Every finding on record at Arlington Health and Rehabilitation

Based on interview and record review the facility failed to provide 3 of 3 sampled residents (Resident 3, 58, and 63) with a notice of transfer/discharge which outlined their specific rights related to their transfer/discharge and failed to notify the Long-Term Care Ombudsman for 2 of 3 residents (Resident 58 and 63) for discharge from the facility as soon as reasonably able. These failures placed residents at risk of not knowing their rights and limited their access for advocacy of their rights. Findings included . <RESIDENT 3> Resident 3 discharged on 01/13/2026 from the facility. Review of Resident 3's electronic record contained no documentation to show they received a notice of transfer/discharge prior to their discharge from the facility. In an interview on 01/26/2026 at 9:16 AM Staff I, Registered Nurse, stated when a resident discharges from the facility there was a packet of information filled out and provided to them. Staff I stated the information was kept in a folder on the wall inside the nurse's station. When asked if they provided a notice of transfer/discharge to a resident at discharge, Staff I stated they had not and were not familiar with the form. <RESIDENT 58> Resident 58 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE]. Record review of Resident 58's Electronic Health Record (EHR) did not show a written notice of transfer or discharge was provided to the resident and to the Ombudsman. <RESIDENT 63> Resident 63 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE]. Record review of Resident 63's EHR did not show a written notice of transfer or discharge was provided to the resident or to the Ombudsman. In an interview on 01/26/2026 at 8:30 AM, Staff H, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated they had a packet that they would send with a resident when they transferred to the hospital. Staff H stated they did not know what a written notice of transfer or discharge was and they don't provide that to the resident when they get transferred to the hospital. Review of the documents in the transfer packet showed no copy of a written notice of transfer or discharge. In an interview on 01/26/2026 at 8:51 AM, Staff A, Administrator, stated Social Services was the primary person that filled out the written notice of transfer/discharge and that Staff A was the back up. Staff A added they don't scan the written notice in resident's EHR and a copy of the notice of transfer/discharge was kept in a binder. Staff A stated, they filled out the notice of transfer/discharge the day following the resident's discharge, in the morning meeting. Staff A, when asked was unable to provide a copy of the written notice of transfer/discharge that was given to Resident 58 and Resident 63 at discharge. In a follow up interview on 01/26/2026 at 9:30 AM Staff A provided filled out notices of transfer and discharge for Resident 58 and Resident 63 both dated 01/26/2026. Staff A stated they would be sending the notices to the Ombudsman. For Resident 58 the notice was sent 30 days after discharge and for Resident 63 the notice was sent 5 days after discharge. Refer to WAC 399-97-0120(2)(a-c) and (5)(b)(i)

Based on observation, interview and record review, the facility failed to ensure respiratory equipment and tubing were regularly cleaned and/or changed and dated for 3 of 3 sampled residents (Resident 2, 8, and 9) reviewed for respiratory care. This failure placed the residents at potential risk for respiratory distress, respiratory infection, and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration, dated 11/15/2023, documented to change oxygen tubing weekly and to store oxygen tubing in plastic bags when not in use. <RESIDENT 8> Resident 8 admitted to the facility on [DATE] with diagnoses of emphysema (a chronic and progressive obstructive lung disease resulting in reduced oxygen intake) and COPD (Chronic Obstructive Pulmonary Disease-a progressive and irreversible lung disease that restricts airflow and makes breathing difficult). In observations on 01/20/2026 at 10:59 AM and 2:13 PM, Resident 8 was receiving oxygen by nasal canula (a thin tube inserted into a person's nose to give oxygen). The nasal cannula was not dated or initialed. Observed some whitish debris in the cannula. In an observation on 01/21/2026 at 12:46 PM, Resident 8's oxygen cannula was lying on the resident's bed and was not dated or initialed. In an observation on 01/22/2026 at 10:40 AM, with Staff K, Licensed Practical Nurse (LPN), observed Resident 8's oxygen cannula lying on the resident's bed and was not dated or initialed. Review of Resident 8's January 20th through 26th, 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR), documented oxygen at two liters per minute via nasal cannula as needed for shortness of breath. There was no order to change the oxygen cannula/tubing. Review of Resident 8's care plan, copy date 01/22/2026 at 11:35 AM, documented no interventions regarding changing of oxygen cannula/tubing related to their respiratory status. <RESIDENT 9> Resident 9 admitted to the facility on [DATE] with diagnoses of emphysema and COPD. In multiple observations on 01/20/2026 at 11:18 AM, 01/21/2026 at 9:36 AM and 01/22/2026 at 9:35 AM, Resident 9 received oxygen by nasal canula. The oxygen cannula/tubing was dated 01/06/2026. In an observation on 01/22/2026 at 10:04 AM with Staff K, observed Resident 9 received oxygen by nasal cannula and the oxygen cannula/tubing was dated 01/06/2026. Observed whitish debris on the nasal cannula. Review of Resident 9's January 20th through 26th, 2026 MAR and TAR, documented oxygen at two liters per minute via nasal cannula as needed for shortness of breath. There was no order to change the oxygen cannula/tubing. Review of Resident 9's care plan, copy date 01/21/2026 at 3:44 PM, documented no interventions regarding changing of oxygen cannula/tubing related to their respiratory status. In an interview and record review on 01/22/2026 at 1:14 PM, Staff K stated per the facility policy, the oxygen cannula/tubing needed to be changed, dated and initialed weekly. Staff K stated there was no order to change oxygen cannul/tubing in the MAR/TAR. In an interview and record review on 01/22/2026 at 1:59 PM, Staff J, Resident Care Manager/ LPN, stated the oxygen cannula/tubing must be changed, dated and initialed weekly. Staff J stated an order must be obtained to change the oxygen cannula/tubing weekly and in the care plan. Staff J confirmed there was no order in the MAR/TAR and no documentation regarding changing of oxygen cannula/tubing in the care plan. In a joint interview on 01/23/2026 at 11:15 AM with Staff L, Nurse Consultant and Staff B, Director of Nursing Services, Staff B stated the oxygen cannula/tubing needed to be changed weekly and they expected an order to be placed in the MAR/TAR. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] and recently readmitted on [DATE]. Resident 2's diagnoses included pulmonary edema (fluid in the lungs causing difficulty breathing), asthma, atelectasis (air sacs in the lungs fail to inflate properly), pleural effusion (fluid builds up in the lungs), congestive heart failure (heart muscle is weak and does not pump blood efficiently causing fluid to back up into the lungs), and pulmonary hypertension (high blood pressure in the lungs). Review of Resident 2's January 2026 MAR documented physician orders for oxygen at 2 liters per minute as needed for shortness of breath, comfort, or oxygen rates lower than 90%. In an observation on 01/21/2026 at 9:13 AM, Resident 2 had an oxygen concentrator by their bed with oxygen tubing connected. The oxygen tubing had white debris on the nasal piece, the tubing was not dated and was not stored properly in a bag. Resident 2's door did not have an oxygen in use sign posted. In an observation on 01/22/2026 at 8:59 AM, Resident 2 had an oxygen concentrator by their bed with oxygen tubing connected. The oxygen tubing had white debris on the nasal piece, the tubing was not dated and was not stored properly in a bag. Resident 2's door did not have an oxygen in use sign posted. In a review of Resident 2's care plan, dated 11/11/2025, there was a respiratory focus on the care plan but it did not include oxygen care, such as changing the tubing, in the interventions. In an interview on 01/23/2026 at 10:17 AM, Staff D, LPN, stated the policy for changing oxygen tubing was once a week with a date. Staff D confirmed that changing the oxygen tubing was not an active order for Resident 2. Reference WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) Level I screening form for an exempted hospital discharge (residents who remained in the facility for more than 30 days) was submitted for a Level II evaluation for 3 of 6 residents (Resident 1, 6, and 18) reviewed. This failure placed the residents at risk of not receiving the appropriate care and services for their needs timely and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities.Findings included:In a review of the facility policy titled PASRR dated 01/01/2025 documented the facility would assure review of PASRR was done at admission. No information related to exempted hospital discharge were present in the policy. <RESIDENT 1> Resident 1 was admitted on [DATE]. Resident 1 had diagnoses to include anxiety disorder. Review of Resident 1's Level 1 PASSR dated 08/07/2025 documented the physician certified the individual is likely to require fewer than 30 days of nursing facility services. It also documented: No level 2 evaluation indicated at this time due to exempted hospital discharge: Level 2 must be completed if scheduled discharge does not occur. In an interview on 01/23/2026 at 9:16 AM, Staff C, Social Services Director stated they sent Resident 1's PASRR on 10/05/2025 for the level ll evaluation since the resident had stayed past the 30 days. Staff C acknowledged this was past the 30-day exemption timeline. <RESIDENT 18> Resident 18 was admitted to the facility on [DATE] with diagnoses to include depression and anxiety. Review of Resident 18's Level 1 PASRR dated 12/09/2025 documented the physician certified the individual is likely to require fewer than 30 days of nursing facility services. It also documented: No level 2 evaluation indicated at this time due to exempted hospital discharge: Level 2 must be completed if scheduled discharge does not occur. In a record review of Resident 18's electronic health record (EHR) there were no other PASRR forms and there was no documentation that the facility followed up regarding the resident's Level 1 PASSR. In an interview on 01/23/2026 at 9:16 AM Staff C acknowledged that Resident 18's PASSR was past the 30-day exemption timeline. They added that they don't document in the resident's EHR but had their own tracking system. <RESIDENT6> Resident 6 admitted to the facility on [DATE] with diagnoses to include anxiety, major depressive disorder, and social exclusion and rejection. Review of Resident 6's PASRR, Level 1, dated 08/11/2025 documented The individual's attending physician certifies that the individual is likely to require fewer than 30 days of nursing facility services. and No Level 2 evaluation indicated at this time due to exempted hospital discharge: Level 2 must be completed if scheduled discharge does not occur. Review of Resident 6's EHR no documentation was found to show they were referred for a Level II evaluation after remaining in the facility past 30 days. In an interview on 01/23/2026 at 9:16 AM Staff C, stated the PASRR process for the facility was to ensure there was a Level I completed prior to admission. When asked the process for when a resident admitted to the facility with a 30-day hospital discharge exemption, Staff C stated they would send the Level I to the PASRR evaluator to have a Level II completed. Staff C stated they had a tracking system, not part of the clinical record, to audit when a PASRR Level I was sent to the evaluator. When asked about Resident 6's exempted hospital discharge, Staff C stated they thought they had sent it to the evaluator on 11/1/2025, 51 days past the 30-day exemption, by email. Staff C stated they did not document in the clinical record; they maintained the information in their tracking system. Refer to WAC 388-97-1915(4)

Based on interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible and systematically organized for 1 of 1 resident (Resident 17) for dialysis and 1 of 2 residents (Resident 5) reviewed for unnecessary medications. These failures placed residents at risk for not having their medical records accurate and incorrect/incomplete information being considered when making medical decisions. Findings included . <RESIDENT 5> Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5 had diagnoses to include chronic pain syndrome and generalized anxiety syndrome. In a record review of Resident 5's physician orders included Methadone 5 milligrams (mg) 1 tablet by mouth every eight hours as needed for severe pain and Acetaminophen (pain medication to relieve mild to moderate pain) 325 mg two tablets every four hours as needed for pain. Resident 5 had as needed pain management non-pharmacological interventions to include reposition, rest, offer activity of choice, quiet environment, or other. In a review of Resident 5's Medication Administration Record (MAR), for January 1st - 21st, 2026 documented administration of two 325 mg Acetaminophen tablets on January 1st, 3rd, 4th, 5th, 6th, 12th, 13th, 14th, 16th, 17th, twice on 18th, 19th and 20th as needed for pain. Resident 5's as needed pain management non-pharmacological interventions had no documentation on any of the days when as need pain medication was administered. In a record review of Resident 5's physician orders included, Hydroxyzine 50mg by mouth every eight hours as needed for anxiety. Resident 5 had three active physician orders for non-pharmacological interventions to be used prior to administration of as needed psychotropic medications and a progress note required for results of interventions as needed. Non-pharmacological interventions included putting on favorite music, assist resident in calling a loved one, place resident near others to not feel alone, assess for comfort, offer snack, massage, make a quiet area, and to offer reassurance. In a review of Resident 5's MAR for January 1st-26th, 2026 Hydroxyzine 50 mg as need for anxiety was documented as administered on January 2nd, 3rd, 5th, 6th, twice on the 8th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th and 21st. Resident 5 had one documented as needed anxiety medication non-pharmacological interventions on January 12th. In an interview on 01/23/2026. at 9:44 AM, Resident 5 stated they had requested as needed medication for pain and anxiety. Resident 5 stated the staff had offered them some non-pharmacological interventions before administering the medication. In an interview on 01/23/2026, at 10:17 AM, Staff D, LPN stated the procedure for as needed medications included offering a non-pharmacological intervention prior to administration. Staff D was unable to locate any documentation of non-pharmacological interventions used for Resident 5. In an interview on 01/26/2026, at 12:35 PM, Staff B, Director of Nursing Services (DNS) stated Resident 5 had one documented non-pharmacological intervention on 01/12/2026 when multiple as needed pain and anxiety medications were administered from January 1 through 26, 2026. <RESIDENT 17> Resident 17 admitted to the facility on [DATE] with diagnoses to include end stage renal disease (kidneys can longer adequately filter waste products from the blood), dependent on dialysis (process of removing toxins and water from the blood). In an interview on 01/21/2026 at 9:20 AM Resident 17 stated they had received kidney dialysis for the last five years prior to admission to the facility. Review of Resident 17's Electronic Medical Record (EMR) documented they had dialysis scheduled on Tuesdays, Thursdays and Saturdays. The dialysis communication sheets directed facility staff to complete the top portion which provided information to dialysis staff, to include resident status changes since last dialysis treatment (i.e. fever, pain, nausea, vomiting, diarrhea, surgical procedures, medication changes) and any medication given for pain and/or anxiety. The bottom portion of the dialysis communication sheet directed facility staff to document blood pressure, pulse and respirations; any bleeding at the dialysis access site, check for bruit and thrill (sound heard over an artery and palpable vibration felt over a vessel). The EMR contained Dialysis Communication Sheets for Resident 17 for the following dates: 01/06/2026 return to the facility information was not complete 01/08/2026 fully completed 01/10/2026 return to the facility was not completed, a note that read VS (vital signs) taken In an interview on 01/26/2026 at 8:47 AM Staff I, Registered Nurse, stated Resident 17 was on dialysis and they send a dialysis communication sheet with the resident, fill out the top portion which contains information on vitals, dialysis fills out the middle portion, and when they return the bottom portion was filled out by the facility nurse. When asked where the completed dialysis communication sheets were located, Staff I stated they were located at the nurse's station, in a binder, that was labeled dialysis. Review of the dialysis binder, located at the nurse's station, dialysis communication sheets were found (not in the EMR) for Resident 17 for the following dates: 1/24/2026-complete 1/22/2026-complete 1/20/2026-incomplete, return to the facility information was not complete 1/17/2026-complete 1/15/2026-complete 1/13/2026-incomplete prior to and return to the facility information was not complete In an interview on 01/26/2026 at 11:08 AM Staff O, Medical Records, stated the dialysis communications are uploaded into the EMR after the nursing staff place them in their box. Staff O stated they were not aware that dialysis communication sheets were kept in a binder at the nurse's station. Reference WAC 388-97-1720(1)(a)(i)(ii)

Based on observations and interviews, the facility failed to ensure resident meals were stored in accordance with professional standards of food safety for 1 of 3 nourishment refrigerators. The failure to ensure nourishment refrigerators were free from potential contaminants left residents at risk for food contamination, food borne illnesses, and consumption of spoiled food. Findings Included .On 01/20/2026 at 1:13 PM observed the refrigerator/freezer unit in the conference room/dining room which contained the following:-the bottom left drawer of the refrigerator contained a plate covered with foil, not dated, with a name and room number. The plate had turkey (dried on the edges), potatoes, stuffing and gravy.-Rice pudding with a name and room number with an expiration date of 01/17/2026.-Plastic bag with [pizza dated 01/18/2026.A printed sign was on the door to freezer that read: items need to be labeled with date, resident name, and thrown out after 3 days. In an interview on 01/20/2026 3:19 PM Staff M, Food Preparation Worker, removed items from the refrigerator. When asked to explain the process of maintaining the refrigerator, Staff M stated checks temperatures on the thermometer and documents them on the paper taped to the side of the refrigerator for both the refrigerator and freezer. Staff M stated they removed any expired items from the refrigerator and discarded them. Staff M stated they discarded expired items from the refrigerator, sandwiches which had expired, nutritional shakes and juice (for a 14-day shelf life).On 01/20/2026 at 3:20 PM observed the bottom left drawer of the refrigerator contained a plate covered with foil, not dated, with a name and room number. The plate had turkey (dried on the edges), potatoes, stuffing and gravy.In an interview on 01/21/2026 1:54 PM Staff M entered conference room/dining room, checked temperatures and filled out the temperature log. When asked if they had found anything else to throw away, Staff M stated they had not. When Staff M was asked to look in the bottom drawers they stated they never looked in left drawer, no one is supposed to put anything in there. Staff M located the plate covered with foil, not dated, with a name and room number and discarded it in the trash. Staff M stated they would inform the dietary manager of food being placed in the left drawer.Refer to WAC 388-19-1100 (3)

Based on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 1 of 2 sampled residents (Resident 12) reviewed for dental services. This failure placed residents at increased risk for continued dental problems, difficulty chewing, associated health complications, and diminished quality of life. Findings included .Review of a facility policy titled, Dental Services, documented the facility would be assessed for dental health needs upon admission and periodically as part of routine health evaluations; the facility will provide or arrange for access dental services and assisted residents in scheduling appointments as needed. <RESIDENT 12> Resident 12 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS-an assessment tool) assessment, dated 01/02/2026, the resident was cognitively intact. In an interview and observation on 01/20/2026 at 11:34 AM, Resident 12 stated they had no teeth, and they could not use either upper or lower dentures because they were too loose to wear. Resident 12 stated they could not chew certain veggies or meat without dentures. Resident 12 stated they wanted to fix their dentures, and they would eat better if the dentures worked. The resident was observed with no natural teeth. In an interview and observation on 01/23/2026 at 3:50 PM, Resident 12 stated they could not even talk with the loose dentures on. Resident 12 put on both upper and lower dentures; observed the upper dentures just dropped and could not remain at all and the lower dentures moved when the resident was talking which caused slur speech. Resident 12 stated they mentioned to some staff in the facility that they would like to have their dentures fixed since they were admitted in June 2025. Review of admission MDS dated [DATE], coded the resident had no natural teeth. In the Care Area Assessment, there was no documentation about whether the resident had/use denture or the reasons why not use dentures or any denture care. Review of a care conference form dated 07/02/2025 at 4:20 PM, under the section of the resident needs accommodation, dentures or other dental needs was checked, but it was blank in the following comments/follow up section. Review of Resident 12's care plan initiated on 09/12/2025, documented that the resident had upper and lower dentures but did not wear them. There was no documentation of the reasons why the resident did not wear them. Review of a consulting dentist report dated 10/06/2025, showed Resident 12 had loose and ill-fitting dentures and recommended reline upper and lower dentures. The form was signed noted and dated and initialed on 10/13/2025. Review of progress notes from 10/06/2025 through 01/22/2026, no documentation was found about denture fixation arrangement. In an interview on 01/21/2026 at 2:16 PM, Staff P, Nursing Assistant Certified, stated Resident 12 did not wear dentures but they did not know why. Staff P stated they were not aware of the dentures were loose or if the resident wanted to fix the dentures. In an interview on 01/22/2026 at 1:59 PM, Staff J, Resident Care Manager/ Licensed Practice Nurse, stated Resident 12 did not wear dentures and they were not aware of the dentures were loose and the resident was seen by consulting dentist on 10/06/2025. Asked if the consulting dentist had any recommendation, Staff J stated no. In a following up interview and record review on 01/23/2026 at 3:52 PM, Staff J confirmed on the consulting dentist form dated 10/06/2025, documented Resident 12's dentures were loose and ill-fitting and the recommendation was to reline upper and lower dentures. Staff J stated they were the one signed noted on the form, dated and initialed on 10/13/2025. Staff J stated the consulting dentist provided denture fixation service and the resident's name should be on the next dentist visit's list. Staff J stated the medical record staff had the dentist to see list. In an interview on 01/23/2026 at 4:07 PM, Staff O, Medical Record, stated Resident 12's name was not on the next dentist visit list. In an interview on 01/26/2026 at 10:26 AM, Staff B, Director of Nurses, stated they were not aware that Resident 12's dentures were loose or that the resident wanted to fix their dentures; and they were not aware of the recommendation of relining the resident's dentures. Staff B stated they expected staff to arrange appointments for residents if they wanted to fix their dentures. Reference WAC 388-97-1060 (3)(j)(vii)

Based on observation, interview and record review, the facility failed to properly label and/or discard undated, opened Aplisol (solution used to test for persons with possible Tuberculosis - an infectious respiratory disease), to ensure refrigerated drugs were stored at proper temperatures, and to ensure expired medications were properly disposed of in 2 of 2 medication rooms reviewed for medication storage and labeling. The facility failed to ensure treatment carts were locked for 1 of 3 treatment carts (200 hall treatment cart). These failures placed residents at risk of receiving compromised or ineffective medications and at risk for having access to treatment supplies and medications, missing medication, and access to medication by unauthorized individuals. Findings included .<LONG TERM CARE MEDICATION ROOM>In an observation on 01/20/2026 at 11:41 AM, Staff G, Registered Nurse (RN), opened the long-term care medication room for this surveyor. Review of the medication refrigerator revealed one bottle of open Aplisol solution. The label documented that the product should be disposed of 30 days after opening but did not have an open date. Review of stocked medications showed a medication called Pure Bone Health with an expiration of 10/2025 with a resident's name written on the bottle. The medication fridge temperature log documented that temperatures should be within 36 degrees and 46 degrees and that temperatures should be checked twice daily if vaccines are present. The long-term care medication refrigerator did contain Influenza vaccines. Review of the medication fridge temperature logs documented the following: January 2026 from the 1st to the 20th, five morning temperatures and six afternoon temperatures below the accepted 36 degrees. December 2025 documented one afternoon temperature below the accepted 36 degrees and two missing afternoon temperatures. November 2025 documented 10 morning temperatures and 10 afternoon temperatures below the accepted 36 degrees and four missing morning temperatures and two missing afternoon temperatures. In an interview on 01/20/2026 at 11:41 AM, Staff G, RN confirmed no documented open date on the Aplisol solution. Staff G stated there should be an open date and to discard after 30 days per the label. Staff G stated that the expired Pure Bone Health medication was a resident's personal property and that is why it was not disposed of. In an interview on 01/20/2026 at 12:35 PM, Staff B, Director of Nursing/RN, acknowledged the out of range and missing medication room refrigerator temperatures for the months of January 2026, December 2025 and November 2025. Staff B stated their expectation is for medication room refrigerators to be checked twice daily and documented and that staff should be notifying maintenance or administration if temperatures are out of range.<REHABILITATION MEDICATION ROOM>In an observation on 01/20/2026 at 11:55 AM, Staff H, Resident Care Manager/Licensed Practical Nurse, opened the rehabilitation medication room for the surveyor. Review of stocked medications showed a Melatonin (sleeping medication) bottle with an expiration date of 12/2025.In an interview on 01/20/2026 at 11:55 AM with Staff H, confirmed expired Melatonin and removed the expired bottle for disposal. <UNLOCKED TREATM/ENT CART>In an observation 01/20/2026, at 9:45 AM, the 200-hall treatment cart was unlocked and unattended. The unlocked treatment cart contained wounds supplies (gauze, pads, dressing supplies), prescription skin creams, hemorrhoid cream, antifungal cream and Nystatin powder (prescription antifungal powder). Multiple facility staff walked by the unlocked and unattended treatment cart. In an interview at 01/20/2026 at 9:56 AM, Staff F, RN, stated they did not know why the treatment cart was left unlocked and that the expectation was for it to be locked when not in use. Staff F then locked the cart. Reference WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to ensure staff provided medications at the appropriate time for 2 of 25 medication observations, creating an 8.33 % error rate. Failure to provide medications at the correct time placed residents at risk of decreased effectiveness of medication.Findings included.Review of an undated facility policy, titled, The 5 rights of Medication Administration, documented staff were to ensure the timing of medications was appropriate, such as timing with food.During an observation on 01/21/2026 at 8:14 AM, Staff D, Licensed Practical Nurse, provided morning medications to Resident 6. The provided medications included Sucralfate (a medication that coats the lining of the stomach for protection against stomach acid) and Pantoprazole (medication that decreases stomach acid production). Resident 6 had their meal tray at the bedside and stated they had finished their breakfast.Review of Resident 6's order summary report, effective date 01/20/2026, showed an order for Sucralfate 1 gram by mouth before meals and at bedtime, and an order for Pantoprazole 40 milligrams two times a day before meals.Review of Resident 6's January 2026 medication administration records showed both Sucralfate and Pantoprazole were scheduled to be given at 7:00 AM before meals.During an interview on 01/21/2026 at 8:18 AM, Staff D stated they were aware the order was to give these two medications before meals. Refer to WAC 388-97-1060 (3)(k)(ii)

