Every finding on record at Americana Health and Rehabilitation

Based on interviews and record review, the facility failed to initiate bowel interventions for 5 of 8 residents (Resident 17, 24, 27, 2 & 6) reviewed for quality of care. This failure placed residents at risk for discomfort, experiencing health complications and a diminished quality of life.Findings included . Record review of the facility policy, titled, Bowel Protocol, revision date, May 2025, documented: 1. The licensed Nurse reviews the bowel monitor daily. 2. If a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program. 3. If the facility has no specific bowel program the nurse administers medications as ordered as follows: Administer milk of magnesia [laxative] per physician order on day four. If milk of magnesia offers no result, administer a stimulant laxative suppository or oral tablet (Bisacodyl, Senna, etc.) per physician order on the next shift, during waking hours only. If a resident continues to have no results from suppository, administer an enema on the next shift, during waking hours only. If no results from enema, notify physician. Resident 17 Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Quarterly Minimum Data Set (MDS, an assessment tool), dated 09/04/2025, documented the resident was alert and oriented. Record review Resident 17's Electronic Health Record (HER), showed Resident 17 had the following 02/01/2025 PRN (as needed) bowel care orders: a) If resident does not have a bowel movement for three days, administer milk of magnesia (MOM) on day four.b) If milk of magnesia offers no results, administer a Bisacodyl suppository rectally, the next shift (during waking hours), as needed, for constipation. c) If resident continues to have no results from suppository, administer a Fleet enema on the next shift. If no results from enema, notify the physician. Record review of Resident 17's Bowel Movement (BM) task sheet, dated November 2025, showed documentation of Resident 17's BM activity on 11/12/2025 at 1:43 PM. Resident 17's next BM was documented on 11/18/2025 at 09:32 AM, approximately 139 hours since the last BM. Record review of Resident 17's EHR, dated November 2025, did not show documentation of bowel interventions from 11/12/2025 to 11/18/2025. Resident 24 Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's Medicare- 5 Day MDS, dated [DATE], documented the resident was moderately cognitively impaired. Record review of the EHR, showed Resident 24 had the following 02/01/2025 PRN bowel care orders: a) If resident does not have a bowel movement for three days, administer milk of magnesia (MOM) on day four. b) If milk of magnesia offers no results, administer a Bisacodyl suppository rectally, the next shift (during waking hours), as needed, for constipation. c) If resident continues to have no results from suppository, administer a Fleet enema on the next shift. If no results from enema, notify the physician. Record review of Resident 24's BM task sheet, dated November 2025, showed documentation of Resident 24's BM activity on 11/08/2025 at 1:59 PM. Resident 24's next BM was documented on 11/18/2025 at 01:59 PM, approximately 228 hours since the last BM. Record review of Resident 24's EHR, dated November 2025, did not show documentation of bowel interventions from 11/08/2025 to 11/18/2025. Resident 27 Resident 27 was admitted to the facility on [DATE]. Review of Resident 27's Quarterly MDS, dated [DATE], documented the resident was moderately cognitively impaired. Record review of the EHR, showed Resident 27 had the following 02/01/2025 PRN bowel care orders: a) If resident does not have a bowel movement for three days, administer milk of magnesia (MOM) on day four.b) If milk of magnesia offers no results, administer a Bisacodyl suppository rectally, the next shift (during waking hours), as needed, for constipation. c) If resident continues to have no results from suppository, administer a Fleet enema on the next shift. If no results from enema, notify the physician. Record review of Resident 27's BM task sheet, dated October 2025, showed documentation of Resident 27's BM activity on 10/23/2025 at 9:59 PM. Resident 27's next BM was documented on 10/28/2025 at 11:59 AM, approximately 110 hours since the last BM. Review of Resident 27's EMAR, dated October 2025, did not show documentation of bowel interventions from 10/23/2025 to 10/28/2025. Resident 2 Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Quarterly MDS 11/25/2025, showed the resident was alert and oriented. In an interview on 11/19/2025 at 08:57 AM, Resident 2 complained of constipation. They reported going days without a BM, and when they did have one the stool was hard and difficult to pass. Record review of Resident 2's HER, showed Resident 2 had the following orders, dated 07/17/2025, for PRN (as needed) bowel care orders: a) If resident does not have a bowel movement for three days, administer milk of magnesia (MOM) on day four.b) If milk of magnesia offers no results, administer a Bisacodyl suppository rectally, the next shift (during waking hours), as needed, for constipation. c) If resident continues to have no results from suppository, administer a Fleet enema on the next shift. If no results from enema, notify the physician. Record Review of Resident 2's BM task sheet, dated September 2025, showed documentation of Resident 2's BM activity on 09/03/2025. Resident 2's next BM was documented on 09/06/2025, approximately 96 hours since the last BM. Record review of Resident 2's September and November 2025 Electronic EHR, showed on both above referenced occasions, facility staff failed to administer bowel interventions on the fourth day without a BM, as ordered. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Quarterly MDS, dated [DATE], documented the resident was mildly cognitively impaired. Review of Resident 6's October 2025 bowel record showed they went from 10/07/2025- 10/13/2025 (7 days) without a BM. Review of Resident 6's October 2025 MAR showed Resident 6 was administered bisacodyl tablets twice on 10/10/2025, at 7:09 AM and 4:30 PM, with no results. The bowel monitor showed Resident 6 went three more days without a BM and staff failed to administer a bisacodyl suppository and a Fleets enema as ordered. In an interview on 11/21/2025 at 2:36 PM, when asked if staff administered PRN bowel care in accordance with Resident 6's physicians orders and the facility bowel protocol Staff C, Resident Care Manger, stated, No, not after the first dose (bisacodyl tablets and MOM were interchangeable per the facility's bowel protocol.) In an interview on 11/21/2025 at 01:39 PM, Staff I, Licensed Practical Nurse, said after three days of no BM, an alert should trigger. Staff I stated, In the morning, we see who pops up in the system for bowels. We check on them and administer what was ordered by physician. Staff I was unable to provide documentation of bowel interventions for residents 17, 24, 27, 2 & 6. In an interview on 11/21/2025 at 1:59 PM, when asked if staff administered Resident 2 MOM on their fourth day without a BM as ordered Staff B, Director of Nursing Services (DNS)/Registered Nurse, stated, No. In an interview 11/21/2025 at 02:13 PM, Staff B, said the BM protocol should have been initiated and documented per policy. Staff B stated, We fell short on bowel management and started doing an audit on Monday 11/17. Staff B was unable to provide further documentation of successful bowel interventions. Reference WAC 388-97-1060(1)-(3)

.Based on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 1 & 46) reviewed for IV therapy. This failure placed residents at risk for unidentified complications including loss of vascular access, infection, and other potential negative health outcomes.Findings included .Review of the facility's Vascular Access Devices and Infusion Therapy Procedures policy, dated August 2021, showed upon admission or insertion staff would measure the external length of a Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart), and the residents arm circumference 10 centimeter (cm) above the insertion site, to establish a baseline. The PICC external length and resident's arm circumference would then be measured weekly with PICC dressing changes. The weekly measurements would be compared to with the baseline measurements to assess for line dislodgement or migration and swelling or deep vein thrombosis (blood clot). Needleless injection caps would be changed at least every seven days and as needed. All valved vascular access devices would be flushed with 10 cubic centimeters (cc) of Normal Saline (NS) before and after infusion and a PICC insertion site would be assessed for signs and symptoms of complication at a minimum every 24 hours.1) Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), dated 10/22/2025, showed the Resident 1 was cognitively intact, had a diagnosis of intervertebral discitis (infection or inflammation of the intervertebral discs) and osteomyelitis (bone infection), and received IV antibiotics during the assessment period. Review of Resident 1's physicians orders, dated 10/18/2025, showed the following PICC maintenance and monitoring orders:a) Change IV administration set/ IV tubing every 24 hoursb) Change needleless injection caps on admission, after blood draws and with dressing changes as needed.c) Flush valved catheters with 5 milliliters (ml) normal saline (NS) before and after infusion. Flush non-valved catheters (clamped) with 5 ml NS before infusion, and then with 5 ml of NS, followed by 5 ml of heparin 10 units/ml after infusion. d) Change PICC dressing every seven days.The orders did not include direction to:a) Change needleless injection caps, for each lumen, weekly with dressing changes (routinely).b) Monitor PICC insertion site every 24 hours for signs and symptoms of infection.c) Measure PICC external length upon admission/insertion, and then weekly with PICC dressing changes and as needed. (.d) Measure arm circumference upon admission, weekly with PICC dressing changes and as needed. The orders failed to identify if the PICC was valved or non-valved, the number of lumens present, where it was located and directed staff to flush with 5 ml NS before and after infusions rather than 10 ml of NS as directed in the policy. Review of Resident 1's comprehensive plan of care, initiated 10/18/2025, showed a care plan was not developed/implemented to address the reason Resident 1 had a PICC, the type, location, number of lumens or the maintenance or monitoring required to care for it.Review of Resident 1's October and November 2025 Medication and Treatment Administration Records (MAR/TAR) showed staff signed daily that they flushed Resident 1's PICC but it was unclear what flush protocol was followed. The order directed staff to flush valved catheters with 5 milliliters (ml) normal saline (NS) before and after infusion. For non-valved catheters (clamped) staff were directed to flush with 5 ml NS before infusion and 5 ml of NS followed by 5 ml of heparin 10 units/ml (a blood thinner) after infusion. The order did not indicate whether Resident 1's PICC was valved or non-valved. Review of the documentation showed it was indeterminable what flush protocol each facility nurse used. Further review showed there was no documentation that staff had changed Resident 1's needleless injection cap(s) with the 10/23/2025, 10/30/2025 or 11/06 2025 weekly dressing changes or that staff were assessing the PICC insertion site daily.Review of Resident 1's electronic medical record (EMR) showed no documentation that staff obtained an initial PICC external length or an initial arm circumference measurement for Resident 1. Nor was there documentation that the external length and arm circumference measurements were obtained at any point thereafter.During an interview on 11/21/225 at 3:12 PM, Staff B, Director of Nursing Services (DNS) said Resident 1's PICC maintenance and monitoring order were incomplete and acknowledged there was no documentation to show Resident 1's insertion site, arm circumference, PICC external length had been assessed and monitored or that the needleless injection caps had been changed. Staff B confirmed Resident 1's flush orders failed to identify if the PICC was valved or non-valved, thus it was unclear what flush protocol facility nurses were following as both protocols were included in the order. 2) Resident 46 was admitted to the facility on [DATE]. Review of Resident 46's admission MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of left lower extremity cellulitis (skin infection), and received IV antibiotics during the assessment period. Review of the Resident 46's physicians orders, dated 10/29/2025, showed Resident 46 had the following PICC maintenance and monitoring orders: a) Change PICC dressing and measure arm circumference 10 centimeters above external catheter every week.b) Change needleless injection caps on admission and weekly with dressing changes as needed.c) Change IV administration set/ tubing every Monday, Wednesday and Friday.d) Flush valved catheters with 5 ml NS before and after infusion. Flush non-valved catheters with 5 ml NS before infusion and then with 5 ml of NS, followed by 5 ml of heparin 10 units/ml after infusion. The orders did not include direction to:a) Monitor PICC insertion site every 24 hours for signs and symptoms of infection.b) Measure PICC external length upon admission/insertion, and then weekly with PICC dressing changes and as needed.Additionally, the orders failed to identify if the PICC was valved or non-valved, the number of lumens present, where it was located and directed staff to flush with 5 ml NS before and after infusions rather than 10 ml of NS as directed in the policy. Review of the November 2025 MAR/TAR showed on 11/01/2025, 11/08/2025 and 11/15/2025 staff signed that the changed the PICC dressing and measured Resident 46's arm circumference. However, no place was provided to record the resident's arm circumference. Review of Resident 46's EMR showed no documentation that upon admission or thereafter, had measured Resident 46's PICC external length or arm circumference.During an interview on 11/21/225 at 3:12 PM, when asked if there was any documentation to show staff were measuring Resident 46's PICC external length, arm circumference and/or were monitoring the insertion site for signs and symptoms of infection daily, Staff B, DNS, stated, No. Reference WAC 388-97-1060 (3)(j)(ii).

