of the mid-back area. There were no listed measurements of the sites nor description of the skin alteration sites. The drainage from the sites was marked as being both sero-sanguineous and purulent (infected-creamy white/yellow in color). There were no other skin alteration record(s) describing the buttocks area(s). The primary care physician (PCP) saw Resident 1 on 2/28/18 and noted a physical exam, large cluster of open blisters 2-5 cm (centimeters) in size, superficial on right mid-[MEDICATION NAME] (back), and diagnosed the area with [MEDICATION NAME]/shingles. The physician ordered an [MEDICAL CONDITION] medication (to reduce the severity and duration of the shingles rash), pain medication and [MEDICATION NAME] cream to the back rash and cover with a non-stick dressing. The physician made a follow-up visit on 3/2/18 to evaluate the resident's pain from shingles, noted the resident's back as 'covered with dressings', and increased her pain-relief medications. There were no further physician notes in the medical record. Review of the (MONTH) (YEAR) electronic Medication Administration Record eMAR and eTAR showed different Licensed Nurses (LNs) completed Resident 1's skin treatments each day and shift. The LNs documented application of [MEDICATION NAME] cream to the lower back, [MEDICATION NAME] cream to back, and antifungal powder to the groin from 3/1/18 to 3/7/18. Antibiotic ointment was applied to gluteal folds on 3/7/18. The (MONTH) (YEAR) eTAR showed there was also had an order for [REDACTED]. Both were initialed as completed as ordered. Associated nursing progress notes for 3/1 - 4/18 mentioned the right back was dry and there was slight redness to left shoulder, but did not identify any other skin alteration such as a groin rash, and/or indicate improvement or decline with treatments: On 3/2/18 at 3:03 am, the resident continued on antibiotic (Resident was receiving an [MEDICAL CONDITION] medication, not antibiotic.) Increased moaning and screaming with repositioning and ADLs. Her pain was managed with routine Tylenol and the treatment to the back was completed. The LN encouraged the resident to lay on her side to relieve pressure off back and decrease discomfort. In addition, she was incontinent. At 3:14 PM, the resident was alert and oriented. The shingles site on right upper back was dry with no new drainage and she was continued on antibiotics. At 5:43 PM, new orders were received for a narcotic pain medication. On 3/3/18, the pain medication appeared to have helped. On 3/4/18, the resident was alert and confused .did not ask for any pain medication. Continued to call out during pericare .Slight redness to Left shoulder. Then on 3/6/18, nursing did the weekly body audit and noted: Shingles to back and gluteal (buttock), observed scattered [MEDICAL CONDITION] palm size to back and gluteal, wound bed with yellow slough (dead tissue), scant serous drainage to upper back [MEDICAL CONDITION], moderate sero-sanguinous drainage to R gluteal lesion. Seen by a facility physician (not the PCP). The note did not comment on the current skin condition of the groin, peri-rectal area or other areas, such as heels. There were no associated skin alteration records documenting a thorough skin assessment of each affected skin alteration, identifying the location, measurement, and description of the alterations. In addition, there was no evidence of further review and revision made to Resident 1's written care plan regarding actual skin impairment. On 3/6/18, an order received from the PCP for an antibiotic ointment be applied to (infected) gluteal [MEDICAL CONDITION] 2 times per day, clean and cover with dry dressing. The order started on 3/7/18. There were no associated physician/PCP note(s) regarding the order or skin alterations. On 3/7/18 at 1:45 AM, a nursing note showed the resident was resting, but demonstrated pain with any movement. Patient was unable to follow commands earlier in the shift. Able to convince resident to take medications, but the resident had declined 'extensive skin clean-up and dressing changes (for the evening of 3/6/18).' There was no mention of the resident's skin status. On 3/8/18 at 12:42 AM, the resident was confused and took meds. She was oriented to self and husband only. Blood glucose was high before and after dinner. She had a poor appetite, but blood sugar (BS) remained high. Then on 3/8/18 at 8:54 am, a nursing note showed the resident was found, lethargic, eyes open but not verbally responsive. Rapid breathing warm/hot to touch. Blood Pressure was 89/57 (low), temperature was 103.5 (high), pulse was 127 (high), and respirations were 54 (high). The LN administered a Tylenol suppository, was placed on 2 litters of oxygen. Her BS registered as hi. The LN called 911, notified family and left voice mail notification to MD. There was no mention of the resident's skin status. During an interview on 3/21/18 at 11:15 am with Licensed Nurse (LN), Staff A, who first noted the resident's acute skin changes on 2/28/18, Staff A said Resident 1 lived in the facility's 2nd floor until she was diagnosed with [REDACTED]. Staff A said that in mid-February, the resident had a small red rash (approximately 4 cm) on her mid-back, that was occasionally itchy. Then at the end of February, Staff A returned to work (on 2/28/18) after a few days off, and found Resident 1's rash had suddenly worsened from a small red area to opened blisters over her whole back. During an interview on 3/21/18 at 3:00 pm with the Director of Nursing (DNS) and a 1st floor nurse manager (Staff B), they were asked whether they had observed Resident 1's skin after the initial shingles diagnoses. They said they had not observed the resident's skin. The DNS said the LN who wrote about the skin audit on 3/6/18 was not presently at work, but said she had asked the infection control nurse to look at the resident's skin on 3/6/18. During an interview on 3/21/18 at 3:10 pm, Staff C stated he did see the resident's skin on 3/6/18 along with one of the facility physicians, who was not the resident's PCP. Staff C said he observed multiple superficial open sites scattered around Resident 1's back. Staff C said he did not view the resident's gluteal or perirectal area. He said the physician suggested getting an order from the PCP for antibiotic ointment because sometimes shingles could get infected. Staff C said he did not write a note about his observation of the resident's skin. Review of hospital records dated 3/8/18 showed Emergency Department (ED) noting a [DIAGNOSES REDACTED]. An infectious disease consult note, also dated 3/8/18, indicated Resident 1 had multiple wounds throughout her body, upper back, lower back, right upper hip, buttock area, heel, and labia. The wound on the left buttock was deep, and there was purulent drainage from right hip posterior wound .noted [MEDICAL CONDITION] secondary to skin and soft tissue infection, multiple open wounds, some with purulent drainage. Resident 1 underwent surgical debridement of the multiple wounds on 3/9/18, as a CT scan radiological report indicated the resident had multiple areas of wound necrosis and abscesses on her buttocks, back, and labia which required surgical debridement to 'resolve the infection issue.' Diabetic Monitoring Resident 1 was a diabetic who required insulin injections on a daily basis. Physician orders [REDACTED]. The (MONTH) (YEAR) eMAR showed blood sugar (BS) readings were obtained 4 times per day, with average BS readings within the mid-100's range. However, between 2/28/18 - 3/8/18, the eMARs showed that Resident 1's BS readings became more elevated, averaging in the low-300's. There was no indication the licensed staff notified the PCP of the consistently elevated BS readings until 3/8/18, and after the resident was sent to the hospital with a BS reading of Hi (greater than 500). The eMARs did not include specific BS reading parameters informing LNs at what BS readings (high/low) to notify the physician to determine if any changes in (insulin) orders were needed. In an interview on 4/3/18 at 11:10 am, Staff C, Director of Nursing said that residents with insulin-dependent diabetes usually have a physician's orders [REDACTED]. Upon review of February/March eMARs, Staff C stated she did not see a BS parameter order for Resident 1, but would have expected to have a parameter for the resident. In an interview on 4/3/18 at 10:50 am, Staff D, Licenced Nurse, said the residents would usually have a BS parameter order on the eMAR and that the common parameter order, would be to call the physician, for BS reading greater than 400 mg/dL and less than 70 mg/dL. There were several BS readings in (MONTH) (YEAR) wherein the BS was documented as being higher than 400: On 3/3/18, at Bedtime Resident 1's BS was 416. On 3/7/18 at 11:00 am was 480. There was no indication the physician was notified of these elevated BS readings. A nursing note dated 3/8/18 at 12:42 am, indicated the resident's blood sugar reading was high at 370 before and 396 after dinner. Insulin was administered. The Patient had poor appetite, but BS remained high .nursing to continue monitoring. There was no indication nursing attempted to notify the physician that the resident's BS readings remained elevated after receipt of the routine dose of fast-acting insulin Then on 3/8/18 at 8:54 am, a nursing note showed the resident was found, lethargic, eyes open but not verbally responsive. Rapid breathing warm/hot to touch. Blood Sugar registered as hi. The LN called 911, notified family and left voice mail notification to MD. Review of hospital notes dated 3/8/18 showed: Emergency Department (ED) notes revealed that due to Resident 1's significant decline in condition, the resident was intubated (tube inserted for ventilation), required intravenous fluids for dehydration, had an elevated BS reading of 600 mg/dL, and was diagnosed with [REDACTED]. In summary, facility staff did not timely identify, thoroughly monitor and assess, and take timely action on acute changes in the resident's condition, especially in (MONTH) (YEAR). Assessment documentation of all skin alterations was incomplete. Staff did not timely or accurately identify of all acute changes in Resident 1's condition (alterations in skin status, [MEDICAL CONDITION] with cloudy drainage, pain with any movement, neurological changes such as Unable to follow commands, poor appetite, and elevated BS readings). Staff did not timely notify and have discussion(s) with the PCP regarding these changes nor were timely revisions made to the plan of care. Reference: (WAC) 388-97-1060