Based on observation, interview and record review, the facility failed to ensure safety assessment and monitoring were conducted and ensure consent and/or physician orders were completed prior to placing resident's bed against the wall for 1 of 2 residents (Resident 38) reviewed for accidents/falls. These failures placed residents at risk for injury and diminished quality of life. Findings included.According to the facility policy titled Devices/Enablers Policy and Procedure, undated, any device/enabler that is ordered for a resident . has been appropriately assessed . ensure that the resident and their responsible party had been fully informed of the risks versus benefits of the device/enabler and are in agreement with it and have signed an informed consent.use of the device/enabler will be appropriately care planned and added to resident's Kardex (resident specific guide outlining care needs).Resident 38 was admitted to the facility on [DATE] with diagnoses to include Guillain-Barre Syndrome (autoimmune disease that attacks nerves causing rapid weakness and tingling), Parkinsons Disease (brain disorder that makes it hard to control body movements) and Prostate Cancer. According to the admission Minimum Data Set (an assessment tool) dated 12/17/2025, the resident had moderate cognitive impairment.In an observation on 1/21/2026 at 9:37 AM, Resident 38's bed was positioned against the wall.Record review of Resident 38's electronic health record (EHR) showed no documentation of an order, consent or care plan regarding resident's bed placement against the wall.Review of the State reporting log showed Resident 38 had falls on 12/13/25, 12/17/25, 12/21/25, 12/23/25, 01/06/26 and 01/13/26.In a record review of the investigations for the falls noted above, bed against the wall was not documented as an intervention to prevent falls for Resident 38.In an interview on 1/22/2026 at 9:48 AM, Staff D, Licensed Practical Nurse (LPN) stated the bed against the wall was considered a restraint and prior to moving the bed against the wall, an order should be obtained from the provider and the resident or Power of Attorney (POA) would need to be notified. Staff D stated risks and benefits would need to be discussed, consent obtained, and the care plan updated.In an observation on 01/23/2026 at 8:55 AM, Resident 38's bed was no longer against the wall which allowed them access to get out of bed from either side. In an interview on 01/23/2026 at 1:33 PM, Staff D, LPN, stated Resident 38's bed was moved away from the wall because there was not an order to have it against the wall.In an interview on 01/23/2026 at 3:00 PM, Staff J, LPN/Resident Care Manager stated a bed against the wall was considered a restraint and they had to assess the need for the bed against the wall, obtain an order and consent from the resident or POA prior to moving the bed. Staff J stated, they moved Resident 38's bed away from the wall because there were no order or care planned to have their bed against the wall. Refer to WAC 388-97-0620(1)(a)(b)

Based on interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being for 1 of 1 residents (Resident 15) reviewed for hospice services and 2 of 3 residents (Resident 1 and 27) reviewed for diabetic care. The facility failed to ensure Resident 15's physician orders from hospice were implemented timely and ensure diabetic monitors were in place for Resident 1 and 27. These failures placed the residents at increased risk of unmet care needs and delay in care and treatment.Findings included .In a review of the facility policy titled Diabetic Management dated 11/2017 documented it was the facility's policy to ensure they properly managed episodes of hyper/hypoglycemia (high/low blood sugar levels). <RESIDENT 15> Resident 15 was admitted to the facility on [DATE] with diagnoses to include history of falling, dementia, psychotic mood disturbance and anxiety. Review of Resident 15's Electronic Medical Record (EMR) documented they admitted to hospice services on 12/31/2025. Review of Hospice Visit Notes, timestamped 01/08/2026 at 3:56 PM as received by the facility, documented Resident 15 had an order dated 12/31/2025 for Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), one tablet every two hours as needed for anxiety/dyspnea (shortness of breath). Review of Resident 15's Medication Administration Record (MAR) documented an order for Lorazepam 0.5 mg, one tablet every two hours as needed for anxiety/dyspnea with a start date of 01/13/2026, five days after the hospice orders were received. Review of Resident 15's EMR documented a consent signed by Power of Attorney (POA) for use of Lorazepam on 01/13/2026. No other information was documented in Resident 15's progress notes regarding the Lorazepam order prior to 01/13/2026. In an interview on 01/26/2026 at 8:55 AM Staff H, Licensed Practical Nurse(LPN)/Resident Care Manager (RCM) stated hospice faxed orders, and the facility would update the orders in Resident 15's clinical record and MAR. When asked about the receipt of orders from hospice for Resident 15 on 01/08/2026 and orders not placed in the MAR until 01/13/2026, Staff H stated they were awaiting consent from the POA. In an interview on 01/26/2026 at 8:59 AM Staff I, Registered Nurse, stated when hospice orders were received, they were processed as quickly as possible within a 24-hour period of time. Staff I stated it was the responsibility of the nurse on the cart to review, process, and clarify any hospice orders. <RESIDENT 1> Resident 1 was admitted to the facility 08/07/2026 with diagnoses to include type two diabetes (a condition that causes sugar to build up in the blood which leads to high blood sugar levels). Review of Resident 1's physician orders included Lantus (a hormone that lets sugar enter into the body's cells and lowers blood sugars) 14 units in the morning and to hold for blood sugar levels less than a 100. Resident 1 had orders for glucagon 0.5 mg every 15 minutes as needed for symptoms of hypoglycemia or blood sugar less than 60. Resident 1 had orders for blood sugar checks one time a day in the morning. Physician orders did not include monitors of symptoms for diabetes management including signs and symptoms of hypo/hyperglycemia. Review of Resident 1's care plan, dated 08/07/2025, did not document a focus area related to type two diabetes. Resident 1's care plan did not include goals, interventions or monitors for type two diabetes. In an interview on 01/26/2026, at 8:32 AM, Staff K, LPN stated that for a resident with diabetes there should be a care plan related to the diabetes management, including monitoring for signs and symptoms of hypo/hyperglycemia. In an interview on 01/26/2026, at 8:54 AM, Staff B, Director of Nursing Services (DNS) stated, that they would expect a resident with a diagnosis of type two diabetes to have a care plan related to their diabetes. Staff B confirmed that Resident 1's care plan did not include a focus area for their type two diabetes. Staff B stated that monitoring for hypo/hyperglycemia should be in the care plan and Kardex (summary of a resident's daily care needs used by the nursing assistant). <RESIDENT 27> Resident 27 was admitted to the facility on [DATE] with diagnoses to include type two diabetes. Review of Resident 27's physician orders included Metformin (medicine in tablet form to control blood sugar) 500 mg twice a day. Physician orders did not include blood sugar checks and monitoring signs and symptoms for hypo/hyperglycemia. In a record review of Resident 27's care plan, diabetes was included under focus however, monitoring for signs and symptoms of hypo/hyperglycemia was not included. Record review of Resident 27's MAR for November and December 2025 and 01/01/2026 through 01/26/2026 did not have monitoring for signs and symptoms of hypo/hyperglycemia. In an interview on 01/26/2026 at 8:51 AM, Staff B, stated for residents who had diabetes, the expectation was to have monitoring for signs and symptoms of hypo/hyperglycemia as an intervention and should reflect that in the care plan. Staff B reviewed Resident 27's physician orders and care plan and stated they would update the care plan and implement monitoring. Reference WAC 388-97-1060(1)(4)

Based on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Resident 17) reviewed for Pressure Ulcers (PU), were provided recommended and physician ordered interventions they required for the prevention and treatment of a PU. This failure placed residents at risk for PU development, worsening of PU, pain and a diminished quality of life.Findings included .Resident 17 admitted to the facility on [DATE] with diagnoses to include fracture of the left upper leg, diabetes mellitus type two (disorder that disrupts the way the body uses sugar), and pressure ulcer of the sacral region and right heel.On 01/21/2026 at 9:25 AM observed Resident 17 in their room, sitting upright in their wheelchair, with a heel protector boot on their left foot only and another heel protector boot sitting on a chair across from them.In an interview on 01/21/2026 at 9:25 AM Resident 17 stated they had pressure ulcers on both of their heels, with the left side being bigger than the right.On 01/23/2026 at 10:21 AM Resident 17 was observed in the hallway with therapy, upright in their wheelchair, with no heel protectors, their feet on the wheelchair footrests. Observed Resident 17's heel protectors in their room, on a chair.On 01/23/2026 at 3:01 PM observed Resident 17 lying in their bed, their feet hanging over the foot of the bed, heels not offloaded (lifted to avoid pressure to the skin), and not wearing any heel protectors on either foot. Observed Resident 17's heel protectors sitting on a chair across from their bed.On 01/26/2026 at 8:44 AM observed Resident 17 lying in their bed, their feet hanging over the foot of the bed, heels not offloaded and not wearing their heel protectors.Review of Resident 17's care plan dated 01/07/2026 documented they had multiple skin conditions to include diabetic foot ulcers, surgical incisions, and shearing to their coccyx. Interventions included encouraging Resident 17 to utilize protective skin measures.Review of Resident 17's Kardex (resident specific guide outlining care needs) dated 01/23/2026 showed the only direction for skin care/intervention was to encourage Resident 17 to utilize protective skin measures.Review of Resident 17's wound care note dated 01/13/2026 documented they had a PUs to their coccyx, right heel and multiple PU's to their left foot. Interventions for pressure relief included: being repositioned every two hours, low air loss mattress and heel offloading boots.Review of Resident 17's Medication Administration Record for 01/01/2026 through 01/22/2026 documented an order dated 01/05/2026 to offer to offload their heels when in bed to maintain skin integrity throughout each shift every shift for impaired skin integrity.In an interview on 01/26/2026 at 9:08 AM Staff I, Registered Nurse, stated Resident 17 slid down in their bed often and the aides had to reposition them by pulling them up in bed frequently. When asked about Resident 17's heel protectors, Staff I stated they were to wear them when up in their wheelchair and their heels were floated when in bed. Staff I stated when Resident 17 was up they were to wear their heel protector boots. When asked how the aides were to know how to care for a resident, Staff I stated the aides followed the resident specific care plan and Kardex.Reference WAC 388-97-1060(3)(b)

Based on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety for 1 of 1 facility kitchens, and 1 of 2-nourishment refrigerators. The failure to ensure the kitchen and nourishment refrigerators were free from potential contaminants, maintenance to ensure the kitchen refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included . On 01/29/2025 at 9:23 AM observed the following in the facility kitchen refrigerator: - applesauce in a container with a green lid-undated and not labeled - opened cottage cheese container with no open date -opened freezer jam with no open date. Observed a note on the front of the refrigerator which read, all items in the refrigerators/freezers need to have labels with item and date on them no exceptions. On 01/29/2025 at 9:23 AM observed a cabinet which contained a refrigerator labeled Fruit Bar. The lower portion of the cabinet was a refrigerator containing trays with multiple small containers containing salad dressings. Two trays marked as blue cheese, and thousand island dressing contained no date as to when they had been prepared. On 01/29/2025 at 9:23 AM observed the refrigerator located outside of the building which contained four cucumbers on the top shelf, the cucumbers were wrapped in plastic and had visible black circles on them and were mushy to touch. In an interview on 01/29/2025 at 9:50 AM Staff HH, Dietary Manager, stated all open food items in the refrigerators should be dated, if not dated they should be thrown away. Staff HH stated the cucumbers were spoiled, they were delivered about five days prior and they had thrown them away. On 01/29/2025 at 1:10 PM observed the refrigerator/freezer in the small dining room/conference room which contained snacks and sandwiches for residents. The refrigerator contained undated and unlabeled foods items which consisted of the following: -an unlabeled/undated fast-food bag with a roast beef sandwich -Egg Nog opened, with no open date -gallon of milk, opened with no open date -med pass supplement, opened dated 8-4 -coconut drink opened with no open date The freezer had a note on the front which read, no ice packs. The freezer contained an ice pack. In an interview on 02/03/2025 at 1:15 PM Staff II, Dietary Aide, stated they checked and maintained the nourishment refrigerators on a weekly basis, usually on Mondays, and cleans it out. Staff II stated the opened items in the refrigerator could only be kept for three days and then needed to be thrown out. Refer to WAC 388-19-1100 (3)

Based on observations, interviews and record review, the facility failed to review, revise and implement a comprehensive plan of care to included resident specific information for 6 of 18 sampled residents (Residents 12, 22, 34, 40, 16, & 33) reviewed for care plans. The failure to establish and implement care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs and preferences. <RESIDENT 22> Resident 22 admitted to the facility on [DATE] with diagnoses that included dementia. <WANDERING> Review of Resident 22's care plan dated 05/11/2022 showed they were at risk for wandering. Interventions for Resident 22's wandering included assessing for fall risk, ensuring needs were met, identifying a pattern of wandering, use of a wander guard and the use of the fenced patio if they were looking for sun. Review of Resident 22's Document Survey Report for 1/01/2025 through 02/05/2025 showed a single documented instance of wandering on 01/03/2025 at night. There were no documented interventions used. In an observation on 02/04/2025 at 12:31 PM, Resident 22 was using their feet and the handrail to self-propel in the hallway of the unit. Resident 22 was seen entering a room other than their own. Staff S, Nursing Assistant Certified (NAC) stated aloud that it was their second time removing the resident from another room. In an observation on 01/31/2025 at 9:33 AM Resident 22 was in their room, the room number outside their door, significantly larger than any other room, handwritten. <DEMENTIA CARE> Review of Resident 22's Care Area Assessment (CAA) for cognition/dementia, completed as part of a significant change assessment, dated 11/24/2024 showed they had cognitive impairment which had been impacted by being placed on hospice services. Additionally, a CAA was completed for communication which noted Resident 22 was heard talking to someone in their room, but no one was in the room with them. Review of Resident 22's care plan consisted of two separate plans to address their impaired cognition related to their dementia process one dated 05/11/2022 and another dated 06/02/2023. Neither care plan included person-centered information, goals or interventions regarding their dementia, dementia process, or the information found in the CAA. In an interview on 02/05/2025 at 9:26 AM Staff A, Administrator, stated they try to meet regulations associated with care plans. Staff A stated part of the care planning process included lining up diagnosis, behaviors, and interventions and reviewing them at least quarterly. Staff A stated they thought Resident 22's behavior of wandering into other rooms was new. <RESIDENT 16> Resident 16 admitted to the facility on [DATE] with diagnoses that included hypertension, history of stroke, and type two diabetes mellitus (DM- a chronic condition that affects how the body uses sugar for energy). In an observation on 01/29/2025 at 2:06 PM observed a green wedge on the shelving unit in Resident 16's room, across from the foot of their bed. When asked what the purpose of the green wedge was, Resident 16 stated it was used to position under them to take pressure off. Review of Resident 16's care plan dated 07/04/2024 showed they were at risk for skin impairment related to their multiple diagnoses. The goal was for Resident 16 to be cooperative with position changes. Interventions included repositioning, use of ointments, use of an air mattress, and green open heel pressure relieving boots while in bed. There was no intervention for the use of a green positioning wedge. Review of Resident 16's progress notes, dated 11/22/2024, showed resident was resistant to change positions while in bed, wanted to lie on their back to watch television. In an interview on 02/05/2025 at 11:05 AM Staff W, Licensed Practical Nurse (LPN), stated Resident 16 did not like to stay repositioned on their side and would return to lying on their back, but had used wedges. Staff W did not know the care plan lacked the interventions currently being utilized with the wedges and Resident 16's resistance and would update it. <RESIDENT 40> Resident 40 admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses that included DM, chronic obstructive pulmonary disease (group of lung diseases that restrict breathing), and high blood pressure. <BATHING/SHOWER> In an interview on 01/29/2025 at 11:14 AM Resident 40 stated they had not had a shower they thought since before they broke their leg, had a bed bath in their chair, and was due for a shower. In an observation on 01/29/2025 at 11:14 AM Resident 40's lower dentures were observed to be in a candy dish, covered by three black licorice sticks, not stored in a container, and were covered in small pieces of green matter. Review of Resident 40's care plan dated 03/13/2024 showed they had a deficit in their ability to perform activities of daily living. Interventions included to provide resident a bath/shower, to avoid scrubbing, and to pat dry sensitive skin. There was no person-centered interventions and no resident preferences for when or how they preferred to be bathed. <UNNECESSARY MEDICATIONS> Review of Resident 40's January 2025 Medication Administration Record (MAR) showed they were taking antibiotics prophetically for a urinary tract infection, insulin (medication used to treat DM), and pain medication. Review of Resident 40's care plan dated 03/14/2024 showed no care plan related to antibiotic use or insulin use. The care plan showed Resident 40 was at risk of pain related to their chronic medical condition however there were not any non-pharmacological interventions. In an interview on 02/05/2025 at 9:26 AM Staff A, Administrator, stated they try to meet regulation associated with care plans. Staff A stated part of the care planning process included lining up diagnosis, behaviors, and interventions and reviewing them at least quarterly. 50725 <RESIDENT 33> Resident 33 admitted to the facility on [DATE] with diagnoses to include Cholecystitis (inflammation of the gallbladder) with a cholecystostomy drain tube (a thin, flexible tube inserted into the gallbladder to drain bile and infected fluid) and dementia. According to the admission Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], the resident had severely impaired cognition. <FEEDING/NUTRITION> In an observation on 01/31/2025 at 8:44 AM, Resident 33 was in bed eating alone, no staff were present in the room. The head of the bed was elevated, and the resident was leaning toward their right side while trying to reach for the food to eat. A staff member entered the room and asked the resident if they liked the eggs. The staff left and ten minutes later went in to take the tray from the resident's room. Observation of the resident's meal tray showed the food appeared untouched. In an interview on 01/31/2025 at 9:10 AM, Staff D, NAC, stated that Resident 33 feeds themself but their condition had been declining and does not eat much. Staff D stated occasionally they assist the resident with eating when they are weaker. Review of Resident 33's care plan, with a print date of 1/30/2025, showed there were no mention on how the resident eats and if they required assistance in feeding themselves. In an observation and interview on 02/03/2025 at 8:47 AM, Staff AA, NAC, was sitting beside Resident 33 in the hallway encouraging the resident to eat some more food. When Staff AA took the tray, they stated that resident only ate about 25%. Staff AA stated it was Resident 33's normal intake. Review of Resident 33's weight record, print date 02/05/2025, showed the resident's weight on 01/11/2025 was 110.2 pounds (lbs.) and their weight on 01/30/2025 was 96.8 lbs. A difference of 13.4 lbs. in less than a month. In an interview on 02/05/2025 at 12:59 PM, Staff G, LPN/Resident Care Manager (RCM) stated that Resident 33 was a one-to-one feed (one staff to feed resident during mealtimes) since admission. When asked how the staff would know that Resident 33 was a one-to-one feed, Staff G stated through shift reports and in the Kardex (a summary of resident's information regarding the care they need based on the care plan). Staff G reviewed the Kardex for the resident but stated that the one-to-one feed was not listed. Staff G stated they were unsure why it was not on the Kardex and they would add that information. <MOBILITY> Review of Resident 33's care plan on 02/03/2025 showed the resident was on a Restorative Program (nursing interventions that promote the resident's ability to adapt ad adjust to living as independently and safely as possible). In an interview on 02/04/2025 at 12:55 PM, Staff H, Restorative Aid stated that Resident 33 was not on Restorative Program. In an interview on 02/04/2025 at 1:15 PM, Staff G stated that Resident 33 was not on a Restorative Program, they stated that when the resident was admitted , they reactivated their old care plan from the past admission and did not update it. 51312 <RESIDENT 12> Resident 12 was a long-term care resident at this facility. According to the MDS dated [DATE], the Resident is severely cognitively impaired and required extensive assistance with turning and repositioning in bed. Review of Resident 12's care plan, print date of 01/29/2025, showed the resident should be turned side to side with pillows. In an multiple observations on 01/31/2025 at 8:36 AM, 9:58 AM, 11:20 AM, 12:00 PM, 1:56 PM Resident 12 was observed in bed on their back with their legs slightly elevated. The head of the bed was at a 45-degree angle. In observations on 01/31/2025 at 3:17 PM and 4:37 PM, Resident 12 was observed lying on their left side in bed. The head of bed was at a 45-degree angle. During an interview on 02/03/2025 at 11:03 AM, Staff GG, RN stated that Resident 12 should be repositioned every two hours and that the nursing staff should alert the Nursing Assistants. Staff GG noted that they had repositioned the resident by lifting the head of the bed. During an interview on 02/03/2025 at 1:37 PM, Staff D stated when residents are dependent, they should be repositioned every two hours Staff D stated that NACs should look at the care plan, and they would also be told in report that residents should be turned every two hours. During a subsequent interview on 02/03/2025 at 1:48 PM, Staff GG stated that dependent residents should be repositioned every two hours. During an interview on 2/3/2025 at 2:15 PM, Staff B, Director Nursing Services (DNS), stated that residents who are dependent should be turned and reposited every two hours and that information should be on the care plan. Staff B stated that Resident 12 should be repositioned every two hours. <RESIDENT 34> Resident 34 was admitted to the facility on [DATE]. According to the MDS dated [DATE], the resident had severe cognitive impairment and required extensive assistance with all ADLs. Review of Resident 34's care plan, with a print date of 1/29/2025, showed the resident should always have their heels floated while in bed. In multiple observations on 01/31/2025 at 8:30 AM, 10:02 AM, 11:28 AM, 11:59 AM, 3:22 PM, 4:39 PM, Resident 34 was observed in bed, lying on their back, and their heels were not floated. During an interview/observation on 02/093/2025 at 1:37 PM, Staff D was in Resident 34's room and was asked to look at their heels; they stated Resident 34's heels were not being floated, but they should be. During an interview on 02/03/2025 at 2:15 PM, Staff B stated NACs should be turning/repositioning Resident 34 every two hours, Staff B stated that information should be in the care plan. Staff B was not sure about their heels being floated. Review of Resident 34's care plan, print date of 1/29/2025, showed that the activity interventions included group activities, introduction to other residents, and invitation to scheduled activities. During an interview on 02/03/2025 at 1:37 PM, Staff D stated that Resident 34 dislikes eating in the dining room; they get agitated around big groups of people. Staff D then answered that Resident 34 likes to watch sports on TV, but they were unsure what other activities the resident enjoyed. During an interview on 02/03/2025 at 2:15 PM, Staff B stated that they were unsure what activities Resident 34 enjoyed and that information should be on the care plan. In an interview on 2/3/2025 at 4:17 PM, Staff FF, Activities Director, stated that Resident 34 does not like group activities and gets agitated. Staff FF then stated that Resident 34's activities are 1:1 with staff members 2-3 times a week and that nothing on their care plan reflects their choices. Refer to WAC 388-97-1020 (1), (2)(a)(e)(f)