.Based on interview and record review, the facility failed to ensure resident funds were conveyed (the act of legally transferring property from one entity to another) to the Office of Financial Recovery (OFR) within 30 days of death or discharge for 1 of 2 discharged residents (Resident 62) reviewed for trust accounts. This failure resulted in a delayed final accounting and conveyance of Resident 62's funds.Findings included . Review of the Discharge Minimum Data Set (MDS, an assessment tool), dated 02/18/2025, showed Resident 62 was transferred to the hospital on [DATE], where they subsequently passed away on the same date. Review of the facility's resident Trust- Audit Report showed Resident 62 had a trust balance of $60 from March - August 2025. A Transmittal of Resident Personal Funds form showed Resident 62's trust balance was not conveyed to the OFR until 08/27/2025. During an interview on 11/20/2025 at 1:34 PM, when asked if Resident 62's trust balance was conveyed to the OFR within 30 days of death or discharge as required Staff E, Business Office Manager, stated, No. Reference WAC 388-97-0340(4)(5).

Based on observation, interview and record review, the facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for 1 of 1 sampled residents (Resident 43) reviewed for physical restraints. This failure placed the residents at risk of injury, unmet needs, and a diminished quality of life.Findings included . Record review of the facility policy, titled, Physical Restraints, revision date, January 2025, documented: 5. The resident and/or resident representative is provided risks/benefits of restraint use or enabler/device use, and consent obtained prior to implementation of the device.6. The care plan is updated for the device use with the goal for the least restrictive measures.7. The care plan is evaluated quarterly and as needed.8. The resident is evaluated using Device Evaluation on admission, re-admission, annually, and with significant change in condition. Resident 43 admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (an assessment tool), dated 09/24/2025, documented the resident was moderately cognitively impaired. In an observation on 11/19/2025 at 11:42 AM, Resident 43's right side of the bed was placed against the wall. In an interview on 11/19/2025 at 11:45 AM, Resident 43 said her bed had always been like that, and nobody discussed with her why that is. Review of Resident 43's Electronic Health Record (EHR), showed no documentation of Safety Device Evaluation, and a Consent and/or physician's order related to the bed placed against the wall. In an interview on 11/21/2025 at 01:39 PM, Staff H, Licensed Practical Nurse (LPN), said a residents' consent is required for placing a bed against a wall. Staff H was unable to find consent for Resident 43. In an interview on 11/21/2025 at 01:20 PM, Staff B, Director of Nursing Services and a Registered Nurse (RN) said with any type of potential restrains, the facility required an evaluation and a consent. Staff B was unable to provide any documentation pertaining to Resident 43's bed placement. Reference WAC 388-97-0620(1)

.Based on interview and record review, the facility failed to ensure admission Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of admission as required, for 1 of 18 sample residents (Resident 2) reviewed for comprehensive assessments. This failure placed residents at risk for unidentified and/or unmet care needs.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1 October 2025, showed admission assessments were required to be completed by the 14th calendar day of a resident's admission. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's admission Minimum Data Set (MDS, an assessment tool), dated 07/19/2025, showed it was not completed until 08/05/2025 20 days after admission. On 11/21/2025 at 1:47 PM, when asked if Resident 2's admission MDS was completed by the 14th calendar day after admission as required, Staff D, MDS Coordinator, stated, No. Reference WAC 388-97-1000(1)(b)(c)(ii)(d).

.Based on interview and record review, the facility failed to ensure assessments accurately reflected residents' health status and care needs for 2 of 18 sample residents (Residents 6 & 2) reviewed. This failure placed residents at risk for unidentified and/ unmet care needs and decreased quality of life. Findings included . 1) Resident 6 was admitted to the facility on [DATE]. Review of the Significant Change Minimum Data Set (MDS, an assessment tool), dated 08/04/2024, showed Resident 6 had a terminal diagnosis and received hospice services. Review of the Hospice intake paperwork, dated 07/29/2024, showed due to severe chronic obstructive pulmonary disease (COPD, an umbrella term for chronic lung diseases that cause airflow obstruction and breathing difficulties), respiratory failure and hypoxia (deficiency in the amount of oxygen reaching the tissues) Resident 6 was determined to have a life expectancy of less than six months and was admitted to Hospice. Hospice documentation showed Resident 6 was repeatedly recertified for Hospice care and remained on Hospice services from 07/29/2024 - 11/21/2025. Review of the Quarterly MDSs, dated 02/04/2025, 05/07/2025 and 10/08/2025, showed Resident 6 received Hospices services but did not have a terminal prognosis (estimated life expectancy is six months or less if disease process runs its normal course). During an interview on 11/21/2025 at 1:47 PM, Staff D, MDS Coordinator, said the 02/04/2025, 05/07/2025 and 10/08/2025 Quarterly MDSs were inaccurate and should have coded Resident 6's terminal prognosis. 2) Resident 2 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed Resident 2 rejected care on 1-3 days during the assessment period. Review of the October 2025 Medication Administration Record showed Resident 2 refused their stool softener on 10/15/2025, 10/17/2025, 10/18/2025 and 10/19/2025. Additionally, review of the October 2025 meal monitor showed Resident 2 refused their alternative meal on 10/16/2025, 10/17/2025 and 10/18/2025. This showed Resident 2 rejected/refused care on five of seven days during the assessment period.On 11/21/2025 at 1:53 PM, Staff D, MDS Coordinator, said Resident 2's MDS was inaccurate and needed to be modified to reflect rejection of care on 4-6 days during the assessment. Reference WAC 388-97-1000(1)(a)(b)(4)(a).

.Based on interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 3 of 18 residents (Residents 1, 2 & 46) whose care plans were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. Review of the electronic health record (EMR) showed an order, dated 07/21/2025, to cleanse Resident 2's anal fissure (a small tear in the thin, moist tissue that lines the anus) with normal saline or wound cleanser, pat dry, and apply zinc oxide ointment (skin protectant) twice a day and as needed. Review of the comprehensive care plan, intiated 07/17/2025, showed no care plan was developed to address Resident 2's anal fissure. During an interview on 11/21/2025 at 2:48 PM, Staff B, Director of Nursing Services (DON), said Resident 2's anal fissure should have been addressed in the comprehensive care plan, but acknowledged it was not. Review of the Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 2 was constipated (two or fewer bowel movements during the 7-day look-back period or most bowel movements were hardand difficult for them to pass). Review of the comprehensive care plan, initiated 07/17/2025, showed a constipation care plan was not developed or implemented. During an interview on 11/21/2025 at 2:48 PM, Staff B said Resident 2's constipation should have been addressed in Resident 2's comprehensive plan of care. 2) Resident 1 was admitted to the facility on [DATE]. Review of the hospital transfer orders, dated 10/18/2025, showed Resident 1 had a peripherally inserted central catheter (PICC, a long, thin tube inserted into a vein in the arm that extends to a large vein near the heart, used for long-term IV fluids, medications, or nutrition) and an order for intravenous (IV) vancomycin (an antibiotic) once daily for septic arthritis (a serious joint infection caused by bacteria, viruses, or fungi that enter the joint through the bloodstream, an injury, or surgery) and spondylodiscitis (an infection of the vertebrae and intervertebral discs). Review of the comprehensive care plan, initiated 10/18/2025, showed no care plan was developed to address type, location, number of lumens (an individual tube or channel within a single PICC), and/or maintenance and monitoring instructions for Resident 2's PICC. During an interview on 11/21/2025 at 2:48 PM, Staff B said the type and location of Resident 2's PICC and associated maintenance and monitoring instructions should have been care planned. 3) Resident 46 was admitted to the facility on [DATE]. Review of the hospital transfer orders, dated 10/29/2025, showed Resident 46 had a PICC and an order for Sodium Thiosulfate intravenous (IV) infusions every Monday, Wednesday and Friday for calcification of muscle in the left lower extremity. Review of the comprehensive care plan, initiated 10/29/2025, showed no care plan was developed to address type, location, number of lumens and/or maintenance and monitoring instructions for Resident 46's PICC. During an interview on 11/21/2025 at 2:48 PM, Staff B said the type and location of Resident 46's PICC and associated maintenance and monitoring instructions should have been care planned. Reference WAC 388-97-1020(2)(c)(d) .

