Every finding on record at Auburn Post Acute

Based on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 4 (Q4, October 2025, November 2025, December 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services. Findings included .<CMS-Electronic Staffing Data Submission PBJ>Review of the June 2022, CMS Long-Term Care Facility PBJ Policy Manual, showed long term care facilities were required to electronically submit direct care staffing information based on payroll and auditable data. The data, when combined with the census information can be used to not only report on the level of staff in each nursing home, but reports staff turnover and tenure, that can impact the quality of care delivered at the facility. The policy manual showed the facility must electronically submit complete and accurate information by the required deadline to include; direct care staff, the category of work for each direct care staff member, resident census data, and direct care staff turnover and tenure. Review of a 06/15/2026 facility October 2025 -December 2025 HPRD discrepancy report showed an issue was identified with the facility total nursing hours reported by the facility payroll system. The payroll system was inaccurate by 1606.80 hours due to extra break times being deducted from employee hours and an employee who did not have a CMS job title code and hours were not counted.During an interview on 06/17/2026 at 11:47 AM Staff A (Administrator) stated an issue was identified with the facility payroll software that did not correctly carry over licensed nurse and certified nursing assistant total hours. Staff A stated if the codes were carried over correctly the facility would have met the 3.4 HPRD and they would expect correct and accurate census and staffing hours to be reported. REFERENCE: WAC 388-97-1090(1)(2)(3)

Based on observations, interview, and record review, the facility failed to ensure the kitchen environment was sanitary and the meal service followed the requirements in accordance with professional standards of food safety for 1 of 1 facility kitchen observed. The failure to ensure: (1) the kitchen ceiling was kept clean and intact; (2) cabinets had working doors and drawers; (3) garbage/trash receptacle had a lid or was covered; and (4) proper food handling practice was observed to avoid cross-contamination placed residents at risk for ingesting unsafe and/or contaminated food and the development of foodborne illness.Findings included <Facility Policy>The facility policy titled, Food Preparation and Service, revised April 2019, showed food and nutrition services staff prepared and served food in a manner that complied with safe food handling practices to prevent the spread of foodborne illness. The policy showed appropriate measures were used to prevent cross-contamination including wearing gloves when handling food directly and changing them between tasks. <Kitchen Ceiling Panel>Observation on 04/29/2026 at 8:20 AM showed the kitchen ceiling panels above the dishwasher area had dry, brown-stained water marks. A panel was observed missing which exposed mechanical drains and pipes covered with dust build-up and spider webs. There were clean/sanitized kitchen utensils in dish trays from the dishwasher below the exposed ceiling.In an interview on 04/29/2026 at 8:22 AM, Staff V (Dietary Supervisor) stated the maintenance department fixed a leaking pipe in the ceiling at one point but did not put the panel back. Staff V stated the ceiling should be covered for sanitation purposes.<Non-Closing Cabinet Drawers And Doors>Observation on 04/29/2026 at 8:44 AM showed multiple kitchen cabinets that contained clean utensils used for food preparation and service had drawers and doors that did not fully close. The drawers and doors had failed magnetic locks and worn-out drawer tracks.In an interview on 04/29/2026 at 8:47 AM, Staff V stated that they notified both administration and the maintenance department regarding the status of the kitchen cabinets. Staff V stated it was important for the kitchen cabinets to be in good working condition to ensure equipment and utensils stored inside them remained clean and free from any contamination.<Food Waste Disposal Equipment/Garbage Bins>Observation and interview on 04/29/2026 at 8:54 AM showed multiple scattered chunks of food waste/debris along the dishwashing area; two bins were half-filled with food scraps and garbage. The two bins were observed without a cover/lid. Staff X (Kitchen Cook) stated the kitchen's food waste disposal unit was not working so all food scraps were physically thrown in garbage bins. Staff X stated the bins should be covered for sanitation purposes and to avoid the risk of contaminating clean dishes/utensils.In an interview on 04/29/2026 at 9:01 AM, Staff V stated the food waste disposal unit was broken for months and the administration was aware of its condition. Staff V stated, We [kitchen staff] need to be sanitary with all our processes at all times.<Tray Line Meal Service>Observation on 05/05/2026 at 12:13 PM during lunch service showed Staff W (Kitchen Cook) sliced the chicken using a fork and knife with their gloved hand, grabbed the pieces that fell along the tray line, and tossed them in the garbage. Staff W smeared chicken residue on the next clean plate with their contaminated gloves and continued on with their task without removing their gloves, washing their hands, and switching out the plate.Observation on 05/05/2026 at 12:28 PM showed Staff W picked up the chicken using a pair of tongs and the meat juice dripped across uncovered foods and into the macaroni and cheese casserole pan. At 12:35 PM, Staff W lifted the metal pan containing blended broccoli and the liquid accumulation underneath the submerged pan touching the steam table dripped across the other uncovered blended foods.In an interview on 05/06/2026 at 9:15 AM, Staff W stated they should have removed their gloves and wash their hands after handling the chicken and in between tasks, but they did not. Staff W stated they should not use contaminated plates when dishing out food to ensure residents did not get sick to their stomach or trigger any food allergies. Staff W stated they should pay more attention to foods that drip and be mindful when removing metal pans from the steam table during meal service.In an interview on 05/06/2026 at 9:23 AM, Staff V stated cross-contamination during meal service could cause negative health outcomes including foodborne illness.REFERENCE: WAC 388-97-1100 (3), -2980.

Based on interview and record review, the facility failed to ensure and designate a qualified staff person to serve as an Infection Preventionist (IP). This failure placed residents at risk for unmet infection control issues and prevented a lack of overside of the facility staff's infection control practices.Findings included.In an interview on 05/05/2026 at 1:07 PM, Staff M (Wound Nurse/Infection Preventionist) stated they were the current IP for the facility and had held the IP position for a week. Staff M stated the previous IP recently left the position and the facility was working to hire a permanent person. Staff M stated they did not have the required infection prevention and control certification. In an interview on 05/06/2026 at 10:00 AM, Staff B (Interim Director of Nursing) confirmed they had oversight over the IP role. Staff B confirmed Staff M did not have the required infection prevention and control certification. Refer to F880 – Infection Prevention and Control Refer to F881 – Antibiotic Stewardship Program Reference: (WAC) 388-97--1620(2)(b)(i)(ii).

Based on observation, interview, and record review, the facility failed to ensure all portions of the communication system were functioning and adequately equipped to allow residents to call for staff assistance to a centralized staff work area from each resident's bedside for 2 of 2 nursing units (North Unit and South Unit) and from toileting areas for 2 of 2 first floor bathrooms (Bathrooms 1 & 2) reviewed for call light system. The facility failed to ensure staff responded timely to residents' call lights and the pull cord at each bathroom was accessible to a resident lying on the floor in case of an emergency. These failures placed residents at risk for delayed care, pain or discomfort, and a decreased quality of life.Findings included.<Facility Policy>The undated facility policy titled, Call Lights: Accessibility and Timely Response, showed the facility ensured the call system alerted staff members and channeled to a centralized staff work area. The policy showed the staff would report problems with a call light or the call system immediately to the supervisor and/or maintenance director and would provide immediate or alternative solutions until the problem was remedied or resolved. The policy showed all staff members who saw or heard an activated call light were responsible for responding. The policy showed the call system must be accessible to the resident lying on the floor at each toilet and bath/shower area.<North and South Units>Observation on [DATE] at 8:36 AM showed the audible sound from the call system turned on but the call system panel at the nurse station did not have any resident room lighted up. Hallway observation showed the call light above room [ROOM NUMBER] was up; Staff GG (Registered Nurse) and Staff HH (Certified Nursing Assistant) were observed sitting at the nurse station; both staff looked at the call system panel, did not respond to the audible sound, and proceeded to do their task in the computer. At 9:18 AM, this surveyor approached the nurse station and validated room [ROOM NUMBER]'s call light that remained on for more than half an hour with Staff GG. Staff GG stated the button assigned to room [ROOM NUMBER] from the call light panel was missing and the call system was malfunctioning for months. The call light panel was observed to be missing several buttons dedicated to resident rooms for proper identification and response. Staff GG stated they would notify the maintenance department regarding room [ROOM NUMBER]'s call light that was not working.In an observation and interview on [DATE] at 9:20 AM, Resident 71, who was the resident in room [ROOM NUMBER]-1, stated they turned on their call light because their stomach was hurting. Resident 71 was observed bent over, guarding their abdomen, with facial grimacing, and was catching their breath while talking despite having supplemental oxygen on via a nasal tube. Resident 71 stated it took staff at least half an hour or longer to answer their call light.Observation on [DATE] at 9:10 AM showed the call light above room [ROOM NUMBER] was on but it did not light up or register the resident's call in the panel at the nurse station.Observation on [DATE] at 9:25 AM showed the call light above room [ROOM NUMBER] was on but it did not light up or register the resident's call in the panel at the nurse station.Review of the facility's [DATE] through [DATE] maintenance logs showed: On [DATE], the call light in room [ROOM NUMBER] was reported not working and the response written in the log showed, [Part of] a big project. On [DATE], the call light in room [ROOM NUMBER] was reported not working and the response written in the log showed, Working with vendor. On [DATE], the call light in room [ROOM NUMBER]-2 was reported not working and the response written in the log showed, Vendor. On [DATE], the call light in room [ROOM NUMBER] was reported not working and the response written in the log showed, Vendor. On [DATE], the call light in room [ROOM NUMBER] was reported not working and the response written in the log showed, Vendor. On [DATE], the call light in room [ROOM NUMBER] was reported broken and the response written in the log showed, Replaced call box. On [DATE], the call light in room [ROOM NUMBER]-1 was not working and the response written in the log showed, Vendor. There logs did not show Staff GG reported Resident 71's (room [ROOM NUMBER]-1) malfunctioning call light.Observation and interview on [DATE] at 8:37 AM showed Resident 71's call light was still malfunctioning; the light above the room door was blinking faintly and it had a broken, high-pitched audible sound. The call system panel at the nurse station was observed still without a button labeled for room [ROOM NUMBER]. Staff M (Wound Nurse/Infection Preventionist) confirmed room [ROOM NUMBER]'s did not have a dedicated button in the panel and stated the call light system remained defective.In an interview on [DATE] at 8:42 AM, Resident 51 in room [ROOM NUMBER]-1 stated it took longer than 30 to 40 minutes for staff to respond to their call light and the resident referred to the North Hall as a ghost town.In an interview on [DATE] at 8:44 AM, Resident 55 in room [ROOM NUMBER]-2 stated they got used to staff not responding to their call light in a timely manner and highlighted night shift as the worst, .at night, forget it.it would take more than an hour for them [staff] to come.In an interview on [DATE] at 8:49 AM, Resident 35 in room [ROOM NUMBER]-1 stated often they saw staff walk by their room two to three times after turning on their call light, but staff would not come in to help them. Resident 35 stated, at one point, they asked their roommate in bed two to turn on the call light from their side of the room because they felt their call light was not working. Resident 35 stated it was difficult for them when staff did not respond timely especially when they were in pain, needed water for hydration, or had bladder discomfort and needed staff to check their urinary catheter.In an observation and interview on [DATE] at 8:59 AM, Staff KK (Medical Records Coordinator), who was observed at the nurse station, confirmed the panel's buttons for rooms [ROOM NUMBERS] did not light up to alert the staff. Staff KK stated the call light malfunction was not ideal and posed as a safety risk for residents.In an interview on [DATE] at 9:13 AM, Staff HH stated it was important to have a functional communication system because it helped them respond faster to residents in need especially during emergent cases such as a fall. Staff HH stated both ends of the North Hall turn around the corner and it was difficult for staff to see the light above the door of those resident rooms. Staff HH stated the audible sound produced when a call light was turned on could come from either the North or South Hall, so it was challenging when buttons on the panel assigned specifically to a resident's room were not working.In an interview on [DATE] at 10:10 AM, Staff R (Maintenance Director) stated vendor meant the call light malfunction was irreparable at their level and required a third-party vendor to fix it. Staff R stated the staff notified them of resident care-related work orders by writing the concern(s) identified in the maintenance log binder located at the South Hall nurse station. Staff R reviewed the maintenance logs and stated there was no call light work order request for room [ROOM NUMBER].In an interview on [DATE] at 10:32 AM, Staff A (Administrator) stated they were aware the facility's call system was malfunctioning and needed repair or replacement.<First Floor Bathrooms 1 & 2>Observation on [DATE] at 10:08 AM showed both bathrooms located on the first floor were locked and did not have a door handle from either the inside or outside. The call light pull cords attached to the metal plate on the wall sticking out was observed to be about half an inch long for both bathrooms.In an interview on [DATE] at 1:19 PM, Resident 47 stated staff instructed them to use the bathroom in their room because the main floor restrooms were for staff and visitors only. Resident 47 stated this negatively impacted their ability to comfortably attend meals and activities on the main floor because they were required to return to their room for bathroom use.In an interview on [DATE] at 11:20 AM, Staff G (Administrator In-Training) stated residents could not use the main floor restrooms due to non-functional call lights creating a safety risk.In an interview on [DATE] at 9:44 AM, Staff A stated the residents were allowed to use the first floor bathrooms. Staff A stated both bathrooms were kept locked since the call light system inside was malfunctioning. Staff A stated the call light pull strings observed from both bathrooms were not accessible to a resident lying on the floor as required.Refer to F584- Safe/Clean/Comfortable/Homelike Environment.REFERENCE: WAC 388-97-2280(1)(a).

Based on observation and interview, the facility failed to ensure residents were provided a safe, homelike environment for 2 of 2 units (North Unit and South Unit) and safe accessible use of 2 of 2 bathrooms (first floor public bathrooms 1 & 2). The failure to ensure resident rooms were free of wall scrapes, floor thresholds, broken window blinds, unpleasant stains, and safe accessible bathrooms placed residents at risk for a less than homelike environment and a diminished quality of life. Findings included .<Facility Policy>According to the facility's undated Safe and Homelike Environment policy, the facility would provide a safe, clean, comfortable, and homelike environment in good repair to maximize resident comfort and independence. <North Unit> Observation and interview on 04/29/2026 at 10:51 AM showed Resident 15's room blinds had broken slats. Resident 15 stated it had affected their sleep quality since the actual break was at their eye-level when lying in bed. In an interview on 05/06/2026 at 12:03 PM Staff R (Maintenance Director) identified the broken blinds and stated they should be replaced. <South Unit> Observation on 04/29/2026 at 10:00 AM showed a dark stain covering two ceiling tiles above Resident 6's window. In an interview at that time, Resident 6 stated they had a leak in their ceiling. Observation on 04/30/2026 at 10:30 AM showed missing flooring thresholds between the hallway and resident rooms #245 and #247. Push levers were missing from wall-mounted hand sanitizer dispensers across from the second-floor elevator and inside room [ROOM NUMBER]. Observation on 05/01/2026 at 10:17 AM showed the staining on the ceiling tiles remained. In an observation and interview on 05/06/2026 at 12:05 PM, Staff R stated they were aware of the stained ceiling tiles and stated there was a previous leak in the ceiling that was repaired. Staff R confirmed the ceiling tiles should be replaced. Staff R stated they expected staff to document daily repair needs in the maintenance log binder located at the nursing station. Staff R stated they toured the facility daily and addressed repair needs listed in each unit binder. After touring the facility, Staff R stated the missing door thresholds and broken hand sanitizer dispensers should be identified by nursing staff and entered in the maintenance log binder but were not. In an interview on 05/06/2026 at 12:35 PM Staff B (Interim Director of Nursing) stated they expected nursing staff to identify and list repair needs in the unit maintenance binder. Staff B stated this ensured timely correction of environmental concerns and maintained a safe, functional, and homelike environment for residents. <Bathrooms 1 & 2> Observation of 05/01/2026 at 12:16 PM showed the emergency pull cords were missing from the wall mounted call light devices in bathrooms #1 and #2 on the main floor. In an interview on 05/04/2026 at 1:19 PM Resident 47 stated staff instructed them to use the bathroom in their room because the main floor restrooms were for staff and visitors only. Resident 47 stated this negatively impacted their ability to comfortably attend meals and activities on the main floor because they were required to return to their room for bathroom use. In an interview on 05/05/2026 at 11:20 AM Staff G (Administrator In-Training) stated residents could not use the main floor restrooms due to non-functional call lights creating a safety risk. In an interview on 05/06/2026 at 1:09 PM Staff S (Receptionist) stated leadership instructed staff that the main floor bathrooms were unavailable to residents due to excessive resident use resulting in decreased availability to staff and visitors. During an observation and interview on 05/06/2026 at 1:11 PM Staff A (Administrator) stated the main floor bathrooms were available to all residents. Call light pull cords were absent in both bathrooms. Staff A tested the call lights by activating the wall switch, which illuminated a ceiling light outside the bathroom; however, no audible alarm sounded. Call lights identified as R11 and R12 illuminated on the second-floor nurse call panel but were not clearly audible on the panel or in the bathroom area. Refer to F919- Call Lights. REFERENCE: WAC 388-97-0880.