Based on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, and included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 5 of 16 residents (Residents 1, 12, 16, 22, and 32) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1, dated October 2024, showed the Care Area Assessment process reflects conditions, symptoms, and other areas of concern that are common in nursing home residents. The CAA process provides for further assessment of the triggered areas by guiding staff to look for causal or confounding factors, some of which may be reversible and obtaining input from the resident and/or family. It is important that the CAA documentation include the causal or unique risk factors for decline or lack of improvement. <RESIDENT 1> Resident 1 admitted on [DATE]. Review of the significant Minimum Data Set (MDS-an assessment tool) assessment, dated 01/22/2025, showed the psychotropic drug use CAA did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's care plan was needed. In an interview on 02/03/2025 at 11:23 AM, Staff N, Licensed Practical Nurse (LPN)/MDS Coordinator stated the psychotropic CAA should be completed with a summary and they were not sure why the CAA was not completed for Resident 1. Staff N stated social services had taken over the responsibility for psychotropic medication reviews as well. In an interview on 02/03/2025 at 1:39 PM, Staff F, Social Service Director, stated they were not responsible for completing the psychotropic medication CAA's. In an interview on 02/04/2025 at 9:23 AM, Staff B, Director of Nursing, stated social services was responsible for parts of the MDS assessment and the MDS Coordinator needed to check and make sure all CAAs were completed. Staff B stated they expected the triggered CAAs should be filled out and completed. 47047 <RESIDENT 16> Resident 16 admitted to the facility on [DATE] with diagnoses that included stroke, and diabetes (a chronic condition that affects how the body uses sugar for energy). Review of Resident 16's significant change MDS assessment, dated 09/25/2024, showed the pressure ulcer/injury CAA did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's care plan was needed. In an interview on 02/05/2025 at 11:05 AM Staff N, stated they typically complete CAA's and the care plan review right after submitting and finalizing the MDS. Staff N described gathering information to complete the MDS solely through review of the resident's medical records with some sections left for social services to complete. <RESIDENT 22> Resident 22 admitted to the facility on [DATE] with diagnoses that included dementia. Review of Resident 22's significant change MDS assessment, dated 11/13/2024, showed the cognition/dementia and communication CAA did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's care plan was needed. In an interview on 02/05/2025 at 11:05 AM Staff N, stated they typically complete CAA's and the care plan review right after submitting and finalizing the MDS. Staff N described gathering information to complete the MDS solely through review of the resident's medical records with some sections left for social services to complete. 51312 <RESIDENT 32> Resident 32 was a long-term care resident of the facility. A review of Resident 32's significant change MDS assessment, dated 03/27/2024, showed the Resident was severely cognitively impaired, and had communication issues due to difficulty hearing. Review also showed that the communication CAA did not contain comprehensive summaries or analyses that included the resident's current goals, preferences, strengths, or needs for the specific care areas, which were necessary to determine whether updates to the resident's care plan were needed. In an interview on 1/29/2025 at 1:32 PM, Resident 32 could not hear questions without loud and significant voice raising. In an interview on 2/3/2025 at 2:15 PM, Staff B stated that when they speak to Resident 32, the resident understands if they talk loudly, but Resident 32 should be assessed for a whiteboard or another way to communicate. In an interview on 2/3/2025 at 2:20 PM, Staff N, indicated that Resident 32's hearing CAAs were completed, and that Staff N was only required to fill out the first and last portion of the worksheet. <RESIDENT 12> Resident 12 was a long-term care resident of the facility. Review of Resident 12's significant change MDS assessment, dated 10/04/2024, showed the pressure ulcer/injury CAA did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, strengths, or needs for the specific care areas, which were necessary to determine if updates to the resident's care plan were required. During record review of a document titled 'Brayden Scale' (a scale that indicates a risk of pressure ulcers) with a print date of 1/29/2025 indicated that Resident 12 was at high risk for pressure ulcer injury. In an interview on 2/3/2025 at 2:20 PM, Staff N stated that they needed to complete the last area of the CAA worksheet. Staff N stated they had a paragraph written for them to copy and paste into that box. Staff N stated they were unaware that other areas needed to be addressed. Reference: (WAC) 388-97-1000 (b)(c)(ii)(2)

Based on observation, interview and record review, the facility failed to ensure 5 of 7 resident's (Resident 13, 19, 20, 40, and 260) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. This failure placed all residents at increased risk of unmet care needs, medical complications and decreased quality of life. Findings included . Review of the facility Policy titled Notification of Change in Condition dated 08/30/2024 showed the facility shall promptly notify the resident, their provider, and primary contact of changes in the resident's condition and/or status. The care provider would be notified by the nurse when necessary or appropriate in the best interests of the resident. <RESIDENT 13> <WEIGHTS> Resident 13 admitted to the facility on [DATE]. Admitting diagnoses to include Congestive Heart Failure (CHF - a chronic condition in which the heart does not pump blood as well as it should), Peripheral Artery Disease (PAD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Right foot toe ulcers - between second and third toes. Review of Resident 13's order summary print date 01/30/2025 showed an order for daily weights (wt.) - notify provider if weight up 3 pounds (lbs.) in one day or up to 5 lbs. in three days one time a day for CHF. Review of Resident 13's Medication Administration Record (MAR) dated January 2025 showed the following weights: - 01/04/2025- 167.2 lbs. - 01/05/2025- 166.9 lbs. - 01/06/2025- 170 lbs., increase of 3.1 lbs. in one day - 01/16/2025- no weight was recorded - 01/20/2025- 168.8 lbs. - 01/21/2025- 173 lbs., increase of 3.2 lbs. in one day - 01/24/2025- no weight was recorded - 01/30/2025- 173.6 lbs. - 01/31/2025- no weight was recorded Review of Resident 13's February 2025 MAR showed the following weights: - 02/01/2025- 174 lbs. - 02/02/2025- 181.1 lbs., increase of 7.1 lbs. in one day Review if Resident 13's progress note for January 2025 showed no notes that the physician had ben notified of the residents wt. gains on 01/06/2025 and 01/21/2025. Review of Resident 13's progress note for February 2025 showed no notes that the physician was notified of the resident's wt. gain on 02/02/2025. Review of Resident 13's progress note dated 01/24/2025, Staff T, Registered Dietician (RD) documented the resident had a wt. gain of 7 lbs. in the past week and recommended re-weigh, check for increased edema and notify provider if confirmed. There were no notes in resident's chart that staff followed up on the wt. gain and that they notified the doctor. Review of Resident 13's February 2025 MAR showed on 02/01/2024, resident's wt. was 174 lbs. and on 02/02/2025 resident's wt. was 181.1 lbs., that's 7.1 lbs. wt. gain in one day. There were no notes in the progress notes that the doctor was notified of the weight gain on 02/02/2025. Record review of Resident 13's progress note showed, on 02/03 2025 at 2:41 PM, Staff U, Registered Nurse (RN) charted that resident was using accessory muscles to breath and with audible wheezing. Oxygen Saturation (O2 sat - refers to the percentage of oxygen carried by red blood cells in the bloodstream) read 83% on room air, resident required 4 liters (l) of oxygen via nasal cannula. They notified the doctor with order for chest x-ray and antibiotics immediately. On 02/03/2025 at 4:02 PM, Staff V, Licensed Practical Nurse (LPN) charted that resident's wt. on 02/01/2024 was 174 and wt. on 02/03/2025 was 182.6 lbs. Resident had noted edema to extremity, and wet moist cough. Provider was notified of the wt. gain with order to continue to monitor resident. Further review of the progress note showed Resident 13 was having a hard time breathing with O2 sat of 82-85% with 3-5 l of oxygen. Resident was sent to the emergency room and was admitted to the hospital. Review of Emergency Department note dated 02/04/2025 stated that Resident 13's chief complaint was shortness of breath. In the medical decision making note it stated that chest x-ray looked more like pneumonia and possible fluid overload, that they have been holding on fluids due to concerns for pulmonary edema (a condition caused by excess fluid in the lungs). They will continue to hold fluids and had given Lasix (also called water pill, used to treat fluid retention and swelling caused by CHF) instead due to the patient was fluid overloaded and extra fluids will be detrimental to the patient. In an interview on 02/03/2025 at 3:48 PM, Staff G, LPN/Resident Care Manager (RCM) stated that the provider notification for wt. changes should be documented in the progress note. The providers were notified via telephone call, messaging in Point Click Care (program facility uses for electronic charting), faxing or leaving a note in the provider's bin. The doctor comes in once a week and the Advance Registered Nurse Practitioner (ARNP) comes in more often. Staff G went to the provider's bin but did not see any notes regarding wt. They stated if they were the one working on a cart and saw the wt. gain, they would notify the doctor and document in the progress note. Staff G stated they don't micromanage their staff and they expected the staff to notify the provider and document in the progress note. In an interview on 02/04/2025 at 3:00 PM, Collateral Contact 1 (CC1), Medical Director stated they were familiar with Resident 13. They stated that they were notified of wt. gain last Monday (02/03/2025). CC1 reviewed the resident's wt. trends for Januar and they stated that they had only started talking about resident's wt. gain last weekend (02/01/2025 or 02/02/2025. <HEEL BOOTS> According to Resident 13's admission Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], resident had mildly impaired cognition. Skin assessment showed three venous/arterial ulcer with treatment. In an observation on 01/29/2025 at 3:58 PM, Resident 13 was observed in bed wearing non-skid socks. Resident was not wearing heel boots. Review of Resident 13's order summary print date 01/30/2025 showed: Heel boots on while in bed three times a day for skin. Review of Resident 13's care plan and there was no care plan regarding the heel boots. Review of Resident 13's January 2025 Treatment Administration Record (TAR) showed the following treatment: Heel boots on while in bed three times a day for skin. Licensed nurses initialed and placed a check mark (administered) for every shift. In an observation and interview on 01/31/2025 at 9:02 AM, entered Resident 13's room and observed the heel boots on the table close to the foot of the bed, Resident 13 stated that they used to wear boots in the hospital but does not think they need it anymore. In an observation on 01/31/2025 at 9:02 AM, Staff I, LPN attempted to put the boots on Resident 13, but resident declined and stated they have not worn them for two weeks and does not want to wear them. Review of Resident 13's January 2025 TAR print date 02/05/2025 showed Staff I, LPN initialed and placed a check mark (indicating this order was complete) on the heel boots order for the shift they worked on 1/31/2025, when the resident had actually refused to wear the heel boots. Review Resident 13's progress notes, print date 02/05/2025, showed there were no documentation regarding the boots or any refusals from the resident. In an interview on 02/04/2025 at 1:00 PM, Staff G stated that if Resident 13 refuse to wear the boots, the nurse should document that in the progress note. 47047 <RESIDENT 19> Resident 19 admitted to the facility on [DATE] with diagnoses that included vascular dementia (brain damage caused by multiple strokes), heart failure, and hearing loss. In an interview on 01/30/2025 at 10:17 AM Staff CC, Nursing Assistant Certified (NAC) stated Resident 19 has had a change in condition related to a recent viral infection and required additional assistance with eating their meals. Review of Resident 19's care plan dated 07/05/2022 showed they were able to feed themselves after set up and to encourage them to eat . Review of a progress note dated 01/28/2025 at 6:51 AM showed Resident 19 had a status change exhibited by being slow to respond, staring into space, and left hand shaking mildly. Review of a progress note dated 01/28/2025 at 7:08 AM showed speech language pathology (SLP) was being requested by the nurse and in the meantime Resident 19 would be assisted with meals. Review of Resident 19's clinical record showed a message dated 01/28/2025 that was sent to their provider informing them of the resident's slow decline and diet downgrade with a request for SLP to assess them. Review of Resident 19's clinical record showed a message dated 01/28/2025 where the resident's provider responded to the message and agreed with SLP evaluation and deferred to another provider for assessment. Review of a progress note dated 01/29/2025 at 11:00 PM showed Resident 19's diet was downgraded to mechanical soft, required one to one assistance with eating/feeding, and liquids were changed to nectar thick consistency. Review of a progress note dated 02/03/2025 at 2:42 PM showed Resident 19 was pocketing their food (storing food inside the mouth without swallowing) at lunchtime. Review of Resident 19's SLP screening assessment form dated 01/29/2025 showed nursing had recommended a screen. There was a check mark in swallowing as the problem area and comments noted no issues and no interventions indicated. In an interview on 02/05/2025 at 10:28 AM Staff BB, Therapy Manager stated a SLP screen was completed for Resident 19 and not an evaluation. Staff BB stated they share the results of the screen in an interdisciplinary team meeting following the outcome of the screen. Staff BB stated they must find out the concerns first before an evaluation. Staff BB stated Resident 19 had no concerns the day of the screen and had no additional concerns noted by nursing staff since the screen and thus an evaluation not indicated. <RESIDENT 260> Resident 260 admitted to the facility on [DATE] with diagnoses that included hip fracture, insomnia (sleep disorder), and history of falling. On 01/31/2025 at 8:47 AM observed Staff D, NAC, tell Staff I, LPN that Resident 260 was asking about their sleep medication, Ambien, and wanted to know if it was out. Staff I responded to Staff D, stated it was a medication used at night, did not know, and would look into it. In a review of Resident 260's January 2025 MAR showed they had an order for Zolpidem Tartrate (Ambien) 5mg, one tablet by mouth as needed for insomnia at bedtime. Review of Resident 260's care plan dated 01/24/2025 showed they were taking Zolpidem for insomnia. Interventions included administering the medication (Zolpidem) as ordered by the physician. Review of Resident 260's progress notes dated 01/30/2025 and 01/31/2025 showed no indication the provider was notified of Ambien not being available. In an interview on 01/31/2025 at 2:10 PM Resident 260 stated they do not sleep very well, had been taking Ambien for the last year. Resident 260 stated that they had slept poorly the night before related to not having the Ambien. Resident 260 stated they had just spoken to the doctor, and they had not ordered it, but the nurses had been giving it to me the whole time. Resident 260 stated the nurse on duty last night had given them another medication, like Tylenol, but it was not effective. In a joint interview on 01/31/2025 at 2:14 PM Staff G stated Resident 260 had admitted with an order for Ambien. Staff I stated there was a pharmacy issue last night and they did not deliver the prescription. Staff G stated the provider should be notified if a medication was not available and they had not read a progress note about the medication not being available. Staff G stated they did not know what had happened because they do not work nights and planned to place a call to the pharmacy. No other information was provided. <RESIDENT 40> Resident 40 admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses that included diabetes type two (a chronic condition that affects how the body uses sugar for energy), chronic obstructive pulmonary disease (group of lung diseases that restrict breathing), and high blood pressure. In an interview on 01/31/2025 at 10:45 AM Resident 40 stated they did not feel good and had been having diarrhea and would not be able to participate in an assessment to have their recliner placed back in their room. In a review of Resident 40's January 2025 MAR showed the resident had an order for a routine stool softer daily, Senna-Docusate Sodium 8.6-50 milligrams (mg) for constipation ordered on 01/07/2025. Resident 40 also had an order for Imodium A-D, 2 mg every eight hours as needed for loose stools. Resident 40 had received daily stool softener, but no Imodium was given. Review of Resident 40's January 2025 Document V2 Report (resident specific report) showed they had loose stools consistently throughout the month. In an interview on 01/31/2025 at 11:04 AM Staff S, NAC, stated Resident 40 had reported three instances of diarrhea that morning. In an interview on 01/31/2025 at 11:23 AM Collateral Contact 2 (CC 2-Resident 40's Family Member) stated they had asked nursing to stop the use of Senna multiple times due to Resident 40's ongoing diarrhea. In an interview on 02/03/2025 at 2:47 PM Staff B, Director of Nursing Services, stated they expected nursing staff to review the MAR when a resident had complaints of loose stools, check prescribed bowel medications, hold the medications if indicated, and contact the provider. 51551 <RESIDENT 20> Resident 20 readmitted to the facility on [DATE] with diagnoses to include urinary tract infection. Review of the hospital discharge summary dated 11/04/2024, showed Resident 20 needed to follow up with the infectious disease doctor in two weeks. Review of a progress note dated 12/11/2024 at 2:01 PM, showed Resident 20 was scheduled a follow up infectious disease telehealth appointment on 01/08/2025 at 1:30PM. Review of Resident 20's Electronic Medical Record, showed there was no documentation of having an infectious disease doctor follow up visit. In an interview on 02/03/2025 at 12:56 PM, Staff K, Licensed Practice Nurse/Infection Preventive Nurse, stated they were not sure if Resident 20 was scheduled or attended the infection disease doctor follop up visits and not sure where the documentation from the infectious disease doctor was. In an interview on 02/03/2025 at 2:20 PM, Staff K stated they could not find any documentation of the infectious disease follow up appointment and they were requesting documentation from the clinic and waiting for the notes. In an interview and record review on 02/03/2025 at 4:48 PM, Staff K provided a fax document that had been received on 02/03/2025 at 4:26 PM of the infectious disease clinic note from 11/13/2024. The infectious disease clinic documentation showed Resident 20 needed another infectious disease follow up visit in four weeks. Staff K stated they could not find documentation of the four week follow up with the infectious disease doctor. Staff K stated they expected the resident care manager to follow up with clinic visits and take care of any orders. Review of a progress note dated 02/03/2025 at 5:03 PM, showed Staff K called infectious disease and requested the clinic to fax the documentation of follow up visit on 01/08/2025. In an interview on 02/04/2025 at 3:24 PM, Staff B, Director of Nursing, stated they expected the nurse to follow up on any changes from appointments on the same day or the next morning. Staff B stated they expected the nurse to document any attempts to contact the clinic if the resident did not bring back any documentation and escalate to the resident care manager if they could not get the appointment visit notes. Staff B stated not getting Resident 20's appointment notes from November 2024 until January 2025 was too long and they should get the visit notes sooner in order to follow up any changes or physician orders. Refer to WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure that staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 4 hallways with Enhanced Barrier Precautions (EBP), 1 of 1 observations for wound care (Resident 33), 1 of 3 residents observed during personal care (Resident 13) and 1 of 1 housekeeping staff observed for hand hygiene. The facility failed to ensure that staff used the Personal Protective Equipment ([PPE] - specialized clothing worn to protect from infection or illness) during high contact resident care activities and failed to perform proper hand hygiene. These failures placed all residents and staff at risk for the potential transmission of infections. The facility was currently in a gastrointestinal virus outbreak. Findings included . Review of a facility policy titled, Enhance Barrier Precautions, dated 10/03/2022 showed - EBP to be implemented for residents with wounds, indwelling medical devices, or residents infected with drug resistant organisms. - Hand hygiene to be performed when entering the room and when exiting the room. - PPE to be used during high contact resident care activities such as toileting, transferring, and use of enteral tube (tube inserted into stomach used for medications and formula). Review of recommendations from the Centers of Disease Control website, Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), showed a strong recommendation to maintain unobstructive urine flow to not rest the catheter bag (a urine collection bag attached to the catheter) on the floor. Review of an undated facility policy titled, Hand Hygiene, showed hand hygiene was required after removing gloves. <PERSONAL CARE> Resident 33 was admitted on [DATE] with a cholecystostomy tube (a thin, flexible tube inserted into the gallbladder to drain fluid and relieve pressure). In an observation and interview on 01/29/2025 at 3:53 PM, Staff J, Nursing Assistant Certified (NAC), provided peri-care (the practice of washing the genital and anal area) to resident 33 after applying gloves but did not apply a gown prior to performing this high contact activity. Staff J removed gloves and applied a new pair without doing hand hygiene. Staff J stated they did not do hand hygiene prior to putting on new gloves, as it will take ten minutes to dry their hands. <WOUND CARE> Resident 13 admitted on [DATE] with a multi drug resistant bacteria in their lungs and a wound to right foot. In an observation and interview on 01/31/2025 at 12:13 PM, Staff I, LPN, placed wound care supplies on the overbed table. The overbed table was not covered and beside the wound care supplies were Resident 33's TV remote and drinking water container. Observed Staff I with mask and gloves, no gown. They took the old gauze between the big toe and second toe in the right foot and used saline and q tip to cleanse the wound, with the same glove, they reached over the package of 4x4 and dried the wound. With the same gloves, Staff I opened an individually wrapped 4x4 and placed the gauze between the first and second toe. Using the same gloves, Staff I took the old dressing on the right outer malleolus, cleansed the wound with saline and using the same gloves reached over to the 4x4 package to dry the wound. Still with the same glove, applied new Opti foam dressing. Staff I then moved to the other side of the bed and with the same gloves, took the old dressing on the left outer malleolus, cleansed the wound with saline reached over the 4x4 gauze package and dried the wound. Using the same glove Staff I, covered the wound with Opti foam dressing. Staff I then took gloves off, covered resident and washed hands. They then took the package of 4x4 gauze and the box of gloves and put them in the treatment cart. When I asked Staff I when were they supposed to change gloves, they stated if their gloves were soiled or if they go from one area of the body to another, such as when they go from the buttocks to another area of the body. They stated since they were doing the feet of the resident and did not go to another area of the body, they did not have to change their gloves. <ENHANCED BARRIER PRECAUTION> <BLUE RECTANGLE> During an interview on 01/30/2025 at 8:00 AM, Staff Y, NAC, stated the blue rectangle on the door jamb for room [ROOM NUMBER] meant the resident in the room required two person assist with care, and the blue rectangle with a flower on the door jamb of room [ROOM NUMBER] meant that resident required two person assist because of behaviors. During an interview on 01/30/2025 at 8:20 AM, Staff S, NAC, stated the blue rectangle on the door jamb to room [ROOM NUMBER] meant the resident was a fall risk. <Resident 12> Resident 12 was a long-term care resident at this facility. According to the MDS dated [DATE], the Resident is severely cognitively impaired and required gastrostomy tube (a tube used to provide nutrition directly into the stomach) for nutrition. During an observation on 02/03/2025 at 9:21 AM, Staff GG entered Resident 12's room, did not perform hand hygiene, then proceeded to lift the resident's bedspread, touched the mattress next to the resident, and adjusted the air mattress controls without donning Personal Protective Equipment (PPE). In an interview on 02/03/2025 at 11:03 PM, Staff GG replied that Resident 12 is not on precautions; the PPE supplies in Resident 12's room were from hospice. Staff GG answered that hand washing should be done before everything, touching residents when they enter or leave the room, and removing their gloves. In an interview on 02/03/2025 at 2:10 PM, Staff Z, NAC, replied that Resident 12 is on precautions due to his gastrostomy tube. <RESIDENT 13> Resident 13 admitted on [DATE] with a multi drug resistant bacteria in their lungs. In an observation on 01/31/2025 at 8:43 AM, Resident 13's room did not show any signs that resident was on any transmission based precautions. In a record review on 01/31/2025, Resident 13's physician's orders showed Enhanced Barrier Precautions (EBP) related to history of respiratory MRSA (drug resistant staff aureus/bacteria) dated 01/07/2025. In an interview on 01/31/2025 at 2:04 PM, Staff I, LPN, stated Resident 13 was not on EBP because it was a history of MRSA and resident was not coughing. In an interview on 02/03/2025 at 12:56 PM, Staff K, LPN/Infection Preventionist (IP) Nurse, stated that residents who were on EBP will have a blue rectangular magnet placed by the resident's door frame and inside the room will have the PPE cart with sign that showed EBP. Staff K confirmed that Resident 33 should have been on EBP. Staff K stated that there was a miscommunication between them and the Resident Care Manager. 51551 <CATHETER CARE> Resident 36 admitted to the facility on [DATE]. In an observation on 01/29/2025 at 1:50 PM, Resident 36 was sitting at the edge of the bed. Their catheter bag was attached to the trash bin with the bottom of the catheter bag was touching the floor. In an observation on 01/30/2025 at 9:19 AM, Resident 36's catheter bag was hanging at the edge of trash bin and the catheter bag was inside the trash bin. The bottom of the bag was touching the garbage. In an observation on 01/30/2025 at 2:25 PM, Resident 36's catheter bag was hanging on the edge of the outside of trash bin with the bottom touching the floor. In an observation on 01/31/2025 at 8:22 AM, Resident 36's catheter bag was inside the trash bin at the bedside lying on top of garbage. In an observation and interview on 01/31/2025 at 10:01 AM, Resident 36's catheter bag was lying on the floor in the bathroom. Staff P, Certified Nurse Assistant, stated they were not sure why the catheter bag was on the floor and the catheter bag was not supposed to touch the floor. In an observation and interview on 01/31/2025 at 11:14 AM, observed Resident 36's catheter bag attached to the trash bin with the bottom touching the floor. Staff K, Licensed Practice Nurse/Infection Preventive Nurse, stated the catheter bag should not be hanging on the trash bin. Staff K stated the catheter bag, the tubing and the bottom should not touch the floor or garbage. Staff K stated it was infection risk and needed to be corrected. <HAND HYGIENE> In an observation and interview on 01/31/2025 at 11:18 AM, observed Staff R, Housekeeper took off the dirty gloves and put on clean gloves without hand hygiene between glove changes. Staff R stated their usual practice was not to perform hand hygiene between gloves change. In an interview on 01/31/2025 at 11:32 AM, Staff K stated they expected staff to perform hand hygiene before and after changing gloves. 42927 <ENTERIC CONTACT PRECAUTION> During an observation on 01/29/2025 at 12:07 PM, Staff GG, Registered Nurse, applied a gown and gloves and entered room [ROOM NUMBER]. A sign outside the doorway of room [ROOM NUMBER] showed Enteric Contact Precautions. The sign showed to apply a gown and gloves prior to entering the room, wash hands with soap and water when leaving room and to clean and disinfect equipment before leaving room. Outside the door was a plastic cart with drawers that had disposable gloves and gowns inside. During an observation on 01/29/2025 at 12:13 PM, Staff GG was observed standing at sink just inside room [ROOM NUMBER]. Staff GG removed their gloves and was noted to be holding a blue inhaler (device to deliver medication to lungs by taking a breath) in their bare hands. Staff GG was still wearing a gown but had not done hand hygiene. Staff GG walked to doorway of room and placed the inhaler on top of the plastic bin, which then fell into the open drawer that had disposable gowns inside. Staff GG then removed the disposable gown they had been wearing and discarded in the garbage can. Staff GG exited the room and used hand sanitizer on hands. Staff GG did not use soap and water for hand hygiene as the enteric contact precaution sign stated. During an interview on 01/29/2025 at 12:20 PM, Staff GG reviewed the enteric contact precaution sign with surveyor. Staff GG stated that they had used hand sanitizer instead of washing their hands when leaving room [ROOM NUMBER] and that they did not disinfect the inhaler before leaving the room. Staff GG stated the gowns inside the plastic bin were contaminated since the inhaler had fallen on top of them. 51312 Refer to WAC 388-97-1320 (1)(c) (2)(a)(b)(5)(c)