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 sample residents (1). Failure to follow the plan of care regarding use of assistive devices, such as a bedside commode for toileting & a gait belt during an assisted standing transfer, resulted in harm due a fall with a subsequent sudden onset and decline in condition. Findings included: A gait belt is a device used by caregivers to assist with safe transfers of residents with mobility or balance issues from one position to another. Review of facility documentation showed a Facility Gait Belt Policy for nursing assistants (CNA) indicated all CNAs must use a gait belt during all lifting of residents unless contraindicated by resident's condition. The record showed, Resident 1 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert & oriented, and able to make her needs known. The resident was identified as at risk for falls due to weakness & pain and was on various medications including an anticoagulant to prevent blood clots. Review of the written plan of care (P[NAME] dated 1/30/18) & bedside Kardex (a brief P[NAME] overview that communicates a resident's daily care information to nursing staff ) showed Resident 1 needed 1 to 2 persons to assist with her activities of daily living such as transfers. Staff were directed to use a gait belt for transfers and ambulation, her mobility device was a wheelchair with which to move about, and the resident used a bedside commode (BSC). Progress notes from 1/30/18 - 2/2/18 noted the resident was unsteady when standing and used the BSC. On 2/2/18 at 5:51 pm, staff a progress note showed the resident required assistance due to weakness, and the resident seemed tired due to all of the activities during the day. Then at 8:30 pm, the resident had a fall in the bathroom. The CNA who was with the resident at the time of the fall told the nurse that the resident was at the sink washing her hands when one leg got weak and she went down onto her bottom. Nursing staff assessed the resident as being able to move all her extremities and a neurological check was within normal limits and were continued every half hour. An hour and a half later at approximately 10 pm, the resident started complaining of a severe front of her head headache. She began having emesis & became unresponsive. Staff called 911 during this time and the resident was taken to the hospital. Facility documentation about the resident's fall on 2/2/18 included the following information: An undated written statement by licensed nurse, Staff B, indicated when notified of resident's fall, she went to the room and saw the resident sitting on the bathroom floor, leaning on the railing next to toilet seat. There were no injuries, and the resident was assisted back to bed via mechanical lift. She documented the resident only complained of bilateral ankle pain that had been present before the fall. Staff B documented that Resident 1 refused to go to hospital. The physician was notified & gave an order for [REDACTED]. Awritten statement by Staff A, nursing assistant, dated 2/2/18, indicated the resident had wanted to go to the toilet. Staff A documented that she recommended the use of the BSC, but there was family present who said resident could walk to the bathroom. Staff A wrote she then said she would call for someone to help her, but family said they thought (Staff A) could do it by herself (transfer/walk Resident 1). Staff A walked the resident to the toilet, after toileting, the resident stood up to her wash hands, and suddenly the resident fell , hitting her bottom to floor. Staff A wrote she was with the resident during this and guided the resident to the floor. During an interview on 3/6/18 at 3:30 pm, Staff A stated the resident needed to toilet. Staff A said she offered the use of the BSC that was near the resident's bed, but that family really encouraging her to go to bathroom so she could get better quicker to go home. So she & I walked to bathroom. It was when she stood up to the sink when one leg started give out so I was right there and helped her down onto sit on her bottom on floor. She didn't hit her head, she was able to talk after. Got the nurse, and after nurse checked her, we got her back to bed with a mechanical lift. (The resident) already had a full day of therapy, but family really wanted her to use bathroom. So we did. Staff A indicated the resident was not wearing a gait belt. During an interview with interview on 3/7/18 at 4:10 pm, Staff C, Director of Nursing Services said she looked into the fall and found out that the aide did not use a gait belt when she walked the resident to the bathroom. Staff C stated that the aide had offered the resident the use of the BSC as per the care plan, but then walked the resident to the bathroom due to family and resident's preference. Resident 1's written plan of care instructed staff to use a gait belt for transfers, use a BSC for toileting, and use a wheelchair for mobility. Facility staff did not use these assistive devices in accordance to the resident's P[NAME] and the resident fell on [DATE]. A few hours later, the resident had an acute change of condition and was sent to an emergency room . Review of the first emergency department records dated 2/2/18 documented the resident arrived (intubated) at 11:03 pm. A physical exam noted no evidence of head trauma, but that the resident's pupils (eyes) were fixed & dilated. Shortly afterwards, a (CT) scan of the head showed the resident had a critical result of a large subdural (intracranial) hematoma. (A subdural hematoma occurs when blood collects between the brain and the skull which can cause pressure on the brain tissue.) Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure appropriate preventive measures were consistently implemented to prevent the development of pressure ulcers for 2 of 2 sample residents (4, 2). Failure to ensure preventive interventions were specific, communicated to staff, implemented, and monitored for consistent implementation & effectiveness resulted in the development of heel pressure ulcers for Resident 4 and 2. Findings include: Resident 4 Resident 4 was admitted to the facility on [DATE] after hospitalization for a right(R) [MEDICAL CONDITION] and other [DIAGNOSES REDACTED]. The resident was assessed to have moderate cognitive impairment and required extensive 2-person assist with bed mobility, transfers, and toileting. The resident no longer resided at the facility. During a telephone intervew with a family member (FM) of Resident 4 on 6/15/17, the FM stated the resident developed a heel blister that was the size of a tennis ball and that facility staff never floated the heels (did not elevate the resident's heels off the mattress to avoid pressure). The FM also said the resident was not accepted back to her previous assisted living residence specifically due to the presence of the pressure ulcers that developed at the nursing home. Review of the medical record revealed a 4/6/17 Patient Admission Screen that documented Resident 4 did not have an existing pressure ulcer on admit. A 4/6/17 nursing admission note indicated the resident was confused and forgetful, able to follow commands & cooperated well with care, and had no skin alteration noted except a right(R) hip surgical incision. It was also noted the resident had high levels of pain during incontinent care and was grimacing & crying when repositioned with relief via application of ice to the incision and pain medication. The admission Braden scale for predicting pressure sore risk indicated the resident was at moderate risk. The written plan of care (POC) was initiated on 4/7/17 related to the resident being at risk for skin alterations due to incontinence, dementia, & impaired mobility with the goal to decrease/minimize skin breakdown risks. The POC included interventions for staff to encourage to reposition as needed, use assistive devices as needed, and float the resident's heels as able. Nursing progress notes from 4/7/17 - 4/12/17 did not have documentation indicating Resident 4 was being repositioned or that her heels were being floated to reduce pressure. On 4/11/17, a physical therapy (PT) note indicated Resident 4 needed maximal assist for bed mobility mainly to manage both lower extremities (LE) on/off the bed. Then on 4/12/17, a PT note indicated therapy was focused on improving the resident's mobility on R LE due to swelling from recent surgery. The therapist noted a blister on Right(R) LE and notified a nurse. The therapist indicated the resident was placed in bed and, Floated both heels using 2 pillows for each leg. On 4/12/17, a nursing note revealed PT had reported a blister on Resident 4's R heel. Nursing assessed the blister and noted it was not open. There were no measurements or description of the heel area such as color, mushy/firm or condition of the skin surrounding the blister. A 4/13/17 nursing note indicated Resident 4 had a fluid-filled blister on the R heel, a stage 2 pressure sore measuring 4 centimeter(cm) by 8.5 cm. without surrounding redness or pain. Nursing requested a physician order [REDACTED]. A dayshift nursing note on 4/13/17 indicated Resident 4 had prevalon boots to both feet & feet elevated with a pillow, & 4/13/17 evening shift noted bilateral feet floated with pillow below the feet. On 4/14/17 evening shift, heel boots were applied. There were no further nursing notes documenting floating heels or wearing boots until a facility wound team assessment with an outside wound care consultant on 4/18/17. The wound care team noted the intact blood-filled blister on the R heel and that Resident 4 was wearing prevalon boots, was compliant with position changes & elevating heels, and had an alternating pressure relief air mattress on her bed. A nursing note on 4/19/17 indicated, Heels (boot?) applied while in bed, always wears one on R foot even when not in bed. Then on 4/20/17, MD & family were notified about a new pressure sore on Resident 4's L heel. An assessment on 4/21/18 described the L heel pressure sore as a dark red suspected deep tissue injury(DTI)*, 1.0 x 1.0 cm (likely related to pressure per the wound consultant note). A wound team assessment on 4/25/17 noted the resident still had an intact Unstageable blood-filled R heel blister and the Unstageable L heel DTI measurement had increased in to 1.6 x 1.6 cm and was black in color. The POC was revised on 4/13/17 for suspected DTI to R & L heels revised intervention to encourage & assist as needed to turn and reposition, and to use pillows &/or positioning devices as needed. The POC did not include specific instructions for staff regarding frequency of repositioning, when to float heels, use of prevalon boots (boots that help minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals) or include information on whether the resident was switched to an air mattress to further reduce pressure. Review of the April & May 2017 electronic treatment administration records (eTAR) revealed 4/13/17 orders for nursing to do a daily skin check/observation and to apply [MEDICATION NAME] to bilateral heels twice a day. The ETARs did not contain information informing/reminding nurses to monitor for consistent repositioning and elevation/floating of heels off the mattress, use of prevalon boots or use of an air mattress. During an interview with a nursing resident care manager (RCM B) on 6/21/17 at 3:40 pm regarding communication and monitoring of daily individual care interventions to staff, RCM B said that communication of care interventions, such as wearing prevalon boots, would be in tasks in the nursing assistant (NA) Kardex. RCM B said the electronic Kardex was not available for viewing after a resident's discharge, but the RCM did find a Kardex task entry in the system for Resident 4 with an initiation date on 4/6/17 to suspend heels prevalon boots (FYI) Patient has pressure sore on bilateral heel- no shoes until pressure sore healed. She said that nurses would then be alerted via the electronic system if an NA hadn't documented completion of the assigned tasks. She said that nurses would most likely communicate new/revised interventions and specific monitoring needs via shift report (nurse to nurse). *Suspected Deep Tissue Injury (sDTI): Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. https://www.mnhospitals.org/Portals/0/Documents/ ./pressure-ulcer-staging-card.pdf RESIDENT 2 Resident 2 was admitted on [DATE] from another nursing facility with [DIAGNOSES REDACTED]. The resident was assessed as requiring extensive 2-person assist with bed mobility, transfers, and toileting with functional impairment of range of motion on 1 side LE. review of the resident's medical record revealed [REDACTED]. The admission Braden scale for predicting pressure sore risk indicated the resident was at risk. The initial 3/30/17 POC for being at risk for skin alteration included interventions to encourage to reposition as needed, float heels as able, and to use pillows &/or positioning devices as needed. A Care Assessment related to pressure ulcers dated 4/5/17 indicated the resident was at risk for skin breakdown and required extensive assist with bed mobility due to weakness and pain with movement. Staff were to provide care and encourage and assist with turn & repositioning as needed. Review of nursing progress notes from 3/29/17 -4/6/17 did not document staff encouragement or assistance with repositioning or floating of the resident's heels to reduce pressure. On 4/7/17 evening shift nursing noted resident has pain with bed mobility Both heels soft Left(L) heel with discoloration,elevated on pillows to keep off mattress. Then on 4/9/17, a nursing note noted Resident 2 had a left heel pressure sore elevated on 2 pillows. A 4/10/17 fax reported to the physician that Resident 2's left heel has a dark discoloration, soft, measuring 3 x 1.4 cm. and the ball of great toe has an intact blood blister; and both heels elevated on prevalon boots. A 4/11/17 described the L heel reddened around and center with dark green soft area and complains of pain when touched. Blood blister to L ball of great toe intact. The POC was revised on 4/10/17 to encourage and assist as needed to reposition, special (air) mattress on bed, administer treatment per orders and reposition resident up in bed so foot is not touching the foot of bed. A nursing skin assessment note dated 4/18/17(late entry) noted the resident ad an Unstageable pressure sore to L heel measuring 3.5 x 2.5 cm with dark purple/black surround & yellow at center; and a blood blister to ball of L great toe. It noted the resident prefered to stay in bed, wore prevalon boots at all times, had an air mattress, and a wound consultant was to evaluate/treat the foot areas. In an interview with a unit nurse 6/15/17 at 10:20 am, the nurse said she has recently seen Resident 2's pressure ulcer, It is small and with new skin approximately 1 inch diameter. He mostly stays in bed, air mattress, he has extreme arthritis pain whenever moved, and gets (a narcotic medication) every 4 hours which helps his pain. During an interview with on 6/21/17 3:05pm with RCM A, the RCM said the resident has a facility-acquired pressure ulcer on his heel that hasn't healed yet. She said the resident came from another nursing home, but we didn't get much information about the resident's care needs at first. (Resident 2) pretty much did not want to get up out of bed from the beginning, we would try to have him get up out of bed, but he didn't really want to, he is essentially bedbound by choice. RCM A said staff know what specific interventions are in place for an individual resident, that's on the tasks from the care plan so NAs know what to do, we don't put it specifically on treatment record. We remind the NAs to make sure all the residents are positioned frequently and to make sure resident have their boots on if ordered. We don't specifically indicate a repositioning frequency, like every 2 hours. Staff can use pillows for elevating heels/repositioning, and we have the blue bridge cushions for those resident with heel problems. This failed practice was not made available to the department until an additional complaint was made and investgated. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review the facility failed to ensure necessary care and services were provided to prevent the development of pressure ulcers in 2 of 3 residents (67 and 199 ) reviewed for pressure ulcers. Failure to timely identify and assess skin changes, follow and update the care plan and implement interventions to prevent skin breakdown caused harm to the residents who developed pressure ulcers. Findings include: Definitions of Pressure ulcer stages: Stage 3: Full thickness skin loss in which fat is visible in the ulcer. Slought and/or eschar may be visible. Stage 4: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Unstageable Pressure Ulcer: Full thickness of skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar Slough: soft, moist dead tissue. It may be white, yellow, tan, gray or green . Eschar: necrotic granulation tissue, muscle, fat tendon or skin. RESIDENT 67 Resident 67 was admitted to the factiliy on 04/07/17 with [DIAGNOSES REDACTED]. In the review of the admission Minimum Data Set (MDS) assessment it was documented the resident had no pressure ulcers on admit, however she had Moisture Associated Skin Damage (MASD) related to incontinence. The MDS also documented the resident was at risk for developing skin breakdown due to impaired mobility and incontinence of bowels. The MDS documented the resident was not on a turning/repositioning program. The Care Area Assessment (CAA) documented the resident required staff assistance to move sufficiently to relieve pressure over any one site. In the review of the Social Service Assessment and History form dated 05/09/17 it was documented the resident was alert and oriented to person, time, and place and had a Brief Interview for Mental Status (BIMS) score of 13 which showed she was cognitively intact. Review of the resident's care plan dated 04/12/17 revealed the focus problems related to skin as follows: 1: risk for alteration in skin integrity with interventions to include barrier cream to peri-area/buttocks as needed (prn), encourage to reposition prn, float heels as able; pressure redistribution device on bed and chair; to provide preventative skin care routinely and prn and to use pillow/repositioning devices prn. 2: left lower leg wound with interventions to administer treatment per physician orders, encourage and assist to turn and reposition prn, special mattress/cushion on bed/wheelchair, and to use pillow and/or positioning devices prn. 3: moisture related blanchable redness to coccyx with interventions to administer treatment per physician's orders [REDACTED]. Review of the Nursing Assistant (NA) Kardex, which directed the resident's care, revealed instructions to report new skin alterations, suspend heels, and to turn and reposition (FYI). No turning/reposition frequency was specified. On review of the NA task there was list no documentation of floating the residents heels or turning the resident found. Review of the clinical record revealed the resident was readmitted to the hospital on [DATE] for acute kidney failure. She readmitted to the facility on [DATE]. In the review of readmission MDS dated [DATE] it showed documentation the resident had no pressure ulcers. Review of the admission nursing skin assessment document no pressure ulcers or MASD. Review of the hospital records from 04/20/17 - 04/27/17 documented the resident's coccyx area was intact with no open areas. Review of the clinical records revealed the resident went to the Emergency Department (ED) on 05/05/17 for an evaluation due to declining health, poor oral intake and resident request to go to the ED. There was no documentation from the ED that the resident's skin was not intact upon discharge. There was no documented skin assessment found upon her return to the facility. Review of the clinical record showed a nursing progress note dated 05/08/17 which documented staff had reported an open area to the coccyx. No further follow up or documentation of an assessment was found of the coccyx. Review of the clinical record revealed the wound care team identified a deep tissue injury (DTI) on the left heel on 05/09/17 during a skin assessment. There was no status documentation of the open area on the coccyx that was documented on 05/08/17. Review of the care plan showed it was not updated with the new problem of the heel DTI, wound care interventions, or protective boots. The Treatment Administration Record (TAR) was updated with the wound care procedure, but the procedure did not include monitoring the use of the protective boots, heel floating, or repositioning. Review of the nursing progress note dated 05/16/17 revealed the resident had 2 new open areas, one on the right buttock and the other open area on the left ischial area (lower buttock). The wound team assess and documented the right buttock wound as a Stage 3 pressure ulcer and the left ischium wound as a rash with an open wound bed. Wound care, a microclimate manager mattress overlay and a new temperpedic wheelchair cushion were ordered. Review of the care plan revealed it was updated on 05/15/17 with documentation of the new problem of open areas to the buttocks, but the left heel deep tissue injury was not addressed. Review of the NA Kardex (care directives) showed no updates on skin care or positioning for the coccyx wounds. In an observation done on 05/12/17 at 10:09 AM Staff A, Licensed Nurse (LN), performed wound care on the left heel ulcer. A dark purple color injury was observed on the posterior heel. The heels were floated and the prevalon boots were placed after the wound was done. The following observations of positioning were made on 05/15/17: 8:44 AM: resident in bed on back with heels bridged and boots on. 9:58 AM: resident in bed on back with head of bed elevated at about 30 degrees, heels bridged. 