Based on interview and record review, the facility failed to follow the required discharge process for 3 of 6 residents (Residents 84, 55, & 8) reviewed for hospitalizations. The failure to inform residents of the facility's bed hold (a process by which a resident can pay a daily rate to ensure they can return to the same bed when they readmit) policy placed residents at risk for losing their right to return to their bad and frustration.Findings included .<Facility Policy>According to the facility's 04/28/2025 Bed Hold Notice policy, the facility would provide residents and/or their representative with a bed hold notice as soon as practical for emergent discharges and at the time of therapeutic leave for scheduled procedures. The policy showed residents could choose to pay a daily rate if they wished to ensure they returned to the bed they had prior.<Resident 84> In an interview on 04/29/2026 at 1:47 PM, Resident 84 stated they recently needed to go out to hospital unexpectedly but did not recall the reason why or when they went out. Resident 84 stated they did not recall if they were informed of the facility's bed hold policy at that time. According to a 02/19/2026 progress note, Resident 84 went to the hospital on [DATE]. A 02/23/2026 progress note showed Resident 84 returned to the facility on [DATE]. Record review showed no progress note or any other documentation indicating the facility discussed their bed hold policy with Resident 84 as required. In an interview on 05/06/2026 at 12:44 PM, Staff C (Resident Care Manager) stated there was an issue with bed holds at the time the resident went to the hospital and it was likely this process did not occur for Resident 84. Staff C stated they would provide any documentation showing the bed hold policy was reviewed with Resident 84. No further documentation was provided. <Resident 55> In an interview on 04/30/2026 at 9:55 AM, Resident 55 stated they were hospitalized for a surgery and did not recall being offered a bed hold. According to a 01/29/2026 Interdisciplinary progress note, Resident 55 went to the hospital on [DATE] for a surgery and was expected to return to the facility the following week. A 02/23/2026 progress note showed Resident 55 returned to the facility. Record review showed no progress note or any other documentation indicating the facility discussed their bed hold policy with Resident 55 as required. In an interview on 05/06/2026 at 12:39 PM, Staff C stated they would provide any documentation showing the bed hold policy was reviewed with Resident 55. No further documentation was provided. <Resident 8> The 02/08/2026 Discharge Minimum Data Set (MDS – an assessment tool) showed Resident 8 discharged to a short-term general hospital. The MDS showed Resident 8 had memory problems and impaired daily decision-making. A 02/13/2026 Entry Tracker MDS showed Resident 8 was admitted back to the facility. Review of Resident 8's medical records showed the resident's family member was delegated as the Durable Power of Attorney (DPOA) for Financial/Healthcare. In an interview on 04/29/2026 at 2:23 PM, Resident 8 stated they remember being sent to the hospital from the facility but could not recall exactly when. Resident 8 stated they did not know if their DPOA was informed of the facility's bed hold policy. According to a 02/08/2026 progress note, Resident 8 was observed very weak, sluggish, and with delayed responses. The note showed the staff notified the physician and received the order to send Resident 8 to the emergency department for further evaluation. In an interview on 05/06/2026 at 1:05 PM, Staff F (Social Services) stated the nursing staff on the floor was responsible for the bed hold policy notification. Staff F stated the admissions coordinator would follow up if the bed hold notification was not done onsite such as during an emergent hospital transfer/discharge. In an interview on 05/06/2026 at 2:36 PM, Staff C (Resident Care Manager) confirmed the nurses on the floor were responsible for offering the bed hold policy to residents and/or their representative(s). Staff C stated a bed hold notification was important because it was a resident's right to be informed and it was necessary for financial decision-making. Staff C reviewed Resident 8's medical records and stated there was no documentation found to support a bed hold was offered to Resident 8 or their DPOA. REFERENCE: WAC 388-97-0140(1)(a)-(c)(i)-(iii).

Based on interview and record review, the facility failed to complete resident assessments within the regulatory timeframes for 10 of 14 residents (Residents 15, 84, 18, 11, 2, 35, 38, 44, 55, & 6) reviewed for comprehensive assessments and timing. The failure to ensure comprehensive admission and Annual Minimum Data Set (MDS - an assessment tool) assessments were completed timely delayed the residents' care planning process necessary to provide the appropriate care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life.Findings included.<Facility Policy>The undated facility policy titled, MDS 3.0 Completion, showed residents were assessed using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary Care Plan (CP). The policy showed an admission MDS was completed within 14 days of admission, counting the day of admission as day #1.<Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual>The October 2023 RAI Manual outlined an Annual MDS was a comprehensive assessment for a resident and must be completed on an annual basis. The manual showed the completion date of an Annual MDS must be no later than 14 days after the Assessment Reference Date.<Resident 15>Review of Resident 15's 02/14/2026 admission MDS showed the resident admitted to the facility on [DATE]. The assessment showed the Registered Nurse (RN) Coordinator completed the assessment on 03/03/2026, nine days past the required regulatory timeframe.<Resident 84>Review of Resident 84's 02/06/2026 Annual MDS showed the RN Coordinator completed the assessment on 02/28/2026, nine days past the required regulatory timeframe.<Resident 18>Review of Resident 18's 12/20/2025 admission MDS showed the resident admitted to the facility on [DATE]. The assessment showed the RN Coordinator completed the assessment on 01/03/2026, five days past the required regulatory timeframe.<Resident 11>Review of Resident 11's 12/22/2025 admission MDS showed the resident admitted to the facility on [DATE]. The assessment showed the RN Coordinator completed the assessment on 01/06/2026, eight days past the required regulatory timeframe.<Resident 2>Review of Resident 2's 12/19/2026 Annual MDS showed the RN Coordinator completed the assessment on 01/02/2026, one day past the required regulatory timeframe.<Resident 35>Review of Resident 35's 01/10/2026 Annual MDS showed the RN Coordinator completed the assessment on 01/30/2026, seven days past the required regulatory timeframe.<Resident 38>Review of Resident 38's 01/21/2026 Annual MDS showed the RN Coordinator completed the assessment on 02/09/2026, six days past the required regulatory timeframe.<Resident 44>Review of Resident 44's 02/02/2026 admission MDS showed the resident admitted to the facility on [DATE]. The assessment showed the RN Coordinator completed the assessment on 02/22/2026, seven days past the required regulatory timeframe.<Resident 55>Review of Resident 55's 01/09/2026 Annual MDS showed the RN Coordinator completed the assessment on 01/30/2026, eight days past the required regulatory timeframe.<Resident 6>Review of Resident 6's 02/04/2026 Annual MDS showed the RN Coordinator completed the assessment on 02/22/2026, five days past the required regulatory timeframe.In an interview on 05/05/2026 at 7:50 AM, Staff O (MDS Nurse) stated they use the RAI manual as their guide in completing MDS assessments. Staff O stated it was important to ensure comprehensive resident assessments were completed timely because it was a federal regulatory requirement for Nursing Homes. Staff O stated timely MDS completion allowed the interdisciplinary team to catch significant changes in residents necessary for care planning. Staff O stated the CP derived from these assessments should reflect the resident's current and actual state or condition so the nursing staff could provide safe and appropriate care. Staff O verified the comprehensive assessments of Residents' 15, 84, 18, 11, 2, 35, 38, 44, 55, & 6 and stated they were all completed late.In an interview on 05/05/2026 at 7:58 AM, Staff B (Director of Nursing) stated they expected the RN Coordinator to complete comprehensive MDS assessments timely as required.REFERENCE: WAC 388-97-1000(1)(b)(c)(ii)(d), (3)(a).

Based on observation, interview, and record review, the facility to ensure Care Plans (CPs) were developed and implemented as required for 5 of 19 sample residents (Residents 35, 55, 15, 9, & 48) whose CPs were reviewed. The failure to ensure CPs were comprehensive, resident-specific, and implemented placed residents at risk for unmet care needs, inappropriate care, and frustration.Findings included .<Facility Policy>According to the facility's undated Comprehensive CP policy, the facility would develop and implement a comprehensive, person-centered CP for each resident to meet each resident's medical, nursing, mental, and psychosocial needs and all services needed. <Resident 35> According to the 04/10/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 35 had diagnoses including a history of stroke, a nerve condition making bladder control more difficult, and a blockage in their urinary tract making voiding more difficult. The MDS showed Resident 35 required an indwelling urinary catheter (tubing to assist with urinary drainage). The MDS showed Resident 35 needed partial assistance with toileting. Record review showed a 04/29/2026 order to change Resident 35's catheter as needed. Observation on 04/29/2026 10:51 AM showed Resident 35 in bed with their catheter hung on their bed frame. At that time Resident 35 stated they needed more consistent catheter care, including emptying their catheter. Review of the 01/27/2026 Catheter CP showed no directions were included to assist Resident 35 to empty their catheter. Review of Resident 35's Kardex as of 04/29/2026 (care instructions for nurses' aides) showed no directions were included to Resident 35's catheter. In an interview on 05/05/2026 at 11:18 AM Staff C (Resident Care Manager) stated it was nurses' aides' responsibility to empty Resident 35's catheter. Staff C stated directions to empty the catheter bag should be on the CP and Kardex. <Resident 55> According to the 02/06/2026 Quarterly MDS, Resident 55 was dependent on staff for toileting assistance and was always incontinent of bowel. In an observation and interview on 04/30/2026 at 9:20 AM, Resident 55 stated they frequently had diarrhea. At that time, Resident 55 was observed in bed with both legs amputated and their bed raised in a high position. Record review showed Resident 55 had a 04/11/2024 physician's order for a probiotic supplement. This order indicated the probiotic should be taken twice a day for diarrhea. Review of Resident 55's CP showed no CP developed to address Resident 55's diarrhea and probiotic supplement use. The only mention of diarrhea in the CP was as a potential side effect of a medication used to treat a different condition. In an interview on 05/06/2026 at 2:38 PM Staff B (Director of Nursing) stated the purpose of a CP was to ensure the appropriate care was provided to residents for their wellbeing and safety. Staff B stated it was important for CPs to address all residents' treatment needs. Staff B stated they expected CPs to comprehensively address residents' care needs. <Resident 15> According to the 02/14/2026 admission MDS, Resident 15 had clear speech, intact memory, and medical conditions including the loss of bladder control and with limited range of motion to their extremities. The MDS showed Resident 15 had an indwelling urinary catheter in place during the assessment period. The MDS showed Resident 15 was assessed to require substantial/maximum assistance with their personal hygiene including shaving. The 04/29/2026 urinary catheter CP showed a privacy cover would be used to ensure Resident 15's dignity. Observation on 04/30/2026 at 9:38 AM showed Resident 15's catheter bag was hanging from the garbage can next to the bed, halfway full, and without a privacy cover as care planned. The revised 04/20/2026 Activities of Daily Living (ADL) CP showed Resident 15 had self-care performance deficits because of functional/mobility impairment, limited range of motion, and pain. The CP directed staff to provide Resident 15 one-person physical assistance with their personal hygiene and grooming needs. Observation on 04/29/2026 at 10:32 AM showed Resident 15 had matted and unruly hair; their beard and mustache were observed long and with several white debris woven in from the resident's dry, peeling facial skin. Resident 15 stated the staff did not provide them any assistance with their grooming/personal hygiene as care planned. In an interview on 05/06/2026 at 11:17 AM, Staff B stated following the CP was important because it ensured the staff understood residents' condition/status as a whole to be able to properly and safely care for them. Staff B stated they expected all staff to implement the interventions listed in the CP. <Resident 9> According to the 03/24/2026 Quarterly MDS, Resident 9 primarily spoke Vietnamese language, was rarely understood by others, and had medical conditions including weakness, joint pain, and memory impairment. The MDS showed Resident 9 was assessed to require moderate to maximum staff assistance with dressing. The revised 04/17/2026 ADL CP showed Resident 9 had self-care performance deficit because of their functional/mobility deficits and directed staff to provide the resident one-person physical assistance with their dressing/undressing needs. Observations on 04/29/2026 at 1:50 PM and 04/30/2026 at 8:21 AM showed Resident 9 was wearing the same yellow t-shirt and was not provided staff assistance with dressing/changing their clothes as care planned. Observations on 04/30/2026 at 8:49 AM and 05/01/2026 at 12:26 PM showed Resident 9 was wearing the same brown, long-sleeved top and was not provided staff assistance with dressing/changing their clothes as care planned. In an interview on 05/01/2026 at 12:42 PM, Staff C stated they expected the nursing staff to implement interventions identified for residents when providing ADL care according to the CP. <Resident 48> According to a 12/19/2025 Quarterly MDS, Resident 48 admitted to the facility on [DATE] with medical conditions including a progressive brain disease with memory deficits, high blood pressure, and malnutrition. The MDS showed Resident 48 needed substantial/maximal assistance with rolling from left to right, from sitting to standing, and with transfers. The MDS showed Resident 48 was assessed to be at risk for developing pressure ulcers/injuries. Review of the revised 03/11/2026 skin CP showed Resident 48 was at risk for skin breakdown because of their fragile skin. A 11/12/2026 CP intervention instructed staff to encourage and assist Resident 48 with repositioning for comfort and pressure relief. In a continuous observation on 05/01/2026 at 7:40 AM, Resident 48 was seen sitting in their tilt-in-space wheelchair (a mobility device with the ability to recline), tilted back at an 80-degree angle in the hallway outside the resident's room. From 7:42 AM until 8:36 AM, Resident 48 was observed eating their breakfast while sitting in their wheelchair in the hallway outside their room. At 8:37 AM immediately following breakfast, Resident 48 was toured around the facility in their wheelchair by a staff; Resident 40 remained sitting at an 80-degree angle in their wheelchair. From 8:40 AM until 8:52 AM, Resident 48 sat in their tilt-in-space wheelchair in the hallway outside their room and remained in the same position. At 8:53 AM, Resident 48 was offered to go to activities and was brought to a waiting area by the facility elevator. At 9:47 AM, Resident 48 was still sitting by the elevator waiting for a staff member to take them to activities. At 9:50 AM, a staff came and brought Resident 48 to activities. From 9:50 AM until 10:10 AM, while in activities, Resident 48 kept the same position while sitting in their wheelchair. At this time, more than two hours had passed from 7:40 AM to 10:10 AM where Resident 48 remained sitting in their wheelchair in the same position and there was no staff observed encouraging or offering the resident any pressure relief intervention or repositioning assistance as care planned. In an interview on 05/01/2026 at 11:42 AM, Staff Z (Certified Nursing Assistant) stated Resident 48 should be repositioned every two hours to prevent skin breakdown. In an interview on 05/06/2026 at 10:19 AM, Staff C stated they expected the staff to follow resident CPs. Staff C stated Resident 48 should have been offered repositioning assistance every two hours as part of the facility's standards of care for dependent residents, but was not. In an interview on 05/06/2026 at 1:30 PM, Staff B stated it was important to encourage and offer repositioning assistance to residents who could not do it independently to provide comfort and prevent skin breakdown. Refer to F677- ADL Care Provided for Dependent Residents. Refer to F690- Bowel/Bladder Incontinence, Catheter, UTI. REFERENCE: WAC 388-97-1020(1)(2)(a)(b).