Based on observation, interview and record review, the facility failed to ensure 2 of 5 sampled residents (1 and 22) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (a drug that affects the brain activities associated with mental processes and behavior). The facility failed to ensure there were valid diagnoses for use of psychotropic medications, implement non-medication and behavioral interventions, accurately monitoring target behaviors and updating care plans. The facility failed to ensure Resident 22's use of an as needed psychotropic medications was limited to 14 days. These failures placed residents at risk for receiving unnecessary psychotropic medications, for adverse events, and diminished quality of care. Findings included . Review of the facility policy titled Psychotropic Medications updated 01/01/2023 showed, residents on psychotropic medications will be reviewed by the psychotropic team quarterly and more frequently, if indicated. During the quarterly review, the team will review the appropriateness and dosage of current psychotropic medications, behaviors, and the care plan associated with behaviors and/or medication. The Federal Drug Administration Boxed Warning which accompanies second generation anti-psychotics states, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. <RESIDENT 22> Resident 22 was admitted to the facility on [DATE]. Admitting diagnoses to include stroke, vascular dementia (brain damage that causes memory loss from multiple strokes), major depressive disorder. According to the significant change Minimum Date Set (MDS- an assessment tool) assessment dated [DATE], the resident had severely impaired cognition. Resident 22 was admitted to hospice services on 11/13/2024. In an observation on 01/31/2025 at 9:29 AM, Resident 22 was in their room in their wheelchair listening to music. Resident was conversant but very hard of hearing. In an observation on 01/31/2025 at 3:19 PM, Resident 22 was wheeling self in their wheelchair and stated feeling terrible and was asking for lunch. Resident was observed singing and talking to staff. Review of Resident 22's Order Summary with print date of 01/30/2025 showed that the resident was taking an anti- psychotic medication called Seroquel for restlessness, agitation and hallucinations. The diagnoses listed were not appropriate diagnoses for the use of an anti-psychotic medications. Further review of Resident 22's medication orders showed the anti-psychotic medication orders as follows: - Seroquel oral tablet 50 milligram (mg). Give one tablet by mouthy one time a day for restlessness. Ordered on 12/26/2024. - Seroquel oral tablet 25 mg. Give one tablet by mouth in the morning for restlessness. Ordered on 12/26/2024 - Seroquel oral tablet 25 mg. Give one tablet by mouth every 4 hours as needed (PRN) for agitation, hallucinations. Ordered on 11/14/2024. Review of Resident 22's November 2024 Medication Administration Record (MAR) showed that on 11/14/2024 an order for a Seroquel 25 mg PRN was started with no stop date. Review showed that the resident received a dose of the PRN Seroquel on 11/21/2024 at 6:05 PM. Review a pharmacist progress note dated 12/05/2024 stated that Resident 22 was taking Seroquel PRN and per CMS guidelines it required a stop date and to add a 14 day stop date unless longer duration is documented. There was a handwritten note at the bottom of the letter which stated, Hospice changed to indefinitely. Unable to read the signature and it was dated 1/17/2025. There were no other notes in resident's chart for follow up. Reviewed Resident 22's MAR for November 2024, December 2024, January 2025 and February 2025, showed that the resident had received PRN doses of Seroquel. There was no documentation indicating that non-medication interventions were done prior to giving the PRN dose of Seroquel. Further review of the February 2025 MAR shows that the PRN Seroquel was discontinued on 02/03/2025. Review of Resident 22's care plan with print date of 01/30/2025 showed the care plan did not address the PRN use of anti-psychotics and there were no non-medication interventions. Review of Resident 22's order summary print date 02/04/2025 showed an anti-anxiety medication as a PRN order with no stop date. Order was dated 01/03/2025. Review of Resident 22's January 2025 MAR showed that resident did not take any PRN medication for anti-anxiety however, the behavior monitoring for anti-anxiety use showed that there were behaviors documented. On 01/11/2025 at 9:00 PM, there was a number 4 documented as the Behavior #, however, the behavior list was only up to number 3. In the chart code at the end of the MAR showed number 4 as vitals outside parameters for administration. There were no behaviors documented on the anti-psychotic behavior monitoring, there were no notes in the progress notes for January 11, and the resident received a PRN dose of Seroquel on 01/11/2025 at 8:32 PM. In an interview on 02/04/2025 at 3:25 PM, Staff EE, Licensed Practical Nurse (LPN) stated that they don't know what the number 4 meant in the Anti-anxiety behavior monitoring. They stated when they document, they pick the numbers that were listed in the MAR. In an interview on 02/04/2025 at 3:32 PM, Staff V, LPN stated that the number 4 was the number of times resident exhibited behaviors and then they document in the progress notes what those behaviors were. In a joint interview on 02/04/2025 at 3:40 PM, when asked what the number 4 meant in the behavior monitoring, Staff C, Director of Operation stated that it probably meant other and then the staff documents it in the progress note. They looked at Resident 22's progress notes but did not see any notes on 01/11/2025. Staff B, Director of Nursing (DON) and Staff G, LPN/Resident Care Manager (RCM) stated that it might be a typo, and it was meant to be a number 1. In a joint interview on 02/04/2025 at 3:40 PM, Staff B stated that when a resident gets started on psychotropic medications, before they even give the medication, they get a consent from resident or the power of attorney or family member, then they review them every quarter and review if the resident will be eligible for the gradual dose reduction (GDR) process. When asked about diagnosis for psychotropic medications, Staff B stated that they just started working with an Advance Registered Nurse Practitioner (ARNP) that specializes in Psychiatry (a branch of Medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders), and they review residents on psychotropic medications to determine if diagnoses and behavior monitoring were appropriate. When asked if restlessness was an appropriate diagnosis for an anti-psychotic medication for Resident 22, Staff C, Director of Operation stated that the hospice agency following Resident 22 were the ones that handles the anti-psychotic medications for the resident. Staff C stated that they have had issues with all their buildings about hospice informing them that they can use their own diagnosis for Seroquel (anti-psychotic medication). When asked about the PRN psychotropic medications, Staff C stated that they have discontinued the medication today and that there were some confusions between the hospice agency and pharmacy. They added that hospice agency staff were the ones that gives the orders, and the facility provider defers things to hospice so it's a battle that the facility cannot fix. 51551 <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnosis to include palliative care (an approach that improves the quality of life of terminal ill patient), dementia (impairs cognitive functioning and reasoning) and depression. According to the Minimum Date Set (MDS - an assessment tool) assessment, dated 01/22/2025, Resident 1 showed severe cognitive impairment and had no diagnosis of anxiety. Review of a consent form for Lorazepam dated 04/17/2024, showed that the diagnosis section was blank. Review of Resident 1's January 2025 Medication Administration Records (MAR) showed a provider's order for Lorazepam (anxiety medication) as needed for anxiety. The medication was administered on 01/18/2025 at 12:01 AM and 3:48 PM, 01/19/2025 at 2:21AM, and 01/27/2025 at 09:51AM. Review of the progress notes from 01/18/2025 to 01/31/2025, showed no documentation of non-pharmacological interventions were provided before administering the as needed Lorazepam. Review of Resident 1's progress note dated 01/19/2025 at 3:39 AM, showed Resident 1 was given Lorazepam as they were not able to sleep, not for anxiety as the order was written. Review of Resident 1's progress note dated 01/27/2025 at 2:48 PM, showed the nurse administered Lorazepam for pain, not for anxiety as the order was written. Review of Resident 1's care plan, print date 01/31/2025, showed the resident used Lorazepam related to terminal agitation. Intervention related to psychotropic medication was to provide non-pharmacological interventions, such as: attempt to redirect by calling daughter, offer activities, offer to assist to library to get a book. Review of Resident 1's medical record showed no assessment, rationale or review for the use of an antipsychotic medication. The medical record showed no duration or stop date for the use of an antipsychotic medication. Review of Resident 1's January 2025 MARs showed a provider's order for Seroquel (used to treat persons that lose contact with reality) as needed for anxiety. Seroquel was initiated on 01/16/2025 with no stop date, and the order continued beyond the 14 days maximum use. Review of a progress note dated 01/18/2025 at 11:42 PM, showed Resident 1 was given Seroquel due to calling out for their daughter and dangling their legs over the side of bed. Review of a progress note on 01/19/2025 at 3:39 AM, showed Seroquel was given due to Resident 1 due to talking to self and calling out for their daughter. Review of Resident 1's progress notes from 01/18/2025 to 01/19/2025, showed no documentation of non-pharmacological interventions were provided before antipsychotic medication was administered. In an interview on 02/03/2025 at 10:26 AM, Staff O, Registered Nurse, stated Resident 1 did not have a diagnosis of anxiety. Staff O stated Lorazepam was ordered for comfort since Resident 1 was on hospice and Seroquel was ordered for delusions. Staff O stated they could not find documentation that non-pharmacological interventions were attempted before staff gave psychotropic medications to Resident 1. In a joint interview on 02/04/2025 at 10:48 AM, Staff B, Director of Nursing, and Staff C, Director of Operation, stated Resident 1 did not have an anxiety diagnosis and the psychotropic medications were for hospice comfort care, delusion and hallucination. Staff B stated non-pharmacological interventions should be provided before psychotropic medications were administered, but they could not find the documentation. Staff C stated the as needed Seroquel order exceeded the 14-day limitation. Refer to WAC 388-97-1060(3)(k)(i)

Based on observation, interview, and record review the facility failed to ensure 2 of 2 residents (Resident 5 and 263) were properly assessed for the safety of self-medication administration. This failed practice placed residents at risk for medical complications and medication errors. Findings included . Review of a facility policy titled, Self-Medication Administration dated 09/16/2022 showed: Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. <RESIDENT 263> Resident 263 was admitted on [DATE] with diagnoses to include left hip fracture with surgical repair. Resident was alert, oriented and can verbalize needs. In an observation and interview on 01/30/2025 at 9:30 AM, an eye drop container labeled Pataday Ophthalmic Solution (eye drop to treat itching and redness in the eyes due to allergies) was observed on Resident 263's overbed table. The resident stated that they self-administered the eye drops every day. Resident stated staff were aware that they had and used the eyedrops. In an observation on 01/31/2025 at 9:40 AM, a bottle of Pataday eye drop was observed on Resident 263's bedside table. Review of Resident 263's current physician orders on 01/31/2025, showed no order was in place for Pataday eye drops. In a record review on 01/31/2025, Resident 263's care plan did not show that resident was on a self-medication program. In an interview on 02/03/2025 at 2:07 PM, Staff I, Licensed Practical Nurse (LPN) stated that the facility did not allow self-medication administration to residents and if they saw medications in the resident's room, they remove them. They were not aware that Resident 263 had an eye drop in their room. In an interview on 02/03/2025 at 3:42 PM, Staff G, LPN/Resident Care Manager (RCM), stated that if a resident wanted to self-administer their own medication, the resident needed to be assessed for safe storage of medication and pass a self-medication assessment. Staff G stated staff should remove medications that were brought to the facility by the resident or family. Staff G was not aware that Resident 263 had an eye drop at bedside. In an interview on 02/04/2025 at 3:15 PM, Staff G stated that they noted the eye drop in Resident 263's room after it was reported by surveyor. 51312 <RESIDENT 5> Resident 5 was a long-term resident of the facility. Review of MDS dated [DATE] showed Resident 5 had no cognitive issues. During an observation on 1/30/2025 at 2:30 PM, Resident 5 returned from a doctor's appointment with an inhaler (A portable device for administering a drug to be breathed in). Staff DD, LPN, brought the resident to the room. Resident 5 had the inhaler in their hand. In an observation on 1/30/2025 at 2:42 PM, the inhaler was observed at the bedside of Resident 5. During an observation and interview on 1/31/2025 at 8:34 AM, Resident 5 stated that I only used the inhaler when needed. Resident 5 then showed surveyor inhaler on the bedside table. During an interview and observation on 1/31/2025 at 2:01 PM, Resident 5 stated that they had only used their inhaler once that day. The inhaler was observed on the bedside table. Review of Resident 5's clinical record on 01/31/2025 at 2:20 PM, showed no self-medication assessment was present in the record. Review of Resident 5's care plan, print date 01/31/2025, showed no documentation of a self-medication program or keeping inhaler at bedside. During an interview on 02/03/2025 at 1:58 PM Staff O, Registered Nurse (RN) stated that residents may have medication in their rooms after being evaluated for safety and if the medication was in a lock box. During an interview on 02/03/2025 at 1:48 PM, Staff GG, RN, stated that the facility would have to have an agreement with the resident in order for residents to have medications at the bedside. No, this was all the staff member GG could say about meds. I can take it out. During an interview on 02/03/2025 at 2:15 PM, Staff B, Director of Nursing Services, stated that for residents to have medications at the bedside, they would need a doctor's order and an evaluation for safety. Staff B stated that if a resident was self-administering medications, nursing staff should assess whether they administered their medications accurately. Staff B stated they were aware that Resident 5 had medication at the bedside and had not been evaluated and were planning on removing the drug until the procedure could be followed. Refer to WAC 388-97-0440

Based on interview and record review the facility failed to provide the required beneficiary notice for 2 of 3 residents (Residents 47 and 265) reviewed for liability notices. Failure to provide the appropriate form for the beneficiary notice and failure to give the Notice of Medicare Non-Coverage (NOMNC) 48 hours before the Medicare Part A's last covered day placed the residents at risk for not being fully informed of their rights to appeal the decision to end skilled services and/or the potential costs of continued services if the residents wished to stay longer at the facility. Findings included . <RESIDENT 47> Resident 47 was discharged on [DATE]. Last covered day of Medicare Part A service was 01/01/2025. Review of the Advance Beneficiary Notice of Non-coverage (ABN) form signed by Resident 47's spouse showed the facility used Centers for Medicare and Medicaid Services (CMS) form R-131. Per CMS guidelines, Skilled Nursing Facilities (SNF) should be using CMS-10055 forms for SNF ABN. In an interview on 01/31/2025 at 2:33 PM, Staff F, Social Service Director, stated that they were not aware that there was a new SNF ABN form. They added moving forward, they will start using the new form. <RESIDENT 265> Resident 265 was discharged from the facility on 09/26/2024. Review of the NOMNC form showed that Resident 265's Skilled Nursing Services ended on 09/25/2024. Signature of resident or representative was signed on 09/24/2024. In an interview on 01/31/2025 at 2:33 PM, Staff F stated that they were the primary person that gives the NOMNC and ABN notices to residents. Staff F stated they did not know why the NOMNC was given 24 hours prior to Medicare Part A last covered day instead of 48 hours per guidelines for Resident 265. Refer to WAC 388-97-0300 (1)(e)

Based on interview and record review, the facility failed to promptly initiate, resolve and document resident grievances for 2 of 4 sampled residents (Resident's 45 and 25) reviewed for grievance resolution. The failure of staff to initiate resident grievances resulted in delays in grievance resolution and an extended period where a resident went without their missing clothing, broken furnishing and placed residents at risk for frustration and diminished quality of life. Findings included . Review of the facility policy, titled, Grievance Policy and Procedure for Residents, revised date 04/15/2024, showed grievances were resolved immediately when possible, by the individual receiving the grievance. The policy showed grievances would be completed within 5 days and the resident would be notified and updated if the grievance took longer than 5 days. <RESIDENT 45> Resident 45 admitted to the facility on [DATE]. According to the Minimum Data Set (MDS-an assessment tool) assessment, dated 12/15/2024, the resident was cognitively intact. In an interview on 01/29/2025 at 11:48 AM, Resident 45 stated they were missing two pairs of socks and one pair of pants since last September. Resident 45 stated they told nurses and laundry staff about the missing items, and the clothes had still not been found yet. Review of the facility grievance logs for 08/03/2024 through 01/27/2025 showed no grievances were logged for Resident 45 regarding missing clothes. In an interview on 01/30/2025 at 2:40 PM, Staff D, Certified Nurse Assistant (CNA), stated Resident 45 had some socks and pants missing quite a while ago and laundry staff were still looking for the missing clothes. Staff D stated they did not know if a grievance form was filled out. In an interview on 01/30/2025 at 2:53 PM, Staff E, Laundry Assistant, stated they were aware that Resident 45 had missing pants since Thanksgiving and Christmas time, and they were still looking for the items. Staff E stated they were not sure if a grievance form was filled out, but the laundry manager knew about it. In an interview on 02/03/2025 at 1:39 PM, Staff F, Social Service Director, stated they were not aware that Resident 45 had missing clothes, and they were not sure if a grievance form was filed. Staff F stated everyone in the facility could fill out a grievance form as soon as possible when the resident reported missing items. In an interview on 02/04/2025 at 12:24 PM, Resident 45 stated no one had communicated with them about their missing clothes yet and they had not received reimbursement or replacement. Review of the updated facility grievance logs received on 02/04/2025 showed no grievances were logged for Resident 45 for missing clothes. 50725 <RESIDENT 25> Resident 25 admitted to the facility on [DATE]. Resident was alert and can make needs known but is forgetful. During a Resident Council meeting on 01/31/2025 at 11:00 AM, Resident 25 stated that the blinds in their room have holes in them. In an observation and interview on 01/31/2025 at 3:05 PM, Resident 25's window blinds had blinds that were cut off on the edges creating holes in the blinds. The resident stated the Maintenance Manager came in and looked at their blinds and informed them that they will order new blinds and replace them. In an interview on 02/03/2025 at 9:16 AM, Staff Y, CNA stated that in each nurse's station, they have a clipboard to write issues down for maintenance to follow up. The Maintenance Director looks at the list and initials it if it was fixed or work was done. Review of the maintenance log from 10/21/2024 to 02/03/2025 did not show Resident 13's broken blinds. Review of the facility grievance log from September 2024 to February 2025 did not show Resident 13's concern regarding their broken blinds. In an observation and interview on 02/03/2025 at 2:58 PM, the blinds in Resident 25's room had not been replaced. Staff X, Maintenance Director stated when there are things that need to be fixed, staff or resident will notify them. They stated that there were 3 window blinds that needed to be replaced, and they ordered replacements, but it will take up to two weeks to get delivered. Refer to WAC 388-97-0460(2)