10:51 AM: resident in bed on back with head of bed flat, heels bridged. 11:38 AM: resident sitting up in wheelchair, prevalon boots on. 1:39 PM: resident sitting up in wheelchair sleeping. In multiple observations on 05/11/17, 05/12/17, 05/15/17, and 05/16/17 the resident was observed to be lying on her back or sitting in her wheelchair. No staff was observed entering the resident's room to encourage or assist the resident to shift her position when she was either in bed or up in her wheelchair. In an interview on 05/12/17 at 8:32 AM, Staff B, Assistant Director of Nursing stated that skin assessments were done weekly and kept at the nurse's station in a notebook. Wounds other than pressure ulcers are documented on the Skin Alteration Record. Pressure ulcers are documented on the Pressure Ulcer Scale for Healing (PUSH tool). The patient just developed the pressure ulcer on her heel this week so she had a new PUSH tool filled out by the wound nurse on 05/09/17. In an interview on 05/12/17 at 1:47 PM, Staff A stated the Nursing Assistants (NA) should be documenting that they are turning residents, floating their heels and putting their protective boots on. They do their charting in the kiosk and that information goes on the task sheet. In an interview on 05/12/17 at 2:14 PM, Staff C, NA stated the NAs don't chart if the resident's heels are kept elevated but we do chart repositioning in the task tab in the kiosk for residents on turning schedules. In an interview on 05/12/17 at 1:54 PM, Resident 67 stated the staff tried to keep her heels elevated with pillows but only turned her when she asked them to. I just got these boots to wear when they found that ulcer on my heel. My tailbone hurts from pressure, I don't know if it's open but it gets painful when I'm on my back too long. In an observation on 05/15/17 at 11:12 AM, wound care was observed to the buttocks area. The wound care was performed by Staff A, LN. Two open areas were observed, one on the right buttock and one on left ischial area (lower buttock area near crease of leg). The right buttock wound had reddened skin surrounding it. Both wounds were in common pressure point areas. During the wound care procedure Staff A. LN, stated these wounds are new, just noted today. We received wound care orders from the doctor and got the resident a new wheelchair cushion. In an interview on 05/15/17 at 2:30 PM, the Director of Nursing Services (DNS), stated that the buttocks wounds were new. She was not aware of the nursing progress note documenting an open area in the coccyx area on 05/08/17 and did not know why there was no follow up. She stated she would look to see if there was anymore documentation of the resident's skin other than the wound care nurses progress notes. She would also look for documentation of the resident being turned or repositioned. In an interview on 05/16/17 at 10:00 AM, the DNS, Staff B, and Staff D. The DNS stated the resident should be on a turn schedule. We are also getting a new mattress for her with climate control because she has so many comorbities and skin issues. Staff B stated the resident had gone to the Emergency Department on 05/05/17 for assessment and was there all day probably lying on her back the whole time but we should have been assessing her. No further medical documentation was provided during the survey. RESIDENT 199 Resident 199 was admitted to the facility December 14, 2016 with [DIAGNOSES REDACTED]. The resident was unable to move her legs and had limited movement in her arms. Per the admission MDS assessment dated [DATE], the resident was cognitively intact, needed assistance of 2 or more staff to reposition or transfer to a wheelchair, was at high risk for skin breakdown and her skin was intact. The Care Area Assessment (CAA) a tool used to assist in developing a care plan dated 12/21/16, identified the rationale for Care Planning for the prevention of pressure ulcers was that the resident was dependent on staff with bed mobility and new [DIAGNOSES REDACTED]. There was no skin issue at that time, but remained a risk for breakdown. The CAA also identified that devices that could cause pressure including an indwelling catheter tubing. A Care Plan was developed and included the following interventions: Barrier cream to peri area/buttocks as needed, observe skin condition with care daily, have a pressure redistributing device on bed, and provide preventative skin care routinely and as needed, use pillows and repositioning devices as needed. The Care Plan was revised on 12/27/16 to include no briefs in bed, chucks only when in bed. The care plan did not agressively document how the facility was going to ensure the resident did not develop skin breakdown. Discharge orders from the hospital directed facility staff to turn the resident every 2 - 3 hours overnight while lying in bed, and every reposition every 15 minutes for pressure relief when up in a wheelchair. The discharge instructions also identified the resident as a Patient at risk for: Pressure ulcers A review of the Nursing Assistant (NA) documentation found that during a 24 hour period for the 18 days of December the resident should have been turned 8 to 12 times. Documentation showed she was turned 1 time on 3 days, 2 times on 6 days, 3 times on 6 days, and 4 times on 3 days. There was no documentation of refusals. During the Month of January documentation showed the resident was turned 1 time on 1 day, 2 times on 8 days, 3 times on 15 days, 4 times on 6 days, and 5 times on 1 day. Documentation also showed that 15 times the same NA documented the resident refused to be turned by the same NA. Review of the NA task list directed staff to turn and reposition the resident every 2 to 3 hours overnight and when lying in bed. Review of the physician and nursing progress notes found on: 12/20/16 the resident complained of soreness on her tailbone, redness was noted. The LPN repositioned the resident at bedside to reduce pressure on her tailbone, but there was no other documented actions taken. 12/23/16 the physician documented the resident reported a sore on her right upper inner thigh. The physician observed it to be a 3 cm x 4 mm linear, pink, clear fluid filled, blister on her right upper inner thigh. The physician ordered antibiotic ointment to be applied two times per day for 7 to 10 days or until healed. 12/24/16 sore on her left lower scapula (shoulder bone) and coccyx (tailbone) open and peeled off There were no other documented interventions put into place. 12/25/16 .new areas of redness on R buttock. Dressing on L posterior shoulder and R medial thigh cleaned and dressing changed. 12/26/16 has redness on left side on brief line that requires monitoring and skin protectant barrier to prevent further breakdown. A letter was written to the facility on [DATE], by a physician from the Harborview Medical center which stated the resident expressed a concern to me today that she begun to develop skin breakdown from her catheter tubing and in her sacral area. I would like to ask that you follow the utmost care to perform frequent repositioning and prevention of firm objects resting against her skin. She has poor sensation and cannot report if compression is damaging her skin.[MEDICAL CONDITION] from skin breakdown is a serious source of morbidity and mortality in spinal cord injury patients. 12/29/17 patient is being provided with wound care for a blister on upper right leg and on bottom side of rt lower half for redness. 01/02/17 pt has some redness and skin breakdown noted on the right side of bottom area, being treated with z-guard (a zinc oxide-white petroleum paste used to treat skin irritation by forming a barrier on the skin to protect it from irritants/moisture). 01/04/17 has a stage two pressure ulcer on her right upper thigh related to pressure from her foley cath. 01/07/17 stage 2 on coccyx .blister on front rt thigh 01/9/17 the Physician's Assistant Certified (PAC) documented to nursing: Please encourage patient to reposition often to avoid ulcerations (the resident needed a two person assist to turn) 01/13/17 dressing changed on open blister posterior right thigh . 01/18/17 the PAC documented: the resident was concerned about the pressure ulcers on her right hip and buttocks and does not want them to get worse. The PAC also ordered an approval for a wound care clinic consult. 01/19/17 wound on upper right thigh. Wound bed is 4 centimeters (cm) x 3 cm. Area was a blistered area that has now worsened and has an area of brown tissue in the center and slough noted to rest of wound. Depth unknown. 01/21/17 .Dressing change to the coccyx and tight thigh was done as well the wound on coccyx appeared black in the center and red around. Thigh wound was open with drainage and red. 01/21/17 the PAC documented: follow up visit regarding her pressure ulcers, states she was advised she didn't qualify for outside visit to wound care clinic, stated it had something to do with transportation. Will discuss with nursing to see how she can get transportation to the wound care clinic covered. 01/23/17 the PAC documented: she still requests to be able to go to the wound care clinic, per nursing, she does not qualify for transportation. I will discuss with the nursing supervisor to see if there are any options. 01/25/17 Wound team assessed resident's right upper back of thigh, area is an unstageable pressure sore, measures 4.0 x 2.0 cm, wound is 90% eschar and 10 % slough . 01/25/17 the PAC documented: Per resident, she was told she did not qualify for outside wound care visit, she asked to speak to the administrator. States the administrator and another person from corporate level told her she would be able to have outside visit to the wound care clinic and the facility would provide transportation. Hopefully, an appointment with the wound care clinic will be scheduled soon. 01/30/17 the PAC documented: states the wound care team has evaluated her right hip ulcerations and has initiated treatment. 