.Based on interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 18 residents (Residents 1, 2 & 46). Failure of nursing staff to follow and/or clarify physicians' orders when indicated, and to notify the physician of weight variances and when medications were held, placed residents at risk delayed changes in medication regimen, hypotension, falls and other adverse outcomes. Findings included .1) Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician's orders showed an order for daily weights, dated 10/25/2025. Review of Residnt 1's November 2025 weight record showed Resident 1 had the following 24-hour weight variances:11/08/2025 weight - 272.6 lbs.; 11/09/2025 - 264.4 lbs. (-8.2 lbs. in 24 hours).11/11/2025 - 262.2 lbs.; 11/12/2025 - 252.2 lbs. (- 10 lbs. in 24 hours).11/14/2025 - 252.2 lbs.; 11/15/2025 - 268 lbs. (+16 lbs. in 24 hours). Review of Resident 1's electronic medical record (EMR) showed no documentation was present to show facility staff notified the provider of Resident 1's weight variances of greater than three lbs. in 24 hours. During an interview on 11/21/2025 at 2:13 PM, Staff B, Director of Nursing Services (DNS), explained if a resident was on daily weights, staff would notify the provider if there was a weight variance of greater than three lbs. in 24 hours or five lbs. in a week. When asked if there was any documentation to show staff notified the provider on the three above referenced occasions Staff B stated, No. 2) Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's electronic Medical Record (EMR) showed an order, dated 08/08/2025, for metoprolol (blood pressure medication) twice daily, hold the medication and notify the physician if the systolic blood pressure (SBP, top number in a blood pressure reading) was less than 95 or the pulse (P) was less than 60. Review of Resident 2's September 2025 Medication Administration Record (MAR) showed on the following dates/times facility nurses held Resident 2's metoprolol when their SBP and P were within the physician ordered parameters. 09/01/2025 8:00 AM dose- SBP= 98, P= 110; staff documented the medication was not administered due to vital signs outside of parameters.09/03/2025 8:00 AM dose- SBP= 98, P= 100; staff documented the medication was not administered due to vital signs outside of parameters. 09/04/2025 8:00 PM dose- SBP= 97, P= 98; staff documented the medication was not administered due to vital signs outside of parameters.09/05/2025 8:00 PM dose- SBP= 109, P= 96; staff documented the medication was not administered due to vital signs outside of parameters.09/13/2025 8:00 PM dose- SBP= 101, P= 71; staff documented the medication was not administered due to vital signs outside of parameters.09/17/2025 8:00 PM dose- SBP= 98, P= 94; staff documented the medication was not administered due to vital signs outside of parameters.During an interview on 11/21/2025 at 2:13 PM, Staff B, DNS, said according to the physicians order, on the above referenced occasions Resident 2's metoprolol should not have been held. Review of Resident 2 's physicians orders showed an order for daily weights, dated 07/18/2025, with direction to notify the physician if of weight changes greater than or equal to three pounds in two days or five pounds in a week. Review of the Resident 2's October 2025 MAR showed the following 24 hour weight variance:10/19/2025 weight - 121.4 lbs.; 10/20//2025 - 115.6 lbs. (-5.8 lbs. in 24 hours). Review of Resident 2's EMR showed no documentation that staff notified the physician as ordered. During an interview on 11/21/2025 at 2:13 PM, when asked if there was documentation to show the physician was notified of Resident 2's 5.8 lbs. weight loss in 24 hours, Staff B stated, No. 3) Resident 46 was admitted to the facility on [DATE]. Review of Resident 46's admission MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of Left lower extremity cellulitis (skin infection), received IV medication and antibiotics during the assessment period. Review of Resident 46's EMR showed an order, dated 10/29/2025, that directed staff to flush a valved PICC with 5 milliliter (ml) normal saline (NS) before and after medication infusion and a non-valved PICC with 5 ml NS before and after medication infusion followed by 10 ml of heparin (blood thinner). Review of Resident 46's November 2025 Treatment Administration Record showed the order was transcribed without identifying if the Resident 46's PICC was valved or non-valved. Thus, it was unclear if the flushes provided by facility nurses included heparin or not. During an interview on 11/21/2025 at 2:48 PM, when asked if facility nurses were flushing with heparin Staff B agreed that you could not tell from the documentation. Staff B said facility nurses should have clarified the order but did not. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i).

.Based on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 2) reviewed for limited Range of Motion (ROM) received treatment and services to maintain and/or improve ROM. The failure to ensure residents were offered/provided Restorative Nursing Programs (RNPs) at the frequency they were assessed to require, placed residents at risk for decline in ROM, contracture formation, reduction in strength and mobility, increased dependence on staff and decreased quality of life. Findings included . Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Quarterly MDS, dated [DATE], showed Resident 2 was cognitively intact and received a passive ROM RNP on two of seven days during the assessment period. Review of Resident 2's impaired mobility related to decreased ROM care plan, revise 09/15/2025, showed Resident 2 was to receive passive ROM to both lower extremities, two sets of 15 reps (hip flexion, hip abduction, heel sliders and ankle pumps) five times a week. Review of the October and November 2025 restorative flowsheets showed from 10/01/2025 - 11/21/2025 (52 days), Resident 2's passive ROM RNP was offered/provided on eight of 36 scheduled days or 1.1 times per week. in an interview on 11/21/2025 at 2:39 PM, when asked if Resident 2's RNP was offered/provided at the frequency they were assessed to require Staff B, Director of Nursing Services, stated, No. Reference WAC 388-97-1060(3)(d)(j)(ix).

Based on observation, record review and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 2 kitchen refrigerators, and in 1 of 1 nourishment refrigerators/freezers reviewed for proper food storage. This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life. Findings included . The facility's policy entitled, Nursing Unit Refrigerator Storage Guide, updated ,d+[DATE], documented, Label all resident food with Name, Room Number, Use By Date. Packaged foods when opened are labeled with use by date. The manufacturer's expiration date is the 'Use By' for unopened items. Use by dates should not exceed the manufacturer's expiration or best 'use by' date. <Kitchen Refrigerator> On [DATE] at 10:18 AM, the top left corner of the kitchen walk in refrigerator was observed with the following undated, unlabeled, used items: 1. Plastic bag of celery sticks 2. Plastic bag of carrot sticks with RO [received on] [DATE] written on the bag 3. Cardboard box containing Rosemary, dated [DATE] At 10:21 AM, Staff N, Dietary Manager, said the items in the refrigerator should have been dated. Staff N was not able to say how long they had been in the refrigerator. Staff N was then observed throwing out the three items. Staff N stated, RO, it's received on, and should not be eaten. <Nourishment Refrigerator/Freezer> On [DATE] at 2:21 PM, the nourishment refrigerator/freezer in central supply room was observed with the following undated, or expired, items: 1. Pumpkin pie, with use by date of [DATE] 2. Quarter sheet of cake, with use by date of [DATE] 3. Jar of 16 oz (ounce) sour cream, with expiration date of [DATE] 4. Plastic container of coffee creamer, with illegible expiration date 5. Partially consumed [NAME] in the Box ice cream shake 6. Ziplock bag containing unknown food items, with use by ,d+[DATE] written on the bag. At 2:27 PM, Staff N stated, It's on the kitchen staff to re-stack the items in the fridge. When asked whether the items in question were safe to consume, Staff N stated, No. Staff N was then observed throwing out the items. At 2:42 PM, Staff B, Director of Nursing Services and Registered Nurse, said she expected food in the refrigerators and freezers to be dated and labeled per facility policy. Staff B stated, It should be dated right away. Reference WAC [DATE] (3) & -2980

Based on observation and interview, the facility failed to label medications with the date first accessed in 2 of 3 medication storage areas (Ocean Side medication storage room and Ocean Side medication cart) reviewed for medication storage and labeling, and the facility failed to ensure medications were kept secure when observed on a bedside table for 1 of 1 sampled residents (6) reviewed for medication storage. These failures placed residents at risk of receiving compromised/ineffective medications, medication errors and diminished quality of life. Findings included . On 12/12/2024 at 3:22 PM, the Ocean Side medication room was observed with Staff K, Licensed Practical Nurse (LPN). A multi dose vial of purified protein derivative (a solution used in Tuberculosis [TB] skin test to diagnose TB) was observed in the medication refrigerator without a date showing when it was first accessed. At 3:30 PM, the Ocean Side medication cart was observed with Staff K. Two multi dose vials of insulin (Humulin and Lispro - medication used to treat chronic disease that affects how the body uses glucose (sugar) for energy) were observed without a date showing when they were first accessed. On 12/13/2024 at 8:39 AM, Resident 6 was observed to have a medicine cup with a variety of pills on her bedside table while she was eating her breakfast. After observing the medications on Resident 6's bedside table, Staff E, Resident Care Manager and LPN, said the medication should have been administered before the assigned nurse left the room. Staff E said it was her expectation the nurse remained with Resident 6 until all medications were ingested; and if the resident was not ready, the nurse should have taken the medication away and secured them until Resident 6 was ready to take them. On 12/13/2024 at 10:53 AM, the Ocean Side medication cart was reviewed with Staff L, LPN. A multi dose vial of Insulin (Lispro) was observed without a date showing when it was first accessed. Staff L said multi dose vials without dates showing when they were first accessed were supposed to be discarded to avoid administering medications that may be unsafe to the residents. On 12/17/2024 at 10:01 AM, Staff B, Director of Nursing Services and Registered Nurse, said it was her expectation nurses did not administer medications without a date showing when they were first accessed. Staff B said nurses were expected to discard multi dose vial medications without an open date. Reference WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering an influenza vaccination for 1 of 5 sampled residents (24) reviewed for right to be informed to make treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about vaccinations and a diminished quality of life. Findings included . Record review of the facility's policy entitled, Prevention and Control of Seasonal Influenza, updated 01/04/2023, showed, .Influenza Prevention Vaccination . 5. Documentation in EHR [Electronic Health Record] on consent or declination for each resident. Resident 24 was admitted to the facility on [DATE]. The modification of Quarterly Minimum Data Set assessment, dated 11/14/2024, documented Resident 24 was moderately cognitively impaired and received this year's influenza vaccination on 10/04/2024. The October 2024 Electronic Medication Administration Record showed Resident 24 received Fluarix Quadrivalent Intramuscular Suspension . (an influenza vaccination) on 10/04/2024. Review of Resident 24's EHR did not show a consent was signed from the resident or the resident's representative for the administration of an influenza vaccination given on 10/04/2024. On 12/17/2024 at 9:53 AM, Staff C, Infection Preventionist and Registered Nurse (RN), said there was not a consent signed for this year's influenza vaccine for Resident 24 and there should have been. At 9:58 AM, Staff B, Director of Nursing Services and RN, said residents should have a consent signed yearly before giving an influenza vaccination. Reference WAC 388-97-0260 (1)-(3)

Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints for 1 of 2 sampled residents (19) reviewed for physical restraints. This failure placed residents at risk for injury and a decreased quality of life. Findings included . Resident 19 was admitted to the facility on [DATE]. The Admission's Minimum Data Set (MDS) assessment, dated 10/23/2024, indicated Resident 19 was moderately cognitively impaired. On 12/12/2024 at 1:49 PM, Resident 19's bed was observed to be against the wall. Resident 19 said there was a little gap, but he was ok with it. On 12/16/2024 at 9:54 AM, Resident 19 was observed lying in bed on his back. The bed was up against the wall. On 12/17/2024 at 10:04 AM, Resident 19 was observed lying in bed on his back. The bed was up against the wall. At 12:27 PM, Staff K, MDS Coordinator and Registered Nurse (RN), said the bed against the wall should have a consent, order and be part of the care plan. At 12:39 PM, Staff E, Resident Care Manager (RCM) and Licensed Practical Nurse, said they did an evaluation to ensure the resident's movement was not restricted when the bed was against the wall. Staff E said there would be an order, and it was put into the care plan. Staff E said she could not find a consent and it was not in the care plan. At 1:03 PM, Staff E said she spoke with the resident's RCM and was told Resident 19's bed was not supposed to be against the wall. At 1:22 PM, Staff B, Director of Nursing Services and RN, said Resident 19's bed was not supposed to be up against the wall. Staff B said staff should be monitoring the beds and following the care plan. If staff moved the bed then they should move it back to its original space. Reference WAC 388-97-0620 (1)(b)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for anticoagulant side effect monitoring (a high-risk, blood thinning medication) for 1 of 5 sampled residents (150) reviewed for comprehensive care plans. This failure placed residents at risk for complications, unmet care needs and a diminished quality of life. Findings included . The facility's policy entitled, Anticoagulation Therapy, updated 07/2014, documented: Residents who are on anticoagulation therapy are monitored to deliver proper care and treatments. This includes monitoring residents for any signs or symptoms of complications from the medication(s) utilized. Resident 150 was admitted to the facility on [DATE]. The Admission Minimum Data Set assessment, dated 11/27/2024, documented the resident was alert and oriented. Resident 150's electronic health record (EHR) documented the following order, dated 11/21/2024: Apixaban Oral Tablet (Apixaban). Give 5 mg [milligram] by mouth two times a day related to PAROXYSMAL ATRIAL FIBRILLATION [a type of atrial fibrillation (upper chambers of the heart beat irregularly and rapidly) that occurs in episodes]. Resident 150's Care Plan, dated 11/21/2024, did not have documentation of anticoagulant therapy or side effects monitoring. Review of Resident 150's EHR did not show orders for addressing anticoagulant side effect monitoring. On 12/12/2024 at 2:12 PM, Resident 150 was observed to be sitting up in bed, with significant discoloration of lower extremities. Resident 150 said she was not concerned, but was unable to provide further information about the discoloration. On 12/17/2024 at 11:08 AM, Staff M, Licensed Practical Nurse, said any resident receiving an anticoagulant was monitored daily for a number of possible issues including bruising and bleeding. Staff M said anticoagulant therapy and side effect monitoring were part of residents' care plans. Staff M was unable to provide documentation of Resident 150's care planned anticoagulant therapy. At 2:29 PM, Staff B, Director of Nursing Services and a Registered Nurse, said Resident 150's care plan should have been updated to include anticoagulant therapy and side effects monitoring. Staff B was unable to provide documentation of care planned anticoagulation side effect monitoring for Resident 150. Reference WAC 388-97-1020 (1), (2)(a)(b)

Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 1 of 6 sampled residents (35) reviewed for quality of care related to constipation. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . The facility's policy entitled, Bowel Protocol, updated 03/2018, documented the following interventions: If a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program. In the event the Center has no specific bowel program the nurse administers medication as ordered as follows: --Administer Milk of Magnesia [laxative] per physician order on day four. --If Milk of Magnesia offers no results, administer a stimulant laxative suppository (Bisacodyl, etc.) per physician order on the next shift, during waking hours only. --If resident continues to have no results from suppository, administer an enema on the next shift, during waking hours only. --If no result from enema, notify physician. Resident 35 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set Assessment, dated 11/19/2024, documented the resident was alert and oriented. The December 2024 Bowel and Bladder Elimination task sheet documented Resident 35 had a BM (bowel movement) on 12/04/2024 at 1:59 PM, and did not have another BM until 12/08/2024 at 1:59 PM, over 96 hours (4 days) since his last BM. The December 2024 Bowel and Bladder Elimination task sheet documented Resident 35 had a BM on 12/08/2024 at 8:06 PM, and did not have another BM until 12/13/2024 at 1:59 PM, over 113 hours (over 4 1/2 days) since his last BM. Resident 35's December 2024 Medication Administration Record (MAR), and December 2024 Progress Notes, did not show the bowel protocol was initiated. On 12/17/2024 at 10:57 AM, Staff M, Licensed Practical Nurse, said if a resident did not have a BM in three days, the bowel protocol was triggered, and documented on the MAR. Staff M said refusals were documented as well. Staff M stated, [Resident 35] wasn't given any milk of mag [magnesia] since September. He should have been on my list. I should go give him something. At 2:27 PM, Staff B, Director of Nursing Services and Registered Nurse, said the BM protocol should have been initiated per facility bowel policy for Resident 35. Staff B was unable to provide additional documentation showing Resident 35's bowel interventions. Reference WAC 388-97-1060 (1), (3)(c)

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for 1 of 2 sampled residents (33) reviewed for infection prevention and control. This failure placed residents at risk for contracting infectious diseases and a decreased quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services (CMS) Memorandum (Ref: QSO-24-08-NH), dated 03/20/2024, with the subject of: Enhanced Barrier Precautions in Nursing Homes documented .EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status . For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care of any skin opening requiring a dressing . Review of the facilities EBP policy documented .Enhanced Barrier precautions are initiated to reduce transmission of multidrug resistant organisms (MDRO's). Initiated for residents known to be colonized or infected with a MDRO or have open wound or indwelling medical devices . Resident 33 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set Assessment, dated 09/19/2024, documented Resident 33 was alert and oriented. Resident 33's electronic health record (EHR) showed the following order: To right heel wound: Paint with betadine, allow to dry, cover with calcium alginate and dry gauze. NO foam. Wrap foot with roll gauze. Change daily, every day shift for Heel wound. Active 11/27/2024. On 12/12/2024 at 12:09 PM, Resident 33 was observed in bed and had a white wound dressing to his right foot secured with elastic net wound dressing. The dressing was observed to have a brown discoloration at the bottom of the foot. At 12:15 PM, an EBP signage or personal protective equipment (PPE) were not observed on Resident 33's door or room entrance. On 12/13/2024 at 2:17 PM, an EBP signage or PPE were not observed on Resident 33's door or room entrance. Resident 33 had a clean dry dressing to the right foot. On 12/16/2024 at 10:46 AM, Staff C, Infection Preventionist and Registered Nurse (RN), stated, If wounds are contained, they [residents] don't necessarily go on precautions. [Resident 33's] wound does not have drainage therefore he does not need EBP. At 10:52 AM, an EBP signage or PPE were not observed on Resident 33's door or room entrance. Resident 33 had a clean dry dressing to the right foot. At 11:07 AM, Resident 33 stated [Staff G, Licensed Practical Nurse,] changed my dressing this morning. At 11:26 AM, when asked about Resident 33's wound care, Staff G stated, I did the dressing this morning with the resident. When asked about the use of PPE, Staff G said she used gloves while assisting Resident 33 with his wound care. Reference WAC 388-97-1320 (2)(b)

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a signification change in respiratory status and failed to notify the physician of the need for oxygen administration orders related to oxygen levels and obtain timely a needed seasonal allergy and asthma medication for 1 of 4 sampled residents (Resident 1) reviewed for notification of changes including a significant change in resident health status. Resident 1 experienced harm when hospitalization and intubation was required for respiratory failure related to untreated respiratory symptoms. This failure placed residents at risk for medical complications and a diminished quality of life. Findings included . A facility policy, dated [DATE], and entitled Respiratory Care; Oxygen Administration documented the following: -- Oxygen is administered per physician order. Oxygen may be administered in the absence of a physician order in emergency situations. -- Oxygen saturations are obtained and documented as ordered by the physician. In the event of an emergency, and/or clinical assessment indicates a change in respiratory function, oxygen saturations are obtained without a physician order. -- Staff members observe and report signs and symptoms of abnormal respiratory function. These may include but aren't limited to: a. Labored breathing b. Tachycardia (heartbeats faster than usual) c. Restlessness d. Nausea e. Headache f. Dizziness g. New or increased anxiety h. New or increase mental confusion i. Cyanosis (bluish skin color due to decreased amount of oxygen) j. Acute change in level of consciousness. Resident 1 was admitted to the facility on [DATE] with diagnoses including moderate persistent asthma with status asthmaticus, a disease process that affects lung function and causes difficulty breathing and coughing every day. The Minimum Data Set assessment, dated [DATE], documented the resident was alert and oriented to person, place, time, and situation. Review of Resident 1's [DATE] Medication Administration Record (MAR), for [DATE] at 8:28 PM, showed Albuterol Sulfate Aerosol Solution was administered for shortness of breath/wheezing related to moderate persistent asthma with status asthmaticus. Guaifenesin cough syrup was administered for congestion. Resident 1's [DATE] MAR, for [DATE], at 7:31 PM, showed Flonase Suspension Spray was administered for wheezing with moderate persistent asthma with statis asthmaticus. Resident 1's [DATE] MAR, for [DATE] at 7:00 AM, showed Albuterol Sulfate Aerosol Solution was administered for shortness of breath/wheezing related to moderate persistent asthma with statis asthmaticus. Guaifenesin cough syrup was administered for congestion. No documentation of physician notification of respiratory symptoms was located related to continued symptoms after medications were administered. Resident 1's [DATE] MAR, for [DATE], at 5:19 PM, showed Albuterol Sulfate Aerosol Solution was administered for shortness of breath/wheezing related to moderate persistent asthma with statis asthmaticus. No documentation of physician notification of respiratory symptoms was located. Resident 1's [DATE] MAR, for [DATE], showed no documentation for administration of any respiratory medications needed for allergies or moderate persistent asthma with statis asthmaticus. Progress note, dated [DATE] at 3:23 PM, showed Staff C, Licensed Practical Nurse (LPN), documented Resident 1 asked for her blood sugars and blood pressure to be checked as she felt something was off. Blood sugar was 217 and blood pressure was ,d+[DATE]. Resident had stated her seasonal allergies got bad in the spring and had requested allergy medications Flonase and Allegra, and asthma medication Albuterol. Oxygen saturations (O2 sats) were checked and were 89%. Resident 1 was placed on Oxygen at 2 liters per minute via nasal cannula. The note showed at 3:45 PM, O2 sats were 95%. Resident 1 stated she felt better. Normal O2 saturations are 95% or above. (No documentation of physician notification of respiratory symptoms or oxygen orders were located.) Progress note, dated [DATE] at 6:45 PM, showed Staff D, LPN, documented Resident 1 with nasal congestion and moist cough. Resident 1 reported bringing up clear and whitish phlegm (which can be an indicator of infection). Lungs slightly rattly which cleared with cough. Blood Pressure ,d+[DATE], Pulse 73, Temperature 97.4, and O2 sats 96% on 2 liters of oxygen. Resident was requesting Advair inhaler, a medication used to treat asthma. A fax was sent to the physician requesting the Advair inhaler. (No documentation of physician notification of respiratory symptoms was located.) Progress note, dated [DATE] at 1:53 AM, showed Staff E, LPN, documented Resident 1 had cough but no shortness of breath. O2 sats were 94% and temperature was 97.9. Progress note, dated [DATE] at 8:00 AM, showed Staff F, LPN documented Resident 1 was found to be unresponsive and pale with O2 sats of 70% on 2 liters of oxygen. O2 increased to 4 liters per minute. O2 sats increased to 78%. Resident unresponsive to touch and 911 called. On [DATE] at 9:17 AM, Staff E, LPN, said she was the nurse caring for Resident 1 prior to the morning ([DATE]) she was sent to the hospital. Staff E said it was policy to have a physician order for oxygen and monitoring of oxygen saturation levels. Staff E said she thought a prior shift had called the physician to request orders. At 9:20 AM, Staff D, LPN, said on [DATE] Resident 1 had looked poorly. Her O2 saturations were in the 90's. Staff D said Resident 1 had asked for an inhaler called Advair that she used to manage seasonal allergies and asthma. Staff D said another nurse had faxed an order but there had been no response. When asked what the process would be if the facility had not received a response from the physician, Staff D said she wasn't sure, maybe fax again. Staff D said she had not re-faxed or called the physician regarding Resident 1's request for an Advair inhaler, oxygen orders, or Resident 1's respiratory symptoms. At 1;51 PM, Staff F, LPN, said when a resident was placed on oxygen emergently it was facility procedure to call and report conditions to the physician and to obtain orders for oxygen flow rate and oxygen saturation monitoring. On [DATE] at 8:58 AM, Resident 1 said she never did receive the Advair inhaler she requested for her seasonal allergies and asthma. Resident 1 said she received the Flonase inhaler, Allegra tablet, and Albuterol inhaler but what was needed was the Advair inhaler. Resident 1 said she utilized the Advair inhaler every year in the spring when plants began to [NAME] and then again in the fall. Resident 1 said the facility had the medication, but it had expired. An order had been faxed but there had been no reply prior to her being sent out to the hospital. Resident 1 said she did not remember being transported to the hospital on [DATE]. When she awoke, she was told she had received too much oxygen. Resident 1 said she was able to take the oxygen in but not breath it out causing her to retain carbon dioxide. Resident 1 said she went into respiratory distress and had to be intubated. Reference WAC [DATE] (1)