Based on interview and record review, the facility failed to provide the needed assessments and timely treatment for 1 of 1 residents (Resident 1) reviewed for an unexpected hospitalization , who experiences ongoing abdominal pain and discomfort for at least two days to the extent that staff moved the roommate out of the room and closed the door because the resident was calling out in pain. The resident experienced harm when treatment was delayed for several hours and there was a lack of effective communication with the physician. The resident was sent to the hospital the next morning and passed away shortly after admission to the hospital. The disregard of the pain the resident experienced and recognizing the need to take timely action constituted an immediate jeopardy. On 08/15/2024 at 3:35 PM, the facility was notified of an IJ in F684. The facility removed the immediacy on 08/19/2024 after they terminated the staff that failed to assess, treat and timely notify the physician of Resident 1's acute change in condition. They audited the records of all residents, educated staff on what to do when a resident has a change in condition, educated staff on identifying abuse and neglect and implemented a plan of correction to sustain ongoing compliance. Findings included . Review of the facility policy titled, Notification Policy, revised 04/17/2020 states the facility should promptly notify the resident, their physician, and primary contact of changes in the residents condition or status .the nurse will notify the physician when there was a change in condition in their physical, mental, or psychosocial status, involvement in any incident, need to alter the residents treatment, and when necessary in the best interest of the resident. Resident 1 admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (irregular heartbeat), long term use of anti-coagulant (medication that thins the blood), diabetes (medical condition in which the body doesn't use insulin properly), and history of stroke. The significant change in condition Minimum Data Set (MDS - an assessment tool) assessment, dated 05/11/2024 showed the resident had intact cognition, no refusals of care, was dependent on staff for toileting, and personal care. The MDS showed the resident was incontinent of bowel and bladder and was taking an anticoagulant medication. Resident 1's physician order for sustaining life (POLST) form dated 02/21/2024 showed that the resident choice indicated selective treatment that designated the primary goal was to treat medical conditions while avoiding invasive measures whenever possible. The resident chose to receive medical treatment, intravenous (IV) fluids (fluids administered through a needle and tubing injected directly into the vein), medications, and cardiac monitor as indicated. The resident chose to have airway support with oxygen and wanted to be transferred to hospital if indicated. Review of a nursing progress note dated 07/22/2024 at 9:45 PM, showed Resident 1 had experienced abdominal discomfort, received an antacid (medication to reduce abdominal discomfort) twice without relief. Review of a nursing progress note dated 07/23/2024 at 4:56 AM, showed Resident 1 continued to experience abdominal discomfort. Review of a nursing progress note dated 07/23/2024 at 1:51 PM, showed Resident 1 had only experienced small bowel movements the last 48 hours, and that the resident needed to be assessed. No assessment was documented. Review of a nursing progress note dated 07/23/2024 at 11:44 PM, showed Resident 1 continued to have abdominal pain, and bowel sounds were slow. Review of a nursing progress note dated 07/24/2024 at 2:20 AM, showed Resident 1 had been restless all night, had called out for assistance multiple times, nursing staff were unable to relieve discomfort with antacids. Staff documented that the resident was calling out, crying and disruptive to their roommate. The note stated staff had to remove Resident 1's roommate from the room as the roommate was in distress from the resident's constant calling out. There was no documentation of additional assessments or that the physician was notified until approximately two hours later. Review of a nursing progress note dated 07/24/2024 at 4:19 AM, showed the nurse notified the physician by fax regarding Resident 1's constant abdominal discomfort, loose stools, and increased restlessness and crying out. The physician responded at 5:36 AM they would come by to see resident later that morning. Review of a nursing progress note dated 07/24/2024 at 6:46 AM, showed Resident 1 was found at the beginning of the shift (6:00 AM) to be vomiting a dark coffee colored substance The resident was short of breath with an oxygen saturation (amount oxygen was absorbed into the body) of 85% (residents' baseline was 96%). The nurse documented that the resident's lung sounds appeared decreased on the right and left side of their body, and that the right lower area of their abdomen was painful. The resident's hands, and feet were cold to touch. The resident was sent to the hospital. Review of Resident 1's vital sign (measurements of body's basic functions i.e. heart rate, blood pressure, oxygen saturation, temperature, and respiratory rate) report showed the last time the residents vitals were assessed was on 07/23/2024 at 3:52 PM. There was no documentation that the residents' vitals were assessed again until 6:00 AM on 07/24/2024, when the resident was found to be vomiting. In an interview on 08/06/2024 at 7:56 AM, Staff C, Nursing Assistant Certified (NAC) stated that at the start of their shift at 11:00 PM, they were told Resident 1 had been uncomfortable, having pain and discomfort in their abdomen and back. Staff C stated that the resident was calling out all shift, placing their call light on as soon as they would leave the room. Staff C stated they were in and out of the room all night, it was a long night. Staff C stated the resident would call the staff's name out, cry, and yell out constantly to the point that it was disrupting the roommate, so staff moved the roommate to another room down the hall. Staff C stated when they got ready to start their last rounds between 4:00 AM and 5:00 AM the nurse [Staff D, License Practical Nurse (LPN)] told them that they would take care of Resident 1 for them as they needed a break. Staff C stated they did not go back into Resident 1's room the rest of their shift. Staff C stated that they did notice around 5:00 AM Resident 1's door was shut, they could not recall if the call light was on. Staff C stated they gave report to the next shift around 6:00 AM, and that was then they learned Resident 1 had vomited and the resident was going to be sent to the hospital. In an interview on 08/06/2024 at 11:10 AM, Staff D, LPN stated they have worked for the facility for about a year. Staff D stated they were educated by the facility that when a resident had a change in condition, they were to call and notify the physician. Staff D stated they were told in report at the start of their shift on 07/23/2024 at 11:00 PM that Resident 1 had been experiencing abdominal discomfort. Staff D stated during their shift the resident had been uncomfortable all night, was calling out, yelling and crying all night for staff to come into the room and help them. Staff D stated Resident 1's behavior was not their baseline and was disruptive to their roommate, so they moved the resident's roommate out of the room. Staff D stated they were aware that the resident had reported abdominal discomfort for a couple of days, as they worked the night before and the resident mentioned then they were having abdominal discomfort and pain then. Staff D was asked if they ever assessed the resident for the source of their abdominal pain and discomfort, Staff D stated they did not and realized that they should have checked the resident's vitals and conducted a head-to-toe assessment. Staff D stated they faxed the doctor; however, they should have called the physician earlier as the abdominal discomfort had been occurring for a couple of days. Staff D stated they probably needed further testing. Staff D confirmed that they shut the door to Resident 1's room between 5:00 AM - 5:30 AM on 07/24/2024 as they had been so disruptive to the other residents all night and was trying to allow the NAC's time to assist other residents. Staff D stated they did not check on the resident after they shut the door to the room. In an interview on 08/07/2024 at 10:08 AM, Staff G, Registered Nurse (RN) stated they have been employed at the facility for a little over a month. Staff G stated that they would call the physician if a resident had a change in condition, faxing the physician was for non-urgent needs. Staff G was receiving report from the overnight nurse (Staff D) when the day shift NAC approached them and stated that Resident 1 had coffee (dark brown) colored vomit all over them and was having difficulty breathing. Staff G stated they immediately went to the resident and assessed their vitals and completed a physical assessment. Staff G stated they asked another nurse to contact the physician to request to send the resident to the hospital. Staff G had not received report on Resident 1, stating they were not aware of the abdominal pain, and the restlessness of the resident until after they were sent to the hospital. In an interview on 08/07/2024 at 10:26 AM, Staff E, NAC stated they were not the staff that found Resident 1 on the morning or 07/24/2024. Staff E stated they arrived shortly after Staff G was assessing the resident. Staff E stated when they arrived in the room the resident was covered in dark brown vomit, the bed was a big mess. Staff E stated they assisted in cleaning the resident up, while they were preparing to send them to the hospital. In an interview on 08/07/2024 at 11:27 AM, Staff F, NAC stated they were the staff member that found Resident 1 on the morning of 07/24/2024. Staff F stated when they came on shift, the previous NAC (Staff C) reported to them that Resident 1 had been calling out all night and was having abdominal pain and discomfort. Staff F stated when they started their shift, they noticed that Resident 1's door was shut. Staff F stated that they have worked with Resident 1 since they admitted and knew that the resident did not prefer their door shut. Staff F stated when they entered the room, the room was very cold, and they noticed that the window was open. Staff F stated that the resident had no covers on them, and their bare legs were exposed. The call light was not within the reach of the resident. Staff F stated the resident was covered in dark brown vomit, their lips were discolored, and their skin was very cold. Staff F stated the resident was saying help, help,. Staff F stated they tried to talk to the resident, but they were not making sense, and this was not Resident 1's baseline, so they ran to get a nurse. Staff F stated that Staff G, RN showed up immediately and began assessing the resident, and was preparing to send the resident to the hospital. Review of Resident 1's hospital records dated 07/24/2024 showed the resident presented to the emergency department (ED) at 7:57 AM on 07/24/2024. The physician note stated the resident presented with coffee-ground emesis (vomit), weakness, and low blood pressure. The ED physician documented that the resident appeared toxic and altered. The ED Physician documented that they were concerned with sepsis (blood infection) and septic shock (blood infection causes low blood pressure, widening of the blood vessels (vasodilation) and organ failure). Resident 1's laboratory blood result showed the resident had a high white blood cell (WBC) count that was indicative of an infection. The note stated that the resident had an acute critical illness with potential for imminent deterioration from septic shock and artery blockage to the abdominal organs. At 11:44 AM, the resident had been transferred to the intensive care unit. The physician noted that they had attempted to stabilize the resident, however the resident had been struggling to breath, and their heart rate was very low. The physician noted that they advised the family present that the resident was likely to only survive for a few more hours. At 3:43 PM the physician noted that Resident 1 had passed away. In an interview on 08/07/2024 at 11:50 AM, Staff H, LPN/Nurse Manager stated their expectation was the licensed staff would complete a vital sign assessment as well as a head-to-toe assessment of a resident whenever a resident was having a change in condition. Staff H stated they were not at the facility on the morning of 07/24/2024 and arrived after Resident 1 had been sent out to the hospital. Staff H stated they would have expected the nurse (Staff D) to have checked the resident's vitals and done a head-to-toe assessment on the resident during their shift. In a joint interview on 08/07/2024 at 2:33 PM, with Staff A, Administrator and Staff B, Director of Nursing Services (DNS), Staff B stated their expectation for all their staff was that the physician was called for any urgent matter or change in condition of the resident. Staff B stated that if a resident was having a change in condition, they expected their licensed staff to assess and monitor the resident continuously, notify the physician by calling them on the phone. Staff B was asked to clarify monitor and assess, and they stated they should be routinely checking their vitals and complete a head-to-toe assessment of the resident to report any findings to the physician. Staff B confirmed that Resident 1 was not properly assessed on the overnight shift of 07/23/2024 - 07/24/2024. Staff B was asked if they were aware that Resident 1's door was closed, and the call light was not within reach on the morning of 07/24/2024, Staff B did not offer any additional information. Staff B confirmed more should have been done for the resident. Staff A stated, In hindsight more should have been done to help the resident. Staff B stated they were alerted around 3:00 PM on the 24th that the resident had passed away. Refer to WAC 388-97-1060(1)

Based on interview and record review the facility failed to provide necessary care and services to prevent neglect for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. Licensed staff was aware of the change in condition and abdominal pain experienced by Resident 1 yet did not conduct a thorough assessment or consult with the physician timely and left the resident alone in their room and in pain during the night shift with door closed for at least 30 minutes. The lack of addressing the residents needs placed all residents at risk for neglect. Review of the facility policy titled, Abuse and Neglect, undated stated the facility has effective procedures to protect and prevent neglect of residents .licensed nurses, and nurse management staff are responsible for the supervision of facility staff to identify inappropriate behaviors such as . ignoring residents and ensuring that staff are providing care as identified in the residents plan of care . The facility defines neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident 1 admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat), long term use of anti-coagulant (medication that thins the blood), diabetes (medical condition in which the body doesn't use insulin properly), and history of stroke. The significant change in condition Minimum Data Set (MDS - an assessment tool) assessment, dated 05/11/2024 showed the resident had intact cognition, no refusals of care, and was dependent on staff for toileting, and personal care. Review of Resident 1's medical record on 08/01/2024 showed that the resident had a change in condition between 07/22/2024 and 07/24/2024. The resident had experienced increased abdominal pain without relief. Review of Resident 1's vitals (measurements of body's basic functions i.e. heart rate, blood pressure, oxygen saturation, temperature, and respiratory rate) report showed the last time the residents blood pressure, temperature and pulse were checked was on 07/23/2024 at 3:52 PM, by the Nursing Assistant Certified (NAC) at the beginning of their shift. The medical record did not reflect any vital assessments were completed on the night shift 07/23/2024 11:00 PM - 07/24/2024 6:00 AM. Review of a nursing progress note dated 07/22/2024 at 9:45 PM, showed Resident 1 had experienced abdominal discomfort, received an antacid (medication to reduce abdominal discomfort) twice without relief. Review of a nursing progress note dated 07/23/2024 at 4:56 AM, showed Resident 1 continued to experience abdominal discomfort. Review of a nursing progress note dated 07/23/2024 at 1:51 PM, showed Resident 1 had only experienced small bowel movements the last 48 hours, and that the resident needed to be assessed. No assessment was documented. Review of a nursing progress note dated 07/23/2024 at 11:44 PM, showed Resident 1 continued to have abdominal pain, and bowel sounds were slow. Review of a nursing progress note dated 07/24/2024 at 2:20 AM, showed Resident 1 had been restless all night, had called out for assistance multiple times, nursing staff were unable to relieve discomfort with antacids. Staff documented that the resident was calling out, crying and disruptive to their roommate. The note stated staff had to remove Resident 1's roommate from the room as the roommate was in distress from the resident's constant calling out. There was no documentation of additional assessments or that the physician was notified until approximately two hours later. The medical record showed that the resident experienced increased abdominal discomfort and pain until they were found on 07/24/2024 at 6:00 AM covered in dark, brown vomit, with right lower abdominal pain and decreased breath sounds noted. Review of Resident 1's progress notes dated 07/22/2024 at 9:45 PM, 07/23/2024 at 4:56 AM, 1:51 PM, and 11:44 PM, showed the resident had experienced abdominal discomfort, and pain. Review of Resident 1's progress note dated 07/24/2024 at 2:20 AM showed the resident was restless all night, calling out for assistance multiple times, and the nurse was unable to relieve their discomfort. The note stated the crying became so disruptive they removed the roommate from the room as it was causing them distress. Review of the progress note on 07/24/2024 at 4:19 AM showed a fax communication to the physician that stated the resident had increased abdominal discomfort, loose stools, and increased restlessness, and requested the nutritional supplement by placed on hold to do possible abdominal discomfort. Review of Resident 1's progress notes on 07/24/2024 at 6:46 AM, the day shift (07/24/2024 6:00 AM - 2:00 PM) showed the nurse noted that at 6:00 AM the resident was found to have vomited a dark brown coffee ground like substance. The day shift nurse assessed the resident, notified the physician and the resident was sent to the hospital. Review of Resident 1's hospital records dated 07/24/2024 the physician note time stamped at 3:43 PM on 07/24/2024 showed that the resident had passed away. In an interview on 08/06/2024 at 7:56 AM, Staff C, Nursing Assistant Certified (NAC) stated that at the start of their shift at 11:00 PM, they were told Resident 1 had been uncomfortable, having pain and discomfort in their abdomen and back. Staff C stated that the resident was calling out all shift, placing their call light on as soon as they would leave the room. Staff C stated they were in and out of the room all night, it was a long night. Staff C stated the resident would call the staff's name out, cry, and yell out constantly to the point that it was disrupting the roommate, so staff moved the roommate to another room down the hall. Staff C stated when they got ready to start their last rounds between 4:00 AM and 5:00 AM the nurse [Staff D, License Practical Nurse (LPN)] told them that they would take care of Resident 1 for them as they needed a break. Staff C stated they did not go back into Resident 1's room the rest of their shift. Staff C stated that they did notice around 5:00 AM Resident 1's door was shut, they could not recall if the call light was on. Staff C stated they gave report to the next shift around 6:00 AM, and that was then they learned Resident 1 had vomited and the resident was going to be sent to the hospital. In an interview on 08/06/2024 at 11:10 AM, Staff D, Licensed Practical Nurse (LPN) stated they were aware that the resident had been experiencing increased abdominal pain and discomfort for the last couple of days when their shift started on 07/23/2024 at 11:00 PM. Staff D stated they did not assess the resident for the source of the abdominal pain, and did not assess the residents vitals on their shift (07/23/2024 11:00 PM - 07/24/2024 6:00 AM). Staff D stated they thought the nutritional supplement drink the resident had been taking might be the source and that was what they communicated to the physician when they sent a fax on 07/24/2024 at 4:19 AM. Staff D stated they should have called the physician and notified them of the increase in abdominal pain and change in condition timelier. In an interview on 08/07/2024 at 2:33 PM, Staff B, Director of Nursing Services (DNS), stated their expectation was that when any resident experienced a change in condition that all licensed staff were to complete a thorough assessment of the resident, notify the physician on the phone immediately after they assessed the resident, and follow all physician orders. Staff B stated that Resident 1 did not have a thorough assessment for their change in condition, and that communication with a fax was inappropriate at that time of the concern. Refer to WAC 388-97-0640(1)(3)(c)

Based on interview and record review, the facility failed to ensure 1 of 1 residents reviewed for burn injuries (Resident 2) received a timely wound care consultation by a wound care specialist and received ordered medications. Resident 2 experienced harm when they required extensive debridement (to remove dead, damaged, or infected tissue of a wound) at the hospital, and the lack of effective wound management placed all residents at risk for skin breakdown. Findings included . Resident 2 admitted to the facility on [DATE] with diagnoses to include Parkinson's disease (a neurological condition that affected a person's ability to move and caused tremors), morbid obesity, diabetes mellitus (a disease that results in excessive sugar in the blood), inability to ambulate (walk), heart failure, a history of frequent falls, a left calf venous ulcer (a wound on the leg or ankle caused by abnormal or damaged veins), and vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) of both legs. Review of Resident 2's admission Minimum Data Set assessment (an assessment tool), dated 10/25/2022, showed they had moderate cognitive impairment and needed extensive two-person assist with bed mobility, transfers, dressing, personal hygiene, and toileting. Review of the facility incident investigation for a fall, dated 12/21/2022 at 1:55 AM, showed Resident 2 fell on [DATE] at 1:55 AM from their bed, landed against a heater, and had what appeared to be burn marks to their left knee and foot. The nurse provided first aid to the areas of injury and sent the resident to the hospital. The facility investigation showed Resident 2 returned from the hospital diagnosed with full-thickness burns (when all three layers of skin were burned/third degree burn) to the left knee and foot. The investigation showed the facility was awaiting a physician order for a referral to the facility's wound care consultant who could follow the resident wounds each week and determine the correct treatment orders for healing. Review of a facility fax from an unknown staff member at the facility to Collateral Contact 2 (CC 2), the resident's physician/former facility Medical Director, dated 12/21/2022, showed the resident had a fall and there was a large open area to their left knee. The fax did not document the left foot burn injury, or reference that the left knee injury was a burn. Review of the emergency room (ER) provider note, dated 12/21/2022, showed Resident 2 had a full thickness burn to their left knee (there was no mention of a left foot burn). Review of Resident 2's ER After Visit Summary Report, dated 12/21/2022, showed a diagnosis to include full thickness burn to the left knee. The ER physician included a referral to the hospital wound care clinic, with instructions for the facility to call the wound care clinic to schedule a follow-up appointment in one week. Review of Resident 2's nursing progress note, dated 12/21/2022, showed there was no documentation reflecting the facility had implemented the ER physician's order to schedule a follow-up at the hospital wound clinic in one week. Review of Resident 2's progress note, dated 12/21/2022, showed CC 2, documented the left lower extremity has dressing and blisters over burn. The assessment and plan documented that the resident had a recent fall from their bed and a burn on their left lower extremity. CC 2 documented we will continue to manage this conservatively at this time. Review of Resident 2's nursing progress note, dated 12/28/2022 at 12:11 PM, showed there was a referral/order for a wound care consult to [the resident's] left knee and foot. Review of a New Patient Referral Form for the facility's wound care consultants, dated 12/29/2022, showed a referral for Resident 2 was made by the facility for their [the resident's] wound care needs for the full-thickness burns to the resident's left foot and left knee wounds. Review of CC 2's progress note, dated 12/29/2022, showed Resident 2 had a large full-thickness wound on their left lower extremity that was roughly seven centimeters (cm) to eight cm by four cm with surrounding mild erythema (reddening of the skin). The note documented Resident 2 would benefit from a wound care specialty and that the wound care specialist was available to see the resident the next day. The physician progress note did not identify the location of the left lower extremity full-thickness burn. Review of a facility wound care healing note, dated 12/30/2022, Collateral Contact 1 (CC 1), Physician Assistant Certified (PA-C) and the facility's contracted wound care consultant, documented Resident 2 was seen for a wound to their abdomen, and no new concerns were reported. The note did not reference an assessment of the resident's burn wounds on the left knee or foot. Review of CC 2's physician progress note, dated 12/30/2022, showed, Today supposedly the wound care specialist evaluated the patient [Resident 2] but only under their abdominal skin fold. CC 2 documented they had removed the left leg and foot wound dressings for further evaluation, then shared that information with the on-call podiatrist who worked in the wound care center, who recommended to place Santyl or MediHoney (medications to help wounds heal) to soften up and help debride (remove damage tissue from a wound) the wounds, agreed the foot wound may benefit from antibiotics, should be evaluated in the wound care center, and they would try to get them in on Tuesday [01/03/2023]. CC 2 documented the wound on the lateral (side) aspect of the left leg across the knee measured roughly 5 cm x 7 cm, and there was a second full-thickness wound at their left foot that appeared deeper nearly down towards the bone that had a white central area at the base of the first metatarsal (any bones of the foot) that measured roughly 3 cm x 4 cm with surrounding erythema over some of the lateral foot. The assessment and plan documented there were severe wounds secondary to burns on their left leg and foot with possibly left foot cellulitis (bacterial skin infection). CC 2 documented, I would like to take the advice of the wound care podiatrist and put them on antibiotic medication and use Santyl or MediHoney with daily dressing changes. I will then try to get them into wound care after this long weekend. Review of Resident 2's nursing progress note, dated 12/30/2022 at 6:49 PM, showed the resident had not been seen by the consulting wound care specialist, staff needed to call them early AM on Tuesday per CC 2, and staff were to do daily dressing changes to Resident 2's wounds using MediHoney. Review of a secured conversation note (a secure communication method for staff to use), dated 12/30/2022 at 7:13 PM, showed CC 2 communicated Resident 2 was not evaluated by wound care today. CC 2 documented they discussed the wounds with podiatry at the wound care clinic, suggested they use MediHoney or Santyl daily, and then a wound care evaluation on Tuesday next week (01/03/2023) the next day the wound care clinic was open. Review of CC 2's physician order, dated 12/30/2022 at 7:34 PM, showed an order for Resident 2 to receive MediHoney daily to both areas on their left foot (there was no mention of treatment to the left knee burn) and to change the dressing daily until the wound team evaluation scheduled on Tuesday (01/03/2023). Review of Resident 2's nursing progress note, dated 12/31/2022 at 6:24 PM, showed the nurse documented the resident was currently getting MediHoney to the wound bed of their left leg. The note did not mention the left foot burns. Review of Resident 2's nursing progress note, dated 01/01/2023, documented the resident received wound care completed per orders to their left knee. The note did not mention the resident received wound care to their left foot burns. Review of CC 2's physician progress note, dated 01/03/2023, showed: - Monitored Resident 2's severe wound on the left leg and foot post burns. Plan was to have the resident go to the wound care center that day (01/03/2023) after the long weekend if they were able to get them in. The resident did not get in for the appointment on that day. CC 2 was able to see the resident after hours. - Assessment and plan: The resident had cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) and full-thickness burns. CC 2 felt that the wound needed wound care specialty care. CC 2 discussed this case with a wound care specialist at the wound care clinic and Santyl or MediHoney had been implemented per the wound care center recommendation. CC 2 did not know if there were barriers to get the resident to the wound care clinic. CC 2 planned to discuss with the daytime nursing staff the morning of the next day (01/04/2023) and come up with a plan for the resident to be seen at the wound care specialty clinic as soon as possible. Review of CC 3's, PA-C/facility contracted wound care consultant, note, dated 01/04/2023, showed: - Strong recommendation for Resident 2 be seen by a burn team to evaluate the extent of the burn as the knee joint and several joints of the left foot were involved. - Current treatment interventions had included moist wound dressings with MediHoney. - The left knee burn wound size was 17 x 9 x 0 (no units listed), signs of infection: possible cellulitis. - The left foot burn wound size was 13.6 x 22.3 x 0 (no units listed). - Impression: Resident 2 was at high risk for infection and possible amputation. Review of CC 2's physician order, dated 01/04/2023, showed Resident 2 should have a wound care appointment at the wound care (outside of the facility) clinic tomorrow. Review of CC 4's, physician from a surrounding hospital wound care clinic, note, dated 01/05/2023 showed: - Resident 2 presented for an initial wound care clinic visit for evaluation of burns on the left knee and left forefoot area, due to a fall on 12/21/2022. The resident's left knee and left foot were resting on a baseboard heater on the floor and sustained the burns. Resident 2 was to have a wound care team follow them at the nursing home. The wound care team apparently did not get around to seeing [the resident] in a timely fashion and did not evaluate the burns on their knee or foot. CC 2 saw the burns and started them initially on medical honey and Augmentin (an antibiotic) due to the erythema surrounding the burns and they arranged for an appointment here at the wound care clinic. - Assessment/plan: Resident 2 had large full-thickness burn areas on the left knee and left forefoot areas and required extensive debridement (to remove dead, damaged, or infected tissue of a wound) which was beyond the scope of what could be done at the wound care clinic on an outpatient basis. The wound care clinic recommended Resident 2 be transferred to the ER for admission to the hospital and consult with general surgery to debride both the knee and the foot or general surgery to debride the knee and podiatry to debride the foot. Review of a nursing progress note, dated 01/05/2023, showed Resident 2 was transferred from the wound care clinic to another local hospital for admission. Review of Resident 2's ER records, dated 01/05/2023, showed the resident was transferred to the ER from the wound care clinic for further management of the resident's burns. The ER contacted a burn center, and it was recommended for the resident to be transferred to another hospital for burn wound care management. Review of Resident 2's December 2022 through 01/05/2023 Medication Administration Records and Treatment Administration Records (MARS/TARS), showed the physician order dated 12/30/2022 to treat the resident's left foot wounds daily with MediHoney had not been transcribed into the MAR/TAR or implemented. In an interview on 07/07/2023 at 10:00 AM, Staff B, Director of Nursing Services, was unable to provide any information about the ER physician's order/referral, dated 12/21/2022, to call the wound care clinic to set up a follow-up appointment in one week. Staff B was unable to provide any information when asked if the nurses were expected to follow-up on the ER orders or referrals. Staff B stated they thought the physician should be looking at the ER orders. In an interview on 07/07/2023 at 11:41 AM, Staff D, Registered Nurse/Resident Care Manager, stated they did wound rounds with the facility contracted wound care specialist on 12/30/2022, but they did not know Resident 2 because Resident 2 was not on Staff D's unit. Staff D stated CC 1 only looked at Resident 2's abdominal wound. Staff D stated they asked CC 1 about the left leg wounds that had a dressing, but CC 1 replied they were not there for that and refused to look at those wounds. In an interview on 07/07/2023 at 2:30 PM, Staff B stated Resident 2's order to treat the burn wounds with MediHoney was never implemented because the nurse that entered the order into the facility's system did not enter it correctly, and the order never made it to the MARS/TARS. Staff B was unable to provide any information regarding why the MediHoney treatment order was only for the left foot and not the left knee because the nurse who processed the order no longer worked at the facility. In a phone interview on 07/07/2023 at 2:40 PM, CC 1 was interviewed regarding their wound care consultation in the facility for Resident 2 on 12/30/2022. CC 1 denied that any nurse had asked them to evaluate any burn injuries. CC 1 stated they had documented in their progress note that there were no new concerns reported to them regarding Resident 2. CC 1 stated they absolutely could have seen Resident 2 during their visit for their burn injuries, but they had not known about them. In a phone interview on 07/07/2023 at 3:25 PM, CC 2 stated the ER did not document Resident 2's foot burn and they had talked to the ER physician regarding this omission and the ER physician recognized they forgot to document this information. CC 2 stated they had seen Resident 2 the same day they returned from theER on [DATE], related to a change in the resident's mental status and stated they had observed a dressing on the upper thigh but did not observe the wound because they did not want to disrupt the dressing since the resident had just been evaluated at the ER. There was no documentation regarding the foot burn because they (CC 2) didn't know about it. CC 2 stated it was a long weekend, and it was a perfect storm over the holiday. CC 2 stated on 12/29/2022, staff had mentioned the facility had concerns and the resident needed to be seen. CC 2 stated this was the first time they saw the foot wound, as I didn't really want to disrupt the dressings that had been applied in theER on ,d+[DATE] when I initially saw [Resident 2]. CC 2 stated they were not happy with what they saw and told nursing Resident 2 needed to be seen by wound care. CC 2 stated the wound care specialist was supposed to see them the next day (12/30/2022), and they (contracted wound care specialist) evaluated the resident for a non-issue (a previous abdominal wound), and it was reported that the contracted wound care specialist refused to see the resident for their burns, but to ask nursing staff regarding that. CC 2 stated at that point (12/29/2022), the resident was not getting adequate treatment, and CC 2 had called the wound care specialist at the hospital to find out how to get Resident 2 into the wound care center as this was more than the facility could manage. CC 2 stated on 12/30/2022, they [CC 2] saw Resident 2 and called the hospital wound care specialist who wanted them treated with MediHoney, debridement with medications, and CC 2 started the resident on antibiotics as it looked a little more cellulitic (redness and swelling from infected areas of skin). CC 2 stated after the long weekend, the resident did not get into the wound care clinic, and CC 2 did not know why, but had started the MediHoney. CC 2 stated it was not their plan that there would be any delay for the resident to be seen at the wound care clinic. CC 2 stated the resident went to wound care on 01/05/2023, and then subsequently sent to a burn center. CC 2 was asked what they meant in their 12/21/2022 progress note when they had documented they were going to manage this conservatively, they stated by conservative they meant they were basically following the advice of the ER physician. CC 2 was asked about the ER referral for a wound care clinic follow-up in one week, they stated they didn't know if the nurses had asked them about that. CC 2 was asked if they knew the order for the treatment with MediHoney never got implemented, no information was provided. In an interview on 07/10/2023 at 8:55 AM, Staff B was asked about the facility's order reconciliation process when a resident returned from the ER. Staff B stated the doctor should be reviewing those orders when a resident returned to the facility. Staff B was asked if nurses were to reconcile orders or call the nursing home attending physician regarding orders when a resident returned to the facility, they were unable to provide any information. Staff B was asked about the lack of notification to Resident 2's physician [CC 2] regarding the extent of their injuries from the incident, Staff B was unable to provide any information. Staff B was asked what time the resident had returned from the ER, and what staff had done with the ER orders that came back with the resident, Staff B did not provide any information. In an interview on 07/10/2023 at 11:10 AM, Staff B was asked for all wound assessments related to Resident 2's burn wounds, they provided a single progress note, by CC 3, dated 01/04/2023. Staff B stated it was their expectation that wounds were assessed weekly to include measurements and descriptions and if the resident was being seen by a wound care provider, they could use that as their weekly documentation, if not being seen by a wound care provider the nurses should be doing an assessment. Staff B was asked about the accuracy of the facility wound care provider's note, dated 01/04/2023, regarding current treatment with moist dressings and MediHoney, Staff B stated the MediHoney order did not get implemented and the treatment records said a dry dressing; Resident 2 received dry dressings here. Reference: (WAC) 388-97-1060 (1)(3)(b)