02/07/17 wound team assessed resident's right upper back of thigh, area is an unstageable pressure sore, measures 4.0 x 3.0 cm with depth of 1.0 cm, wound is 100% mix of eschar and slough Measurements of the pressure ulcer on the posterior right thigh were documented weekly in the progress notes and on the Pressure Ulcer Healing Chart. There were no measurements of the scapula wound or the coccyx pressure ulcer in the clinical record. The facility did not provide further information regarding the scapula wound or the coccyx pressure ulcer. There was no decrease in size of the pressure ulcer prior to Resident 199's admission to the hospital. On 02/07/17 the resident was discharged to a hospital for fever and respiratory distress. Review of the 02/07/17 hospital admission/discharge records found Resident 199 had [DIAGNOSES REDACTED]. Upon admission to the hospital on [DATE], Resident 199 had an unstageable pressure ulcer to the right ischial tuberosity that had breakdown (down to muscle or bone) that was debrided at the hospital and was identified as a stage 4. There was also a second wound to sacro-coccygeal area. In an interview on 05/12/17 at 1:47 PM, Staff A stated the Nursing Assistants (NA) should be documenting that they are turning residents, floating their heels and putting their protective boots on. They do their charting in the kiosk and that information goes on the task sheet. In an interview on 05/12/17 at 2:14 PM, Staff C, NA stated the NAs don't chart if the resident's heels are kept elevated but we do chart repositioning in the task tab in the kiosk for residents on turning schedules. In an interview on 5/16/17 at 1:10 pm, at a current facility, the resident stated that she got the pressure ulcers while she was at the old facility. The one sore developed from the foley catheter drainage tubing that was about ½ inch long by ¾ of an inch and there was not much depth. The nurse on day shift looked at it and did not know what to do so after a couple of days they got the nurse practitioner. During the same interview the resident's husband stated they were getting scared about the wound not healing. They (staff) were not trying to turn her. By Februaary 1, 2017 there were two pressure ulcers. On 05/16/17 at 10:00 AM, the Director of Nursing Services, (DNS), and Staff D, Licensed Nurse, were interviewed. They said, when the pressure ulcer on the posterior upper right thigh was identified on 01/19/17, the Care Plan was updated to include daily skin observation, a wound team referral, and a new pressure reducing mattress was ordered. On 12/27/16 No briefs in bed, Chucks only when in bed were added to the Care Plan. The resident was hospitalized before the wound care team saw the resident and before the new pressure reducing mattress arrived. No further information was provided by the DNS. Resident 199 has been identified as being part of a past non-compliance. WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers (PU) for 1 of 1 sample residents (2). Failure to timely identify/recognize a leg brace as increasing the risk for PU development, and timely implement specific interventions to closely monitor & reduce the risk of pressure from the brace resulted in the Resident 2 developing 2 unstageable pressure ulcers with eschar (necrotic tissue). Findings include: Resident 2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to be non-weight bearing on the R leg & wear a R knee brace. The Admission nursing skin assessment dated [DATE] indicated there was no existing pressure ulcer. The only body mark listed was the surgical incision down the front shin on the R lower extremity (LE). The Care Area assessment (CAA) for PU dated 10/25/16 indicated Resident 2 was admitted with a R tibia fracture for surgical wound care & monitoring. There were no other skin issues identified, but it indicated the resident remained at risk for skin breakdown due to decreased mobility & incontinence. A plan of care was developed to maintain skin integrity & prevent breakdown containing information for staff provide incontinence care, assist with turn & reposition as needed, and skin monitoring during daily care & assessment weekly. The CAA did not identify the leg brace as potential risk factor for increased rubbing and/or pressure to the skin potentially leading to skin breakdown. The electronic Treatment Administration Record (eTAR) record for October 2016 contained an order for [REDACTED]. The eTAR did contain orders to do a weekly skin observation & Braden scale (pressure sore risk tool). The eTAR did not include a nursing order directing/instructing licensed staff to assess Resident 2's skin under the brace during surgical incision care, with special attention to possible pressure points where metal or rigid hard part of the brace may touch/press on the skin. Progress notes from October 18 - 25 indicated dressing changes to the R LE surgical incision site and LE brace in place: On 10/26/16, a weekly skin check was completed and noted a purple area to inner right ankle, as well as 'slight redness to R heel area' & no open area. There was no documented evidence of continued ongoing monitoring of the 'redness to R heel area'. The was also no documented evidence of a review or revisions made to the resident's Plan of Care for the skin integrity section. Progress notes from October 28 - 25 indicated dressing changes to the R LE surgical incision site, a splint boot and LE brace, with no new skin issues. Then on 11/5/16 documentation showed that during a dressing change to the surgical incision, a black area was noted to the R Achilles, just above the heel area. There was no open area. The note indicated the resident wore the Leg brace at all times. On 11/7/16, a Skin wound team progress note indicated Resident 2 had a black area on her back R LE at the Achilles area that measured 4 x 4.5 centimeters(cm). It was noted as dark purple in color surrounded with red. The note indicated that the brace worn by the resident has a 1 inch metal type piece in back which appeared to have caused the breakdown. The facility staff checked with orthopedics who stated the brace must be worn at all times & to pad the bottom area of the brace to prevent further breakdown. Therapy was to assist with padding. However, the progress note did not indicate whether the rest of the resident's R LE was thoroughly assessed for any other potential pressure areas related to the brace. On 11/13/16, a progress note indicated a second eschar area was discovered on the posterior (back) R calf. On 11/16/16, the areas were assessed by the facility Skin Wound team: 1st site = R Achilles became larger, 5 x 5.4 cm with 100% eschar. 2nd site = A new pressure ulcer to the right calf was 3.2 x 2.4 and unstageable. Areas likely related to the brace, therapy notified who will assess & pad brace .Achilles portion of brace already padded. The November 2016 eTAR contained new orders including: On 11/5/16, a treatment was initiated related to the black area on the R Achilles (heel area), apply skin prep twice a day. On 11/8/16, daily skin checks and skin observations were updated on the skin sheet. On 11/18/16, staff were to cleanse & apply liquid skin protectant to the R calf every 3 days for eschar. On 11/30/16 at 10:30 am Resident 2 was lying in bed with her lower legs resting on pillows. When asked if she had any skin problems caused by her leg brace, Resident 2 briefly lifted the bed sheet to show the top section of the brace on her leg and pointed at a special boot on floor, I also have a boot. During an interview on 12/8/16 at 2:15 pm, Staff B stated she was familiar with the resident, I did her incision dressing/wrap several times. She(Resident 2) was to wear the full R leg brace at all times. I tried to figure out what may have caused the PU & looked at the brace. The brace had a hard metal strip all the way up the back of the leg from ankle to above knee/thigh. The rest of the brace was soft with Velcro straps on top. The only time it came off was for showers, I think, and then opened it each time we did dressing care & wrap of the incision site. I think daily skin checks started after we found the eschar area. So when found the first PU, it was low end of Achilles above the heel, circular looking eschar. Used marathon skin protectant on it after initial skin prep. So OT padded and foamed up the lower part of the metal strip by the Achilles PU. But then approximately a week later, a second area eschar was found right on back of calf, longer thin shaped (like the metal strip). I think OT then applied more padding to that area. When asked about use of the boot observed in Resident 2's room, I think that was to prevent footdrop, therapy tried it. During an interview on 12/8/16 at 4 pm with Staff C & D, Staff C said the wound team progress notes was where the facility documented information regarding pressure ulcers, and that the other skin sheets kept in nursing unit treatment binders were used by the floor nurses to document other (non-pressure) skin issues such as bruises, skin tears, etc. Staff C indicated the resident's 1st PU site was just above the R heel & already had full eschar when it was first observed, then OT padded the brace around that area. Then some days later, the 2nd PU area of eschar was found on the back center of the R calf & appeared to be along the area of the brace's metal piece, Then we had OT pad the brace in that area. Review of Occupational therapy (OT) notes showed: On 11/7/16 showed that the resident was not wearing brace on the R LE; not mobilized until orders clarified. On 11/9/16, positioning of the R LE was to achieve neutral positioning and assure pressure relief. On 11/18/16, padding was added to the lateral supports of brace to increase skin protection. Review of Physical therapy (PT) notes showed: On 11/7/16, gentle repositioning on RLE as the brace was off, awaiting padding modification and the brace had not arrived. On 11/9/16, a heel lift boot was placed on the R foot as suggested by nursing and fitted to assist in proper positioning. The facility's Braces/Splints Nursing Procedures dated 12/2009 included the following: 8. Hand or foot should be supported and straps secure, but not too tight. 9. Follow wearing schedule as outlined by therapist or physician. 10. Carefully inspect skin and appearance during applications. The facility failed to timely identify & recognize Resident 2's leg brace as potentially increasing the risk for presure ulcer development, and timely implement specific interventions to reduce the risk of pressure from all potential pressure points and friction points with the brace resulted in the Resident 2 developing 2 unstageable pressure ulcers.