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 3 of 5 residents (Residents 9, 15, &1) reviewed for ADLs. The failure to provide dressing assistance (Resident 9) and personal hygiene/grooming needs (Residents 15 & 1) left residents at risk for body odors, unmet care needs, diminished feeling of self-worth, and a decreased quality of life.Findings included .<Resident 9> According to the 03/24/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 9 primarily spoke Vietnamese language, was rarely understood by others, and had medical conditions including weakness, joint pain, and memory impairment. The MDS showed Resident 9 was assessed to require moderate to maximum staff assistance with dressing. The revised 04/17/2026 ADL Care Plan (CP) showed Resident 9 had self-care performance deficits because of functional and mobility impairment. The CP directed staff to provide Resident 9 one-person physical assistance with their dressing and undressing needs. Observation on 04/29/2026 at 1:50 PM showed Resident 9 was observed in their room lying in bed and wearing a yellow t-shirt. Observation on 04/30/2026 at 8:21 AM showed Resident 9 was observed in their room sitting up in the wheelchair while eating breakfast; the resident was still wearing the same yellow t-shirt observed from the day before. At 8:49 AM, Staff J (Certified Nursing Assistant - CNA) came to the room, changed Resident 9's yellow t-shirt to a brown, long-sleeved top with black print, and wheeled the resident out of the room. Observation and interview on 05/01/2026 at 12:26 PM showed Resident 9 was touring the first floor main dining area in their wheelchair with Staff MM (CNA). Resident 9 was observed still wearing the brown, long-sleeved top with black print from the day before. Staff MM stated they were the morning shift staff assigned to Resident 9. Staff MM stated they did not change Resident 9's clothes when they got the resident up from bed. In an interview on 05/01/2026 at 12:42 PM, Staff C (Resident Care Manager) stated it was important to provide dependent residents' ADL assistance to enhance their sense of dignity and quality of life. Staff C stated they expected the nursing staff to provide Resident 9 morning and evening care, which included changing the resident's clothing, to ensure the resident felt clean and comfortable. <Resident 15> According to the 02/14/2026 admission MDS, Resident 15 had clear speech and intact memory. The MDS showed Resident 12 had medical conditions including a motor vehicle accident resulting in their inability to voluntarily move or feel the lower parts of their body. The MDS showed Resident 15 was assessed to require substantial/maximum assistance with their personal hygiene including shaving. The revised 04/20/2026 ADL CP showed Resident 15 had self-care performance deficits because of functional/mobility impairment, limited range of motion, and pain. The CP directed staff to provide Resident 15 one-person physical assistance with their personal hygiene needs. Observation and interview on 04/29/2026 at 10:32 AM showed Resident 15 had matted and disheveled hair; their beard and mustache were observed long and with several white debris woven in from the resident's dry, peeling facial skin. Resident 15 stated, I feel like a caveman. Resident 15 stated they need staff assistance to help them shave their beard and mustache safely. Resident 15 stated they wanted a haircut badly. Observations on 04/30/2026 at 1:04 PM and 05/01/2026 at 1:05 PM showed Resident 15 remained with unkempt hair, and long beard and mustache. In an interview on 05/01/2026 at 1:30 PM, Staff HH (CNA) confirmed Resident 15 needed personal hygiene assistance with shaving their beard and mustache. Staff HH stated the facility's shower aide was responsible for shaving residents (as residents would allow) during bath days. In an interview on 05/01/2026 at 1:55 PM, Staff A (Administrator) stated the activities department was in charge of scheduling outside services for residents who wanted a haircut because they used to, but did not have salon services in-house at the moment. In an interview on 05/04/2026 at 10:31 AM, Staff C validated Resident 15's ADL care concerns and stated they expected the nursing staff to provide residents personal hygiene and grooming assistance they were assessed to require for safety. <Resident 1> According to the 04/02/2026 Quarterly MDS, Resident 1 admitted to the facility on [DATE] and had medical conditions including heart failure and history of a stroke. The MDS showed Resident 1 required substantial/maximal assistance with personal hygiene including combing their hair and shaving. Review of Resident 1's 06/27/2025 ADL CP showed the resident had self-care deficits and required one person physical assistance for personal hygiene. The CP did not show if the resident preferred to keep their hair or facial hair short or long. In an interview and observation on 04/29/2026 at 1:50 PM, Resident 1 was lying in bed in a hospital gown. Resident 1's hair was observed to be greasy, long, and unkempt and their beard extended several inches past their chin. Resident 1 stated they would like to get a haircut and did not have a haircut since their admission to the facility, nearly one year ago. Observation on 05/04/2026 at 8:35 AM showed the facility had a designated barber shop area. A clipboard hanging on the wall showed a list of residents who wished to have barber shop services. The list was dated 02/13/2026 and Resident 1's name was not listed. In an interview on 05/05/2026 at 9:11 AM, Staff II (CNA) stated the facility used to have a beautician, but they left a while ago. Staff II stated they were not sure what the facility's process was currently for when a resident wanted a haircut. In an interview on 05/06/2026 at 1:15 PM, Staff A stated the facility did not have a barber since 02/2026 and that the facility was working to hire someone. Staff A stated they did not have anyone in the facility providing haircuts but they should assist residents to get their haircut outside of the facility when appropriate. In an interview on 05/06/2026 at 1:22 PM, Staff JJ (Activities Supervisor) stated they were working to hire someone to perform haircuts at the facility. Staff JJ stated the facility did not have a current process for coordinating or tracking which residents wanted a haircut. Refer to F656- Develop/Implement Comprehensive Care Plan. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to: ensure the main entrance to the facility was safely accessible to all residents for 1 of 1 main entrances, failed to ensure sharps containers were emptied before becoming a hazard for 3 of 4 nurse carts, and failed to provide sufficient fall management for 2 of 4 (Residents 24 & 40) residents reviewed for falls. These failures placed residents at risk for injury, blood borne pathogen exposure, avoidable falls, and other negative health outcomes.Findings included .<Facility Policy>According to the facility's 10/05/2025 Fall Management policy, the facility would assess residents upon admission/readmission, quarterly, with a significant change in condition, and with any fall events for fall risk. The policy showed residents would be assessed for fall indicators upon admission, readmission, quarterly, change in condition, and with any fall. <Front Doors> Observation on 05/05/2026 at 12:21 PM showed the facility's main entrance had twin doors that opened to the outside. When the ADA (Americans with Disabilities Act) Operators (square metal, easy-to-press buttons placed by the doors to enable residents with disabilities to pass through the door safely) located on the interior side of the entrance was pressed, neither door opened. The exterior button also failed to open either door. At that time, Staff S (Receptionist) was seated at the front desk with a kiosk arrangement In an interview at that time Staff S stated the ADA Operator was broken for some weeks and that they helped residents in wheelchairs or other mobility needs pass through the door when they wanted to come in or out. Staff S stated some of the residents could squeeze themselves through the door when there was no one at the front desk. Staff S declined to answer if that was a safe arrangement and stated they believed the was a work order for the Operator repair. Observation at 05/05/2026 12:25 PM showed Resident 77 coming down the hall from the front door toward the elevator using a wheelchair. In an interview at that time Resident 77 stated the front door used to work but it no longer did. Resident 77 stated they felt cheated by the inconvenience. Observation on 05/06/2026 at 8:25 AM showed Resident 74 in a wheelchair, typing in the code to the twin doors. The doors did not open automatically, and the resident required assistance to have the door opened so they could exit the facility. In an interview at that time, Resident 74 stated they could not open the door by themselves. Review of the facility's maintenance book on 05/06/2026 at 8:28 AM showed nothing logged regarding the functionality of the ADA Operators on the front door. In an interview on 05/06/2026 at 8:30 AM, Resident 37 stated they used the facility's front door independently, but it was a pain to use the door now the ADA Operators did not work. Resident 37 stated the door was heavy and a pain to use as they needed to pass through in their wheelchair. Resident 37 stated they told the facility of the issue, but it was not yet fixed. Observation on 05/06/2026 at 8:54 am showed Resident 22 sitting in a specialized wheelchair at the front door. Resident 22 entered a code in the keypad and attempted to activate the ADA Operator. The door did not open automatically. Resident 22 attempted to use a second button next to the door and the door did not open automatically. Resident 22 stated they used their wheelchair to physically push the door open, but doing so did not feel safe. Resident 22 stated the ADA Operators did not work for a couple of months. In an interview on 05/06/2026 at 1:15 PM, Staff R (Maintenance Director) stated they began working at the facility in February 2026, and the door/ADA Operators had issues going back further than that. Staff R stated there was a lot of management turnover at that time but in March/April 2026, they and Staff A (Administrator) began seeking bids for repair In an interview on 05/06/2026 at 8:36 AM, Staff A Staff A acknowledged the ADA Operators to the main entrance were not working. Staff A stated there was not dedicated staff responsible to assist residents with mobility issues through the doors while the ADA Operators were broken but either the receptionist or the security officer was in that area for all but four hours of the day. Staff A stated there was not a specific process to assure resident safety while the ADA Operators were inoperative. Staff A stated they had an estimate from a vendor to repair the ADA Operators. Staff A provided emails between the facility and the vendor. Review of the emails between the facility and a vendor discussing the need to repair the ADA Operators showed an estimate was provided on 04/03/2026. The estimate for repair was valid until 05/04/2026. In an interview on 05/06/2026 at 12:15 PM Staff A acknowledged the facility allowed the estimate to lapse to repair the ADA Operators but they discussed the situation again with the vendor that morning and were now waiting for the part(s) to arrive. Staff A stated once the parts were available, repair would be quick. <Resident 40> According to the 01/15/2026 Quarterly MDS, Resident 40's cognitive status was unable to be assessed. The MDS showed Resident 40 had diagnoses including a fracture, inability to control blood sugar levels, and stroke. The MDS showed Resident 40 had impairment to one of their upper extremities and had a fall since their prior assessment. Review of a 12/31/2025 nursing progress note showed nursing staff documented Resident 40 had a fall on 12/31/2025 at 4:00 PM. The resident was walking with their walker and another staff member witnessed Resident 40 start to fall and assisted the resident to the ground. Review of the 12/31/2025 facility's fall investigation report showed the resident was walking with their walker when they felt their feet letting go. The resident was assisted to the ground by a nurse. Resident 40 reported their walker was faulty and that the brakes were not working. The fall investigation did not include documentation showing staff reassessed Resident 40's fall risk. Review of Resident 40's evaluations tab on 05/06/2026 showed no documentation staff reassessed Resident 40's risk for falls during the time of the fall on 12/31/2025. In an interview on 05/06/2026 at 11:32 AM, Staff D (Resident Care Manager) stated the facility process was to complete a new fall assessment with each resident fall. Staff D reviewed Resident 40's records and confirmed a fall assessment was not completed after the resident's fall on 12/31/2025. In an interview on 05/06/2026 at 1:15 PM, Staff B (Interim Director of Nursing) reviewed Resident 40's fall investigation and records and confirmed an updated fall assessment was not completed by staff but should be. <Resident 24> According to the 02/13/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 24 had medical conditions including Multiple Sclerosis (a progressive, debilitating disease causing numbness, vision loss, and extreme fatigue), a brain injury with resulting muscle weakness to one side of their body, and memory impairment. The MDS showed Resident 24 had limited range of motion to both their upper and lower extremities and required substantial/maximum staff assistance with bed mobility. The MDS showed Resident 24 was under hospice (end of life) care and a significant change assessment was completed for the resident. The revised 06/18/2024 fall Care Plan (CP) showed safety devices were put in place and a 09/14/2023 intervention instructed the nursing staff to follow the facility's fall protocol. Observation and interview on 04/29/2026 at 1:45 PM showed Resident 24 had their bed against the wall; there were bilateral mobility rails in place and a blue mat was on the floor next to Resident 24's bed. Resident 24 stated they had a fall but could not recall exactly when, and that they were scared of everything around them. Review of the 03/22/2022 fall risk assessment upon Resident 24's admission showed the resident was identified to be high fall risk. The fall risk assessment log showed Resident 24's fall risk was not consistently assessed by the facility; there was no fall risk assessment observed to be completed when Resident 24 had a significant change in condition and was admitted to hospice care on 11/06/2025. Review of the 04/27/2026 investigation report after Resident 24 sustained a fall showed the facility identified the root cause of the resident's fall was from rolling out of their bed during repositioning. Review of the 04/27/2026 safety devices assessment showed the facility did not capture Resident 24's recent history of rolling out of the bed (as the identified root cause of the resident's most recent fall) to consider as a fall risk factor and ensure resident safety. In an interview on 05/05/2026 at 10:02 AM, Staff C (Resident Care Manager) stated they should have captured Resident 24's identified risk factors when completing the resident's 04/27/2026 safety device assessment to prevent reoccurrence of falls, but they did not. In an interview on 05/05/2026 at 2:02 PM, Staff B (Director of Nursing) reviewed Resident 24's fall risk assessments log and stated they were untimely and incomplete. Staff B stated they expected the nursing staff to conduct fall assessments per their facility protocol to prevent falls from reoccurring and avoid negative outcomes. <Sharps Container> In an observation on 05/01/2026 at 11:13 AM a sharps container on North Long-Term Care (LTC) nurses' cart was filled past the fill line. In an observation and interview on 05/01/2026 at 11:20 AM Staff B (Director of Nursing) verified the sharps container was over-filled and stated the container should have been changed. Staff B stated the over-full sharps container presented a risk of exposure to used needles and infection control concerns. In an observation on 05/05/2026 at 11:10 AM a sharps container on South LTC nurses' cart was filled past the fill line. In an observation and interview on 05/05/2026 at 11:11 AM Staff Y (Registered Nurse) verified the sharps container was over-filled and stated that the containers are usually changed on night shift. Staff Y stated it was important to change the sharps containers for staff safety as it is important to have a safe place to dispose of used needles. In an observation on 05/05/2026 at 11:15 AM a sharps container on South LTC Nurses' cart was filled past the fill line. In an observation and interview on 05/05/2026 at 11:31 AM Staff L (Registered Nurse) verified the sharps container was over-filled and stated it should be replaced prior to being over-full so that staff can dispose of used needles safely. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to ensure urinary catheters were maintained according to professional standards of nursing (tubing used to facilitate bladder drainage) for 2 of 3 residents (Residents 35 & 15) reviewed for urinary catheter. The failure to ensure catheter bags were placed correctly and emptied as needed placed residents at risk for infection, discomfort, and other negative health outcomes. Findings included .<Facility Policy>According to the facility's 03/03/2025 Catheter Care policy, the facility would ensure residents with indwelling catheters received appropriate catheter care. The policy showed catheter bags should be emptied when half full. The policy showed catheter bags should be kept below bladder level to prevent backflow but did not discuss if it was acceptable for the catheter bag to be placed on the floor.<Resident 35> According to the 04/10/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 35 had diagnoses including a history of stroke, a nerve condition making bladder control more difficult, and a blockage in their urinary tract making voiding more difficult. The MDS showed Resident 35 required an indwelling urinary catheter. Recorded review showed the following physician orders related to Resident 35's catheter care: a 04/29/2026 order to change the indwelling catheter and drainage bag as needed for blockages, soiling, and dysfunction; a 01/02/2025 order to change Resident 35's catheter dressing daily and keep the tubing secured with to their leg or thigh at all times, and ensure the catheter tubing did not pull from Resident 35's body. According to the 01/27/2026 catheter Care Plan (CP) Resident 35 had goals to be free of urinary infections and catheter-related trauma. The CP showed nursing staff should check for kinks and monitor Resident 35 for pain and discomfort. The CP did not direct nursing staff to empty the catheter bag either periodically or as needed, or to ensure the catheter bag remained off the floor. Record Review showed Resident 35's Kardex (resident-specific care directions for nurses' aides) as of 04/29/2026 did not include instructions to empty the catheter or ensure it did not lie on the floor. In an interview on 04/29/2026 at 10:51 AM Resident 35 stated they had a concern with the catheter care provided by the nursing staff. Resident 35 stated their concern was the frequency the catheter bag was emptied by staff and the associated health risks. At that time Resident 35's catheter was suspended above the floor with a hook on the bedframe and was mostly empty. Observation on 05/01/2026 at 1:47 PM showed Resident 35's catheter bag was completely full with eight inches of urine visible in the tubing connected to the top of the bag. The bag was not hung on the bedframe with a hook and rested on the floor beneath the resident's bed. Observation on 05/04/2026 at 10:01 AM showed the catheter bag was resting on the floor. At 10:03 AM, a nurses aide came to assist Resident 35 in bed and did not notice the catheter bag on the floor. On 05/04/2026 11:52 AM catheter bag was still not hooked to the bed and was placed on the floor and was again observed on the floor at 12:36 PM. In an interview on 05/05/2026 at 7:55 AM, Resident 35 stated there could be an issue with the catheter bag as a staff member told them yesterday there was urine on the floor. Observation on 05/05/2026 at 10:41 AM showed Resident 35's catheter bag was again on the floor. In an interview on 05/2026 at 11:18 AM, Staff D (Resident Care Manager - RCM) stated Resident 35 was at risk for Urinary Tract Infection (UTI) due to their indwelling catheter status. Staff D stated catheter bags should be emptied before they became completely full and before urine backed into the tubing for infection control purposes and to minimize the risk of UTI. Staff D stated nursing aides should complete these tasks. At this time Staff C (RCM) stated directions to empty the catheter bad should be included on the Kardex and CP and stated that catheter bags should be hung and not resting on the floor. In an interview on 05/06/2026 at 2:38 PM, Staff B (Director of Nursing) stated they expected catheter bags to be kept off the floor for infection control reasons. <Resident 15> According to the 02/14/2026 admission MDS, Resident 15 had medical conditions including loss of function/mobility from their waist down to their feet, loss of bladder control, urinary retention, and recurrent Urinary Tract Infection (UTI). The MDS showed Resident 15 had an indwelling urinary catheter in place during the assessment period. The 04/29/2026 urinary catheter CP showed a privacy cover would be used to ensure Resident 15's dignity. Review of Resident 15's physician orders showed a 04/14/2026 order directing staff to empty the catheter bag every shift four times a day because the resident was at high risk for UTI. The order showed the staff must ensure Resident 15's catheter bag was emptied without exception. Observation and interview on 04/30/2026 at 9:38 AM showed Resident 15's catheter bag was hanging from the garbage can next to the bed, halfway full, and without a privacy cover. Resident 15 stated there were several instances where their catheter bag would be full and the staff did not empty it as they should. Resident 15 stated they had to call staff for their catheter bag to be emptied. Observation on 05/04/2026 at 10:13 AM showed Resident 15's catheter bag was full and sitting on the floor next to the bed, still without a privacy cover in place. In an interview on 05/04/2026 at 10:15 AM, Staff GG (Registered Nurse) verified Resident 15's catheter bag was full, sitting on the floor, and without a privacy cover. Staff GG stated nursing staff should have emptied the catheter bag, kept it off the floor, and put it inside a privacy bag but they did not. In an interview on 05/04/2026 at 10:22 AM, Staff C (RCM) stated they expected the nursing staff to empty Resident 15's urinary catheter bag as ordered, ensure it was not left sitting on the floor for infection control, and provide a privacy cover/bag for resident dignity. Refer to F656- Develop/Implement Comprehensive Care Plan. REFERENCE: WAC 388-97-1060(3)(c).