Based on interview and record review, the facility failed to ensure bathing opportunities were provided for dependent residents for 1 of 2 sampled residents (145) reviewed for activities of daily living (ADLs). This failure placed residents at risk of skin infections, decreased dignity, and a diminished quality of life. Findings included . Resident 145 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 01/05/2024, documented the resident was moderately cognitively impaired. Resident 145's shower record, dated 12/30/2023 to 01/09/2024, did not show bathing opportunities were completed in 11 days. The bathing record documented a resident refusal on 12/30/2023, the day of Resident 145's admission to the facility. On 01/08/2024 at 12:30 PM, Resident 145 said he had not had a shower or bath since admitting to the facility. Resident 145 said he used personal wipes to clean himself as needed. On 01/09/2024 at 1:08 PM, Staff D, Certified Nursing Assistant (CNA), said shower aides would shower residents for the day, and CNAs would assist the shower aides as necessary. Staff D said residents would be showered once or twice a week. Staff D said if a resident refused a shower, staff should ask again two or three times then document the refusal in the resident's record as well as inform the nurse of the refusal. At 1:16 PM, after reviewing the facility shower book for Resident 145, Staff D said Resident 145 was scheduled for showers twice a week on Mondays and Thursdays. At 1:19 PM, Staff C, Licensed Practical Nurse, said shower aides were responsible for showering the residents in the facility. Staff C said if a resident refused a shower, she would expect the CNA to re-approach the resident. If the CNA was unsuccessful, the CNA should inform the nurse, and the nurse should write a progress note about the refusal and the education provided to the resident. After reviewing Resident 145's record, Staff C said she did not see a progress note related to refusing a shower. After reviewing Resident 145's shower record, Staff C said the resident had a refusal documented on 12/30/2023 and no other refusals or completed showers were documented. At 1:29 PM, Staff B, Director of Nursing Services and Registered Nurse, said the facility used shower aides to complete resident showers in the facility. Staff B said Resident 145's shower days were Mondays and Thursdays. Staff B said if a resident refused a shower, she would expect staff to re-approach the resident and if the resident refused a second time, the CNA was expected to inform their nurse and the nurse would attempt to educate the resident. If the resident refused again, the nurse was expected to document the resident's refusal in the resident's progress notes. Staff B said she did see an entry for a refusal on 12/30/2023, but did not see any other entries. Staff B said she would expect to see showers documented or a documented refusal notes written by the nurse. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to ensure performance reviews were completed for 1 of 2 sampled nursing assistants (NA) (Staff E) reviewed for performance reviews. This failure placed residents at risk for receiving care from unskilled staff. Finding included . Staff E, Nursing Assistant, was hired on 08/04/2017. Staff E's personnel records did not have a Performance Evaluation for the previous year. On 01/10/2024 at 6:57 PM, Staff B, Director of Nursing Services and Registered Nurse, said performance evaluations were supposed to be completed annually. When asked about Staff E's performance evaluations, Staff B stated, We missed it. Reference WAC 388-97-1680 (2)(b)(I)

Based on interview and record review, the facility failed to ensure nursing hours were accurately posted daily for 12 of 30 days reviewed for nurse staff posting. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census. Findings included . The nursing home daily staff postings had not been updated for 12 days, from 12/09/2023 through 01/08/2024, to accurately reflect the number of nursing assistants working per shift. On 01/11/2024 at 9:15 AM, Staff F, Staff Coordinator, said the floor nurse should adjust the staff numbers if the posting were not accurate at the start of a shift. At 10:06 AM, Staff B, Director of Nursing Services and Registered Nurse, said the shift nurses were supposed to update the postings to reflect the staffing level. No WAC Reference