Based on observation, interview and record review, the facility failed to provide care and services for highest well-being for one of one resident (#1) reviewed for pain management. Although some initial interventions were implemented, the facility failed to thoroughly assess the etiology of the resident's pain and functional limitations. Failure to perform complete ongoing pain assessments and develop appropriate nursing and treatment interventions delayed timely treatment for [REDACTED]. These failures caused harm to Resident 1 by not being able to have satisfying or sufficient pain relief so she could participate in turning and repositioning. Findings include: Review of a policy flowchart titled Pain Practice Guide Flowchart (boxes with lines attaching to other boxes) on 8/4/16 at 8:30 am, which the Administrator stated that staff use, began with the word Assess. Under Assess it directed staff to complete the Pain section of the Patient Admission / Readmission screen, the MDS (minimum data set) assessment and pain CAA (Care Area Assessment). The flow chart also indicated that after the CAA, staff were to plan care, implement and then evaluate. Review of the CAA showed that it was not a thorough assessment and consisted of being approx. three sentences, which did not follow the facility pain policy. On 8/15/16 at 12:15 pm, the pain policy that directed staff in detail, on how to handle residents with pain. The policy directed staff to use a pain scale of 0-10 to evaluate pain, (zero being no pain and 10 being the worst pain). Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record showed an initial nursing note and an assessment indicated the resident was alert and oriented, and was able to communicate her needs. It was also noted that on admit the resident had no pain at that time, but would have pain with movement or position change. On 5/19/16, per the facility pain policy, a Patient Admission / Readmission Screen was completed by the Resident Care Manager (RCM). The Patient Admission / Readmission Screen showed that sections F - M were blank and had not been completed even though the resident indicated that she would have pain on movement. These sections included subjects: What exacerbated the pain, what relieved the pain, how the pain negatively affected daily life and non-pharmacological interventions that worked. These were all blank. The Patient Admission / Readmission Screen also included a section for a Pain Care Plan, which the RCM documented the goal for Resident 1 was to: express that pain management was within acceptable limits. One of the interventions was to: Notify the physician if the pain frequency / intensity was worsening or if current [MEDICATION NAME] regimen had become ineffective. Review of the progress notes and Medication Administration Records for 5/18/16 to 6/16/16, for Resident 1, showed inconsistencies of a pain management program. For example, the resident was admitted on [DATE] and on 5/19/16 a progress note indicated the resident had no pain at the time of interview, but the resident reported that if she were repositioned her pain could become a 5 to an 8 on a pain scale of 0 - 10. The Flow chart did not direct staff how to document or assess to determine if the resident reached her goal of no pain. A review of the progress notes showed that when a pain pill was given for pain, the Licensed Nurses (LNs) would not do a thorough assessment of how the resident responded to the intervention. Instead they would document effective or ineffective and not use 0-10 as directed in the facility pain policy. Review of physician's orders [REDACTED]. Give 1/2 tablet every 6 hours as needed for a pain level of 3-6 or. Give 1 tablet every 6 hours as needed for a pain level of 6-10. Tylenol 500 mg every 4 hours as needed for pain. [MEDICATION NAME] apply to back one time per day for back pain. There was no documented clarifications on what to do if the resident's pain level was 6, considering both orders included a pain level of 6 and the pain policy did not direct staff on what to do. There was also no clear directions on when to give Tylenol vs. [MEDICATION NAME]. Progress notes dated 5/19/16 to 6/19/16 also showed that the resident's pressure ulcer was not progressing as planned along with her pain escalating. On 5/24/16, a Weekly Skin rounds note indicated the resident's wound had increased and the resident preferred be flat on her back due to pain (see F 314). There was no documentation of an intervention or change in care planning to resolve the resident's pain, even though they documented they encouraged her to be out of bed more. Review of the care plan showed that the goals for the resident's pain were that the resident would express pain management was within acceptable limits, the resident's pain goal was 0 and Pain or [MEDICATION NAME] would not affect the resident's participation in activities of daily care. There was no documentation to show this happened. The care planning goal was for the resident to have zero pain and nowhere in the progress notes was there any documented assessment after administration of the pain medication where the resident was at zero and able to function or that the [MEDICATION NAME] or medications were relieving the pain. Instead documentation showed that the resident would not move or reposition due to pain. In another part of the care plan documented under Behaviors the resident was resistive or noncompliant with treatment, care or getting out of bed, or allowing staff to reposition her related to: Pain or the belief that the treatment was not needed or working. The interventions did not address the pain, instead indicated the resident had behaviors instead of pain. On 6/6/16 Resident complained of level 6 pain at the sacrum after the dressing change. The LN administered [MEDICATION NAME] even though the care plan directed staff to adjust times of treatments after pain medication was given and had taken effect. On 6/9/16 a care conference was documented in the progress notes with the resident and family present. There was no documentation regarding the resident's repositioning, or pain management program. Review of a Pain Evaluation dated 6/13/16, four weeks after the resident was admitted , showed that the resident reported her pain at a 10, but there was no revisions to her pain plan. 6/13/16 notified physician of resident's pain from back. Requesting orders for routine pain medication (in addition to the as needed pain medication orders) There was no documentation of any medication changes until 6/15/16. Review of the MARs for June of 2016, showed that even though the resident reported her pain at a level 6 or even a 10 on 6/12, she was given Tylenol. On 6/16/16 an LN documented, the resident was transferred to the hospital for treatment. On the same day another entry indicated the resident's pain meds had been increased to address the resident's increasing pain. On 6/17/16 the Social Worker (SW) documented a late entry, for an unknown date, that the resident was refusing to get out of bed and reposition. The resident was made aware of the consequences of such behavior in affecting her home transition plan. There was no documentation by the SW as to any interventions in regards to the resident's pain. On 08/11/16, Resident 1's family member reported that every time she came to visit, the resident complained of pain. The family would report the pain to the LNs, but the family did not feel that the LNs responded appropriately. She would lie in pain for hours The resident called the family member one and reported that the head nurse had told the resident she was going to die if she did not move, but the resident stated that she was in pain. In an interview on 08/15/16 at 11:10 am, Resident 1 stated that she had been in horrible pain while at the facility. It was so bad that she could not move. She also stated that one nurse told her if she did not move she was going to die. A progress note date 6/13/16 showed that an RN documented that risks gone over with pt as to refusal of repositioning and getting out of bed up to and including death. The resident went on to say that after she was admitted to the hospital she was given pain medication and her pain was relieved. She also stated that she now is not having as much pain and is able to move and turn as needed. The prn narcotic pain medication orders indicated the medication was to be given based on the resident voicing a pain level/already having pain which did not necessarily mesh well with Resident 1's pain management plan of care intervention to adjust the times of ADLs (i.e. frequent turning/repositioning) and treatment activities so that occur after [MEDICATION NAME] benefits have been achieved. There was no documented indication whether a routinely administered pain medication, in addition to the [MEDICATION NAME], had been considered in terms of possibly achieving consistent management of Resident 1's pain, so that pain and/or the anticipation of pain did not interfere with movement and/or repositioning.

Based on interview and record review, it was determined that the facility failed to identify and/or prevent and treat pressure ulcers for one of three resident's (#1) reviewed for pressure ulcers. Failure to consistently implement individualized interventions to attempt to stabilize, reduce or remove underlying risk factors such as pain with movement and immobility, monitor the impact of interventions, and timely modify interventions for an existing pressure sore resulted in harm to Resident #1, who had significant worsening of her existing pressure sore. In addition, the facility failed to ensure consistent thorough wound assessments were completed for 2 of 3 sample residents (#2, and #3) which placed Resident 2 & 3 at risk for unrecognized changes in pressure ulcer status. Findings include: See also F 309 for additional information. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial nursing note and assessment indicated the resident was alert and oriented, was able to communicate her needs, and had a Stage 2 pressure sore on her coccyx (tailbone area). The resident had pain with movement and position change. The resident had no strength, required 2 person assist with bed mobility, and used a mechanical lift to get in/out of bed. The record also indicated the resident developed several other additional potential skin at risk factors which included a urine infection, treated from 5/2416 to 5/30/16. Episodes of diarrhea between 5/26/16 to 5/31/16. Wound measurements: On 5/18/16, the day of admit the facility documented the size of the wound was 2 cm x 0.8 cm. On 5/24/16 a wound round note indicated the wound area was 3 cm x 0.8 cm. It was also noted the resident declined to get out of bed most shifts and the resident preferred to lie flat on back due to pain (see F 309). On 6/2/16 during weekly wound rounds the facility documented the size of the wound as 3.1 cm x 0.8 cm. There was no weekly wound round note for the week of 6/5 to 6/11. On 6/13/16 during weekly skin rounds, there was a hugh increase, the facility documented the size of the wound was 8.75 cm x 6.8 cm and it was noted that the resident has refused to get out of bed or reposition, and prefers lying flat or go all day without repositioning (due to pain see F 309). Medical Practitioner The Medical Practitioner (MP) notes showed that on 5/19/16, 6/3/16, 6/6/16, 6/8/16, 6/13/16 the MP requested that nursing: Please nursing, assessment for skin issues On 6/13/16, when the wound was at its largest, the MP documented in a note, unable to visualize today due to dressing. There was no documentation that nursing was communicating with the MP about the wound getting worse until that day, even though they were documenting in the progress notes, but the MP continued to ask for an assessment. In addition, there was no documentation that the MP ever assessed the wound. In a progress note dated 6/9/16 during the evening shift there was a large amount drainage the wound bed was dark in color, the skin around sore was swollen. The LN shared concerns to physician for re-evaluation/treatment adjustment. A License nurse documented in a progress note dated 6/13/16 that they requested an order from the MP for the wound care center (WCC) to consult with the wound because the resident refused to get out of bed or to be repositioned, the resident spent all her time in bed and the wound was much worse. On 6/16/16 spoke to medical practitioner about plan for coccyx wound. Appointment with WCC 6/16 Phone call received that resident to be transferred to hospital for treatment of [REDACTED]. During an interview with 2 licensed nurses (LN A & LN B) on 7/15/16 at 1:15 p.m., the LNs were asked what a treatment order for 'Skin check for daily skin observation' entailed for a resident with a pressure ulcer. The LNs indicated that kind of order would include looking at the actual wound if the resident was scheduled for a dressing change/treatment to the wound. Otherwise, the order indicated an LN was to check to make sure the resident's wound dressing was in place and intact. LN A stated she would also look at the actual wound if she was unfamiliar with the resident to see what's there. The LNs said if they notice the wound getting worse, they would inform the facility managers, as the managers do the in-depth weekly skin rounds on residents with pressure ulcer/skin issues. Skin Check every evening shift for skin observation until pressure ulcer resolved: -The skin check was initialed as done 5/19 - 5/31. However, there were no daily nursing progress notes with mention/description of wound status, except for the weekly skin checks on 5/18 & 5/24. Check every evening for skin observation until pressure ulcer resolved: -The skin check was initialed as done June 1-15. However, there were no daily nursing progress notes with mention/description of wound status until 6/9/16 (except for the weekly wound rounds done on 6/2/16 & 6/13/16). An interview with a licensed nurse (LNC) on 6/29/16 at 11:30 a.m., the LNC indicated pressure ulcer management was difficult with regards to Resident 1. LNC said the resident came to the facility with an unstageable sore on her coccyx, and the resident didn't want to move, It could take 2-3 of us over 20 minutes to encourage her to sit on side of bed. We put an Alternating Pressure Mattress (APM) on her bed on admission due to having a pressure sore, and she also had special cushion on her chair. The resident could get up, but did not want to get up and out of bed. The resident often refused her dressing changes, and I talked to her several times regarding the need to move (reposition). The last time LN C discussed this with the resident, LN C said she really emphasized the possible negative outcomes from not moving and refusing to reposition. LNC said then Resident 1 ended up going to the hospital related to a low blood count and pressure sore. On 6/16/16 the progress notes showed a phone call was received from the resident's specialist for the resident to be transferred to hospital for treatment of [REDACTED]. Review of 6/16/16 hospital emergency department record indicated the resident had a sacral ulcer, Stage 4/unstageable with tunneling. The plan was for wound care consult, changes in current prn pain management as resident was with significant pain from the pressure ulcer, and plastic surgery for [REDACTED]. A 6/17/16 wound care consult indicated the pressure ulcer measured 9 cm x 8 cm x 3 cm (depth) with 100% slough. Although Resident 1 was totally dependent on staff for repositioning & needed tissue off-loading to assist with wound healing, there was no documented evidence that Resident 1's plan of care was consistently, adequately, and timely reviewed and/or revised when inconsistent or incomplete pressure off-loading (turning & repositioning in bed) and pain management plan related to repositioning were identified as ongoing concerns, and/or included consideration of whether the APM was adequate to meet Resident 1's individualized needs, until the coccyx pressure sore was found to have significantly deteriorated (increased in size). RESIDENT 2 Resident 2's Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, required extensive staff assistance with all ADLs, was at risk for developing pressure sores, and did not currently have any unhealed pressure sores. A Progress note dated 5/18/16 & 5/19/16 revealed Resident 2 had a sacral area redness with small open area. The physician was notified with an order to leave it open to air and monitor every shift. There were no further nursing notes regarding the sacral area redness/open area between 5/20 - 7/15/16, except a medical practitioner note dated 6/24/16 noted under physical exam for skin that per staffs has sacral ulcer. During an interview with LN D on 7/15/16 at 11:30 a.m., the LN stated Resident 2 did not currently have an open area on her bottom, but had small discoloration, never really had an open area. A 7/15/16 review of Resident 2's record did not indicate any electronic skin assessment form(s), skin alteration record and/or other documented evidence of ongoing thorough assessment of the 5/18/16 sacral open area with measurements/descriptive information (no information indicating whether the wound healed or not). On 7/25/16, a continued review of the resident's record revealed a 7/23/16 progress note that Resident 2 has open areas to her coccyx/sacral area measuring 1 cm x 0.5 cm and 2 cm x 1 cm red center with red and purple around the wound. During an interview with LN D on 7/25/16 at 2:15 p.m., the LN stated that Resident 2 was just found with an open area on her coccyx over the weekend. RESIDENT 3 Resident 3's MDS dated [DATE] revealed the resident was cognitively intact, required extensive staff assistance for most ADLs, was at risk for pressure sores, and did not have any unhealed pressure sores. Progress notes: On 6/21/16 documentation indicated Resident 3 had a sore on the right buttock that measured 1 cm x 1.5 cm, dark discoloration measuring 0.5 cm x 0.4 cm with a pink center; and sore on the left buttock measuring 2 cm x 2.5 cm. 6/24/16 L butt open sore pinkish red in color & R buttocks dry crusty skin. 6/26/16 R buttocks scant bleeding, pink & yellow center surrounding wound dry skin peeling & pink around; L buttocks with dry peeling skin. 6/29/16 progress note: L buttocks wound discoloration (resident) complained sore and c/o sore and painful area R buttocks pink center .scant drainage noted. A 7/1/16 progress note indicated the resident had a Left (L) buttock sore spot discoloration and dry skin peeling, and Right (R) buttocks open sore pink center and dry skin surrounding it. 7/16/16 buttocks sore spot (no further descriptive information). Review of the July 2016 Treatment Administration Record (TAR) revealed an order for [REDACTED]. On 7/25/16, there was only 1 skin sheet (Skin Alteration Record) observed in the unit treatment binder for Resident 3 with a single entry for 7/19/16 diagram circling the coccyx area noted as skin intact with peeling red skin. During an interview with LN D on 7/25/16 at 2:15 p.m., the LN stated that Resident 3 currently did not have an open area on her bottom, only peeling skin. Although there were TAR weekly skin assessments completed on 7/2, 7/9, and 7/16, there was no documented evidence of thorough assessments with detailed description(s) of both buttock areas indicating whether each buttock area had remained the same, worsened, improved, or healed between 7/2/16 - 7/18/16.

Based on interview and record review, it was determined the facility failed to ensure residents who entered the facility without a pressure sore did not develop a pressure sore while in the facility for 1 of 1 sampled resident(1). Failure to ensure staff consistently, thoroughly, and/or accurately evaluated the resident's pressure sore risk factors related to changes in clinical condition, defined & implemented specific individualized interventions that were consistent with the resident needs, and consistently monitord, evaluated & revised the interventions for effectiveness resulted in the development of an infected necrotic pressure sore causing harm to Resident #1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data set assessment ((MDS) dated [DATE] indicated the resident had very limited communication abilities, and memory impairment with severely impaired decision-making ability. The resident had a urine catheter, was incontinent of bowel, and required extensive 2 person assist for bed-mobility, transfers, and toileting. The MDS indicated the resident had no pressure ulcers. The Admission nursing skin assessment indicated Resident 1 did not have any skin issues or pressure ulcers on admission. The resident was identified as being at risk for pressure ulcers due to extensive assist with activities of daily living (ADLS), immobility, altered mental status, incontinence, and 1-sided weakness. A Braden scale for predicting pressure sore risk was done on 2/10/16. Resident 1 was assessed as being, At risk for pressure sores related to his slightly limited mobility, ability to make frequent changes in body position independently, no apparent problem with friction/shear, and the ability to independently move in bed & chair. Another Braden scale done on 2/23/16 indicated Resident 1 was at Hi risk related to being bedfast, completely immobile, and requiring moderate to maximal assist in moving. A third Braden scale completed on 3/1/16 indicated Resident 1 was at Moderate risk related to being chairfast, making frequent changes in position independently, and requiring minimum assist with moving. A review of the February & March 2016 Electronic Treatment Administration records (ETAR) revealed a physician's orders [REDACTED]. Do a Skin Check one time a day, every 7 days for skin observation and update the skin sheet: The skin checks were initialed by nurses as being completed on: 2/10, 2/17, 2/24, 3/2, & 3/9/16. But, there was no evidence of updated skin sheets in the chart. There were 2 nursing notes dated 3/1/16 & 3/13/16 that indicated the resident had redness to his coccyx. The ETAR indicated there was a new physician's orders [REDACTED]. On 4/7/16 at approximately 11:15 a.m., the Director of Nursing (DON) was asked if there were any skin sheets filled out by nursing staff related to the weekly skin checks. The DON indicated skin worksheets were completed by the shower aides. The shower aides mark skin issues (if any) on body diagram & give them to the Licensed Nurses (LNs). A review of all provided shower aide skin worksheets for Resident 1 revealed the following: On 2/23/16, documentation showed an Old red area and there was circle on buttock crease area; On 2/29/16, documentation showed a Red area and there was a circle on buttock crease