Based on interview and record review, the facility failed to consider readmission of one of one resident (4) reviewed for facility denying a resident's readmission after a hospitalization . This failure resulted in the resident remaining at the hospital while the resident's representative worked to find them a new nursing home. This failure resulted in harm to Resident 4, under the Reasonable Person Concept, when the resident was not allowed to return to the resident's home, a reasonable person would feel dismayed and depressed if not allowed to return to their home after a hospitalization . Findings included . Definition: Reasonable Person Concept - used when a person's psychosocial outcome may not be determined, as in cognitively impaired residents, used to determine the severity of the psychosocial outcome or potential outcome the deficiency may have on the reasonable person in the residents' position. Review of the facility policy titled, Bed Hold Policy, dated 07/20/2017, showed if a bed hold was not signed the resident would be able to return to the facility with the next available semi-private room that was open if the facility determined they could meet the resident's needs and the resident qualified for a skilled nursing facility. Resident 4 admitted to the facility on [DATE] and discharged to the hospital emergency department on 11/29/2021. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also on hospice care (a type of health care for terminally ill persons, it prioritizes comfort and quality of life by reducing pain and suffering). According to the quarterly Minimum Data Set (MDS) assessment, dated 11/20/2021, the resident had moderate cognitive impairment. The MDS assessment showed the resident had hallucinations, delusions, daily verbal behaviors and one to three days of physical behaviors during the assessment period. These behaviors interfered with Resident 4's care and ability to participate in activities or to social interactions. Review of hospital emergency department encounter notes, dated 11/29/2021, showed the resident was hospitalized for being aggressive in the setting of hospice care and was sent to the emergency department for a psychiatric evaluation which seems entirely unnecessary given that the patient is on hospice. The notes indicated the resident had an acute urinary tract infection ([CONDITION(S)]) which could have exacerbated the resident's agitation, and the facility told the hospital staff they could not take the resident back because of the agitation, so resident was admitted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 12/08/2021 at 12:54 PM, the Director of Nursing Services stated the facility would not be taking the resident back in the facility. In a phone interview on 12/14/2021 at 1:50 PM, Collateral Contact 1 (CC1), the resident's representative, stated the resident was still in the hospital, a lot of the resident's medications had been changed, and the resident had been quite sleepy. In a review of the resident's nursing home clinical records, there was no documentation the nursing home had reassessed the resident for readmission since they had been hospitalized . In summary, the resident discharged to the hospital on 11/29/2021 due to agitation/aggressive behaviors, as of 12/14/2021 Resident 4 remained in the hospital and the facility did not permit the resident to be readmitted to the nursing home. Resident 4, who was cognitively impaired, based on the reasonable person concept, would have felt dismayed and depressed had they been able grasp the concept they were not able to return home after their hospitalization , this resulted in harm to the resident. Reference: (WAC) 388-97-0120 (4)(b)

Based on observation, interview and record review the facility did not provide the assistance and supervision as required for one of three residents (1) to prevent accidents related to residents requiring assistance with hot liquids. This failed practice caused the resident pain, discomfort and skin damage from a second degree burn (affecting the first and second layer of skin). Findings included . Review of the facility's undated policy titled, Hot Beverages, showed a Hot Beverage safety assessment would be done on each admission. Appropriate interventions would be put into place. Documentation of the interventions would go into the electronic medical record. Resident 1 was admitted to the facility on [DATE], with diagnoses to include [CONDITION(S)], with mild cognitive impairment, rigidity (the muscle tone of an affected limb is always stiff), [CONDITION(S)] (abnormal muscle tightness due to prolonged muscle contraction), tremors and difficulty swallowing. Review of the Hot Beverage assessment dated [DATE], showed the resident should have lukewarm beverages to avoid [CONDITION(S)] and required a lid on hot beverages for safety because the resident had upper extremities weakness and tremors. The hot beverage would be cooled to 100 degrees Fahrenheit (°F). Review of the Functional Ability assessment dated [DATE], showed the resident needed partial/moderate assistance to bring food or liquid to the resident's mouth. Review of the Admission Minimum Data Set assessment dated [DATE], showed the resident required extensive assistance of one person for physical assistance to eat and drink. Review of the Occupational Therapy (OT) Treatment Encounter Note dated 03/12/2021, showed the resident had variable strength and activity tolerance secondary to an underlying condition ([CONDITION(S)] and muscle weakness) continued to be a barrier to increase independence during self-care. Review of the OT Discharge Summary dated 03/12/2021, reiterated the resident's required variable assistance with self-feeding secondary to their underlying condition. Resident 1 was discharged from OT at the same level of minimal (resident able to participate 75 % [percent] or more needing assistance 25%) to moderate assistance (resident patriciates 50-74%) required as the OT initial baseline assessment. Review of the care planned Focus Problem for Activity of Daily Living self-care performance deficit and/or limited physical mobility related to advanced [CONDITION(S)], and weakness with an initiated date of 03/13/2021, showed the resident required set up and assistance to eat. The resident was to use a lip plate and a Sippy cup. Review of the Speech Therapy (ST) Treatment Encounter Noted dated 04/09/2021, showed the NACs had been assisting the resident with all meals. The resident discharged from ST on 04/09/2021 with the requirement of 1:1 supervision for oral intake. Review of the ARNP (Advanced Registered Nurse Practitioner) Comprehensive Visit Note dated 04/13/2021, showed the resident was unable to feed himself with noted hand weakness in both of their hands. The note identified the resident to have functional [CONDITION(S)] (refers to paralysis from the neck down, including the trunk, legs and arms) with weakness and rigidity from [CONDITION(S)] and was dependent with their ADL's (Activity of Daily Living) which included eating. Review of the Kardex (a guide for the direct care givers) as of 04/25/2021, showed the resident required set up and assistance to eat, use a lip plate and a Sippy cup. (The amount of assistance was not defined and the Hot Beverage Assessment directives were not listed). Review of the Documentation Survey Report (documented care provided by the direct care givers) for April 2021, showed that on 04/26/2021, the resident received extensive assistance of one person with the noon meal. Review of the Progress Note dated 04/26/2021 at 1:28 PM, showed the resident had been sitting up in bed drinking coffee. The resident spilled hot coffee on their chest. The Nurse Aide Certified (NAC) and Licensed Practical Nurse (LPN) cleaned the resident up and placed cold washcloths on the resident's chest and applied some burn cream to the area. Review of the tray line temperature log on 04/26/2021, showed for lunch the hot beverage temperature was measured at 159 degrees °F. Review of the Progress Note dated 04/26/2021 at 9:26 PM, showed the resident had spilled hot coffee on their chest that afternoon, chest remained pink and tender to touch. No blisters were present at that time. The resident stated the coffee had a lid on it and they had dropped it. The resident stated that they were so slow to realize it took them a minute they had a bib (a clothing protector) on and they could just have pulled it off. The resident stated most of the coffee was on the bib. Review of the Progress Note dated 04/27/2021 at 5:54 PM, showed the resident had stated their chest was less uncomfortable that evening and complained of muscle aches and pains. Review of the facility's reported incident dated 04/27/2021, showed the NAC had brought in a meal tray and set the resident up to eat on 04/26/2021 at 12:38 PM. The resident had requested coffee and was given a cup, which the type of cup was not defined, with a lid on it. The coffee temperature from the kitchen was 158 degrees. The resident ate their meal and was drinking their coffee when they dropped the cup, coffee spilled out the hole in the lid that allowed for drinking. The resident had a bib over their chest, but the resident was surprised and did not think to remove the cloth. The resident put the call light on and the staff came in and removed the bib and put ice on the resident's chest. There was a small pinkish red area yesterday. Today (04/27/2021) there were 4 .5 cm (centimeter) of blisters in that area. Review of the facility's incident report dated 04/28/2021, showed on 04/26/2021 at the noon meal the resident was given their lunch tray and had asked for coffee. The coffee was placed on the tray and was set up to begin lunch. The resident took a sip of coffee after lunch and was drinking it when accidentally dropped the cup onto their chest. The coffee cup had a lid on it but some seeped out the hole meant for drinking. (Not served in the care planned directed sippy cup.) The coffee went through the bib on the resident's chest and caused a burn to the resident's bare chest. On the 26th (04/26/2021) there it left a pink mark to the resident's chest and ice was applied. On the morning of the 27th (04/27/2021) blisters approximately 4.5 cm round appeared to the resident's chest area. Review of the witness statement for the incident dated 04/26/2021, showed the LPN noted the resident had been in bed sitting up at 80 to 95 degrees for lunch. The resident was drinking a cup of coffee. The resident was wearing a tee-shirt and a clothing protector when the resident spilled their coffee. Review of the Progress Note dated 04/28/2021 at 10:15 PM, received an order for a referral to the wound clinic for evaluation and treatment as indicated. Review of the ARNP visit note dated 05/11/2021, confirmed the resident had second degree [CONDITION(S)] on their chest. In an observation and interview on 05/11/2021 at 1:50 PM, Staff C, LPN, stated that the dried peeling area on the resident's chest was approximately 7.0 cm by 5.0 cm in size was from the coffee burn. Resident 1 stated that the area had hurt for days. The resident stated that the area was still sore. As Staff C touched the area, Resident 1 stated that it still hurt when it was rubbed. In an observation and interview on 05/14/2021 at 8:20 AM, Resident 1 had their breakfast tray with no staff in their room to assist the resident to eat. Resident 1 stated that they would try to feed themselves but they did not do too good with their left hand which they had never used prior and would not get much help from the staff again. Staff F, NAC, came into the resident's room. Resident 1 stated that Staff F was the only one who helped the resident. In an interview on 05/14/2021 at 8:43 AM, Staff A, NAC, stated that they use the Kardex to know the level of care the residents' need. In an interview on 05/14/2021 at 9:15 AM, Resident 1, stated that on the day they spilled their coffee, no one had helped them to eat or drink their lunch. Resident 1 stated the staff help them eat a little bit but they told the resident they had to take care of other residents. Resident 1 stated a lady who worked there had put ice on their skin, after they spilled the coffee, but the nurse had not. The resident stated they did have a bib on and the lid on the coffee cup (not a sippy cup) had come off. The resident stated it was the first time (they) saw coffee steaming off a bib. The resident stated that it was some time before the staff applied salve to their burn. In an interview on 05/14/2021 at 11:15 AM, Staff B, NAC, stated that the resident's roommate and the resident requested coffee on the day the resident had a coffee burn. Staff B stated they gave the coffee to the resident with a lid and a straw. Staff B stated that they placed the coffee on the table, told the resident the coffee was there and left to go to another resident's room. Staff B stated that their NAC coworker saw the resident's call light and they called the nurse. Staff B stated that their NAC coworker reported they placed a wet washcloth on the resident's skin where the coffee had spilled. Staff B stated that they knew the level of care the residents' need by referring to the Kardex or care directives (a document by the closet or an electronic document accessible via computer) and if something was new the nurse directed the caregivers. Staff B stated that Resident 1 required extensive assistance (which indicated the resident required hands on assistance) with meals, and staff needed to help the resident. Staff B stated that they encouraged the resident to do as much as they could but that Staff B had to leave to pass meal trays to other residents. In an interview on 05/14/2021 at 11:25 AM, Staff D, LPN, stated that they supervised the nursing staff by talking with the NACs throughout the day. Staff D stated that the NACs received report, had a care plan in the resident's room and had access to the care needs of the residents on the computer. In an interview on 05/14/2021 at 12:01 PM, Staff E, Certified Occupational Therapist Assistant, stated that Resident 1 had been a moderate to maximum assistance while on therapy. Staff E stated that the resident could do some self-feeding but would get fatigued. In an interview on 05/14/2021 at 12:31 PM, Staff F stated that the care plan in the resident's closet directed the level of care the residents required. Staff F stated that Resident 1 required full care. In an interview on 05/14/2021 at 1:06 PM, Collateral Contact (CC) 1, family member stated that they were not too happy with Resident 1s care. CC 1 stated that the resident was a, feeder, but the facility staff were bringing in the meals and just leaving without assisting the resident to eat or drink. CC 1 stated that was why they brought the resident into the facility because they wanted the resident to be kept comfortable and they were supposed to be feeding Resident 1. CC 1 stated that Resident 1 was helpless and it really bothered them. CC 1 stated that Resident 1 took care of their family and was very independent and would not ask for assistance. CC 1 stated that Resident 1 had conveyed to CC 1 that they felt that on the day of the coffee burn, the NAC's were in a hurry and did not get the lid on the coffee cup securely. In a follow up phone interview on 05/19/2021 at 9:44 AM, the resident stated that he had not removed the lid from the coffee cup on the day of the coffee burn. Resident 1 stated that the lid came off when they dropped the cup. In a phone interview on 05/19/2021 at 4:08 PM, CC 2, family member, stated that the resident told them that they dropped the coffee cup and the lid came off. CC 2 stated that staff should have probably stayed with the resident. CC 2 stated that they did not feel Resident 1 could hold a hot cup without dropping it. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure one of five residents (#1) reviewed for admissions, was free of significant medication errors. The facility failed to accurately process and provide admission ordered medications, and thoroughly assess the etiology of the resident's behavioral symptoms and medical conditions. These failures resulted in significant medication errors and subsequent harm to the resident related to clinical compromise, psychosocial and mental anguish, and overall decline. Findings included . Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review to the facility admission orders [REDACTED]. The admission orders [REDACTED]. If she is at the SNF (Skilled Nursing Facility) at that time, they will need to initiate anticoag (anticoagulant therapy) there . Record review of the September 2020 Medication Administration Record [REDACTED]. Furthermore, the directive to start the anticoagulant treatment had not been implemented. Review of the September 2020 MAR indicated [REDACTED]#1s medical record. Further review of Resident #1's medical record, showed no documentation to indicate the discontinuation of the admission orders [REDACTED]. Review of the Admission Summary nursing progress note dated 09/04/2020, showed the resident was alert and oriented to person, place, time and situation. Review of the facility's History and Physical dated 09/08/2020 showed, the resident's attending physician while at the facility, noted the resident's [DIAGNOSES REDACTED]. The medication list showed, the medications for depression, [MEDICAL CONDITION], [MEDICATION NAME] degeneration, gastritis, [MEDICAL CONDITION] and the as needed medication for chest pain. The physician's Assessment/Plan noted the resident's [DIAGNOSES REDACTED]. The physician note directed to monitor and continue the resident's medications (which the facility had not administered or recognized the medication error as directed by the hospital discharge orders). Review of a progress note dated 10/25/2020, showed the resident had possible hallucinations, hearing people talking about her, and saw a man in the hall who hit someone. Review of a progress note dated 10/28/2020, showed the resident had a hallucination and reported she saw a mouse in her room. Review of a physician progress notes [REDACTED]. Review of a progress note dated 11/09/2020, showed the resident had delusional behavior towards her roommate. Review of a progress note dated 11/12/2020, showed the resident had delusional behavior. Review of a Physician Visit Note dated 11/17/2020, showed the physician documented the resident's [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Review of a progress note dated 11/22/2020, showed the resident had confusion, combative behavior and disturbing delusions. Review of a progress note dated 11/23/2020, showed the resident had confusion with combative behavior, and disturbing delusions. Review of progress note dated 11/26/2020, showed the resident was reported to have been throwing items across her room throughout the night. Review of a progress note dated 12/03/2020, showed the resident had delusional behavior and had kicked over her bedside table. The resident was discharged to the community on 12/04/2020. Review of the resident's Collateral Contact (CC), family member, email dated 12/08/2020, showed a concern that the resident had not received physician ordered medication for the management of her [MEDICAL CONDITION] for three months while the resident was at the facility. The CC stated the resident had a significant decline in her overall health while at the facility, including experiencing increased confusion and was diagnosed with [REDACTED]. Review of the a progress note dated 12/10/2020, by the resident's community Primary Care Physician (PCP), showed the resident had been at a Skilled Nursing Facility (SNF) for about three months. The resident had not been given any of her medication which included her [MEDICAL CONDITION] and antidepressant medications. The resident had depression, anxiety, hallucinations, confusion, and anger as a result of not receiving her medications. Review of a Pulmonologist progress note dated 12/11/2020, showed a note from the PCP that the resident was never started back on anticoagulant therapy during her SNF stay, in fact they did not provide her with any of her home or hospital discharged medications. The Pulmonologist noted that this was a challenging case, the resident did have a [MEDICAL CONDITION] emboli and an inferior vena cava filter to prevent blood clots which was scheduled to be removed in three months. Review of laboratory tests dated 12/13/2020 (when the resident was no longer in the facility), showed the [MEDICAL CONDITION] TSH ([MEDICAL CONDITION] stimulation hormone) test result was 90.5 (normal range is 0.5 to 3.0 milli-international units per liter). Reviewed of a Skilled Nursing Admission Summary Home Care Note from the community long term care home dated 12/13/2020, showed while the resident was at the rehabilitation facility, the resident became delirious, agitated, anxious, and aggressive after some prescriptions including an antidepressant were abruptly stopped. The resident's symptoms were slowly resolving with continued anxiety, sadness and confusion at times. In a phone interview on 02/08/2021, the Pulmonologist stated that the anticoagulant therapy was to be restarted which there was a high likely hood of more progression, and the resident needed the anticoagulation along with the removal of the IVC filter after three months. The Pulmonologist stated that the hospital discharge orders were not followed and the lack of restarting the anticoagulant was far below the standard of care and unsafe which, placed the resident at risk for a bad outcome. In a phone interview on 02/17/2021 at 9:30 AM, Staff C, facility Medical Director, stated that the facility would send over a request to accept a new resident. Staff C stated that the facility would send over a medication list and in the past, the nursing staff would take the medications from the hospital discharge summary and place those onto a medication list for Staff C to sign off on. Staff C stated that he usually would visit the newly admitted resident within 48 hours or within two working days from the resident's admission. Staff C stated that with an admission there was paperwork and potential for errors. Staff C stated that in general we tried to make errors less likely, it was like a moving target to know how to not make errors happen. Staff C stated that he had quickly looked over the 70 page discharge summary report for Resident #1s facility admission from the hospital. Staff C stated that the facility nursing staff's job, was to enter the hospital discharge medications into the facility orders, and Staff C would look over them along with the discharge medication, for potential errors. Staff C stated he had to rely on others around him and if they did not gather information correctly, it placed him in a tough spot. Staff C confirmed he was not aware of the directive on the discharge summary to start the anticoagulant treatment. In a follow up interview on 02/17/2021 at 2:32 PM, the DNS stated that she had reviewed the information regarding the investigation that was shared during a phone interview with the Administrator the morning of 10/17/2021 at 10:12 AM. The DNS stated that she found the facility entered the orders incorrectly for Resident #1 and was unsure how that occurred. Reference: (WAC) 388-97-1060 (3)(k)(iii)(4)

Based on interview and record review the facility failed to provide pharmaceutical services which assured the accurate receipt, dispensing and administration of medications for one of five (1) residents reviewed for resident admissions pharmaceutical services. Failure to: 1) accurately process hospital discharged medication orders, 2) administer only the medications ordered from the discharged orders from the hospital, 3) ensure there was an effective communication process between the pharmacy and the nursing home, and 4) to identify, document, evaluate, and report medication errors, when they occurred. This failed practice caused harm for Resident 1 who had a significant cognitive, behavioral and psychosocial decline after the abrupt discontinuation of long term medications when the facility failed to accurately process the hospital discharged medications then subsequently process and administration another resident's medication. Findings included . Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's discharged orders from the hospital discharge summary dated [DATE], showed the following medication orders [REDACTED] - Rosuvastatin 20 mg nightly (used for [MEDICAL CONDITION]); - [MEDICATION NAME] 75 mcg daily (used for [MEDICAL CONDITION]); - [MEDICATION NAME] 20 mg twice daily (used for gastritis); - [MEDICATION NAME] 40 mg daily (used for depression); - [MEDICATION NAME] (used for eye health); - Senna-[MEDICATION NAME] 8XXX,[DATE] mg twice daily (used for constipation); - [MEDICATION NAME]/[MEDICATION NAME] as needed (used for constipation); - [MEDICATION NAME] 4 mg (milligram) as needed nightly (used for [MEDICAL CONDITION]) and - [MEDICATION NAME] 0.4 mg as needed (used for chest pain). Review of the Medication Adminsitration Record (MAR) from [DATE] until [DATE], showed the facility did not implement the discharge medications listed above. Additionally, review of the [DATE] to [DATE] MAR, showed the facility processed and implemented MEDICATION ORDERS FOR [REDACTED] - [MEDICATION NAME] as needed (Schedule II narcotic); - Omega 3 daily (fish oil); - Multi-Vitamin daily; - Sennosides (a medication to treat constipation) and - Geri-Lanta (medication for heartburn, indigestion) as needed. Review of the facility History and Physical dated [DATE], showed the facility's attending physician noted the resident's [DIAGNOSES REDACTED]. The physician documented the Assessment/Plan was to follow the resident's [MEDICAL CONDITION], mood and to continue with the medication, (even though the facility had not implemented the medications). Review of the facility progress notes from [DATE] through [DATE], showed the resident had a change in her behaviors (including both verbal and physical), increase in agitation, confusion, and delusions. Review of a Physician visit note dated [DATE], showed the Diagnosis/Plan included [MEDICAL CONDITION] which was documented as stable (there was no [MEDICAL CONDITION] laboratory tests to assess the effectiveness of the [MEDICAL CONDITION] medication located in the resident's medical record). Record review of a complaint report dated [DATE], showed a complaint that Resident 1 had not received her [MEDICAL CONDITION] medication over a three month period while at the facility. The complaint report showed that the resident had a significant decline while at the facility with increased confusion and rapid onset of dementia which was felt to be a directly related to the facility's failure to provide the resident with medication for [MEDICAL CONDITION]. The report showed the facility failed to discover the medication error through the facility's internal monitoring process. In a phone interview on [DATE] at 1:03 PM, the Collateral Contact (CC), family member, stated that the resident's behavior had changed within the first four weeks of admission. The resident began demonstrating signs of anxiety, depression, hallucinations and delusions (which included both verbal and physical behaviors). The CC stated that after about two weeks of being on the antidepressant the facility wanted to place the resident on an antipsychotic medication, but the CC declined to consent to the initiation of this medication. The CC stated that the resident continued to be solemn, weeping and would mouth the words, help me, during their window visits. The CC stated that on discharge from the facility, while reviewing her discharged medication, the resident's medications were not correct. The resident had been on a prescription medication for years for her [MEDICAL CONDITION], cholesterol, and a medication for depression. All of these medication the resident did not receive while residing at the facility. The CC thought Resident 1 received her prescribed [MEDICATION NAME] (which she was not) in conjunction with the [MEDICATION NAME] medication (which the facility had initiated). The CC stated that she was very upset and requested to see the resident's chart. The CC stated, at that time, the nurse flipped through the resident's chart and was pointing at several pieces of paper. The CC stated that she looked up at the top of the papers and the name on the papers was a completely different resident. The CC stated that the resident would have died if she had left her in the facility, being at the facility took her, down a very very dark road. In a phone interview on [DATE] at 2:49 PM, Staff D, Licensed Practical Nurse, stated that the process for a new admission was to obtain the physician orders [REDACTED]. In a phone interview on [DATE] at 3:00 PM, the Director of Nursing Services stated that admission orders [REDACTED]. In a phone interview on [DATE] at 1:24 PM, Staff B, Pharmacist Consultant, stated that the pharmacy's process to dispense medications for the facility's admissions, included an electronic trigger from the facility's electronic medical record that there was a new medication order along with the receipt of the discharge orders from the discharging hospital. Staff B stated that if there were any discrepancies the pharmacy would notify the facility. Staff B stated the pharmacy monthly reviewed basic information, allergies [REDACTED]. Staff B stated that the pharmacy would have filled Resident 1s medications off the discharge summary. Staff B stated that it looked like the pharmacy had stapled two residents information together, and confirmed the two residents were Resident 1 and Resident 2. Staff B confirmed the medication dispensed for Resident 1 was the medications from Resident 2s discharge summary. Staff B stated that the facility had not faxed over a discharge summary for Resident 1. In a follow up phone interview on [DATE] at 4:24 PM, Staff B stated that the monthly pharmacy reviews were conducted remotely with the information that the facility scanned into the electronic medical record. Staff B stated that before medications were dispensed from the pharmacy, the orders went through five different people. The facility pharmacy process failed to identify the inaccurate dispensed and administered medications for Resident 1. Additionally, the monthly pharmacy review of the discharge summary and nursing and physician progress notes [REDACTED]. Refer to F760 Reference: (WAC) [DATE] (1)(b)(i)(ii)(3)(a)(4)(d)