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent falls for 1 of 3 sampled residents (#49) reviewed for accident hazards. This placed residents at risk for injury, diminished quality of life and death. This caused harm to Resident #49 when he fell and sustained a neck fracture. Findings include . Resident #49 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Set, an assessment tool, dated 06/28/18, showed the resident had severe cognitive impairment, was cooperative with care, required extensive assistance with activities of daily living (ADLs), and used a wheelchair for mobility. On 07/23/18 at 11:13 AM, Resident #49 was observed with a neck brace and an abrasion to his right forehead. A family member said the resident was a huge fall risk because he thinks he can do more than he can. The family member said the resident had broken his hip and ribs in the past from falls. The family member said the resident had fallen a couple days ago, at the facility, and broke his neck. Review of the Incident and Accident log showed Resident #49 had 11 falls in the facility between 12/25/17 and 07/21/18. Five of those falls included injury. Two of the five injury falls resulted in a fracture. The fall investigation report, dated 07/21/18 at approximately 9:00 PM, documented Resident #49 was found on the ground in the courtyard laying on his right side. The resident complained of pain to an abrasion to the right side of his forehead and was sent to the emergency room for evaluation. The resident was evaluated at the hospital and found to have a neck fracture. The resident returned to facility with a hospice referral. The investigation report showed the resident was wheelchair bound, and was self-propelling throughout the facility and out in the courtyard, per his norm. A telephone interview with Staff U, a Licensed Practical Nurse (LPN), documented, She did try and get the resident to lay down prior because he was slumping to the right side which is not abnormal when resident is tired. The Resident's Care Directive Form (a form that details resident care needs), last reviewed 07/23/18, did not list an intervention of how to manage the resident when tired/leaning in his wheel chair. The Activities of Daily Living Care Plan, reviewed (MONTH) (YEAR), did not list an intervention to addressed how to manage the resident if tired/leaning in his wheel chair. The Fall Risk Care Plan, last reviewed 07/23/18, showed the resident was a fall risk (did not indicate high, moderate or low) related to issues including confusion, balance problems, poor communication/comprehension, unaware of safety needs and actual falls with injuries. The care plan did not list interventions addressing how to manage the resident if tired/leaning in his wheel chair and supervision, including wheelchair self-propelling in the facility and courtyard. The Dementia/Alzheimer's Care Plan, dated (MONTH) (YEAR), identified potential risk for injury relate to inappropriate judgement and wandering. A hospice progress note, dated 07/23/18 at 1:00 PM, documented the admission of Resident #49 to hospice services with a [DIAGNOSES REDACTED]. A nurse progress note, dated 07/25/18 at 10:00 PM, documented Resident #49 was transported by ambulance to an in-patient hospice facility. On 07/26/18 at approximately 9:00 AM, staff indicated Resident #49 had passed away. On 07/30/18 at 12:03 PM, Staff L, a LPN, said Resident #49 would at times fall asleep in the wheel chair and staff would gently wake him and offer to lay him down. At 4:09 PM, Staff V, a Nursing Assistant, said Resident #49 typically went to bed soon after dinner, between 7:00 - 8:00 PM. On 07/31/18 at 9:10 AM, when asked if the resident, with his fall risk, should have been accompanied in the courtyard, Staff B, the Director of Nursing Services, said the resident should be supervised. Staff B said Resident #49 had passed away at the in-patient hospice facility. At 1:46 PM, when asked about interventions to address the resident leaning to the right when he was tired and would not lay down, Staff B stated, He could have been sat up. The facility's failure to supervise and have interventions in place to prevent a fall from a wheel chair, for a resident with a history of injury causing falls, resulted in harm to Resident #49 when he had an unsupervised fall in the courtyard and sustained a neck fracture. Reference WAC 388-97 -1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure the necessary care and services related to communication were provided to attain and/or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 12 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk for frustration, inadequate services and a diminished quality of care. This caused psychosocial harm to Resident #1. Findings include . Resident #1 was admitted to facility on 09/23/17 with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 04/06/18, documented the resident was rarely or never understood. The resident's care plan, dated 03/2018 documented the resident used an electronic device/computer to communicate and used hand gestures to answer yes/no questions. No specific hand gestures were identified. The care directive guide, dated 3/23/18, documented the resident held up one (1) finger for yes and two (2) fingers for no, to ask yes/no questions, and the resident used a tablet or computer for communication. An Investigation Report, dated 04/10/18, documented during a neurological appointment, the resident reported the staff were cruel to him. The Social Services Director (SSD) and Resident Care Manager (RCM) spoke with Resident #1, and via hand gestures, the resident indicated he felt staff were rough with care, and did not treat him with dignity and respect. The resident said the staff were not rough with transfers, but with care. The resident did not elaborate further or provide the staff member's name, and was unable to provide dates. The investigation determined this was a perception of one person to another. At 12:14 p.m., Resident #1 was observed in his room in a wheelchair slumped to the right side with his right arm dangling on the outside of the wheelchair with a white dried substance on his face. The call light was hanging on the bedside table, about three (3) feet away from the resident. When asked about staff being rough, Resident #1 put up one (1) finger (yes). When asked if things were better, the resident put up two (2) fingers (no). The resident indicated the staff treat him nice, and typed, Still rough. They are in a hurry. When asked if anyone was hurting him, Resident #1 typed, Physically, no. The resident typed, I don't get the care I need. They don't wait for me to respond. At 1:57 PM, the SSD stated, (Resident #1) was quicker with his typing on the computer, and he's much slower now. At 2:44 PM, Resident #1 was observed in his room in a wheelchair slumped to the right side with his right arm dangling on the outside of the wheelchair with a white substance on his face. The resident's call light was hanging on the bedside table about three (3) feet away from the resident. At 2:50 PM, Nursing Assistant (NA) C said he worked with Resident #1 occasionally. The Administrator (ADM) and NA C were in the resident's room and were observed to pull Resident #1 up in his chair. NA C left the room without asking resident if he needed anything. Resident #1 was observed typing I need on his computer. The ADM indicated NA C did not ask Resident #1 if there was anything the resident needed. The ADM then left the resident's room and did not wait for Resident #1 to finish typing. At 3:12 PM, the DNS stated, I would expect them to wait for him to respond. On 5/25/18 at 1:10 PM, when asked if staff wait for him to communicate, Resident #1 held up two (2) fingers (no). At 1:59 PM, NA E said when the resident used the tablet and I ask yes/no questions, it takes 10-15 minutes for (Resident #1) to type something out. NA E said he was not able to wait for him to type something out. I tell him I will be back. He gets frustrated when not able to communicate. At 2:05 PM, NA E was observed sitting with Resident #1 helping him to communicate on the tablet. Resident #1 was observed having difficulty operating the tablet, hands shaking and unable to touch buttons on tablet. At 2:50 PM, the SSD was observed with Resident #1 trying to help with communication on the tablet. Resident #1 was observed having difficulty operating tablet, hands shaking and unable to touch buttons on the tablet. At 3:06 PM, Resident #1's family member stated, I visit once a week. He has gradually declined due to his diagnosis. It takes him a long time to communicate. Sometimes he can't get anything typed out. At 3:44 PM, the SSD stated, I have noticed when (Resident #1) is frustrated . I usually use yes/no questions. With the tablet he cannot get his fingers right. It is not very effective. We did use the communication binder and it worked. I don't know why he doesn't use the book or his computer. I asked him, and he wouldn't respond. When asked if she had the time to sit with Resident #1 as she did today, the SSD stated, I don't have that kind of time and staff does not have the time. His current plan is not effective for his communication. At 3:52 PM, when asked if using the tablet was effective in communicating with the staff, Resident #1 put up two (2) fingers (no). When asked if he gets frustrated using the tablet, the resident put up one (1) finger (yes). When asked if staff were meeting his needs, the resident put up two (2) fingers (no). When asked if he used his computer to communicate, the resident put up one (1) finger (yes). When asked if the computer was easier to use, the resident put up one (1) finger (yes). At 4:13 PM, when asked if the communication system Resident #1 was using currently was effective, the ADM stated, It depends on the day. Everyone has good and bad days. At 4:15 PM, the DNS stated, If (Resident#1) is unable to use the tablet, (the staff) should be using yes/no questions. I believe he can turn on the computer. The tablet is not effective today. At 4:20 PM, the ADM stated, It looks like a reassessment is needed. The facility failed to review and revise interventions after staff observed a decline in effective communication with the resident. This failure caused frustration and psychosocial harm to Resident #1. WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure the resident environment was safe and free from hazards when a resident received a significant burn from a hot beverage for 1 of 3 sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident #1. Findings include . The facility hot beverage policy, dated 12/2014, documented the temperature of a hot beverage for resident contact should not exceed 150 degrees Fahrenheit (F). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 04/09/18, indicated Resident #1 had a severe cognitive impairment, was dependent on staff for activities of daily living including eating and had impairment on both sides in arms and legs. The facility investigation, dated 05/07/18, documented Resident #1 had a blister to his right thigh measuring 5.5 cm (centimeters) x 3.0 cm with a raised fluid blister measuring 2 cm x 1.5 cm. Resident #1 reported it occurred the day prior and he had tipped over his mocha, which had a lid and a straw. Resident #1's preference was not to wear pants and to wear a hospital gown. The care directive, used to provide guidance to staff, dated 05/08/18, documented the resident was extensive assist of one (1) person for meals. A service invoice, dated 03/22/18, documented a new coffee machine was in the kitchen. On 05/09/18 at 10:42 AM, the Dietary Manager (DM) stated, We have a brand new coffee machine and they have had to come out and turn (the temperature) down twice because it was too hot. They are coming out again this week to turn it down again. At 11:07 AM, the coffee machine, with three (3) containers, was observed in the kitchen with the following temperatures taken by the DM: 1st one 155 degrees F, 2nd one 149 degrees F, and 3rd (water) 164 degrees F. A sign was observed on the side of the machine that read, Under no circumstance should anyone come and get coffee/water for a resident from the kitchen until the water temps are fixed. They are way too hot! **All coffee/water must be temped before leaving the kitchen. It must be 150 degrees or less. The DM stated, It is typical for the (Nursing Assistants) to come in and get coffee for certain residents. They will come and get it straight from the coffee pot. This happens every morning. At 11:17 AM, Resident #1 stated, They brought me a hot cup of mocha and it tipped over with the straw in it. I couldn't get it and it kept dripping, and it burned my thigh. They got it from the kitchen. At 11:55 AM, Resident #1's right inner thigh was observed with a red area circular in shape with a tail like area at the bottom going toward the back of the leg. There appeared to be a blister that had opened. At 12:11 PM, the Director of Nursing (DON) stated, We have instructed the aides not to go into the kitchen. The kitchen provides the hot air pots and fills them. They got a new machine and I know the rep has been out twice to fix it. (The DM) called again this week. At 12:34 PM, the DM stated, There is no way to determine who temped and if it was out of the actual pot or the air pots, so in (MONTH) (2018) I told kitchen staff to just temp the air pots because the machine was temping too hot. The aides still come in and get the coffee directly out of the pot. The DM indicated on Sunday, 05/06/18, the aides came in and got it out of the machine. At 12:45 PM, the Administrator (AD) indicated she was unaware the aides were going into the kitchen and getting water and/or coffee right out of the new coffee machine. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review it was determined the facility failed to ensure 3 of 9 current sampled residents (#20, 53 & 18) reviewed received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility caused harm to Resident #20 when they failed to adequately monitor and intervene promptly to seek advanced care when the resident had an acute change in condition. The facility failed to ensure adequate monitoring and assessment of Resident #53's skin condition and failed to monitor and follow physician's orders [REDACTED]. These failures placed residents at risk for delayed healing, ongoing complications and not attaining or maintaining their highest practicable level of well-being. Findings include: 1) Resident #20 was admitted on [DATE] with multiple diagnoses, which included [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. Vital signs at the time of admission were a blood pressure of ,[DATE], pulse of 90, respiratory rate of 18 and oxygen saturations were 95% on room air (without oxygen). The resident was documented as a Full Code (attempt of CPR and resuscitation expected) with Full Treatment, which directs staff that the resident wants to be transferred to the hospital with intensive care if and when indicated. A nursing note, dated [DATE] at 4:45 a.m., documented the resident was complaining of fearfulness, anxiety and nausea. [MEDICATION NAME] (an antianxiety medication) was given. A nursing note, dated [DATE] at 12:30 p.m., by Licensed Nurse (LN) D documented the resident's vital signs were with blood pressure of ,[DATE], pulse of 94, and respiratory rate of 20. Resident had increased sleepiness, confusion and weakness and was nauseated over the weekend. This a.m. resident with increased confusion and low oxygen saturation at start of shift. A call to the doctor was placed and [MEDICATION NAME] (a medication that can effect blood pressure) was discontinued. No documentation of monitoring over night from [DATE] to [DATE] was located in the chart. On [DATE] at 10:48 a.m., LN C stated that, I would have expected a note for evening and night shift. She should have been on alert. A review of the following nursing progress notes revealed: > On [DATE] at 7:35 a.m., LN D documented the resident had a fall out of her wheelchair. Resident #20's vital signs were documented as blood pressure of ,[DATE], an oxygen saturation of 84% on 3.5 liters per minute of oxygen and her lungs were assessed as being very diminished. > On [DATE] at 9:40 a.m., LN D documented a call was placed to the resident's doctor's office and a voicemail message was left with a Medical Assistant (MA). > On [DATE] at 9:50 a.m., LN D documented that the MA returned the call and the MA had said she would inform the physician and call back. > On [DATE] at 10:45 a.m., LN D documented an order for [REDACTED]. > On [DATE] at 11:00 a.m., LN D documented lungs more audible, clear but still diminished and oxygen saturations remain ,[DATE]%. A call was placed again to the MA. > On [DATE] at 11:15 a.m., LN D documented the resident was complaining of anxiety and oxygen saturations were 83%. [MEDICATION NAME] was given and resident was instructed to breathe in through nose and out through mouth and oxygen saturations went up to 85%. > On [DATE] at 11:45 a.m., LN D documented oxygen saturations were 88% on 3.5 liters per minute and the resident was exhibiting confusion. Another call was placed to the MA and LN D was informed that the MA would inform the Nurse Practitioner and call back. >On [DATE] at 12:45 p.m.,LN D documented the resident was asleep with oxygen saturations of 85% on 3.5 liters per minute and resident's fingers with dusky and gray. > On [DATE] at 2:00 p.m., LN D documented the resident had increased lethargy, green colored mucous coming out of her nares and an oxygen saturation of 79%. A call was placed to MA to inform her that resident was being sent to hospital. On [DATE] at 10:48 a.m., LN C stated that, Maybe some things weren't really stressed or pressed enough. Maybe she (LN D) should have asked to talk to the doctor or written her assessment and faxed it to then and asked the MA to show it to the doctor. Those saturations seem pretty low on 3.5 liters of oxygen. An SBAR form (form used to give report or updates in resident change of condition) dated [DATE] at 2:35 p.m., was used to give report to the hospital nurse after the resident's transfer to the hospital. It was completed by LN D and stated that the change the nurse was calling about was the resident's decrease in cognition and decrease in oxygen saturations and it started at the onset of shift at 6:30 a.m. Review of hospital records for the resident's stay from [DATE] through [DATE] documented the resident was diagnosed as being septic (an infection in the bloodstream), being positive for Influenza, having had a non-ST elevation [MEDICAL CONDITION] infarction [MEDICAL CONDITION] with severe hypoxemia (low amount of oxygen in blood), and an acute kidney injury. Medical Doctor (MD) 1 documented, The patient met criteria [MEDICAL CONDITION] with [MEDICAL CONDITION] (low blood pressure), tachypnea (fast breathing), [MEDICAL CONDITION](fast heart rate), altered mental status, and an identifiable source of infection. On [DATE] at 11:08 a.m., the Director of Nursing Services (DNS) stated, I would have expected other shifts to have documented on her. The DNS also confirmed that LN D was no longer employed with the facility. The facility failed to adequately monitor the resident overnight when she had a change in condition, failed to speak directly with a doctor when the resident was experiencing a rapid decline in condition, and failed to intervene promptly and seek advanced care after over 24 hours of symptoms, which included; low blood pressure, low oxygen saturations, and a change in mentation and which ultimately led to a hospital admittance with multiple preventable [DIAGNOSES REDACTED]. 2) Resident #53 was admitted to the facility on [DATE]. The resident's Minimum Data Set (MDS), an assessment tool, dated [DATE], indicated the resident was cognitively impaired and required extensive assistance with activities of daily living. On [DATE] at 11:27 a.m., when asked if she had any discomfort, the resident stated, My feet, I have open sores. They healed, but now they are open again. They are so dry, they crack. The resident's Care Plan and Treatment Administration Record (TAR) did not reflect the resident was being treated for [REDACTED]. On [DATE] at 10:12 a.m., when asked about the care and services provided for Resident #53, LN A stated, The resident goes out to a clinic for care. They wrap it and it stays on until she goes back again. I don't know exactly how often she goes. When asked if the facility monitored the dressings and condition of her feet, LN A said, No, everything is done there. When asked if the facility had progress reports from the appointments, LN A said he had not received anything after yesterday's appointment. When asked if there was a care plan, documenting the care and services being provided about the resident's foot condition, LN A said, What do you mean? After looking at the nursing assistant care directive, he stated, I don't see it there. At 10:18 a.m., the DNS said, It is not on the TAR because we aren't changing the dressing unless it is absolutely necessary. If we got it wet in the shower or if it was visibly soiled, we would change it. They told us they want to do everything themselves. The DNS was asked to provide those instructions which were not available in the chart. The DNS said, I know we are responsible for all of her care. Instructions from the clinic were not provided at the time the survey was completed. When asked how the facility maintained a clear understanding of the resident's condition and how it was assessed and treated, the DNS said the facility completed weekly skin checks. At 1:18 p.m., Resident #53 said she went to the clinic yesterday and her feet were red and swollen. She stated, I need to have antibiotics. Resident #53 said she went to the clinic about every two weeks and LN B changed her dressing once or twice between visits. At 2:10 p.m., LN B said, We weren't given specific orders. I have changed the dressing a few times when it came off. When asked about a missed appointment on [DATE]th, LN B said, The nurse who worked on that isn't here anymore. I don't know what happened. There are no progress notes about it. She did go on [DATE]nd. When asked if the chart had information about the resident's condition from the [DATE] appointment, LN B said, No, I don't see anything. When asked if they took the dressing off during the weekly skin check, LN A and LN B both said no. The facility failed to document specific care and services provided to the resident related to the resident's condition, failed to consistently monitor for placement and cleanliness of the dressing, failed to have a clear picture of the resident's progress following visits at the clinic and failed to visualize the resident's feet during the weekly skin assessment. 3) On [DATE] at 8:57 a.m., LN E was observed to administer one sulfacetamine sodium 10% drop in each of Resident #18's eyes. At 8:58 a.m., when asked how many eye drops were administered to the resident, LN E stated, I put one drop in each eye. Record review showed a physician's orders [REDACTED]. Review of the July Medication Administration Record (MAR) on [DATE] at 10:03 a.m., documented the resident did not receive the sulfacetamine sodium 10% eye drops 12 times since beginning the medication on [DATE]. There was no explanation documented on the MAR or in the Nursing Progress Notes regarding why the resident did not receive the ordered medication 12 times. Review of the Nursing Progress Notes on [DATE] at 10:05 a.m., revealed one note on [DATE] which documented the resident was tolerating the eye drops without any difficulty. No other documentation could be located in the medical record to indicate staff had conducted ongoing monitoring of Resident #18 who had a [DIAGNOSES REDACTED]. On [DATE] at 4:05 p.m., Resident #18 was observed with dried tan flakes noted to both his eyelids and redness to both lower eyelids. The resident stated, They are a little sore. At 4:10 p.m., the Director of Nursing Services (DNS) stated the most recent documentation regarding Resident #18's eyes was on [DATE]. The DNS indicated the resident may have been refusing the eye drops and staff should have documented a reason the medication was not administered on the back of the MAR. WAC [DATE] (1) .