area; On 3/2/16, documentation showed a Red blanchable & circled on buttock crease area. The initial 2/15/16 Care Plan, identified the resident as being, At Risk for alteration in skin integrity r/t incontinence & impaired mobility. There were 3 listed Interventions: -barrier cream to peri/buttock area prn (as needed); -observe skin condition with ADL care daily, report abnormalities; -provide preventive skin care routinely & prn. Resident 1's At Risk for Alteration Skin integrity Care Plan was revised/updated on 3/1/16 to include the following interventions: -Encourage fluids, -Encourage resident to reposition as needed, -Use assistive devices prn, and float heels as able. The Kardex, a information tool, used by the nursing assistants (NA) as a quick reference guide for the particular nursing care needs of each patient, that included the following tasks to be done for Resident 1: Encourage and/or assist the resident to reposition frequently. Task descriptions included: ADLs usually needed 1-2 person extensive assist, Bed mobility, Pressure reducing cushion for chair and/or wheelchair; Pressure reducing mattress; Repositioned (every shift); Special need frequent checks/reposition frequently; Turn and/or Reposition (Every Shift). During an interview on 4/7/16 at 11:10 a.m., the Administrator, stated the NAs worked 8-hour shifts. She said the NAs expected to document the completion of specified Karedex tasks every shift, rather than documenting the completion of the task each time it was done throughout a shift. Review of the provided NAC documentation for the 'Repositioned' section of the Karedex task revealed inconsistent documentation as to whether the resident was repositioned every shift while at the facility. Review of nursing progress notes from 2/9/16 - 2/29/16 documented the resident required variable assistance for ADLs (extensive assist 1-3 persons to total assistance). There were no nursing notes in this time period which indicated ongoing nurse monitoring of resident's positioning, bed mobility or notes describing the condition of Resident 1's skin. Review of nursing progress notes from 3/1/16 - 3/14/16 revealed the following: On 3/1/16, it was noted the resident required a 2-3 person assist with tranfers using a hoyer (lift device), bed mobility, and toileting. The residents coccyx (tailbone) area had some blanchable redness, there were new orders for a skin cream (to be applied to the area for prevention), and frequent turning & repositioning applied this shift. On 3/11/16, an interdisciplinary care conference was held in which the DON addressed multiple questions from family regarding medications, the UTI, the catheter, repositioning, and hydration. On 3/12/16 and 3/13/16, there were day shift progress notes indicating the frequent turning of Resident 1, but there was no other documentation that the resident was being turned or that his coccyx area was being assessed. On 3/13/16, an evening progress note indicated Resident 1 was being frequently turned .'Resident has a redness at coccyx area, slight swollen and warm to touch. Medication applied for redness. MD notified, new order for blood tests & wound culture.' There was no documentation of an assessment of a wound that would justify a culture being done. On 3/14/16, there was a late entry nursing note at 10:30 a.m. that indicated an RN had been attempting to feed the resident since 9 a.m. The note indicated Resident 1's family member came in and asked whether the RN had looked at the (resident's) wound. The note indicated the RN informed the family that the RN had not seen the wound, as the Resident had been repositioned & was currently being fed, but the RN would look at wound at some point. There was no further indication that nursing staff had observed the resident's skin condition or wound, as the resident was then sent out to a hospital emergency room for an acute change of condition. Review of physical therapy (PT) documentation revealed the following: PT assessments on 2/10/16, 2/23/16, 3/8/16, & 3/14/16 resident 1 was Total Dependent on staff for bed mobility. A PT note on 2/24/16 indicated the resident was lying supine (flat on back) in his bed. An attempted transfer with a 2 person assist was unsuccessful due to the resident being extremely stiff & resistant, and he required a 3-person assist. For wheelchair(wc) management: the assessment of his current seating system for appropriate modifications and design of new wheelchair was to enable functional independence from a standard manual wc to tilt-in-space to allow for pressure relief and safety. On 2/26/16, it was noted the resident was resistant to movement .repositioning in tilt-in-space wc several times due to sliding forward. On 3/4/16, it was noted by the therapy department per their documentation that wounds were present: transfer & standing activities in parallel bars to promote pressure relief .very stiff and resistant .family reported about pressure sore in sacral area. Nursing already aware and monitored wound. On 3/8/16, PT noted the resident's progress has been slower than initially anticipated due to illness & significant cognitive impairment .bed mobility Max assist of 2 person. (Resident 1) was left in room, sidelying on Left side in bed to relieve pressure off sacral area. As per family, pressure sore on sacral area. This therapist noted redness on same area. During an interview on 4/7/16 at 8:50 a.m., LN A was asked if Resident 1 could move in bed or chair by himself: No, not at all, he needed to be fed and was total care. It took 2-3 people to move him. Because he was so stiff & rigid. He 'kind of' stayed in place when repositioned. Later at 10:50 a.m., LN A was asked whether Resident 1 had a pressure ulcer: Not really, it was probably developing .but I remember his skin as being red, that's why I started him on frequent turning (in the beginning of March 2016). In regards to a wound culture being ordered/done, I don't remember a wound culture being done .maybe because the wife wanted it? She often insisted on things whether or not needed. The LN was unable to provide any information about the condition of the resident's skin. During an interview with the DON on 4/7/16 at approximately 11:15 a.m., the DON was asked regarding why & in what area did staff obtain a wound culture and whether it was an open wound on 3/13/16. The DON shrugged and said, The wife wanted it done, she often wanted things done, even though there was nothing there . The DON was unable to provide any information in regards to the wound or what her expectations of how staff should have assessed or documented the wound. On 3/14/16 day shift, Resident 1 was sent to a hospital emergency department (ED) related to fever and low blood pressure. A review of the initial ED triage nurse at 12:37 p.m. noted Resident 1 found to have a large wound to mid coccyx. The wound is linear and runs vertically. It is 5 centimeters (cm) long and 1 cm wide fissure-like wound. There is deep tissue involvement as wound is roughly 0.5 cm deep with pink/reddened tissue with some slough (necrotic) tissue. Around the wound it is reddened and swollen throughout the entire low back, buttocks area. The ED physician noted the resident had a sacral decubitus ulcer with central fissuring. A hospital wound care consult note dated 3/15/16 noted Resident 1 had an unstageable sacral pressure ulcer with signs of infection width 2.2 cm, length 4.0 cm with 50% slough. Throughout the resident's stay in the facility, there was infrequent documentation in the progress notes to indicate ongoing consistent nurse monitoring for frequent repositioning & turning of Resident 1. There was little to no documentation for the ongoing effectiveness of the skin at risk interventions especially in regards to Resident 1 needing total assistance for bed mobility, ADL needs, his physical rigidity and the changes in his skin condition. There was no documentation of increased monitoring of the resident's condition of skin after coccyx redness was identified. Nor was there a thorough description(s) with measurement of the coccyx redness and whether the skin had a pressure-related open skin area(s) on the coccyx even though a wound culture was ordered.

Based on interview and record review, the facility failed to provide adequate education for staff to prevent accidents. Affected was one of three residents who were reviewed for accidents. Failure to train staff on equipment use prior to using it resulted in harm of a fractured ankle for Resident 7 and placed residents at risk of possible accident when using equipment without proper training. Findings include: Resident 7 was admitted in October 2010 with [DIAGNOSES REDACTED]. Her most recent minimum Data Set (MDS) assessment, dated 07/27/11, identified her recall and memory as reasonably intact (13/15 points on the memory assessment tool). She was unsteady in her balance and required a mechanical lift for transfer to and from bed to the wheelchair. On 08/02/11 at 12 noon, Physical Therapist (PT) 1 moved a mechanical lift into Resident 7's room. The lift was rented specifically for use for Resident 7. PT 1 intended to teach the nursing staff how to use and position the sling of the lift as it was slightly different from the slings the facility owned. PT 1 had not used the lift before. There was no instruction manual. PT 1 practiced using the remote control for a few minutes prior to moving the lift into Resident 7's room. Licensed Nurse (LN) 1 and Nursing Assistants (NA) 1 and 2 were with PT 1 in Resident 7's room. PT 1 instructed LN 1 and NA 1 on positioning the sling of the lift while Resident 7 was in the sling. The staff elevated the sling above the bed with the resident in the sling. As the staff maneuvered the lift past the foot of the bed, they failed to extend or spread the legs at the base of the lift. The lift fell over. Its beam landed across the bed. Resident 7, falling from 4 feet above the ground, landed on the floor, fracturing her right ankle. On 09/23/11 at 2:40 p.m., Resident 7 recalled the fall. The staff used a new lift and it tipped over. She fell 4 feet to the floor. Her right ankle was broken so they sent her to the hospital. Resident 7 stated they use a different lift now. At 4;30 p.m., the Administrator reported although the facility had no specific policy for use of rental or any other new equipment when the incident occurred, staff were expected to have training and know how to operate any equipment prior to its use with a resident. In this instance, the staff had no knowledge of the manufacturer recommendation to spread the legs at the base of the lift when a person was in the sling. Because the legs were not extended, the lift toppled over. Review of the facility investigation revealed none the staff had any training of how to use the new mechanical lift. No instruction manual was present with the lift when it was delivered. The delivery person only demonstrated how to use the remote control to raise and lower the lift and open or extend the legs on the base of the lift. No staff sought out or requested additional information or training prior to placing Resident 7 in the sling and operating the mechanical lift. About an hour after the incident, a representative of the company that owned the mechanical lift inspected it. He found no faults; the lift worked appropriately. See F225 for additional details of the investigation.