Based on observation, interview, and record review the facility failed to ensure narcotic logs were maintained in a manner which preserved original documentation and accurate controlled substance accounting for 1 resident (Resident 18), ensure expired medications were discarded timely and refrigerator temperatures were logged for 1 of 1 medication storage rooms (Medicare Medication Room) and 2 of 4 medication carts (Long term care south medication cart and Medicare south medication cart) reviewed for medication storage, and failed to ensure the treatment cart was secured for 1 of 1 treatment carts. This failure placed residents at risk of receiving incorrect or expired medications, ineffective treatment, and diminished quality of life.Finding included.<Facility Policy>According to the facility's undated Medication Storage policy the facility would store all drugs and biologicals in a locked compartment, ensure only authorized personnel had access to locked compartments, and store all medications according to manufacturer's recommendations. The facility would maintain controlled substance accounting in an accurate, legible, and traceable manner. This policy showed all medications requiring refrigeration were stored in the refrigerator and temperatures would be maintained within 36-46 degrees Fahrenheit. The policy showed charts would be kept on each refrigerator and temperatures would be recorded daily by the charge nurse or other designee. The policy showed all medication rooms were routinely inspected for discontinued, outdated, defective, or deteriorated medication and these medications would be destroyed. <Narcotic Log> According to the 03/22/2026 Quarterly Minimum Data Set, Resident 18 had diagnoses of chronic pain. Review of the archived January/February 2026 Narcotic Ledger for Resident 18 on page 109 showed the medication label for a liquid opioid indicated a starting quantity of 400 milliliter (mL). On 02/15/2026 at 9:00 AM, Staff E (Charge Nurse Licensed Practical Nurse - LPN) documented administration of 18 mL with 10 mL remaining. On 02/16/2026 at 7:10 AM, Staff NN (LPN) documented administration of 18 mL and wrote count corrected leaving 15 mL written directly over the original reaming quantity in darker, thicker handwriting, obscuring the initial entry rather than correcting it with a single-line strike-through. The correction signatures included Staff NN and a second signature that could not be identified from the ledger signature page. Directly below, the word discard was documented with 0 mL remaining. Review of the Disposition of Unused Medication section at the bottom of page 109 showed Staff D (Residential Care Manager) and Staff E documented disposal of 15 mL into a drug buster (a medication disposal container). Review of the February 2026 Medication Administration Record (MAR) showed Resident 18 was ordered to receive 18 mL of the narcotic daily. Staff NN documented administration on 02/16/2026 and that the resident refused the narcotic on 02/17/2026. No progress notes detailing the administration discrepancy, count correction, or refusal were documented in the medical record. In an interview on 05/05/2026 at 9:14 AM with Staff D and Staff E, Staff D stated medication bottles may arrive from the pharmacy with more medication than reflected on the labeled quantity. Staff D stated this discrepancy was often recognized during the final doses and required reconciliation of the remaining quantity. Staff E stated the documented 10 mL remaining was inaccurate and should have been reconciled to show a remaining quantity of 15 mL but did not. Staff D stated Staff NN later clarified by telephone that 18 mL was administered to the resident and 15 mL remained. Staff D stated corrections to the narcotic ledger should be completed with a single-line strike-through to clearly show the corrections but were not. In an interview on 05/06/2026 at 12:35 PM, Staff B (Interim Director of Nursing) stated corrections to narcotic count logs should be completed with a single-line strike-through so the original entry remained visible, but it was not. Staff B stated Resident 18's MAR record for refusing the pain medication was inaccurate and staff were expected to accurately document in the residents' medical record, but they did not. <Medication Storage Room> Observation on 05/01/2026 at 1:55 PM of the medication storage room showed the medication room refrigerator had an opened bottle of Tuberculin (highly contagious respiratory disease) testing solution dated 03/25/2026. The refrigerator contained 10 influenza vaccinations with an expiration date on 03/16/2026. Observation at this time showed no log or documentation was available showing staff were monitoring and documenting the refrigerator temperatures. Observation on 05/01/2026 at 2:05 PM of a drawer in the medication room showed the drawer contained a bottle of an anticonvulsant medication with an expiration date of 12/24/2025. The drawer contained a bottle of opened glucose tablets without an expiration date. In an interview on 05/01/2026 at 2:20 PM, Staff LL (Registered Nurse) confirmed refrigerator temperatures should be recorded, and the log should be in the medication room or at the nurse's station, but they could not locate the log. Staff LL confirmed all the expired and undated medications and biologicals should be discarded. In an interview on 05/06/2026 at 12:40 PM, Staff B stated if staff could not verify the refrigerator temperatures were maintained at the appropriate temperature, items in the refrigerator needed to be disposed of. <Medicare South Medication Cart> Observation on 05/01/2026 at 1:29 PM of the Medicare South Medication Cart showed an open bottle of antibiotic eye drops dated 03/21/2026 and a bubble pack of water pills with an expiration date of 03/29/2026. In an interview at this time, Staff K (Registered Nurse) stated the eye drops were no longer in use and should be discarded. Staff K stated the expired water pills should be discarded as they were expired. <Long term Care South Medication Cart> In an observation on 05/01/2026 at 1:30 PM the south long term care medication cart was found to have a box of opened respiratory medication solution cartridges with no open date, an opened box of eye drops with no open date, and a bottle of prescription eye drops expired on 2/26/2026. In an interview on 05/01/2026 at 1:45 PM Staff AA (Registered Nurse) stated they were not aware of the medication open dates, or how long it would take the medications to expire once opened. Staff AA stated that expired medications should be disposed of prior to the expiration date to prevent medication errors. In an interview on 05/05/2026 at 1:32 PM Staff B stated medications should be reviewed for expiration date before being given. Staff B stated that medications should be removed from the cart and disposed of prior to the manufacturers' expiration date to prevent the risk of errors. <Facility Treatment Cart> In an observation on 05/01/2026 at 9:03 AM the facility's treatment cart was locked, though the bottom drawer was able to be accessed without use of a key. Within the drawer were medicated ointments, creams, and wound cleansing supplies, as well as various non-medicated wound treatment supplies. In an interview on 05/01/2026 at 9:04 AM Staff M (Wound Nurse/Infection Preventionist) stated the cart should be secured, and that they were able to close the bottom drawer and have it lock appropriately. In an observation on 05/01/2026 at 2:00 PM, the facility's treatment cart was locked, though the bottom drawer was able to be accessed without use of a key. In an interview on 05/01/2026 at 2:01 PM Staff A (Administrator) stated the cart should be secured and opening when locked presented a safety concern if residents were to access it due to the medicated creams, ointments, and cleansers. In an observation on 05/06/2026 at 10:08 AM, the facility's treatment cart was locked, though the bottom drawer was able to be accessed without use of a key. In an interview on 05/06/2026 at 10:10 AM Staff D stated the cart was not secured due to supplies behind the drawer preventing it from closing all the way. REFERENCE: WAC 388-97-1300(1)(b)(ii)(c)(ii-iv), -1320(2), -2340.

Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents (Residents 31, 32, & 5) and 1 family member were educated and provided the facility policy regarding the use and storage of foods brought by family and visitors in the facility from outside sources including safe food handling practices. This failure placed residents at risk for foodborne illness.Findings included.<Facility Policy>The undated facility policy titled, Use and Storage of Foods Brought by Family and Visitors and Food Reheating Policy & Procedure, showed the facility would provide safe and sanitary storage and handling of foods brought in from the outside by family and visitors and would ensure staff assisted residents to access, reheat, and consume these foods. The policy showed residents and families would be given a copy of the policy and offered a handout on safe food handling practices. The policy showed food brought in from the outside would be checked by a member of the food and nutrition department or a licensed nursing staff to ensure it did not conflict with the resident's prescribed diet. The policy showed non-perishable foods would be stored in air-tight container bags to prevent staleness and pest infestations.<Resident 31>Review of Resident 31's 12/04/2025 physician order showed the resident was prescribed a regular diet with east-to-chew texture.Review of Resident 31's 03/12/2026 Nutritional Assessment showed the resident had cognitive and behavioral problems including altered mental status which affected their food intake.Observation and interview on 05/06/2026 at 10:39 AM showed Resident 31's family member (son) was observed entering the resident's room with a restaurant-bought Mexican food in a plastic bag. The nurse was standing by the medication cart parked next to Resident 31's room, saw the son enter the resident's room with the food on hand, and did not check the food brought from outside. Resident 31's son stated they had been bringing outside food for the resident for a while now and no staff had checked the food they brought in. Resident 31's son stated they did not know if the resident had dietary restrictions. Resident 31's son stated they were not provided a copy of the facility's policy.<Resident 32>Review of Resident 32's 02/12/2024 physician order showed the resident was prescribed a cardiac diet.Observation and interview on 05/06/2026 at 10:28 AM showed a half-eaten meal next to a food delivery service bag on top of Resident 32's bedside table. Resident 32 stated it was the left-over food they ordered yesterday from door dash. Resident 32 stated they were not informed of the facility's food storage practices or provided a copy of the facility's policy.<Resident 5>Review of Resident 5's 04/30/2026 physician order showed the resident was prescribed a regular diet after Resident 5 signed a risk agreement to liberalize their diet according to their preference.Observation and interview on 05/06/2026 at 10:25 AM showed Resident 5 had several snacks and canned beverages in their room; a snack bag was left open. Resident 5 stated they did not know they needed to store their opened food/snacks in air-tight bags nor did staff assist/provide them with any. Resident 5 stated they were not informed of the facility's food storage practices or provided a copy of the facility's policy.Review of the facility's admission Agreement provided to residents and their representatives showed the policy titled Use and Storage of Foods Brought by Family and Visitors and Food Reheating Policy & Procedure was not included in the packet.In an interview on 05/06/2026 at 10:43 AM, Staff V (Dietary Supervisor) stated they educated the residents regarding safe food handling and storage as they encounter the residents and their needs. Staff V stated they did not know how the residents' family members were educated on the facility's policy regarding foods brought in from outside sources.In an interview on 05/06/2026 at 11:24 AM, Staff A (Administrator) stated it was important for residents and their family members to be aware of the facility's policies and procedures when bringing outside food into the facility for safety.REFERENCE: WAC 388-97-1780(1)(2).