Based on observation, interview and record review, the facility failed to provide care and services necessary to prevent an avoidable accident for 1 of 1 residents (1) reviewed for accidents. The failure to ensure adequate supervision to a Nursing Assistant (NA) student caused harm to Resident 1 when she was being transferred from her wheelchair unsupervised, resulting in a fracture to her arm. Findings included: Review of the facility's policy titled, Orientation of Nursing Assistant Students, un-dated, stated the Staffing Coordinator, with the college instructor, walked around the facility with the students before clinical instructions began. The college instructor was then available to the students at all times during their clinical instruction in the facility. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment dated [DATE], Resident 1 was cognitively impaired and required 2 person physical assist with bed mobility, transfers and toileting. During an observation and interview on 11/26/18 at 10:30 AM, Resident 1 was able to express that she hurt her arm when a NA transferred her from her wheelchair. She denied abuse and was unable to recall additional information. Review of the facility incident/investigation report dated 11/19/18, revealed Resident 1 was being transferred from her wheelchair and was unable to bear weight. The NA student was performing the task unsupervised and lowered the resident to the floor. Resident 1 received a fracture to her left arm. Review of a written statement from Staff L, a local Community College NA Instructor, stated, Student A, NA, stated she did not check Resident 1's care plan. The resident could not bear weight and was lowered to the floor. The NA student was unsupervised at the time of the transfer. Review of the Kardex, a care plan directing the NA how to provide care, directed staff to transfer Resident 1 with a gait belt, a left ankle-foot orthosis (AFO, which was a support intended to control the position and motion of the ankle) and with two people assistance. The Kardex directed staff if the resident was not wearing the AFO, she was to use a sit to stand lift with one person assistance. If the resident refused to wear the leg brace, then staff were to use a sit to stand lift for the transfer. Review of Resident 1's current care plan, copy date 11/26/18, revealed she was care planned for problems of risk for falls, alteration in mobility, history of stroke, alteration in sensory perception, alteration in comfort, and cognitive deficits. The care plan directed staff the resident used a mechanical lift for all transfers. During an interview on 11/26/18 at 12:15 PM, the Director of Nursing Services (DNS) stated the facility's policy was no student was to be alone while performing care to a resident. The student should have either an assigned NA or the college instructor present. At 12:30 PM, Staff K, Resident Care Manager (RCM), stated the resident sustained [REDACTED]. The student did the transfer by herself and the gait belt was observed under the resident's arm pits instead of around the resident's waist. At 3:15 PM, Staff N, Staffing Coordinator, stated she would orient the NA students to the facility and they (the students) had to find items, like a scavenger hunt. Staff N stated the college instructor had been doing the student NA orientation. In a joint interview on 11/26/18 at 3:48 PM, the Administrator and DNS acknowledged the NA student was unsupervised by facility staff or the student's instructor at the time of the incident. The Administrator and DNS confirmed the facility had no policies regarding students in the facility and no documentation of what training was provided to the NA student before performing their clinical at the facility. In a phone interview on 11/28/18 at 8:45 AM, Staff I, NA, stated she was assigned to Resident 1 on the day of the incident. I'm not sure why the NA student was transferring Resident 1, she was not assigned to me or Resident 1. In a phone interview on 11/28/18 at 8:50 AM, Staff J, NA, stated she was assigned to Student A. Staff J stated Student A would go her own direction and not stay with her. Staff J stated Student A did not ask her for assistance with transferring Resident 1. Staff J stated It was known that the students are not to perform transfers by themselves. Multiple attempts have been made to the college NA instructor to interview regarding the incident. As of 12/05/18, the college instructor had not returned any calls. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to implement their Abuse policy and to follow state incident reporting/investigation guidelines for 1 of 3 residents (1) reviewed for potential abuse/neglect. Failure to investigate and report an unexpected resident death had the potential for abuse/neglect to go undiscovered which would preclude the facility from taking necessary corrective actions depending on the results of the investigation. Findings include: Review of the Purple Book reporting guidelines revealed an unexpected death was a type of incident that was required to be reported and investigated. Additional failed practice included the facility failure to include the required information indicated on the model Reporting Log Form seen at Appendix E in the Purple Book. RESIDENT 1 Resident 1 was admitted to the facility on 5/ 16/15 with [DIAGNOSES REDACTED]. Resident 1's POLST form signed 5/16/15 revealed she was a DNR (Do Not Attempt Resuscitation) and indicated if not in cardiopulmonary arrest she would receive full treatment (intubation, advanced airway intervention, transfer to hospital if indicted). On 06/21/17 at 1:15 p.m., the Resident Care Manager (RCM F) stated the facility follows the purple book as part of the Abuse Policy for the facility when investigating allegations. In an interview on 06/21/17 at 1:15 p.m., RCM F stated when a resident's death is unexpected she would review the clinical record and investigate whether appropriate measures had been taken and the facility's procedures were followed and the resident's wishes were honored. On 06/23/17, a review of the facility state reporting log from October 2015 to December 2015 revealed the facility had not logged/reported Resident 1's unexpected death. In an interview and review of the 2015 reporting log on 06/23/17 at 11:55 a.m., the RCM F stated Resident 1's unexpected death was not logged in the 2015 reporting log book. No investigative report was available. This was a past non-compliance immediate jeopardy situation and is no longer outstanding. Reference: WAC 388-97-1640

Based on interview and record review, the facility failed to follow their advance directive policy and ensure a resident's choice was honored for 1 of 3 Residents (1) when choking. Failure to initiate emergency interventions and/or implement Resident 1's documented wishes regarding full treatment and/or transfer to hospital resulted in consequences for Resident 1 who died following a choking episode. Findings include: The facility's policy for Advance Directives dated 2002 indicated the facility would honor residents' advance directives and that the Physician order [REDACTED]. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident 1 was cognitively impaired, inattention and disorganized thinking. The MDS indicted she required extensive assistance of staff for eating and oral hygiene and was on a mechanical altered diet. Resident 1's POLST form signed [DATE] revealed she was a DNR (Do Not Attempt Resuscitation) and indicated if not in cardiopulmonary arrest she would receive full treatment (intubation, advanced airway intervention, transfer to hospital if indicted). The Speech Therapy (SLP) Note dated [DATE] documented to facilitate safe and efficient swallowing, Resident 1 would be required to be in an upright position during oral intake, be provided one bite or sip at a time, have her swallow before adding another bite and alternate liquids and solids frequently. The SLP recommended that Resident 1 continue with PSFP (Progressive Self Feeding Program) and be supervised with oral intake. A nursing progress note dated [DATE] documented Resident 1 continued in PSFP although she frequently refused to go to DR (dining room). The note revealed that she was appropriate for PSFP as she required cueing to slow down and to swallow before taking another bite. The note indicated an attempt was made to upgrade her diet, however SLP downgraded the diet back to a dysphagia mechanical diet as Resident 1 continued to cough after a trial upgrade in diet texture. At this time, the Plan of Care revealed staff would continue to monitor her in PSFP. Review of the Registered dietitian (RD) note dated [DATE] revealed that per discussion with SLP who had worked with Resident 1 extensively in the past indicated Resident 1 was not safe for a texture upgrade due to the potential for [MEDICAL CONDITION] spasms. The RD documented Resident 1 would continue on a dysphagia mechanical diet. The facility's Meal Alternates revealed that if a sandwich, dinner roll or hamburger was served on the menu, a resident who was prescribed a dysphagia mechanical textured diet would not receive the bun, dinner roll or bread. During an interview with the SLP on [DATE] at 10:30 a.m., she stated if a resident is on a dysphagia mechanical diet, no bread should be given to the resident. The progress note dated [DATE] at 1:16 a.m., by a Licensed Nurse (LN) documented she was called to Resident 1's room at 10:40 p.m. The LN documented the resident was coughing and not breathing and turning blue, unresponsive. The note indicated the LN began to suction and bag patient and turning resident onto her side and attempted to clear throat encouraging coughing. Other nurse check code status and it was DNR with advanced interventions. We were able to suction some chunks out of throat. Resident did not return to spontaneous breathing. Heart rate dropped to 0. No heart rate or breathing at 2250 (10:50 p.m). Unable to get any vital signs. On [DATE] the Director of Nursing (DSN) stated that Resident 1 had been given a sandwich and choked. The DNS stated the 2015 Reporting Log revealed there was no documented evidence that the incident had been logged in 2015 to reflect an investigation of the incident ([DATE]). On [DATE] at 3:40 p.m., a family member stated Resident 1 had swallowing issues, had been seen by SLP. The family member stated a staff member had given Resident 1 a sandwich and left the room. The family member stated when the staff member returned Resident 1 was blue so she left the room to find the LN. The LN got a little bit of food when she suction. The family member stated the facility did not call 911. Review of the facility's in service records for 2017 revealed Licensed Nurses (LNs) were informed on [DATE] that if a resident is a DNR and wishes to have intervention, emergency interventions (911) should be activated. The in service informed LNs should a resident who is choking, interventions should be initiated. Only is the resident is discovered without a pulse would CPR (Cardio [MEDICAL CONDITION] Resuscitation) be initiated. Review of the nursing progress notes revealed that the staff did not follow resident's wishes. LNs did not initiate 911 or do [MEDICATION NAME] while Resident 1 was still choking/coughing. This was a past non-compliance immediate jeopardy situation and is no longer outstanding. Reference: WAC [DATE]

Based on interview and record review, the facility failed to provide services in accordance to accepted standards regarding interventions ([MEDICATION NAME] maneuver) when Resident 1 was choking. Failure to immediately initiate emergency (911) services to reverse Resident 1's distress resulted in complications and death. Findings include: The facility's job description for Licensed Nurses (LNs) and Nursing Assistant Certified (NAC) revealed staff would hold a current CPR (Cardiac [MEDICAL CONDITION] Resuscitation) Certification. The facility's policy for Advance Directives dated 2002 indicated the facility would honor advance directive when notified. Part of the facility's policy for Physician order [REDACTED]. The [MEDICATION NAME] maneuver is a first aid procedure used to treat upper airway obstructions (or choking) by foreign objects. The Advanced Critical Life Support (ACLS) recommendation states if you are successful in removing the obstruction, you still need to activate EMS. They may not need to go to the hospital, but it is a good idea to have them evaluated for any unnoticed sequelae to the choking and the [MEDICATION NAME] maneuver. If the obstruction is not removed and the patient passes out, you need to gently lower them to the floor. Open the mouth with the head tilt/ chin lift and look inside. If you can see the blockage, use your forefinger to hook the object and drag it out of the mouth. At this point, you should also check for breathing and a pulse. If there is no pulse, commence with hands only CPR. If there is a pulse but no breathing, you may want to give further thrusts to the abdomen. Straddle the victim and, using both hands, deliver thrusts in and up toward the head. Your hands should be in about the same place as with the standing [MEDICATION NAME] maneuver, and you should hold them in roughly the same configuration as when performing compressions. After five thrusts, check the mouth for the object and remove it if necessary. Also, check for breathing and pulse until the paramedics arrive. The American Heart Association's (AHA) 2010 state is someone is not breathing, or not breathing normally (only gasping), call 911. The progress note dated [DATE] at 1:16 a.m., by a Licensed Nurse (LN) documented she was called to Resident 1's room at 10:40 p.m. The LN documented the resident was coughing and not breathing and turning blue, unresponsive The note indicated the LN began to suction and bag patient and turning resident onto her side and attempted to clear throat encouraging coughing. The note revealed another nurse checked the code status and Resident 1's POLST form indicated a DNR with advanced interventions. The note indicated when Resident 1 was suctioned, chunks were obtained from the throat. The LN documented that Resident 1 did not return to spontaneous breathing. Heart rate dropped to 0. No heart rate or breathing at 10:50 p.m. Unable to get any vital signs, Resident modeling. Even though the resident was discovered coughing and in distress, the LNs did not initiate the emergency system (911). On [DATE] at 12:43 p.m., the restorative NAC (NAC A) who assists resident in PSFP (progressive skilled feeding program) was interviewed regarding Resident 1. NAC A stated Resident 1 required supervision and was not to be left alone when eating. NAC A stated Resident 1 required set up due to her visual impairment and needed supervision as she needed to be reminded to slow down and reminded to swallow a bite of food before taking another bite of food. NAC A stated staff needed to be with her as she could not see portions and would spill items. NAC C stated if Resident 1 would request food when she was in bed, staff needed to remain with her and keep the bed in an upright position. During interviews on [DATE] with NACs regarding residents with altered diets due to swallowing problems, NAC B and NAC C stated if a resident would have a issue with choking or a swallowing issue they would not leave them unattended in room to eat and if a resident required supervision with eating that meant to stay with a resident until the resident finished eating the food. On [DATE] at 2:08 p.m., NAC D stated if a resident requires supervision and or cueing with eating, that means you need to stay with the resident. NAC D stated if a resident was choking, she would perform a [MEDICATION NAME] maneuver, stay with the resident and call for help. NAC D stated precaution for a resident with dysphagia and on an altered diet would include making sure the resident would be upright in bed if eating and to remain upright after eating and remain with that resident to make sure no choking. On [DATE] at 2:13 p.m., LN E stated if a resident is a DNR and was choking you would attempt to suction the resident, initiate 911 (emergency) and notify physician. LN E stated if the POLST form reveals full treatment interventions to alleviate the distress may include the listed interventions (transfer to hospital, airway intervention). On [DATE] at 3:35 p.m., RCM F stated if a resident's POLST revealed DNR and the resident was choking, she would work on the resident and call 911. The staffing for [DATE] was reviewed and two Licensed Practical Nurses (LPNs) and 3 NACs were listed. LN G, LN H, NAC X, NAC Y and NAC Z personnel files were reviewed on [DATE] with facility staff. There was no documented CPR (Cardiopulmonary Resuscitation) certification cards for 2015 found in their personnel files. A facility fax containing CPR/BLS sign-in sheets for 2013 was received on [DATE]. The CPR/BLS sign-in sheets revealed LN G had taught the CPR/BLS classes for the facility. The sign in sheets revealed NAC Z had attended one of the classes. LN H, NAC X, NAC Y's name were not noted on the faxed 2013 sign-in sheets. The Director of Nursing (DNS) indicated LN H had informed her that she had attended one of the CPR/BLS class. This was a past non-compliance immediate jeopardy situation and is no longer outstanding. Reference: WAC [DATE]

Based on interview and record review, the facility failed to ensure a therapeutic diet was provided for 1 of 4 residents who was identified at risk for swallowing problems (1). Failure to implement the appropriate diet texture change placed Resident 1 at risk for complications. Finding included: RESIDENT 1 A Speech Therapist (SLP) note from 7/13/15 to 8/9/15 documented that the goal for Resident 1 was to continue on a dysphagia mechanical diet due to increased [MEDICAL CONDITION] symptoms. Review of the Registered dietitian (RD) note dated 10/2/15 revealed that per discussion with SLP who had worked with Resident 1 extensively in the past indicated Resident 1 was not safe for texture upgrade due to potential for [MEDICAL CONDITION] spasms. The RD documented Resident 1 would continue on a dysphagia mechanical diet. The RD note also documented that the nursing staff had reported Resident 1 had some increased sedation and was adjusting to a new medication ([MEDICATION NAME]). A Nursing Progress Notes dated 10/18/15 documented that Resident 1 had a large coughing episode at dinner, coughing up eggs and increased mucous. The note revealed she was able to clear her airway and had stated that was scary. At this time she was placed on alert charting and her diet was downgraded to a puree. Review of the October 2015 Restorative Dining/Eating Program Foresheets revealed Resident 1 required cueing during meals and had episodes of coughing during oral intake. During an interview on 6/21/17, the Resident Care Manager (RCMP Fé) stated if a resident was assessed to have difficulties managing their current texture of a diet, the nursing staff would downgrade the resident's current diet, send a slip to the kitchen and place the resident on alert charting for 3 days. The Licensed Nurse (LN) would also notify the physician regarding the diet change due to the condition change. RCMP Fé stated prior to upgrading the diet texture, the resident would be evaluated by the LP as LN's are not permitted to upgrade the texture until a LP evaluation if completed. Review of the clinical record with RCM F revealed there was no documented evidence that a diet slip for the downgrade diet (puree) was completed or notification for a LP evaluation for was assessed to need a diet texture change due to coughing on 10/18/15. RCM F stated Resident 1 was last seen by SLP on 7/17/15. On 6/21/17 at 2:55 p.m., during an interview with the Rehabilitation Manager (PTA) stated if nursing downgrades a diet (dysphasia to puree), SLP is notified to perform an evaluation. The PTA stated prior to upgrading a diet texture, the SLP would do a trial diet for safety and the resident would be on alert charting. This was a past non-compliance immediate jeopardy situation and is no longer outstanding. Reference: WAC 388-97-1060

Based on interview and record review, the facility failed to provide necessary diet texture change or implement immediate interventions for Resident 1 who experienced an episode of coughing and distress of choking. Failure to change diet texture placed Resident 1 at risk for repeat coughing episodes and failure to initiate emergency (911) services and/or perform the [MEDICATION NAME] maneuver to reverse Resident 1's distress resulted in complications and death. Findings include: RESIDENT 1 Resident 1 was admitted to the facility on 5/ 16/15 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively impaired and required extensive assistance of two staff for bed mobility and staff assistance for eating and oral hygiene. The MDS documented her weight was 225 pounds and she was on a mechanical altered (texture) diet. Resident 1's POLST form signed 5/16/15 revealed she was a DNR (Do Not Attempt Resuscitation) and indicated if not in cardiopulmonary arrest she would receive full treatment (intubation, advanced airway intervention, transfer to hospital if indicated). The Registered Dietitian (RD) consulting note dated 5/16/15 documented Resident 1 had coughing and decreased swallowing. The note documented she was observed to eat and drink too fast and had increased confusion. The Care Plan was to have Resident 1 on a mechanical altered textured diet with small portions. The SLP (Speech Language Pathologist) evaluation and Plan of Treatment for 5/19/15 to 6/15/15 documented Resident 1 was legally blind and needs to be told what is happening or she gets extremely anxious. The SLP's note further documented Resident 1 had clinical signs & symptoms of dysphagia and assessed her to have increased bolus preparation issues with decreased breakdown of bolus and her vocal quality is wet after swallow and that she tended to eat too fast which increased her risk of choking. The SLP recommendations were to provide Resident 1 with close supervision with food intake with an altered diet texture (dysphagia). The SLP also recommended swallowing strategies which included having the resident in an upright position, small boluses, one at a time, alternate liquids and solids, reduce pace and have meals in the PSFP (Progressive Self Feeding Program). The nursing progress notes dated 7/9/15 revealed Resident 1 was to continue meals in PSFP and indicated she still required cueing to slow down and swallow before taking another bite of food and that she continued to cough after meals. A SLP entry for 7/5/15 documented Resident 1 was observed to continually feed herself multiple small bites into her mouth even though she is still chewing her initial bite of food and that she ends up with a bolus 4-5 times the original bite size and is totally unaware of her intake style and cannot understand what she is doing. The SLP indicated staff were reeducated regarding Resident 1's need for close supervision and direct cueing to intercede with this intake style with direct verbal cues demonstrated. A SLP note from 7/13/15 to 8/9/15 documented that the goal for Resident 1 was to continue on a dysphagia mechanical diet due to increased [MEDICAL CONDITION] symptoms. Review of the Registered dietitian (RD) note dated 10/2/15 revealed that per discussion with SLP who had worked with Resident 1 extensively in the past indicated Resident 1 was not safe for texture upgrade due to potential for [MEDICAL CONDITION] spasms. The RD documented Resident 1 would continue on a dysphagia mechanical diet. The RD note also documented that the nursing staff had reported Resident 1 had some increased sedation and was adjusting to a new medication ([MEDICATION NAME]). A Nursing Progress Notes dated 10/18/15 documented that Resident 1 had a large coughing episode at dinner, coughing up eggs and increase mucous. The note revealed she was able to clear her airway and had stated that was scary. At this time she was placed on alert charting and her diet was downgraded to a puree. Review of the October 2015 Restorative Dining/Eating Program Flowsheets revealed Resident 1 required cueing during meals and had episodes of coughing during oral intake. During an interview on 6/21/17, the Resident Care Manager (RCM F) stated if a resident was assessed to have difficulties managing their current texture of a diet, the nursing staff would downgrade the resident's current diet, send a slip to the kitchen and place the resident on alert charting for 3 days. The Licensed Nurse (LN) would also notify the physician regarding the diet change due to the condition change. RCM F stated prior to upgrading the diet texture, the resident would be evaluated by the SLP as LNs are not permitted to upgrade the texture until a SLP evaluation if completed. Review of the clinical record with RCM F revealed there was no documented evidence that a diet slip for the downgrade diet was completed or notification for a SLP evaluation for was assessed to need a diet texture change due to coughing on 10/18/15. Review of the KARDEX used by nursing assistance revealed that Resident 1's vision was poor, eats in MDS/PSFP and is independently after set up but supervision and cues (prn) are recommended related to dysphagia. The Plan of Care (POC) dated 6/15/15 revealed that due to Resident 1's dementia with poor safety awareness and impaired vision she required supervision and cues (prn-as needed) due to dysphagia. Ensure upright while eating and drinking report any swallow problems to LN and document on her flowsheet. The POC directed staff to monitor for choking, coughing and drooling while eating. Even though the facility noticed a fluctuation in Resident 1's alertness and the need to downgrade diet texture (dysphagia to puree on 10/18/15), there was no documented evidence LNs provided the necessary change in diet texture to avoid possible aspiration risk and/or supervision to decrease her risk of choking. This was a past non-compliance immediate jeopardy situation and is no longer outstanding. Reference: WAC 388-97-1060