Based on observation, interview and record review, the facility failed to ensure 3 of 4 sampled residents (#1, #2, #3), reviewed for services met professional standards of quality, received care based on accepted professional standards of nursing practice related to assessments, monitoring, accurate documentation without falsification, correct transcription of orders, physician notification, and providing safe medication administration for residents in the facility. This failure resulted in harm to residents #2 and created the potential of harm to all residents when standards of professional clinical practice were not correctly implemented. Findings include: 1) Resident #2 was admitted to the facility on [DATE] with multiple health conditions including [MEDICAL CONDITIONS], high blood pressure and a Stage IV pressure ulcer to her coccyx (tailbone). The quarterly Minimum Data Set (MDS), a comprehensive assessment tool, dated 2/22/17, showed the resident needed extensive assistance with Activities of Daily Living (ADL) which required two person assist. The resident was frequently incontinent of bowel and bladder. She was at high risk for skin breakdown and was on blood thinning medication which made any injury to her more prone to easily bleed. The clinical record showed, on 4/3/17, the resident had an accident with her electric wheelchair (w/c) which resulted in injuries to her face, arms and legs. After evaluation at a local hospital, she returned to the facility. On 4/5/17 at 11:00 a.m., the resident was observed in her w/c with bruising to her right eye, face, neck and legs, and complained of pain to her feet. The resident said her heels hurt from being pushed against the footrests of the w/c. The resident said she told the nurses about her heels hurting but no one had looked at her feet yet. Observation of her feet showed a bloody area on her white sock of her right foot. The resident said she was not aware of any injury to her feet. When asked to assist with observing the resident's feet, Licensed Nurse (LN) B, the nurse on duty, said he normally did not work with the resident and had not seen her feet. Upon removal of the right foot sock, the resident had skin injuries to the top of her toes with blood dripping to the floor. The resident complained about her heel hurting and an examination showed a quarter size, pink, open area to the back of her heel. No documentation was found to show the injuries to the right toes and heel had been assessed, reported to the physician, and that treatment orders were received per professional standards to ensure the wounds were protected from potential infection and to promote healing. On 4/12/17 at 2:00 p.m., when nursing assistant (NA) C pulled the resident's sock from the resident's right foot, the dry gauze pulled away from the right heel with the sock and started to bleed. No dressing was observed to her right toes. At 3:15 p.m., review of the wound documentation treatment sheet, dated 4/10/17, showed the Director of Nursing Services (DNS) had signed a blank assessment form. When the DNS was asked about the blank assessment form, she stated she needed to fill in her findings from her assessment earlier and was not sure where she would have put measurements of the wounds. On 4/5/17, 4/12/17 and 4/19/17, when asked about the accuracy of the skin assessments and treatments, both LN B and the DNS stated the resident's skin injuries had been accurately assessed and documented by them at the time of the resident's accident on 4/3/17. On 4/19/17 at 4:00 p.m., during interview with the DNS, LN B and the Administrator, related to the accuracy, observations and documentation of skin injuries and treatments, the Administrator told LN B and the DNS, to tell the truth about the clinical record documentation. LN B and DNS stated the initial assessments and subsequent documentation forms were created to appear as though they had been completed on 4/3/17, prior to the injuries being brought to their attention on 4/5/17. There was no documentation regarding the 4/5/17 observations and subsequent treatments by LN B. When asked why they falsified the record by creating documents and signing them when they knew they had not performed the assessments and accurately documented their findings, LN B and the DNS stated the facility's corporate nurse instructed them to create the documents and give them to the surveyors. Falsifying records violated the standards of nursing practice and prevented the resident from receiving assessments and treatment in a timely manner. 2) Resident #1 was admitted on [DATE] after surgery on her upper spine. She had multiple medical [DIAGNOSES REDACTED]. The initial MDS, dated [DATE], showed the resident required extensive assistance of two staff members with most daily living tasks and needed help from two staff members for bed mobility and transfers. On 3/27/17, the resident incurred a fall while transferring with only one staff member. According to the facility policy and professional practice, the resident should have been monitored for neurological deficits and potential late effects from the fall every shift for 72 hours. Documentation of the occurrence on the day of the fall did not accurately reflect what the nursing assistant (NA) had reported happened. On the day after the fall, there was not an entry and indication the resident was assessed or monitored per professional standards of practice or facility policy. On 4/12/17, review of the documentation in the resident's record showed little information about her condition in the hours after the fall. 3) Resident #3 was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], showed the resident needed maximum assistance with his ADL's, and substantial assistance with bed and chair mobility. Review of physician orders, dated 3/29/17, showed dosage changes to [MEDICATION NAME] (a medication to treat the symptoms of [MEDICAL CONDITION]) were made by the neurologist due to the spouse's observation of the resident's change/decline in function by slumping in his wheelchair. Physician orders [REDACTED]. The resident's needed medication was not transcribed per professional standards. Staff failed to recognize the resident's inability to sit upright until it was brought to the nurse's attention by the spouse, and staff failed to ensure medications were given as ordered and the responses to the medications were monitored. <Medication Administration Records (MAR)> As required by professional standards: Safety is the main concern in medication administration .preparing medications carefully and recording their administration. Use of the MAR indicated [REDACTED].Regardless of the type, all MARs provide a space for documenting when a drug is given, along with a place for the signature, title and initials of each nurse who administers a medication (Fundamentals Nursing Skills and Concepts, 9th Ed. (2009) Lippincott, Williams and Wilkens, Chapter 32, page 771). During observation of medication administration on 4/5/17 at noon, LN C did not place her signature or title on the MAR. When asked where her signature could be found, she pointed to initials on the MAR. She stated she was new to the facility and could not say whose initials were already on the MAR for administering and monitoring previous residents' medications. LN C said it was a facility-wide practice of not placing signatures on the MARs and agreed it would be difficult to know who administered/assessed/monitored residents' medications. Review of facility residents' MARs showed the facility-wide practice of not placing signatures and titles on the MARs to correlate with legible initials. The practice of not placing signatures and titles on the MAR, violated professional nursing practice standards and placed all residents in the facility at risk of not knowing who was responsible/accountable to them for safe mediation administration and monitoring for effectiveness and/or adverse side effects for current and discharged residents. Reference (WAC) 388 97-1620(2)(b)(i)(ii), (6)(b)(i) Refer to F 514 .

Based on observation, interview and record review, the facility failed to ensure initial and ongoing skin assessments and monitoring were provided to promote healing of right toes and heel injury for 1 of 3 sampled residents (#2) reviewed for skin integrity. Failure to assess and determine the cause of the toes and heel injuries and accurately document and monitor the areas, resulted in a lack of timely assessment/treatment and continued discomfort. This failure caused harm to Resident #2 when timely assessments and treatments were not implemented and created opportunity for delayed healing and development of complications. Findings include: Resident #2 was admitted on [DATE] with multiple health conditions including [MEDICAL CONDITION] (MS), [MEDICAL CONDITIONS], high blood pressure and a chronic Stage IV pressure ulcer to her coccyx. She was at high risk of skin breakdown. The quarterly Minimum Data Set (MDS), a comprehensive assessment tool, dated 2/22/17, showed the resident required extensive assistance for toileting, transfers and bed mobility and relied on staff to ensure mobility and positioning to prevent skin breakdown. Resident #2 was observed on 4/5/17 at 11:00 a.m , in a wheelchair (w/c), wearing white socks on both feet that were positioned on the metal footrests of the w/c. Resident #2 said, My feet hurt on the backs. They rub against the back (of the footrests). The resident said she told staff her feet hurt and no one had assessed her feet. When Licensed Nurse (LN) B was asked to take the resident's socks off, blood was dripping from two toes on the right foot and the heel had an open, non-draining, blister-like, pink area the size of a quarter. LN B said he did not normally take care of the resident and had not seen her feet. LN B said he thought the injury to her right toes might have been from an accident the resident incurred on 4/3/17 while out of the facility and maybe the heel was injured at that time. On 4/12/17 at approximately 2:00 p.m., nursing assistants (NA) C and D were observed transferring the resident from her chair to bed. When the NA pulled the right sock off, observation of the foot showed no dressing to the right toes and a 2 x 2 dry gauze pulled away from the heel with the sock and started to bleed. The wound was larger than when observed on 4/5/17, and the back of the heel appeared as a cut about 1.5 inches across and 1/4 inch deep. There was a dark circle, the size of a pencil eraser, on the right side of the bottom of the foot about 3 inches below the two injured toes. Reveiw of the skin assessment form, dated 4/10/17, was blank and signed by the Director of Nursing Services (DNS). Review of the comprehensive care plan (CCP), since the 4/3/17 fall, failed to include interventions for the foot injuries. On 4/19/17, an Admission Body Assessment, dated 4/13/17, and progress notes timed at 10:00 a.m., was found in the record and showed multiple skin integrity issues. A Stage II pressure ulcer was identified on the right heel by the Registered Nurse (RN) and another nurse showed, .possible Stage II pressure ulcer that looks like a popped blister measuring 0.4 centimeters (cm) by 0.2 cm. and there is a dark smooth area below that measures 0.8 cm by 0.8 cm . Resident #2 was harmed due to lack of timely recognition, assessment, monitoring, treatment and accurate documentation of the foot injuries that placed the resident at risk for continued discomfort, delayed healing and infection. Reference (WAC) 388 97-1060 (3)(b) Refer to F 281, 514.