Based on observation, interview, and record review the facility failed to adhere to Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms) for 3 of 10 residents (Resident 46, 78, & 1) reviewed for infection control, failed to ensure resident equipment was able to be hygienically cleaned for Resident 8, and failed to ensure the facility's washing machine was maintained at the proper temperature. These failures placed residents at risk for communicable diseases, poor quality of life, and adverse health outcomes.Findings included.<Following EBP> <Resident 46> Review of Resident 46's 12/21/2024 physician orders showed they were on EBP due to having a wound, requiring staff to wear a gown and gloves when providing high contact care including bathing, dressing, transfers, and handling of linens. In an observation on 04/30/2026 at 9:54 AM Staff BB (Certified Nursing Assistant- CNA) and Staff CC (CNA) entered Resident 46's room without wearing gown or gloves. Staff BB and Staff CC transferred Resident 46 back to their bed following a shower. In an interview on 04/30/2026 at 9:59 AM, Staff BB stated that they should have been wearing a gown and gloves for Resident 46's care. In an interview on 04/30/2026 at 10:03 AM, Staff CC stated that they should have been wearing a gown and gloves when providing care for Resident 46, and that it was important to protect themselves and others from potential communicable diseases. <Resident 78> Review of Resident 78's 03/17/2026 physician's orders showed they were on EBP due to having an indwelling urinary catheter (a tube that drained urine from the bladder), requiring staff to wear a gown and gloves when providing high contact care such as transfers, dressing, and emptying the catheter drainage bag. In an observation on 04/30/2026 at 9:39 AM Staff DD (Restorative Nursing Assistant) entered Resident 78's room without gown or gloves and transferred Resident 78 back to bed and emptied their urinary drainage bag. In an interview on 04/30/2026 at 9:41 AM, Staff DD stated they should have worn proper Personal Protective Equipment (PPE) to care for Resident 78, and that it was important to have a barrier to prevent the spread of diseases. In an interview on 05/05/2026 at 1:35 PM, Staff M (Wound Nurse/Infection Preventionist) stated they expected staff to wear appropriate PPE when caring for a resident that was on EBP. Staff M stated it was important to follow precautions to prevent the spread of potentially communicable diseases. <Resident 1> Review of Resident 1's physician orders showed a 01/28/2026 order directing staff to implement EBP due to the resident having an indwelling catheter. The order directed staff to wear appropriate PPE when providing care. Observation on 04/29/2026 at 2:01 PM showed Staff II (CNA) enter Resident 1's room, put on gloves and empty the resident's catheter bag into a urinal. Staff II did not put on a gown prior to emptying the catheter. After emptying the catheter, Staff II stated I was supposed to wear a gown and I totally forgot. <Laundry Room Washing Machine Temperatures> Observation of the facility's laundry room on 05/01/2026 at 10:47 AM showed the facility had two washing machines. One washing machine was in use and connected to low temp solid detergent solution, chlorine sanitizer, and a laundry softener. Review of the facility's temperature log showed the last temperature recorded for the washing machine was 07/2025, nearly 10 months prior. In an interview at that time, Staff KK (Medical Records Coordinator) stated they just recently took over the role as the laundry manager. Staff KK stated the temperatures should be documented at least daily and confirmed the temperatures were not monitored or documented since 07/2025. In a follow up interview on 05/01/2026 at 12:08 PM, Staff KK stated they called the service company who reported the washing machine temperature needed to reach 120 degrees Fahrenheit to dissolve the detergent. In an interview on 05/06/2026 at 12:37 PM, Staff B (Interim Director of Nursing) stated the washing machine temperature should be checked and logged daily. Staff B confirmed staff were not monitoring the washing machine temperatures but should be. <Equipment surfaces> Observation on 04/30/2026 at 8:37 AM showed Resident 8's wheelchair was parked next to the nurse's med cart in front of room [ROOM NUMBER]; both arm rest covers were torn/tattered along the edges and with exposed foam padding. In an interview on 05/05/2026 at 1:42 PM, Staff M stated if the foam was exposed, the surface was not cleanable and could pose as an infection risk. REFERENCE: WAC 388-97-1320 (1)(a), (2)(a)(c), (3).

Based on interview and record review the facility failed to establish an infection prevention and control program that included implementation of the Antibiotic (ABO) Stewardship Program to promote appropriate use of ABOs and reduce the risk of unnecessary ABO use for 1 of 5 residents (Resident 1) reviewed for unnecessary medications. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABOs.Findings included.<Policy>Review of the facility's 05/2025 Antibiotic Stewardship Program policy showed the facility would use the updated McGeer's criteria (a set of standardized definitions and criteria used to define infections and guide ABO use) to define infections and review new ABO orders for appropriateness.<Resident 1>According to the 04/02/2026 Quarterly Minimum Data Set (an assessment tool) Resident 1 admitted to the facility on [DATE] with diagnoses of high blood pressure, a respiratory infection, and a traumatic brain injury.Review of Resident 1's health record showed a 02/05/2026 ABO to be administered by staff two times a day for ten days for a bacterial skin infection affecting both legs. Review of providers notes showed Resident 1 had redness, warmth, and tenderness to the affected areas.Review of the updated McGeer's criteria showed that Resident 1's condition only met three out of four criteria used to define an infection.In an interview on 05/05/2026 at 2:22 PM, Staff M (Wound Nurse/Infection Preventionist) stated Resident 1's infection did not meet criteria, and that it should have been reported to the provider for review. Staff M stated it was important to ensure appropriate use of ABOs due to the risk of adverse side effects they may have.REFERENCE: WAC 388-97-1620(2)(b)(i)(iii).

Based on interview and record review, the facility failed to provide informed consent and risks and benefits of treatment for 3 of 5 residents (Residents 1, 84, & 40) reviewed for unnecessary medications. This failure placed residents at risk for unwanted treatments, diminished quality of life, and adverse health outcomes.Findings included .<Facility Policy>Review of the facility's undated Use of Psychotropic Medications policy showed prior to initiating or increasing a psychotropic medication, the resident and/or resident representative must be informed of the benefits, risks, and alternatives for the psychotropic medication. The policy showed the residents and/or representatives had the right to accept or decline the medication and the facility would document the residents and/or representatives were informed in advance of the risks and benefits. This policy showed when a medication was prescribed as an alternative to a psychotropic medication rather than the original approved indication, then the medication was subject to the requirements pertaining to psychotropic medications.<Resident 1> According to the 04/02/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 1 admitted to the facility on [DATE] with diagnoses of a traumatic brain injury, an anxiety disorder, and depression. The MDS showed Resident 1 had feelings of isolation and verbal behaviors during the assessment period. Record review of physician orders for Resident 1 showed an antianxiety medication ordered on 02/11/2026 for one tablet to be administered two times a day for treatment of their anxiety disorder. The physician's orders showed Resident 1's antianxiety medication was increased to two tabs to be administered two times a day on 03/24/2026. Review of Resident 1's health records showed that no consent for treatment was obtained for the antianxiety medication on 02/11/2026 or 03/24/2026. In an interview on 05/05/2026 at 10:55 AM Staff C (Resident Care Manager - RCM) stated Resident 1 should have had an informed consent prior to the use of psychotropic medications. Staff C stated no informed consent was completed for Resident 1's antianxiety medication. In an interview on 05/05/2026 at 11:50 AM Staff B (Director of Nursing) confirmed that Resident 1 did not have an informed consent for the antianxiety medication but should have. Staff B stated it was important to obtain informed consent for psychotropic medications to ensure residents were aware of potential adverse side effects and to honor their rights. <Resident 84> According to the 02/06/2026 Annual MDS, Resident 84 had diagnoses including Post Traumatic Stress Disorder (PTSD), an adjustment disorder, and hallucinations. The MDS showed Resident 84 sometimes refused care and took antipsychotic medications. Review of the physician's orders showed Resident 84 resumed taking an antipsychotic medication on 02/10/2026 after previously discontinuing the medication on 02/27/2025. Record review showed the facility obtained consent from Resident 84 for the antipsychotic medication on 02/25/2026, 15 days after the resident began treatment. The consent form showed the medication was intended for long-term use. In an interview on 05/06/2026 at 2:38 PM, Staff B stated they expected consent for antipsychotic medications to be obtained prior to treatment. Staff B stated consent was not obtained timely from Resident 84. <Resident 40> According to the 04/17/2026 Quarterly MDS, Resident 40 had moderate cognitive impairment and multiple diagnoses including PTSD. Review of a 10/27/2025 physician progress note showed Resident 40 stated they were experiencing flashbacks and nightmares. The note showed the physician ordered a blood pressure medication that had an off-label use for treatment of PTSD. Review of Resident 40's order history report showed the blood pressure medication was first ordered to treat the resident's PTSD on 10/27/2025. Resident 40 had taken the medication since it was ordered, for nearly six months. Review of Resident 40's Psychotropic Medication Therapy consent form, showed the facility did not obtain consent from Resident 40 for the use of the blood pressure medication treating their PTSD until 05/05/2026, over six months after the resident initially started the medication. In an interview on 05/06/2026 at 11:42 AM, Staff D (RCM) reviewed Resident 40's records and confirmed the consent was not completed prior to initiating the medication. Staff D stated staff should have completed the consent prior to the resident starting the medication. REFERENCE: WAC 388-97-0260, 1020(4)(a)(b).

Based on interview and record review, the facility failed to initiate, log, and complete thorough grievance investigations for 1 of 5 residents (Residents 18) and 1 supplemental resident (Resident 39) who were reviewed for grievances. This failure to ensure thorough investigations and resolutions placed residents at risk for frustration and a diminished quality of life.Findings included .<Facility Policy>According to the facility's undated 'Resident and Family Grievances' policy, staff would receive grievances verbally or in writing, ensure grievance forms were completed with the nature and specifics of the grievance, log the grievance, identify each allegation within the grievance, analyze contributing factors, document corrective actions, and communicate outcomes to the resident. The grievance official would keep the residents informed regarding progress toward resolution.<Care in pairs><Resident 18>According to the 03/22/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 18 had diagnoses including anxiety, depression, chronic pain, and muscle weakness. The MDS showed Resident 18 required a wheelchair and had limited lower body mobility.Review of a progress note dated 03/22/2026 showed Resident 18 asked Staff K (Licensed Practical Nurse) why two staff came to their room when assistance was requested. Staff K informed Resident 18 it was because they were considered a 2-person transfer. Resident 18 verbalized not being happy being placed on care in pairs.Review of the facility's March 2026 grievance log showed no grievance reported for Resident 18.In an interview on 04/29/2026 at 10:15 AM, Resident 18 stated they were unhappy with the care in pairs intervention and were not satisfied with the response regarding being a 2-person transfer.In an interview and record review on 05/05/2026 at 11:02 AM, Staff F (Social Services Director) stated Staff K should have completed a grievance form when Resident 18 verbalized their grievance with the care in pairs intervention, but they did not.In an interview on 05/06/2026 at 1:46 PM, Staff B (Interim Director of Nursing) stated they expected staff to assist residents in completing grievance forms when resident concerns could not be immediately resolved.<Pain management>Review of a grievance form completed on 02/27/2026 by Staff G (Administrator in Training) showed Resident 18 reported they were not assessed for pain upon return from an outside clinic and alleged they were left without adequate pain management resulting in extreme pain and vomiting. The facility's response to the grievance focused on outside provider requirements and did not evaluate the facility's role in ensuring continuity of care, addressing pain management needs upon return, or responding to the resident's reported physical and psychosocial distress.In an interview and record review on 05/06/2026 at 12:02 AM, Staff G stated they initiated Resident 18's grievance and understood the expectation was to address each allegation but they did not. <Prompt investigation and resolution><Resident 39>According to the 03/22/2026 Quarterly MDS, Resident 39 had medically complex conditions including depression and bipolar disorder. The MDS showed Resident 39 was able to communicate their needs.In an interview on 05/04/2026 1:19 PM, Resident 39 stated they submitted several grievances to the facility, but staff did not communicate resolutions back to them.Review of a grievance form completed on 04/09/2026 showed Resident 39 reported three concerns related to Staff Q (Certified Nursing Assistant) including a broken phone, being made to feel like a bother when asking for help and waiting for assistance at the front door. The grievance investigation and resolution sections were blank.Review of the facility's April 2026 grievance log showed no grievance reported for Resident 39.In an interview and record review on 05/05/2026 at 11:02 AM, Staff F confirmed they were the Grievance Official responsible for ensuring grievances were logged, investigated, and resolved timely. Staff F stated Resident 39's grievance was not logged or thoroughly investigated. Staff F acknowledged the failure to investigate grievances and communicate outcomes to residents could cause frustration and feelings that concerns were ignored or unimportant.REFERENCE: WAC 388-97-0460.

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status for 3 of 19 sample residents (Residents 1, 4, & 18) reviewed for accuracy of assessments. This failure placed residents at risk for unmet and/or unidentified care needs, and a diminished quality of life.Findings included.<Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual>According to the current RAI Manual dated October 2023, the completed MDS must accurately reflect the resident's overall status and the information collected in this assessment would be used as the basis for ensuring that residents received appropriate and quality care. The manual showed the MDS assessment was used to develop, review, and revise the resident's comprehensive care plan.<Resident 1> According to the 07/01/2025 admission MDS, Resident 1 admitted to the facility on [DATE]. The MDS showed Resident 1 was at risk for developing pressure ulcers but did not have any current pressure ulcers. Review of the 06/27/2025 hospital discharge summary showed Resident 1 had two pressure ulcers upon discharge from the hospital. Review of the 06/27/2025 Admit/Readmit Assessment showed the nurse made several attempts to complete an admission skin check for Resident 1, but the resident declined. The nurse documented has known wound to bilateral buttocks on the skin integrity section of the assessment. Observation on 04/29/2026 at 1:47 PM showed Resident 1 lying in bed on an air mattress (specialty mattress for the treatment/prevention of pressure ulcers). Resident 1 stated they had some wounds on their legs and hips. In an interview on 05/06/2026 at 10:25 AM, Staff O (MDS Nurse) reviewed Resident 1's admission MDS and records. Staff O confirmed the MDS was coded incorrectly and required modification. Staff O stated the process for assessing pressure ulcer status on an admission MDS was to review hospital documentation and included a physical assessment of the resident. <Resident 4> According to the 02/13/2026 Quarterly MDS Resident 4 had unclear speech and intact cognition. The section of the MDS dedicated to assessing Resident 4's routine and activity preferences had a resident interview section to be completed if a resident was able to be interviewed and an assessment for staff to complete if the resident was not. Both sections were empty with the resident interview answer spaces all filled with a dash mark. In an interview on 05/06/2026 at 10:26 AM, Staff O stated if a resident was able to answer for themselves, the resident interview should be completed, and if not, the staff assessment should be completed. Staff O stated if section F was dashed, it meant staff did not complete the interview before the MDS assessment was finalized. Staff O stated Section F should be completed. <Resident 18> According to the 12/20/2025 admission MDs and 03/22/2026 Quarterly MDS, Resident 18 admitted to the facility on [DATE]. Both MDS records indicated Resident 18 had diagnoses of anxiety and depression (other than bipolar). Review of the 12/29/2025 physician progress note showed Resident 18 had bipolar disorder with current episodes of mild to moderate depression. Observation on 04/29/2026 at 10:15 AM showed Resident 18 lying in bed with multiple personal belongings, including books, paperwork, electronics snacks and beverage containers positioned around the bed and on tables within reach. Resident 18 appeared visibly distressed and stated they were upset regarding recent behavior contracts they refused to sign and a notice they would be forced to discharge to an adult family home. In an interview and record review on 05/04/2026 at 11:10 AM, Staff O confirmed Resident 18's bipolar disorder diagnosis was missing from both MDS records. Staff O stated the bipolar disorder diagnosis should have been included but it was not. Staff O stated Resident 18's MDS assessment should be modified to include their bipolar disorder diagnosis. REFERENCE: WAC 388-97-1000(1)(a)(b)(4)(a).