Based on observation, interview and record review the facility failed to ensure 1 of 2 (9) wheelchair dependent residents were secured in the facility van. This failure resulted in harm when Resident 9 fell forward out of a w/c when the van stopped and resulted in a right tibia fracture. Additionally the facility failed to assess and ensure 4 of 4 residents (62, 64, 68 and 36) were free from environmental hazards and safety concerns. Resident's were observed to have unsecured medications at their bedside placing them and other residents for ingesting medications. Findings include: RESIDENT 9 On 12/17/15 at 5:30 PM, Resident 9 fell forward out of the wheelchair (w/c) while in the facility van and sustained a right tibia fracture. In an interview and observation at 7:25 PM, Staff D, Activity Director, stated she had assisted eight residents into the facility van for an outing. Two of the residents where in wheel chairs. Staff D stated she loaded and secured Resident 9's w/c in the van by placing four straps from the w/c to the floor of the van. Staff D demonstrated how this was done by placing safety straps on the w/c, then to the van floor and tightening the straps which secured the w/c in place. Staff D stated she forgot to place the seat belt on Resident 9 which would cross over from the resident's left shoulder to the right side to secure the resident in the w/c. When the facility van stopped at the stop light, Resident 9 fell forward out of the w/c and landed face down on the van floor. Staff D did not see Resident 9 fall out of the w/c but another resident told Staff D that Resident 9 had fallen out of her w/c and was on the floor. Staff D stopped the bus and had to call 911 and the facility for assistance. Staff D stated she had received training on how to properly place and secure w/c's in the van. At 7:58 PM, Resident 9 was lying in bed. The resident stated she was going to the hospital after she finished her dinner. Resident 9 stated she fell forward, out of the w/c, when the van stopped and landed on her right leg. The resident stated she did not have her seat belt on when she fell . Review of the chart on 12/18/15 indicated the resident came back from the emergency room with a new right tibia fracture. In an interview at 9:31 AM, the Administrator stated she had trained Staff D on how to position/secure w/c's in the facility van. The Administrator stated Staff D has been removed from loading the facility van until further notice. MEDICATIONS HAZARDS IN RESIDENTS ROOMS Resident 62 Observations of Resident 62 on 12/14/15 at 11:00 AM revealed the resident sitting in a chair in her room. Eye drops, ear drops, and Pepto-Bismol were noted to be on her night stand, by her bed. An empty bottle of Pepto-Bismol was in the trash can. Observations on the same day at 3:51 PM concurred the same medications, with a medicine cup of Pepto-Bismol at the bed side. When interviewed, the resident stated she had an upset stomach. When asked about locking the medications, the resident indicated she did not do that. A review of the resident's record on 12/14/15 indicated a self medication assessment had been completed on 07/16/14. However, the over the counter medications observed at the bedside were not on the year old assessment. Resident 64 Observations and an interview of Resident 64 on 12/17/15 at 10:10 AM revealed the resident sitting in her room with ear drops on her dresser. When asked what the drops were for, she stated it was for her eyes. The resident was interviewed again at 11:00 AM by a different surveyor. Resident 64 again stated the ear drops were for her eyes. A review of the resident's record did not indicate the resident had been assessed to have medications at her bedside. Resident 68 An observation on 12/17/15 at 10:30 AM revealed a bottle of liquid vitamin D and a bottle of Vick's Vapor Rub at the bedside. No assessment was found to indicate the resident was assessed to have these at her bedside. The facility policy and procedure for having medications at the bedside were reviewed on 12/15/15. It stated all medications were to be assessed by the facility and the resident had to safely demonstrate knowledge and safe usage. Additionally, all medications were to be locked at all times in the resident's night stand. Resident 36 During observations on 12/17/15 at 10:20 AM, the resident was observed in bed with a rolling overbed table at the side of the bed. On the table were various personal items and an approximate 7 inch knife. Staff A, the Unit Manager was interviewed the same day at 12:35 PM. She stated That resident has had that knife for as long as I can remember. Staff F, another Unit Manager was unable to locate any assessment to indicate the resident was safe in handling the knife for cutting vegetables brought in by her family.

Based on observation, interview, and record review, the facility failed to provide individualized pain management for one of one resident (Resident 1) who was admitted with an effective pain program in place. Failure to proactively ensure that the facility had immediate access to needed pain medication and failure to be proactive in ensuring that the resident was receiving his medication per his individualized pain management plan caused the resident and his family undue stress. Resident 1 The facility's policy for " Pain Management Overview", dated 11/10, indicated that pain management program is based on the nursing process and includes assessment of pain, develop and implement interventions to manage pain and when pain medications are given, the Licensed Nurses need to monitor the effectiveness. Resident 1 was admitted to the facility on [DATE] at 2:30 p.m. Review of the hospital's history and physical (H&P) revealed the resident had hip surgery 5 days prior to admission and was treated for [REDACTED]. The H&P indicated he was on routine narcotic pain medication twice a day (BID) and a prn (as needed) narcotic pain pill every three hours for his pain management due to his chronic pain and recent acute surgery. The facility's Resident Admission Profile documented that the resident had pain. The facility's pain interview form, dated 7/18/12, indicated that the resident had chronic hip and back pain which he rated as a 8 on a 0 to 10 scale ( 0 being no pain and 10 being very severe or horrible pain). When asked, " Do you have pain or hurting anywhere now." He stated "yes". The resident informed the Licensed Nurse (LN) that his pain is relieved with his prn pain medication ([MEDICATION NAME]) and his current pain management plan was effective. The faxed physician's narcotic prescription order, 7/18/12, for narcotic pain medication, revealed that the resident was to receive routine pain medication BID and his prn narcotic medication every 3 hours as needed for pain. The initial nursing progress note, dated 7/18/12, at 3:00 p.m., documented that the resident was alert and oriented and was able to make needs known. "Request px (pain) rx (prescription)- unavail in e-kit (emergency kit). Pharmacy faxed,...request to satellite". The skilled therapy notes read: pt (patient) demonstrating pain, muscle weakness and decreased functional mobility; pain level 3/10 at rest and 7-8/10 with movement. On 8/14/12, at 11:20 a.m., during an interview with the resident's spouse she stated her husband went without prn pain medication the day of admit to the facility. She stated the LN had informed her that they needed to order the narcotic pain medication. She stated by 4:00 p.m., her husband's pain medication was not available. She stated her husband usually took his prn pain medication 6 times a day in addition to his routine narcotic medication he had twice a day. She stated the LN told her to go home and get his prn pain medication. She stated she had gone home and got his prn narcotic medication and returned to the building and gave her husband his narcotic pain medication. On 9/17/12 at approximately 9:30 a.m., a telephone interview was done with Resident 1. He stated he needed a pain pill at 4:00 p.m., but the facility did not have the pain medication. The nurse told his wife to go home and get my pain medication. His wife went home and got his pain medication. The resident stated that in order to control his pain he took routine medication twice a day and needed his prn [MEDICATION NAME] every 3 hours. He stated, "If they can't get it (medications), they shouldn't say they can". During an interview with the Director of Nursing on 9/25/12, she verified that the admit orders for medications were faxed to Resident 1's physician on 7/18/12 at 2:28 p.m., and the physician had faxed a signed prescription for narcotic pain medication which was faxed to the facility on [DATE] at 12:56 prior Resident 1's arrival to the facility. Review of the nursing notes and prn medication pain management flow sheet did not indicate that the resident had received his prn medication as ordered every 3 hours nor was there indication that they had checked with the resident specifically about his pain. The pain flow sheet indicated the resident received his prn narcotic medication at 9:05 a.m. and 3:00 p.m. on 7/19/12. But did not indicate that he had received or been offered medication during the night. On 9/25/12, the Licensed Nurse (LNA) who provided care for the resident on 7/18/12 was interviewed. Upon review of Resident 1's record she verified that she had administered Resident 1's routine narcotic at 9:00 p.m. that night. She stated "if he did not ask for one (prn pain medication), he wasn't given one". The facility failed to ensure they continued Resident #1's routine pain program that had proven effective in managing his acute and chronic pain.

Based on observation, interview and record review, the " no smoking " facility failed to recognize their responsibility to ensure the safety of 2 of 3 residents (121 and 104), who resumed active smoking habits while residing in the facility. When aware the residents were smoking, the facility failed to do timely assessments of each resident ' s ability to smoke safely. When the assessments were completed and the facility determined the residents were unsafe to smoke without supervision, the facility failed to ensure these residents were provided with a safe place to smoke and had appropriate supervision while smoking. In addition, when Resident 121 was found by facility staff with cigarette ashes on her lap after smoking, the facility failed to recognize the increased danger for burns this represented for this resident, and did not put appropriate preventative interventions in place to address this. These failures placed the residents at imminent risk for harm from injury while smoking. On 7/13/12, this was determined to constitute an immediate jeopardy situation. Additionally, the facility failed to ensure 1 of 7 resident's (48) reviewed for accidents received adequate supervision to ensure safety measures interventions were consistently implemented. The facility also failed to ensure potential liquid hazards were stored in a secure location, to store over the counter medications in an area not easily assessable to residents and failed to monitor the locking of a door located at the entrance to a boiler room. These failures placed Resident 48 at risk of harm during a fall, and placed facility residents at risk for exposure to medications, dangerous chemicals, and/or harmful temperatures. Findings include: SMOKING RESIDENT 121 Resident 121 was admitted [DATE] with [DIAGNOSES REDACTED]. Her admission orders [REDACTED]. The resident was wheelchair dependent for mobility. A review of the resident's record revealed the facility was aware that Resident 121 continued to smoke after her admission to the facility. Both nursing and the social service staff documented in the progress notes that the resident struggled in her efforts to stop smoking and continued to smoke despite the resident's use of a nicotine patch. Although aware of the resident's continued smoking, the facility did not do a timely assessment of her ability to smoke safely. Once the facility assessed the resident as being unsafe to smoke unsupervised, they failed to ensure the resident had a safe place to smoke and failed to provide the supervision for the resident that she was assessed as needing. According to a social service progress note, dated 5/22/12, the resident had cigarettes and matches in her room. That same day, staff added to the resident's care plan that the resident was smoking while wearing a nicotine patch and that staff explained the risk and benefits of doing this to the resident. Review of progress notes found documentation that the resident continued to go outside to smoke. On 5/30/12, social services recorded the resident was observed by staff smoking alone outside. On 6/28/12, a nurse recorded in the progress notes, " The resident stated she is just not ready to quit smoking. " On that same day a LN wrote, " Resident is known to exit facility property to smoke. The resident was reminded that she had agreed not to smoke prior to facility admission. The resident stated she remembered that and was doing what she had agreed. When the nurse asked her where she got her cigarettes from, the resident stated from a family member. The nurse documented that she told the resident she needed "to confiscate " the cigarettes. The nurse removed a pack of cigarettes with 2 butts and a lighter from the resident's room. The LN continued, "The resident verbally agreed not to smoke. " Another LN progress note, dated 7/2/12, read, "Resident outside off property smoking, came back into the facility with ash on her clothing, no burn marks, no holes on clothing. Appears resident may need to have someone with her even off property. " The LN documented that at that time (two months after admission), a Smoking Safety Assessment was completed for the resident. A review of the facility's Smoking Safety Evaluation for Resident 121, dated 7/2/12, revealed the resident was assessed to need supervision when smoking, due to her allowing ashes to fall on her clothing. The resident's care plan was revised to include a statement that read, "The resident is not to have smoking paraphernalia in facility, if found notify LN. The resident is to be observed after returning from out of the building for ash or burn holes on clothing & hands. " The resident' s revised care plan did not mention the need for supervision to ensure the resident's safety while she was smoking. A subsequent nursing noted written on 7/2/12, read, "The resident has befriended another resident who also goes off property to smoke with a friend...appears resident will be going with other resident and (named friend), whom is keeping the resident's smokes". The named "friend" was a non-related individual who lived in the neighborhood and had met the resident while she was outside smoking. On 7/8/12, a LN's progress note stated that a call was received by a staff member, who was not on duty at that time, but "just happened to drive by" and saw Resident 121 outside the facility smoking by herself. When the LN went to speak with the resident, the resident was found in her wheelchair by the street between the facility and a house next door. The resident stated the "friend" next door lit her cigarette, then went back into the house to answer a phone call. On 7/11/12 at approximately 12:30 p.m., as the surveyors left the facility, the resident was observed outside in her wheelchair alone, with her back to the road. The resident was located across the road from the facility, sitting at the corner of a cross side street that ran beside the facility. Her wheelchair was parked at the entrance to the ramp leading to the sidewalk, with her back wheels in the street. The area where the resident was sitting was not visible from facility or the facility parking lot due to bushes and evergreens located around the parking lot. The unsupervised resident's safety was also at risk due to the location where she was seated. On 7/12/12, a LN's progress note indicated the Resident was found outside alone, down the street by fire hydrant smoking and talking on the cell phone. The LN wrote, "She is not to be out smoking off property without someone with her due to her coming back with ash on her clothing. Resident stated, named friend lit her cigarette, and went home. " Another progress note dated 7/12/12, stated that when the DNS asked the resident if she had any smoking paraphernalia on her person, the resident "pulled out a green tube with a cigarette and a pink lighter. " The Resident was also found to have a cigarette inside a box on her bed. At 4:35 p.m. that same day, an interview was conducted with the DNS and Staff B, a Licensed Nurse. When asked if the resident was provided the risks and benefits of smoking, and for smoking without supervision, Staff B stated, " The resident knew it was a non-smoking facility prior to coming into the facility, however, we haven't been able to find the form she signed showing she was informed. " When asked who had been supervising the resident while she was smoking, the DNS stated that a friend of another resident usually supervised the resident and kept her cigarettes. When asked if this " friend " was educated by facility staff about smoking safety measures including not leaving the resident unsupervised while the resident smoked, the DNS answered, " No ". When asked if the facility had provided supervision after the resident's smoking assessment showed she was unsafe to smoke without supervision, the DNS stated, "No, we are a non- smoking facility and the resident is smoking off the premises. " RESIDENT 104 Record review revealed Resident 104 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was wheelchair dependent. On the day of admission to the facility, the resident signed the facility's no-smoking policy form, in which the resident agreed not smoke during her stay, either in the building or on the grounds. It was also indicated that she understood smoking paraphernalia would not be allowed on the property. In an interview with Resident 104 on 7/13/12 at 1:00 p.m., she stated she had done pretty well with not smoking for a few days after first being admitted to the facility. As she became more anxious she wanted to smoke. The resident stated she asked the administrator about it and he told her it was okay as long as she smoked off the premises and she did not bring smoking items into the building. She said she then smoked outside off the property many times. Even though the facility had knowledge the resident was actively smoking, they did not assess her ability to safely to do so without supervision at that time. According to a licensed staff progress note, dated 6/4/12 , the Director of Nursing Services (DNS) and the nurse manager (RCM) spoke with the resident regarding the resident's tendency to also go outside of the facility at night alone to smoke. The resident had requested the facility's outside door remain unlocked at night in order for her to get back into the facility after smoking. The DNS explained the risks and benefits, including the safety risk for all residents if the facility door was not locked at night. On 6/28/12 (over 3 months after her admission to the facility), staff completed a Smoking Safety Evaluation for Resident 104. It read, "Resident is alert and oriented to person, place and time, and takes narcotics at times may not make good decisions. Resident has limited range of motion in her right lower leg and the resident has left hand numbness at times. Resident self propels her wheelchair. The resident's medications include narcotics, hypnotics, anti-anxiety medications and muscle relaxants. Smoking habits: many years, smokes off property, no ashtray, will need supervision secondary to all narcotics psychotropic's and muscle relaxants as well has complaints of left hand numbness ...Resident had neighbor friend whom keeps her smokes and comes to take her. Plan is staff to monitor resident not out smoking on her own, give her risk and benefits, ask to return to building and if she had smoking items on her and document " . On 6/28/12, the resident's careplan was updated with the following: "If resident goes outside to smoke or not, Licensed nurse (LN) is to go check if by self, if smoking res is unsafe d/t(due to) narcotic use. If outside alone ask if she has cigarettes, if so is to hand over to licensed staff. Interventions also included no smoking allowed on facility property. Cigarettes, lighters, matches, and all smoking paraphernalia not allowed on person or premises. Notify licensed staff of violating smoking policy. Violating smoking policy could result in 30 day notice of intent to discharge. Administrator is aware of violation of smoking agreement. " A Licensed staff nursing progress note, dated 6/28/12 read, " New care plan implemented. If resident goes outside to smoke or not LN is to go check if she is by herself. If smoking then resident is unsafe due to narcotic use and needs to come into building ...resident currently outside with friend. " The careplan did not include a plan to provide the resident a safe place to smoke or safe supervision while the resident was smoking. A later nursing progress note written on that same day (6/28/12) read, " Resident continues not to follow facility smoking policy... Resident goes out on sidewalk, in front of the building and smokes often with friend ...who resident states keeps her cigarettes. ...Due to amount of narcotics and muscles relaxants and her peripheral neuropathy puts resident at risk for sleepiness, which makes her safety questionable to be outside off property smoking by herself, as well her peripheral neuropathy makes her at risk for numbness in her hands as documented in 5/26/12 progress note, and her legs. This makes her at risk for inability to hold a cigarette and at that point increases the risk of getting burned. Therefore resident is not safe to smoke without someone accompanying her off the property...resident care manager and minimum data assessment LN went out to where resident was smoking off property on side walk south corner of driveway. No butts, but lots of ashes in the grass. There were no ashtrays. " On 7/2/12, in a progress note the night licensed staff documented that the resident had received her sleeping pill at 10:30 p.m. and had a narcotic pain pill at 11:30 p.m. , after which the " Resident left building with friend at midnight and was seen in the south parking lot smoking with friend. " A review of the resident's sign in and out sheets from 6/23/2012 to 7/12/12 found the resident had intermittently signed out of the facility to smoke at 10:00 p.m. or later. On 7/2/12 evening licensed staff documented, " This resident and another resident have befriended each other and ...(friend) is taking them off property to smoke as well as a new person (named person) was also out with this resident while she was smoking. On 7/10/12 a licensed progress note read, " This RCM notified the administrator that this resident had a can of butane setting inside her wheelchair. administrator spoke with resident butane given to administrator." In a social service progress note, written for 7/11/12, it was documented that the " Resident had smoking paraphernalia (butane fluid) in her room, administrator aware and will follow-up. The DNS and administrator were interviewed on 7/12/12 at 1:45 p.m., regarding the how the resident was being supervised while smoking. The DNS stated "the friend" came and got the resident to smoke and kept the resident's cigarettes. When asked if the staff had discussed the need to stay with the resident while smoking with the friend, the DNS stated they had not. The administrator said the friend had not been talked to because the resident was smoking off the facility premises. They both also stated they did not know anything about the friend other than what the resident told them. According to a progress note in the resident's clinical record dated 7/12/12, the facility issued the resident a 30 day notice for discharge due to non-compliance with the no smoking policy. The Administrator confirmed he had issued the 30-day notice for discharge. In an interview with the resident on 7/13/12 at 1:45 p.m., the resident stated she was just coming in the door from the outside when the butane was found on her chair. " I had forgotten it was there, I had helped my friend fill up the lighter then sat it down on my chair. I didn't even make it in the door. " RESIDENT 48 Resident 48 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to resident ' s 14 day Minimum Data Set (MDS) assessment, dated 6/12/12, the resident had a recent history of falls prior to her admission to the facility. The MDS assessment indicated the resident had memory loss and required extensive assistance with toileting, bed mobility, transferring, and ambulation. The resident ' s fall risk plan of care/safety plan, dated 5/29/12, indicated a goal for the resident was for her to have " No injury with falls " . Interventions to meet that goal included: low bed at all times, use of a personal alarm while in bed and the wheelchair, staff to provide safety checks on the resident every 2 hours, to assist the resident with toileting before and after meals and as needed, and to ensure the resident wore non-skid socks at all times. On 7/9/12, at approximately 11:00 a.m., the resident was observed lying in bed with the bed at normal height not in low position. A fall mat (a padded mat used beside a bed to reduce injury in case of a fall) was observed folded up, upright and leaning against the end of the resident ' s bed. On 7/11/12 at 10:57 a.m., Resident 48 was again observed in her bed. The height of the bed remained at a normal not low height and the fall mat was observed completely under the bed. The resident had a personal alarm in place. The resident was observed to be restless, and the caregiver answered the resident ' s sounding alarm twice in a 20 minute period. The first time the caregiver answered the alarm, the resident was asked what she needed. When the resident did not respond the caregiver showed her the call light and reminded her to use it. The caregiver did not move the fall mat from under the bed and the height of the bed was not adjusted by the caregiver to the lowest position, as was indicated in the resident ' s plan of care. The plan of care did not mention use of a fall mat. According to a facility incident report, the resident had a fall from her bed on 7/13/12 that resulted in a bump on the resident ' s head. The investigation report indicated the resident was found on the floor at the end of her bed, the fall mat was in place. The facility incident report further documented the personal alarm was not on the resident and had not sounded when the resident got up. It was documented that the resident had a history of [REDACTED]. On 7/17/12, at 9:10 a.m., the resident was observed in bed. Her bed was in the low position, approximately knee high, and a fall mat was positioned at the resident ' s bedside. On 7/20/12, the licensed nurse, (Staff A), stated Resident 48 had a previous admit to the facility and had a history of [REDACTED]. " When readmitted to the facility, staff implemented the following fall precautions immediately. The resident was placed in a room closer to the nursing station, her bed was to be kept in the low position, the resident was to have a personal alarm, and a fall mat was to be kept in place beside the resident ' s bed. When asked to clarify when the fall mat intervention was put into place Staff A stated, " I think we put the fall mat into place when she was readmitted because of her history. " LIQUID HAZARDS During observations in the main dining room on 7/9/12 at 10:55 a.m., four bottles of alcohol, one bottle of shampoo, and two bottles of lotion were found unsecured in the cupboard above a sink. A warning label located on all the bottles warned "keep away from children". Observations at 12:10 p.m. that same day revealed 22 residents in the dining room. Staff and several residents were observed to open the cupboard doors and retrieve items. Observations on the same day at 2:30 p.m., 3:15 p.m., and 4:20 p.m. showed the bottles of liquids remained in the cupboard. At 4:22 p.m., Staff A, a Resident Care Manager was shown the items by a surveyor. When asked if the liquids should be located there, the RCM replied, "No". I have no idea how they got there because they can be dangerous". The bottles were then removed. BOILER ROOM DOOR On 7/9/12, at approximately 11:40 a.m., the entrance door to the broiler room containing the facility ' s two boilers (hot water heaters) was observed to be unlocked. The entrance was located in the 300 hallway, and a key was hanging on a cord just outside the boiler room. The door remained unlocked throughout the day and residents were observed going up and down the hallways past the boiler room. None were observed attempting to open the boiler room entrance. On 7/9/12, at 5:25 p.m., the Administrator stated the entrance to the boiler room was to be kept locked at all times. He said the door of the boiler room automatically closed and locked when the door closed. Upon accompanying the surveyor to the boiler room entrance, the Administrator turned the knob on the door and the door opened. A key was not used to open the door. The Administrator stated the door was supposed to be locked and the key was hanging beside the door to remind staff that it should be kept locked. The Administrator locked the door. When asked if the residents would have been in danger had they entered the boiler room, the Administrator stated, " If a resident got in there and they were able to get to the pilot light that could be a problem. "

Based on observation, interview and record review, the facility failed to administer services effectively and efficiently in order to ensure each resident received the necessary care and services to attain, and/or maintain, their optimal level of physical, mental and psychosocial well-being. The "non-smoking facility" admitted and retained at least 3 residents who actively smoked. Failure to provide a safe smoking area with staff supervision for 2 residents (104 & 121), who were assessed by the facility as being as being unsafe to smoke independently, placed both residents at imminent risk for harm from injury while smoking. On 7/13/12, this was determined to be an immediate jeopardy situation, which was abated on 7/24/12. In addition, the facility failed to ensure adequate Registered Nurse staffing levels to ensure safe supervision of resident care and services. Findings include: Residents 104 and 121 were both assessed by the facility as needing supervision while smoking due to their medical conditions and physical functioning levels. However, even after the facility identified smoking hazards for these residents, the facility continued to require that the residents go off the facility property to smoke and did not ensure their smoking was safely supervised. Refer to CFR 483.25(h) , F-323, Accidents and Supervision