Based on interview and record review, the facility failed to prevent an avoidable fall for 1 of 3 residents (#1) reviewed. This failure resulted in significant injury to Resident #1. Findings: Resident 1 was admitted to the facility 1/22/14 and was care planned to not be left unattended in the bathroom. On 5/1/15 Resident #1 took herself to the bathroom in her wheelchair after turning on her call light and the aide came in and placed her on the toilet. The aide left to attend to another resident. Resident#1 was found lying on the floor of the bathroom on her stomach with blood ozing from her head. The Resident #1 said upon interview by staff that she "couldn't keep herself from falling forward". She also stated that her head hurt like a '10' on the pain scale. Resident #1 was sent to the emergency room and received 9 stitiches in her forehead, a CAT scan and X rays. Interview of the Director of Nursing on 5/15/15 revealed that the aide had worked with this resident before and knew not to leave her alone in the bathroom. Interview of Resident#1 revealed a cheerful person, with sutures on the right side of her forehead into the scalp that were healing.

Based on observation, interview and record review, it was determined the facility failed to ensure pain was managed for 2 of 5 current sampled residents (#54 & #89) reviewed for pain. This failure placed residents at risk for uncontrolled pain and decreased quality of life. This failure caused harm to Resident #54 and Resident #89 when they experienced inadequately managed pain. Findings include: 1) Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 8/19/15, indicated the resident was severely cognitively impaired and required extensive two person assistance with all activities of daily living. The resident's care plan for pain, dated 2/10/15, identified indicators of pain including groaning and moaning and interventions included repositioning to resident's comfort and provide pain medications as ordered. Resident #54's Care Directive, dated 4/2/15, did not document any pain related interventions to direct how personal care was to be provided. On 4/6/15 at approximately 9:00 a.m., Resident #54 stated, I always have back pain. On 4/13/15 at 9:29 a.m., the resident said she had pain when she moved too much and indicated that was the reason she was not getting out of bed. On 4/13/15 at 11:10 a.m., peri-care was observed. While Nursing Assistant (NA) B and NA C were preparing to provide care, Resident #54 asked for pain medication. NA B assured the resident she would ask the nurse for pain medication as soon as they were done. During the provision of peri-care, the resident groaned intermittently and complained of low back pain. The resident asked again if she could have pain medication. The resident was rolled side to side multiple times during the peri-care, applying a brief, changing the resident's gown and changing the sheets with the resident in the bed. The care was continued until completion. NA B was not observed reporting the resident's complaint of pain to the nurse before, during or after the care had been completed. At 11:49 a.m., Resident #54 reported pain in the low back to the surveyor and stated the pain was 6/10 on the pain scale. The resident put on the call light and made another request for pain medication which was provided by the nurse. At 12:44 p.m., Licensed Nurse (LN) D stated, For residents with pain issues, staff should be more cautious and be sure they don't jerk them around. We can give a pain pill a half hour before, if requested, or if there was difficulty during the care. The nurse indicated if the medication was as needed the resident would have to ask for it. LN D stated she had not received a report from the NAs that Resident #54 had been in pain during care. The LN said the resident could be pre-medicated (medications for pain given prior to care) and stated, Yes, I would expect NA's to tell me about pain. They should stop at that point (when a resident complains or is groaning) and come tell me. On 4/14/15 at 11:06 a.m., Resident #54 stated her pain is not bad right now. When I get to moving it hurts pretty bad. That's why I don't go down to breakfast, lunch or dinner. It gets excruciating by the time the meal is done. I can't live without the pain pills. That's one thing I can't stand; to sit up. At 11:11 a.m., LN E came in to give the resident medications. She raised the head of the bed, without asking the resident's permission first and stated, We have to have your head up to give you medications. I know this hurts you. You don't like to have your head up. The LN asked Resident #54 what her pain level was. The resident stated, It was nothing until you came in. The nurse then applied a new pain patch to the resident's upper back. The resident asked, Can you put my bed down? LN E said, In a moment, then proceeded to look for the old patch on left upper back. At 11:15 a.m., after LN E left the room Resident #54 stated, Some people think if it doesn't hurt them, it doesn't hurt you. At 11:30 a.m., LN C stated, NA's are expected to report any sort of facial grimacing, guarding, grabbing, verbal complaints such as ouch, that hurts to the nurse. LN C stated she would have expected the nurse to have laid the resident down after she swallowed her pills, then had someone help turn her to find the old patch. 2) Resident #89 was admitted from a hospital to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to have rehabilitation for strengthening, then return home. According to chart notes, the resident was alert and oriented. The resident required assistance of two staff for transfers into and out of the wheelchair. According to chart notes dated 3/28/15, the resident was admitted at 11:30 a.m. The resident was reported no current pain, but reported experiencing pain in the last 7 days. The resident was admitted with physician orders [REDACTED]., and [MEDICATION NAME] (for muscle spasms, requiring a prescription) to be given routinely 3 times a day. The facility experienced a delay in obtaining the medications from the pharmacy because the hospital had not sent appropriate prescriptions. The pharmacy was not able to fill prescription medications without proper prescriptions. A review of the Medication Administration Record [REDACTED]. The resident was not assessed for pain after admission, despite having a [DIAGNOSES REDACTED]. On 3/28/15 at 10:50 p.m., nearly 12 hours after admission, the resident demanded discharge and signed out of the facility AMA (against medical advice). On 4/8/15 at 10:45 a.m., the Executive Director stated, We have an e-kit where we keep an emergency supply of medications. The pharmacy should be able to get medications to us within 1-2 hours. At 11:50 a.m., LN B stated We have [MEDICATION NAME] and [MEDICATION NAME] available in our e-kit, I don't know why those weren't given. I think we had a problem getting medication for the resident because prescriptions were not sent with the resident from the hospital. The resident wanted her medications. At 12:10 p.m., the Director of Nursing Services (DNS) stated, I don't see where the resident's pain was evaluated after admission. I am not sure why the medications we had available were not given. I wasn't in the building, but I knew about this situation because of phone calls. I don't think we tried to call our Medical Director for assistance. I know we made phone calls to the hospital that sent the resident. When asked if 12 hours was a long time for someone with chronic pain to not be assessed for pain or to be offered available medications for discomfort, the DNS stated, I see your point, we could have done more for the resident.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well being for 2 of 6 residents (#3 & 1) when they failed to accurately assess decline and failed to take timely action to prevent further decline and failed to monitor a PICC line. These failures caused harm to Resident #3 when the resident's health deteriorated to the point where emergency hospitalization was required for 10 days, between 9/16 and 9/24 and caused the potential for harm when a PICC line was not monitored for Resident #1. Findings include: According to the American Nurses Association, Scope and Standards of Practice, 2011, "according to standards of care, a licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient." <Resident #3> Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 7/14/13, the resident was cognitively impaired and was dependent on the assistance of 1-2 staff members for activities of daily living (ADL's). The Resident was unable to make legal decisions and a guardian had been appointed by the court on 7/31/13. The Resident's "Meal monitor flowsheet for September 2013 shows the Resident refused to eat breakfast, lunch and dinner and refused fluid intake at each meal on 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15 and 9/16 (10 consecutive days) with no alternate being recorded as offered. Record review reveals the Resident had no bowel movement on 9/9, 9/10, 9/11 and 9/12. The Resident had "declined bowel protocol" on 9/11 and 9/12. It was not clear if the Resident was making urine. On 9/9/13, according to nursing notes, the nurse practioner was faxed regarding resident complaints of "left abdominal pain. Resident stated 'I think I pulled a muscle'." On 9/13/13, a nursing note entry, states "Resident cooperative with care and staff this noc {night} shift - declined snack - sleeping quietly this noc shift." On 9/14/13, according to nursing notes, "The resident requested to get out of bed. Drinking water, ate 1/2 container of strawberry ice cream. Drank 2-3 sips of chicken broth. VS {vital signs within normal range}, One wet pad." Nursing notes do not show any assessments were completed regarding the Residents' abdominal pain, lack of food and fluid intake, bowel and bladder function, except as described above between 8/28 and 9/16. On 9/16/13, weight records show the Resident with a 12 pound weight loss in one week, from a weight of 196 pounds on 9/9/13 to a weight of 184 pounds on 9/16/13. On 9/16/13 at 12:00, a nursing note indicates abdominal x-rays, lab work, antibiotics and pain medications were to be given for Resident complaints of "Abdominal pain. Res {Resident} has had minimal - 0 intake since 9/7/13." The Resident was sent to the hospital on [DATE] at 2:50 p.m. at the request of the Guardian. On 9/16/13, Emergency department notes state "Apparently the patient has been complaining of lower abdominal pain for the past 1 week, and the patient has not been drinking or eating for the past 1 week. The patient was found to be dehydrated, with a creatinine at 4.5 ( baseline was 0.9) and a BUN at 168 (baseline around 19). The skin is dry, tented and mottled. The patient looks extremely dehydrated." On 9/27/13 at 2:15 p.m., the Director of Nursing stated "We were completing weekly weights for {Resident #3}. Once we identified the significant weight change over one week, then we had the RCM do an assessment. That is when we started trying to figure out what was going on with the resident. There had been meal refusals and the RCM was notified." On 9/30/13 at 11:20 a.m., the Director of Nursing stated "I went back and interviewed staff and got statements about what happened with {Resident#3} during the time of 9/7 through 9/16 and I have concluded the Resident was at baseline and there were no urgent signs or symptoms to justify documented assessment of abdominal pain. Although the Resident was not taking in solid foods, he continued to consume water and void. I guess we didn't write everything down. We have no written policy related to documentation or late entries. We use standards of practice for condition or changes in resident status or deterioration from baseline." <Resident #1> Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A PICC {Peripherally inserted central catheter}, a type of IV inserted into the arm that delivers medication and/or fluids directly into the circulatory system, had been placed at the hospital. The PICC line was a preferred method of delivering the antibiotics the Resident would be receiving. According to the facility policy from the pharmacy labeled "Infusion Maintenance Table", a PICC line should have a transparent dressing change completed 24 hours after insertion or on admission, then every week and as needed. The external catheter length should be measured on admission, with each dressing change and as needed. According to information provided by the hospital, complications of a PICC line could include infection, the catheter moving out of proper position, clot formation, pain, nerve damage and breakage of the catheter. On 9/6/13, at the time of admission, the PICC external length was noted to be 12.5 cm (centimeters). A review of the TAR (Treatment administration record) shows the dressing was scheduled for a change on 9/9, but was not completed until 9/11/13. There was no measurement recorded regarding the external catheter length. On 9/13/13, the Resident pulled out the PICC line. The entire PICC was measured, but there was no assessment of whether the entire line, including the insertion tip, had been removed, or what the insertion site was like. On 9/14/13, a peripheral IV was started in the Resident's arm for delivery of the antibiotics. On 9/15/13, the Resident pulled out the peripheral IV line. On 9/17/13, the Resident was sent to the hospital to have another PICC line inserted. When the Resident returned from the hospital, no measurements were recorded regarding the external catheter length. The dressing was scheduled to be changed on 9/23/13, but was not completed until 9/27/13. There no measurement completed of the external catheter completed with the dressing change. On 9/27/13 at 9:35 a.m., Licensed Nurse (LN) E stated "The PICC lines should be measured on admission and weekly and as needed. The dressings should be changed on admission and weekly and as needed. I haven't been here for a few days, but I would expect that information to be recorded on the TAR." Refer to F 157 and F 279 .