Based on observation, interview, and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessment was accurate to reflect the residents' mental health conditions for 1 of 7 residents (Residents 18) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included .<Facility Policy>According to the facility's undated Resident Assessment - Coordination with PASRR Program policy, the facility would coordinate resident assessments with the PASRR program to ensure individuals with mental disorders or related conditions received services in the most integrated setting appropriate to their needs. The policy required a Level I screening prior to admission and Level II evaluation for positive screens to determine appropriate placement and specialized services.<Resident 18>According to the 12/20/2025 admission Minimum Data Set (MDS, an assessment tool), Resident 18 had diagnoses including anxiety and depression (other than bipolar disorder). The MDS showed Resident 18 was admitted to the facility on [DATE] and the MDS showed no PASRR was initiated.Review of a progress note dated 12/26/2025 showed Staff N (Medical Director) documented Resident 18 had bipolar disorder (a mental disorder causing dramatic shifts in a person's mood or energy) with current episodes of mild to moderate depression.Review of the 01/03/2026 Care Area Assessment (CAA) Summary showed additional observation and assessment were needed to determine the relationship between pain, cognition, and behavioral symptoms. The CAA documented Resident 18 experienced delirium, described as inattention and disorganized thinking, as well as behavioral symptoms including screaming, babbling, cursing, repetitive questioning, pacing, kicking, and scratching.Review of Resident 18's medical record showed the facility implemented care in pairs (a restrictive two-to-one observation intervention) on 12/19/2026. The facility implemented two punitive behavior agreements (a written agreement outlining behavior expectations and possible consequences or interventions) on 02/19/2026 and 03/30/2026. Resident 18's record showed a 30-day notice of transfer was initiated on 03/30/2026 and submitted to the Office of Administrative Hearings (OAH) on 04/29/2026.Record review showed a Level I PASRR was completed for Resident 18 by Staff F (Social Services Director) on 03/22/2026. This PASRR listed diagnoses of depression, anxiety, history of homelessness, and polysubstance use disorder under the Serious Mental Illness (SMI) Indicators section. It did not include Resident 18's bipolar diagnoses.Review of the 03/30/2026 Nursing Home Transfer or Discharge Notice showed the facility identified the reason for discharge as the safety of other individuals in this facility is endangered due to the clinical or behavioral status of the resident. The facility stated despite repeated education on behavioral expectations and the implementation of multiple behavior contracts, the resident continues to violate these agreements through ongoing verbal and physical aggression toward staff.In an interview on 04/29/2026 at 10:15 AM, Resident 18 stated they did not want to transfer to another facility because they enjoyed their current care team. Resident 18 stated they were being forced out of the facility and feared being placed in a new facility with staff they didn't know.In an interview and record review on 05/05/2026 at 11:02 AM, Staff F stated Resident 18's Level I PASRR should have been completed adequately and prior to admission but was not. Staff F stated Resident 18's bipolar disorder diagnosis should have been included, when the PASRR was submitted late, but it was not. Staff F stated it was important to initiate an accurate and timely PASRR process to ensure residents receive the necessary mental health care services they need.In an observation and interview on 05/06/2026 at 10:55 AM, Resident 18 was observed apprehensive during the conversation; their voice was shaky, had tense hand gestures and a distressed facial expression. Resident 18 stated the facility's behavior contracts and involuntary discharge notice caused them to feel significant fear, mistrust, and negatively impacted their quality of life. REFERENCE: WAC 388-97-1915(1)(2)(a-c).

Based on interview and record review the facility failed to provide routine care conferences for 2 of 3 residents (Resident 7 & 40) sampled for care planning. This failure placed residents at risk for unmet care needs, frustration, and diminished quality of care.Findings included .<Resident 40> According to the 10/17/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 40 had clear speech, was understood and able to understand others. The MDS showed Resident 40 had moderate cognitive impairment and had diagnoses including a fracture, blood sugar disorder, poor nutrition, depression, and a psychotic disorder. This MDS showed Resident 40 had a goal to discharge back to the community and active discharge planning was occurring. Review of Resident 40's 04/27/2026 Discharge/Transfer Preference care plan showed the resident had a history of homelessness and was homeless prior to admission to the facility. This care plan showed interventions for staff to hold interdisciplinary care conferences for the resident and family to address discharge planning and directed staff to review the plan of care initially and quarterly or as needed. In an interview on 04/29/2026 at 9:12 AM, Resident 40 stated they did not have a care conference since their admission to the facility. Resident 40 stated they wanted to go home and asked when they would be able to go home. Review of Resident 40's progress notes from October 2025 to April 2026 showed no documentation Resident 40 was offered or provided a care conference until 04/20/2026, six months after their admission to the facility. Progress notes showed staff did not provide or offer a care conference on the resident's admission or during their first quarterly assessment period in 01/2026. Review of Resident 40's evaluations showed there was only one care conference assessment completed on 04/20/2026. There were no other care conference assessment documents. In an interview on 05/05/2026 at 9:23 AM, Staff F (Social Services) stated the facility was working to get caught up with care conferences. Staff F stated the facility's process was to offer residents and/or representatives a care conference upon admission and quarterly. Staff F reviewed Resident 40's records and confirmed staff did not provide a care conference on admission or during the resident's first quarter. Staff F stated care conferences were important so facility staff could address any concerns or grievances, review the resident's goals of care, and ensure the facility provided care that aligned with the resident's goals. <Resident 7> According to the 04/15/2026 Quarterly MDS, Resident 7 admitted the facility on 09/22/2023 with diagnoses of high blood pressure, stroke, and a seizure disorder. The MDS showed Resident 7 did not have memory deficits. Review of Resident 7's health records showed that care conferences were conducted annually on 11/22/2023, 03/21/2024, and on 03/31/2026. In an interview on 05/05/2026 at 8:31 AM, Resident 7 stated they first had a care conference about a month ago. Resident 7 stated it would have been nice to have had a care conference before that to be able to communicate and address their needs. In an interview on 05/06/2026 at 10:51 AM, Staff F stated care conferences should have occurred quarterly and as needed for Resident 7. Staff F stated they were new to the building, aware of the lack of care conferences for residents, and were working to make sure residents got caught up on missing care conferences. REFERENCE: WAC 388-97-1020(2)(e)(4)(b)(d)-(f).

Based on observation, interview and record review the facility failed to ensure resident to resident altercations including alleged sexual, physical, and verbal abuse incidents the facility was aware of or witnessed was investigated, logged, and reported for 8 of 10 residents (Resident 9, 11, 16, 17, 6, 7, 4, 5) reviewed for abuse. The failure to investigate these incidents deterred the facility from preventing re-occurrence and taking appropriate corrective actions resulting in repeated abuse that placed all residents at risk for unidentified abuse and/or continued abuse, psychological harm, and diminished quality of life, and constituted an Immediate Jeopardy (IJ). On 02/13/2026 at 5:35 PM, the facility was notified of an IJ at CFR 483.12(c)(2)(4) F610 Alleged Violations-Investigate/Prevent/Correct, related to the facility's failure to identify allegations of abuse, ensure alleged abuse were reported and thoroughly investigated. The IJ was determined to begin on 11/04/2025 when Resident 9 inappropriately touched Resident 11 that staff were aware of, documented the incident, and failed to report, investigate and prevent further reoccurrences. The facility removed the immediacy on 02/15/2026 with an on-site verification from an investigator by conducting resident and staff interviews, ensuring residents with sexual behaviors were placed on one-on-one supervision. All staff were re-educated regarding abuse policies/procedures, which ensured an effective system was in place to safeguard, protect and prevent residents that were at risk for abuse.Findings included.According to the 2025 facility policy, Abuse, Neglect and Exploitation, the facility would establish policies and procedures to investigate allegations of abuse and train all new and existing staff on activities that constitute abuse, reporting procedures, and resident abuse prevention. The facility would designate an Abuse Prevention Coordinator who was responsible for reporting allegations of suspected abuse to the state survey agency in accordance with state law. The policy showed the facility would provide oversight and supervision of staff to ensure that the abuse policies are implemented as written, an immediate investigation would be warranted when suspicion of abuse or reports of abuse occurred, and staff would provide complete and thorough documentation of the investigation.In a joint interview on 02/13/2026 at 11:32 AM with Staff A (Administrator), Staff B (Director of Nursing) and Staff D (Regional Market Leader), Staff A stated they were the abuse coordinator for the facility. Staff A stated staff were educated on abuse policies and procedures upon hire, annually, and as needed.<Sexual Abuse><Resident 9>Review of the 12/30/2025 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 9 had clear speech, rarely made self-understood or was able to understand others, had confusion and memory loss, had a preferred language that was not English, and required an interpreter. The MDS showed Resident 9 had medically complex conditions including heart failure, Alzheimer's disease, anxiety, and depression. The MDS showed Resident 9 had physical and verbal behaviors directed at others, other behavioral symptoms not directed towards others, and wandering behaviors.Review of a revised 02/05/2026, sexual inappropriate care plan, showed Resident 9 had behaviors of grabbing private areas and hitting buttocks related to dementia and poor impulse control. The care plan directed staff to intervene as soon as the resident expressed sexually inappropriate behavior, staff should guide the resident away from other residents, and re-direct Resident 9 to a private area. An additional behavior care plan, revised 02/15/2025, showed Resident 9 had intrusive behaviors, would wander into others spaces, and take their belongings.Review of a facility investigation, dated 02/03/2026, showed on 02/03/2026 a nurse overheard Resident 10 on the phone and stated another resident touched them. Facility staff interviewed Resident 10 who stated at 11:30 AM on 02/03/2026, while near the elevator on the second floor Resident 9 grabbed their breasts. Resident 10 told Resident 9 to stop and went to speak to staff. The investigation showed no staff witnessed the interaction, interviews with residents were conducted, revealed no resident witnesses to the incident and showed Resident 9 would wander into resident's rooms and not exit when asked. The investigation concluded that due to Resident 9's dementia, behavioral history and cognitive impairment the incident is determined to be behavioral rather than intentional abuse, and abuse was ruled out.In an interview on 02/03/2026 at 2:45 Staff A (Administrator) stated the inappropriate touching between Resident 9 and Resident 10 occurred at 11:30 AM, no staff witnessed the incident, and Resident 10 was alert, oriented, and cognitively intact. When asked what the skin assessment for Resident 10 revealed, Staff A stated because it just happened (three hours prior) they would do a skin assessment and put Resident 9 on one-on-one supervision.Observations on 02/03/2026 at 3:00 PM showed Resident 9 sitting in their wheelchair in their room and no one on one staff member observed. Observations at 3:08 PM showed Resident 9 sitting in their room with no one on one supervision. Observations at 4:45 PM showed no one on one supervision for Resident 9.In an interview on 02/03/2026 at 5:00 PM Staff Q (Certified Nurses Assistant, CNA) stated they were the one on one for Resident 9. Staff Q stated Resident 9 would grab and touch anybody, mostly females but would grab the front area and buttocks of men as well when passing by or in reaching distance. Staff Q stated they would watch themselves as they passed by Resident 9 to avoid being grabbed.Review of Resident 9's progress notes, dated 01/30/2026, four days prior to the incident with Resident 10, showed Staff E (Registered Nurse, RN) documented Resident 9 displayed behavioral issues. The note showed Staff E was informed by an aide that Resident 9 was grabbing and touching various staff and residents. The progress note did not indicate what was done to protect the other residents, prevent further abuse, what notifications were made, and if staff determined who the other residents were, if the incident was reported and/or an investigation initiated.Review of Resident 9's progress notes, dated 01/22/2026, eight days before the other two incidents. Staff E documented that Resident 9 was hitting staff and residents, touched the buttocks of another resident and grabbed onto another resident's coat as they walked by. The progress note did not indicate what was done to protect the other residents, prevent further abuse, what notifications were made, and if staff determined who the other residents were, if the incident was reported and/or an investigation initiated.Review of the January 2026 facility abuse log showed no entries logged, reported or investigated for Resident 9.<Resident 11>Review of a 10/11/2025 admission MDS showed Resident 11 was cognitively intact, able to make their own decisions and had no behaviors. The MDS showed Resident 11 was able to make themselves understood, could understand others, and had diagnoses including a fracture and abnormal gait. During record review of Resident 11's progress notes, a progress note dated 11/04/2025, showed Staff F (Licensed Practical Nurse, LPN) documented that Resident 11 reported that when they bent over to get some condiments off the coffee cart Resident 9 spanked their buttocks. Staff F stated Resident 11 found the incident strange and reported the incident to the Director of Nursing. The progress note did not indicate what was done to protect the other residents, prevent further abuse, what notifications were made, and if the incident was reported and/or an investigation initiated.In a joint interview on 02/13/2026 at 11:32 AM with Staff A (Administrator), Staff B (Director of Nursing), and Staff D (Regional Market Leader), Staff B stated they completed the investigation for Resident 9 and Resident 10, did not identify the other inappropriate touching incidents and stated those incidents should be logged, reported, investigated, and a plan put in place to prevent reoccurrence to ensure all resident's safety at the facility.During an observation and interview on 02/18/2026 at 1:20 PM Resident 11 was observed in the smoking area outside on their cell phone. Resident 11 stated Staff A talked with them after the incident with Resident 9. Resident 11 stated they were bending over, getting sugar off the coffee cart when they were swatted on the buttocks by Resident 9. Resident 11 stated they thought the incident was weird and stayed clear of Resident 9 since the incident.<Physical Abuse><Resident 16>Review of the 12/01/2025 Quarterly MDS showed Resident 16 had clear speech, was able to make themselves understood, and could understand others. The MDS showed Resident 16 was able to make their own decisions, was cognitively intact, and had no behaviors. The MDS showed Resident 16 had diagnoses including debility, vascular disease, anxiety, and depression.Review of a progress note dated 12/08/2026 showed Staff G (LPN) documented Resident 16 notified them that morning they had a physical altercation with their roommate (Resident 17) that resulted with Resident 16 being scratched on their left arm, Staff G offered Resident 16 a room move, and Resident 16 declined. The note showed Resident 16 was placed on alert charting to monitor the scratches for infection and the provider was notified. The progress note did not indicate what was done to protect the resident, other residents, prevent further abuse, and if the incident was reported and/or an investigation initiated.In an interview on 02/13/2026 at 1:43 PM Resident 16 was observed in their room they shared with Resident 17. Resident 16 stated they had no concerns related to their roommate.<Resident 17>Review of the 01/19/2026 Quarterly MDS, Resident 17 had clear speech, was able to make themselves understood, and could understand others. The MDS showed Resident 17 had no behaviors and diagnoses including a history of brain bleed, anxiety, depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder.Review of a 07/24/2025 Brief Interview for Mental Status (BIMS, an assessment tool) showed Resident 17 was cognitively intact and able to make their own decisions.Review of progress notes dated 12/08/2025-12/17/2025 showed no documentation of the physical altercation with their roommate on 12/08/2025 and what actions staff took in response to the physical altercation.In an interview and observation on 02/13/2026 at 1:31 PM Resident 17 stated they and their roommate (Resident 16) had arguments, fought like siblings and were over it.Review of the December 2025 facility abuse log showed no entries logged, reported or investigated for Resident 16 and Resident 17's physical altercation.During an interview on 02/13/2026 at 11:35 AM Staff A stated if a resident informed staff they had a physical altercation with another resident they would expect staff to immediately separate the two residents, complete a skin assessment, notify the provider, administrator and director of nursing. Staff A stated the police should be notified, the incident should be logged, reported and investigated, and staff should monitor and treat any wounds sustained from the altercation. At 12:15 PM Staff D stated this incident should have but was not logged, reported and investigated as they would expect staff to follow the facility abuse policies and procedures.<Verbal Abuse><Resident 6>Review of a 10/20/2025 Medicare MDS showed Resident 6 had clear speech, was able to make themselves understood, and could understand others. The MDS showed Resident 6 was cognitively intact, able to make their own decisions, and had no behaviors. The MDS showed Resident 6 had medically complex conditions including high blood pressure, anxiety and depression.Review of a 12/06/2025 progress note showed Staff J (RN) documented Resident 6 was verbally aggressive and demeaning towards their roommate (Resident 7), called Resident 7 derogatory names, told Resident 7 they stink, and it was disgusting they needed to be changed in bed. Staff J documented Resident 6 was offered and accepted a room move and had no further concerns. The progress note did not indicate who was notified if the resident-to-resident verbal abuse was reported, logged and/or an investigation initiated.<Resident 7>Review of a 11/18/2025 Quarterly MDS showed Resident 7 had clear speech, was able to make themselves understood, and could understand others. The MDS showed Resident 7 was cognitively intact, able to make their own decisions, and had no behaviors. The MDS showed Resident 7 had medically complex conditions including respiratory failure, heart failure, depression, borderline personality disorder, and post-traumatic stress disorder.Review of progress notes dated 12/03/2025-12/10/2025 showed no documentation on 12/06/2025 from staff on the resident-to-resident verbal incident with their roommate (Resident 6).In an observation and interview on 02/03/2026 at 3:12 PM Resident 7 was observed in bed on their phone. Resident 7 stated they recorded the verbal altercation with their roommate, at first did not say anything back to Resident 6 and eventually couldn't hold back after hours of Resident 6's rude comments. Resident 7 stated they were called a [NAME] and a fat pig all because the staff moved Resident 6's phone cord which made them upset. Resident 7 stated they felt terrible, had low self-esteem and was relieved when Staff J moved Resident 6 out of the room.Review of the December 2025 facility abuse log showed no entries logged, reported or investigated for Resident 6 and Resident 7's verbal altercation.During an interview on 02/13/2026 at 12:18 PM Staff D stated they would expect the resident-to-resident verbal altercation to be logged, reported, and investigated.<Resident 4>Review of the 12/14/2025 admission MDS showed Resident 4 had had clear speech, was able to make themselves understood, and could understand others. The MDS showed Resident 4 was cognitively intact, able to make own decisions, and had physical and verbal behaviors directed at others that put Resident 4 as significant risk for injury, interfering with the resident's care and participation in activities and social interactions. The MDS showed the behaviors significantly disrupted the living environment and Resident 4 had medically complex conditions including anxiety, depression, and schizophrenia.Review of a 12/16/2025 progress note showed Staff E documented Resident 4 was aggressive, engaged in loud arguments with staff and surrounding roommates, used foul language, and was name calling neighbors. The progress note did not indicate what staff did to protect the residents, determine which residents were involved, who was notified of the incident, and if an investigation was initiated.<Resident 5>Review of a 12/19/2025 Quarterly MDS showed Resident 5 had had clear speech, was able to make themselves understood, and could understand others. The MDS showed Resident 5 was cognitively intact, was able to make own decisions, and had no behaviors. The MDS showed Resident 5 had medically complex conditions including fractures and adult failure to thrive.Review of Resident 5's progress notes dated 12/09/2025-12/17/2025 showed no indication staff put Resident 5 (Resident 4's roommate) on alert charting, made a progress note about the verbal incident, documented who was informed of the incident, what actions staff took to protect the residents and if an investigation was initiated.During an observation and interview on 02/03/2026 at 4:45 PM, Resident 5 was observed in bed. Resident 5 stated their roommate (Resident 4) would cuss at them for anything, would go off on the staff, cuss at everybody, throw things, and staff were aware but didn't do anything. Resident 5 stated they didn't like being yelled at or called names and was happy the roommate is no longer at the facility.Review of the December 2025 facility abuse log showed no entries logged, reported or investigated for Resident 4 and Resident 5's verbal altercation.During an interview on 02/13/2026 at 12:20 PM Staff D stated they would expect the resident-to-resident verbal altercation to be logged, reported, and investigated timely. Staff D stated they reported the resident-to-resident altercation on 02/13/2026 and agreed it was not reported timely as they would expect.In a phone interview on 02/17/2026, Staff R (Interim Administrator) stated the facility made change in their administration and Staff R would be the new administrator and abuse coordinator at the facility. Staff R stated changes were made to ensure all allegations of abuse were properly reported, logged, and investigated as required. REFERENCE: WAC 388-97-0860(1)(2)(a)(4)(5)(a)(6)(a-c)

Based on observation, interview, and record review the facility failed to timely and accurately assess resident's ability to smoke safely; implement a resident specific care plan for smoking; secure smoking supplies; ensure a safe designated smoking area; and implement, and enforce the facility smoking policy for 7 of 9 residents (Residents 13, 8, 12, 14, 15, 18, & 19) reviewed for smoking. In addition, the facility failed to re-assess Resident 16's ability to smoke independently after a cigarette burn, and failed to provide supervision to 1 of 3 residents (Resident 8) who was assessed to require supervision outside of the facility, used a Wander Guard device (a device that sets off an alarm to notify staff if the resident is close to the exit door) and eloped from the facility five times. The failure to ensure residents were free from elopement and dangerous accident hazards from smoking placed all residents at risk for serious adverse outcomes with the potential for fire and an explosion and/or serious harm, serious injury, and possible death and constituted an Immediate Jeopardy (IJ). On 02/13/2026 at 5:35 PM, the facility was notified of an IJ at 42 CFR S483.25(d), F689- Free of Accident Hazards/Supervision/Devices related to the facility's failure to ensure safety when residents were smoking. The IJ was determined to begin on 12/25/2025 when Resident 8 was identified smoking inside the facility. Resident 8 continued to smoke inside the facility on 01/13/2026, 01/16/2026, and 01/31/2026. Resident 13 was smoking inside the facility on 12/26/2025, 12/29/2025 and 02/10/2026. Both Residents were assessed as not safe to smoke independently. There were no new interventions implemented by Administration when both residents continued to smoke inside and outside the facility. The facility removed the immediacy on 02/15/2026, with onsite verification from investigators, by ensuring all residents were accurately assessed to smoke, educated all smokers and staff of the revised smoking policy, provided a safe designated smoking area, and secured smoking supplies which ensured an effective system was in place to safeguard, protect, and prevent harm or injury to all residents. Findings included.<Smoking> Review of the undated Facility Smoking policy showed Smoking cigarettes, marijuana, and the use of any/all tobacco products as well as electronic cigarettes and vaping devices anywhere on the premises by residents is strictly prohibited. Residents admitted after 04/18/2024 must smoke off the facility premises under direct supervision by a non-staff responsible party. The policy directed the non-staff responsible party to store all smoking supplies off the facility premises. The policy showed staff would assess smokers for smoking safety, handling smoking materials, and use of a wheelchair or walker while outside. Smokers were expected to sign out when going out to smoke and sign in upon return. Observation and interview on 02/13/2026 at 11:39 AM showed the designated smoking area was in the back of the parking garage, the ground was littered with hundreds of cigarette butts, a fire extinguisher was lying on the ground, a smoking blanket and second fire extinguisher was secured to the wall but blocked by two large trash cans, a chair, and a bed frame making them not accessible. Staff W (Maintenance Assistant) observed the designated smoking area, stated certain residents were allowed to smoke there, identified the hundreds of cigarette butts on the ground and stated people should use the ash tray, lifted the fire extinguisher, stood it up on the pavement, and stated the fire extinguisher laying on the ground was unsafe. <Resident 13> Review of a 12/12/2025 admission Minimum Data Set (MDS, an assessment tool) showed Resident 13 was admitted to the facility on [DATE] for skilled services and had impairment to both legs requiring a wheelchair. Resident 13 was assessed to depend on staff for personal care and mobility. Review of an undated Non-Smoking Tobacco and Marijuana Free Notice and Agreement showed Resident 13 was informed of the facility policy and signed the agreement on 12/08/2025 agreed to read, understand and fully comply with the policy. Review of a 12/26/2026 progress note showed Resident 13 was smoking and/or vaping in their room with another resident using the other resident's smoking supplies. The note showed a smoking assessment was completed. Review of a 12/26/2025 Smoking assessment showed Resident 13 indicated they wished to smoke, had impaired short-term memory, and was not safe to smoke independently. This assessment was the only evaluation found in Resident 13's medical record. Review of a 12/29/2025 provider progress note showed Resident 13 was observed by the provider and a nurse manager smoking in the second-floor courtyard (atrium) inside the facility. The note showed Resident 13 stated they wanted to smoke because of stress. The provider offered alternate nicotine treatment options. Review of the 12/2025, 01/2026 and 2/2026 Medication Administration record showed Resident 13 had a physician order for nicotine lozenges as needed. Resident 13 did not have any lozenges administered on any of the medication records reviewed. Review of a 13-page comprehensive care plan from Resident 13's admit to the facility on [DATE] showed no record of their preference to smoke cigarettes, no noted failed smoking assessment, no prior events of smoking inside their room or the courtyard, no interventions to prevent smoking inside, no alternate treatments for nicotine dependance, and no interventions for smoking safety or assistance. Review of a 02/10/2026 progress note showed Resident 13 was smoking in their room inside the facility, refused to give staff the lighter, and there was a cigar on the floor. The progress note showed the Resident 13 was educated on the smoking policy and the nurse manager was notified. Review of a 02/12/2026 progress note showed Staff A (Administrator) met with Resident 13 and presented a behavior contract regarding smoking inside the building. The note showed the resident agreed, signed, and was provided with a copy of the contract. An observation and interview on 02/13/2026 at 11:19 AM, Resident 13 was observed in their wheelchair in the road outside of the facility, bent over to pick up a cigarette butt from the ground, pulled a lighter from their pocket, flicked the lighter on while it was in their lap, brought the butt to the lighter in their lap then put the butt into their mouth and inhaled to light the cigarette. Resident 13 was wearing thin blue pants with a drawstring; they were open in front and could see the plastic disposable brief they were wearing under the pants. Resident 13's lap had tobacco debris and ashes on the blue pants. Resident 13 stated they smoked cigarettes, did not have any cigarettes but usually picked up butts in the street or other residents would share cigarettes with them. Resident 13 stated they came outside to smoke multiple times a day and tried to get cigarettes from other people outside smoking. Resident 13 observed Resident 20 toss a lit cigarette butt into the street and rushed over to them to ask for the remaining cigarette. Resident 20 stated No, I am not giving it to you, get it yourself. Resident 13 continued down the sidewalk in their wheelchair. In an observation and interview on 02/13/2026 at 11:54 AM, Resident 12 was sitting on a walker, Residents 18 and 19 were sitting in wheelchairs in the driveway of the parking garage all smoking cigarettes. Resident 18 stated they were breaking the rules and should be off property to smoke because they were not allowed to smoke in the designated smoking area on the other side of the parking garage. Resident 14 was using a cane and joined the three residents and lit a cigarette. At 11:57 Resident 13 yelled over to Resident 18 and asked for a smoke. Resident 18 was observed giving Resident 13 a lit cigarette then Resident 13 sat with other residents smoking in the driveway of the parking garage. In an interview and record review on 02/13/2026 at 12:27 PM, Staff V (Receptionist) stated Resident 13 went out to smoke often and should sign out when going outside. Observation of the sign out book on the reception desk showed Resident 13 did not sign out on 02/13/2026. Staff V stated they did not know if it was safe for Resident 13 to go outside and smoke independently. Staff V stated they were not told that Resident 13 was not allowed to go outside by themselves or that Resident 13 was not allowed to smoke outside independently. Review of the December 2025 and February 2026 abuse reporting log showed Resident 8's incidents of smoking inside the facility were not recorded on the incident log. In an interview on 02/13/2026 at 11: 45 AM Staff A stated smoking incidents should be reported to the administrator, written on the incident log, investigated, and interventions implemented to prevent re-occurrence. Staff A stated Resident 13's incidents of smoking inside the facility were not on the incident log or investigated. In an interview on 02/13/2026 at 12:52 PM Staff D (Regional Market Leader) stated residents were not allowed to share cigarettes and staff were to secure smoking supplies. Staff D stated they expected staff to intervene when a resident was found smoking inside the facility, secure smoking materials, report incidents to management, and to document the event. Staff D stated incidents are expected to be logged and investigated to prevent recurrence and ensure all residents' safety at the facility. <Resident 8> Review of the 11/19/2025 Annual MDS, showed Resident 8 was re-admitted to the facility on [DATE] after hospitalization, had moderate cognitive impairment, memory loss, poor judgement, and unable to make decisions. The assessment showed Resident 8 had multiple diagnoses including debility, dementia, a traumatic brain injury, and severe mental illness. Resident 8 was assessed to depend on a wheelchair for mobility and required staff assistance with care. Review of Resident 8's medical record showed no documentation that Resident 8 was informed of the Non-Smoking Tobacco and Marijuana Free Notice and Agreement as stated in the policy would be provided on admission. Review of Resident 8's medical record showed no assessment was completed for smoking safety. Review of a 12/22/2025 elopement assessment showed Resident 8 had a history of wandering, exit seeking, elopement, and was able to deactivate exit alarms. Review of Resident 8's comprehensive care plan showed a 01/21/2026 intervention that Resident 8 may be assisted by staff outside to smoke to alleviate smoking perseverance. Review of a 12/25/2025 progress note showed Resident 8 was observed smoking in their restroom. Staff confiscated the cigarette and lighter, provided education on the dangers of smoking in the facility, and monitor the resident's behavior. The progress note did not show notification of management. Review of a 01/13/2026 progress note showed Resident 8 was observed smoking in the shared bathroom with another unnamed resident. The note showed smoke had filled the room causing the non-smoking roommate discomfort. The note showed Staff A and a nurse manager addressed the incident immediately after the event, the room was searched and an ash tray was collected from the room. Review of a 01/16/2026 progress note showed an aide found Resident 8 smoking in the atrium. There was no other information in the progress note and no subsequent notes addressed the smoking event. Review of a 01/29/2026 interdisciplinary team note showed a review of Resident 8's behaviors including frequent perseverating on smoking, unsafe to smoke independently and plan to contact representative. Review of a 01/31/2026 progress note showed residents reported to staff that Resident 8 was smoking marijuana with other residents in the atrium in previous days. There was no further documentation of follow-up actions. Review of the January 2026 facility incident log showed no record of Resident 8's incidents of smoking inside the facility. <Resident 12> Review of a 01/05/2026 admission MDS showed Resident 12 was cognitively intact, able to make their own decisions, and had no behaviors. Review of Resident 12's medical record showed no assessment or care plan for smoking safety. Review of a 01/10/2026 progress note showed Resident 12 was observed at 11:12 AM on the facility camera in the garage smoking an unknown substance with a second unnamed resident. The progress note showed both residents were approached, informed of the observed behavior and that the area was under video surveillance and both residents left the area. The progress note showed the smoking incident would be reported and discussed during the next morning's staff meeting. The progress note did not show an investigation was started to collect details, no actions taken to protect residents, or interventions to prevent re-occurrence. There were no further progress notes for follow up. Review of the January 2026 incident log did not show the smoking incident of Resident 12. In an interview on 02/13/2026 at 12:56 PM Staff A stated staff should have absolutely reported a resident smoking an unknown substance on facility property and enter the incident on the incident log. Staff A could not provide documents that an investigation occurred. <Resident 14> Review of a 01/21/2026 admission MDS showed Resident had mild cognitive impairment but was able to make their own decisions. Review of Resident 14's medical record showed no assessment or care plan for smoking safety. Review of a 02/11/2026 progress note showed there was a strong smell of cigarette smoke coming from Resident 14's room. The note showed ash was observed on the floor, a second staff member confirmed the smell of smoke. Resident 14 denied smoking in the room. The note showed Resident 14 was told it was a fire hazard to smoke in a room while their roommate's oxygen was in use. The note showed Staff A and Staff B (Director of Nursing) were notified of the incident. The progress note did not indicate if smoking materials were located or removed or if interventions were implemented to protect Resident's 14's roommate or prevent Resident 14 from future incidents of smoking inside. Review of the February 2026 facility incident log showed no incidents of Resident 14 smoking indoors. In an interview on 02/13/2026 at 12:56 PM Staff A stated staff should have reported any resident smoking inside their room. The incident should be placed on the incident log. Staff A could not provide documents that an investigation occurred. In an interview on 02/13/2026 at 1:03 PM Staff D stated staff were expected to log and investigate any incidents of smoking inside the facility. <Resident 15>Review of the 01/23/2026 Annual MDS showed Resident 15 was cognitively intact, able to make own decisions, and had wandering behaviors. Review of Resident 15's medical record showed no assessment or care plan for smoking safety. Review of a 06/18/2025 smoking assessment showed Resident 15 was not a smoker. Sections of the assessment for sensory perception, functional ability, medications, behaviors and nursing assessment of Resident 8 were not completed. There were no other smoking assessments in the record after 06/18/2025. Review of Resident 15's comprehensive care plan initiated on re-admission of 01/16/2025 showed no mention of Resident 15 smoking plan. Review of a 01/19/2026 provider note showed Resident 15 was observed smoking outside, was offered nicotine cessation and Resident 15 refused. The progress note did not show what staff did to assess smoking safety, implement safety interventions, report resident changes in smoking preferences. In an observation on 02/13/2026 at 12:02 PM, Resident 15 was sitting in a power wheelchair to the east of the facility across a private driveway and near a wooden fence. Resident was off the facility property. Resident 15's wheelchair had coats and bags hanging from the back and sides of the chair and Resident 15 had a blanket over their lap. Resident 15 was observed smoking a cigarette. <Residents 12, 14, 18, & 19> In an observation and interview on 02/13/2026 at 11:54 AM, Resident 12 was sitting on a walker, Residents 18 and 19 were sitting in wheelchairs in the driveway of the parking garage all smoking cigarettes. Resident 18 stated they (residents) were breaking the rules and should be off facility property to smoke because they were not allowed to smoke in the designated smoking area on the other side of the parking garage. At 11:56 AM Resident 14, with a cane, walked up to the group of residents and pulled out a cigarette and lighter and began smoking. A review of medical records for Residents 18 and 19 showed these residents had no assessments or care plans for smoking safety. In an interview and record review on 02/13/2026 at 4:08 PM with Staff A and Staff B, a list of residents who smoked was provided, 17 residents were identified by the facility as known smokers. Staff A stated residents were identified as smokers on admission; residents signed the non-smoking facility policy, and alternate treatments for smoking were offered. Staff A stated three residents were grandfathered into the prior smoking policy which allowed the residents to smoke in a designated smoking area in the parking garage, but other residents must go off property to smoke. Staff B stated residents that are active smokers were assessed to be independent with smoking, the assessment would be in their medical record, and they would have a smoking focused care plan. Staff B stated smoking supplies were kept on the medication cart and the residents would check out their supplies from the nurse, then sign out to go smoke outside. Staff A stated smoking inside the facility and the atrium was prohibited. Staff A stated the smoking policy was unclear and was not followed by residents or staff. Staff B reviewed the medical records for Residents 8 and 13 and stated they were assessed as not safe to smoke independently. Staff A and B stated both residents were frequently observed outside smoking and acknowledged they were listed on the list of residents who smoked. Staff B reviewed the records for Residents 8, 13, 12, 14, 15, 18 and 19. Staff B stated these residents did not have smoking assessments for smoking safety and should have been assessed if they were smokers. Staff B stated there was a breakdown in the system of residents smoking. <Resident Cigarette Burn> <Resident 16> Review of the 11/24/2025 progress note showed Resident 16 informed the shower aide they accidentally burned their leg with a cigarette when smoking outside. The progress note did not show how the burn occurred or new interventions to protect Resident 16 from future burns. Review of the state tracking and reporting system showed facility staff did not report Resident 16's burn injury when the incident occurred in November 2025. During an observation and interview on 02/18/2026 at 2:25 PM Resident 16 was sitting in their wheelchair in their room. Resident 16 stated they were one of the smoking residents that was grandfathered in when the facility became a non-smoking facility, was able to smoke independently, and facility staff updated them on the smoking policies and procedures. In a joint interview on 02/13/2026 at 12:25 PM Staff D stated a resident burn was expected to be reported, logged, and investigated. Staff B stated they would expect the nurse to assess the burn, perform first aide, notify the provider, obtain and implement treatment orders, re-assess the resident's ability to smoke independently, offer a smoking apron and a smoking cessation plan. <Elopement> <Resident 8> Review of the 11/19/2025 Annual MDS, showed Resident 8 was re-admitted to the facility on [DATE] after hospitalization, had moderate cognitive impairment, memory loss, poor judgement, and unable to make decisions. The assessment showed Resident 8 had multiple diagnoses including debility, dementia, a traumatic brain injury, and severe mental illness. Resident 8 was assessed to depend on a wheelchair for mobility and required staff assistance with care. Review of Resident 8's elopement care plan initiated on 07/13/2024 showed Resident 8 was at risk for elopement based on an elopement screening assessment. A revision of the care plan on 09/13/2024 showed Resident 8 was a wanderer, and directed staff to monitor whereabouts frequently, intervene for safety, a wander guard device was attached to the back of the wheelchair, and staff to ensure device placement and functioning. A revision of the care plan on 01/21/2026 showed Resident 8 repeatedly talked about smoking and staff should assist them outside to smoke. A 01/21/2026 care plan revision showed Resident 8 was placed on 1:1 monitoring from 6:00 AM to 10:00 PM until an alternate intervention was found. The care plan did not show any revised interventions after 09/13/2024 until 01/21/2026. A 12/19/2025 10:15 AM progress note showed Resident 8 stated they needed to go to the bank to buy two bus tickets. The note showed this was Resident 8's usual behavior. A 12/20/2025 10:21 AM progress note showed Resident 8 was agitated and was exit seeking. A 12/20/2026 6:30 PM progress note showed Resident 8 left the facility unassisted. The nurse directed two staff to follow Resident 8 who went to the store two blocks away and staff returned with Resident 8 to the facility. The progress note did not indicate if Resident 8 had the wander guard device, if the event was reported to management, or any new interventions to prevent future events of Resident 8 leaving unassisted. Review of a 12/21/2025 progress note showed Resident 8 went to the store two blocks away with a staff member. The note showed Resident 8 disappeared from the staff member's supervision after arriving at the store, and the staff member returned to the facility without Resident 8. The note showed the administrator and local police were notified, and staff searched the area for Resident 8. Resident 8 was found by staff, returned to the facility, then placed on 1:1 supervision. Review of a 12/22/2025 progress note showed Resident 8 continued with exit-seeking behavior, with verbal aggression, pushing and banging on the exit door, redirection was provided and behavior continued. The note showed the physician was notified for advice and 1:1 supervision continued. Review of a 12/22/2025 elopement assessment showed Resident 8 was high risk for elopement due to statements of leaving the facility, behaviors of wandering and exit seeking, and prior elopements from the facility. Review of a late entry progress note, dated 12/26/2025 and created on 12/28/2025, showed Resident 8 was watching the elevator for opportunities to leave the facility without supervision. The note showed Resident 8 exited the building on 12/26/2025 without authorization and was observed by staff heading to the store. Staff assisted Resident 8 to return to the facility. The note showed Resident 8 exited a second time on 12/26/2025 without staff awareness and was later found at a store six blocks from the facility. Staff found Resident 8 and returned them to the facility. Resident 8 stated they were going to the bank. The notes did not indicate if Resident 8 was still on 1:1 supervision from the 12/21/2025 elopement. The note stated Resident 8 would be on 1:1 supervision. Review of the December 2025 accident and incident log showed no elopement events reported or investigated for Resident 8's elopements on 12/20/2025, 12/21/2025, or two separate elopements on 12/26/2025. Review of a 01/21/2026 progress note showed Resident 8's representative was notified of an elopement and investigation in process. Review of progress notes 01/01/2026 through 01/21/2026 showed no documentation of elopement. Review of the January 2026 facility accident and incident log showed Resident 8 was a missing person / Elopement on 01/20/2026 and the incident was reported to the state agency. Review of the 01/20/2026 facility investigation documents showed Resident 8 could not be located and the facility missing person policy was implemented. The investigation showed Resident 8 wanted a cigarette and was let out of the facility by another resident at 7:13 PM. Resident 8 was located at the store two blocks away unsupervised and returned to the facility at 7:49 PM. The investigation did not identify why the wander guard system did not alarm when Resident 8 left the facility. The intervention implemented by the investigation was to initiate 1:1 supervision of Resident 8. During observation and interview on 02/03/2026 at 3:02 PM, Resident 8 was self-propelling in their wheelchair on the second floor, there was no 1:1 staff supervising. Resident 8 was near the elevator, a wander guard device was observed on the wheelchair, and the wander guard system did not alarm. At 3:06 PM, Resident 8 moved closer and pushed the elevator button, then the alarm sounded. Resident 8 stated they wanted their money, had $5000 and needed to get to the bank. At 3:07 PM the alarm was still sounding; Resident 8 stated, I'm going to [the store] by myself. At 3:09 PM Staff P (Housekeeping Manager) arrived and turned off the alarm when Resident 8 self-propelled away from the elevators. No 1:1 supervision by staff was observed. Review of a binder at the nurses station contained an undated document named 1:1 supervision guideline elopement prevention plan for Resident 8. The plan directed staff to always maintain a continuous line of sight of Resident 8, stay within arm's length when near exits or high-risk areas, accompany Resident 8 during all movement throughout the facility, do not leave unattended for any reason, if relief was needed ensure proper hand off before stepping away. Staff logs in the book showed staff signing in from 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM starting on 01/23/2026. A staff member signed in on 02/03/2026 at 2:00 PM to supervise Resident 8. In an interview on 02/03/2026 at 5:25 PM, Staff B stated Resident 8 was able to get on the elevator from the second floor without staff knowledge. Staff B stated Resident 8 often expressed desire to smoke which increased their risk of elopement. Staff B stated Resident 8 eloped from the facility on 01/20/2026. In an interview on 02/13/2026 at 11: 45 AM Staff A stated an elopement, or missing resident would be a resident who was not cognitively able to manage themselves outside of the facility. Staff A stated staff were expected to follow the policy for a missing resident. Staff A stated the incident should be reported to the administrator, written on the incident log, investigated, and interventions implemented to prevent re-occurrence. Staff A stated Resident 8's incidents of elopement were not on the incident log or investigated. In an interview on 02/26/2026 at 3:00 PM, Staff R (Interim Administrator) stated an administrator is responsible for the safety of residents and staff are required to report resident incidents so interventions can occur timely. Staff R stated the facility should have, and did not, implement a smoking policy that supports resident rights and safety. Staff R stated the facility had a policy for elopement and the policy was not followed by administration or staff for Resident 8. Reference: WAC 388-97-1060 (1)(3)(g); -1620(7)(b)-3220(1).

Based on observation, interview and record review the facility failed to ensure 3 of 3 residents (Resident 1, 2, & 3) reviewed for Pressure Ulcers (PU-injury to the skin and underlying tissue due to prolonged pressure) received the necessary care and services, consistent with professional standards of practice to prevent new PU's from developing. Failure to implement wound prevention interventions, assess PU risk, complete and document skin and wound assessments, ensure treatments were carried out as ordered, to notify the facility dietician of new PU's, and to ensure skin was assessed thoroughly during skin assessments and during care activities. Resident 1 experienced harm when they developed avoidable full thickness (wounds that extend beyond the first two layers of skin into the fat and muscle tissue) PU's on each elbow. This failure placed residents at risk for PU development, increased pain and discomfort, and diminished quality of life.Findings included. Review of the facility policy titled, Pressure Injury Prevention and Management, revised 03/19/2025, showed the facility was committed to preventing avoidable PU's and would provide care and services to heal PU's. The policy showed a Braden Scale (a standardized tool to assess risk of PU's) would be completed on admission, weekly for four weeks, quarterly, and as needed. A skin inspection would be completed weekly by a Licensed Nurse (LN), any open areas identified or soiled, saturated or dislodged dressing would be reported to the LN by the Certified Nurses Assistants (CNA), and the LN would complete further assessment and treatment if needed. The policy showed a care plan would be developed that included measurable goals for prevention and management of PU's. Interventions would be implemented for residents who are assessed at risk of PU development, documented on the care plan, and communicated to staff. The provider would be notified of the presence of a new PU, and of complications or worsening of wounds. <Resident 1>Review of a 12/20/2025 admission Minimum Data Set (MDS- an assessment tool) showed Resident 1 had moderate cognitive impairment, able to make own decisions, and no behaviors. The MDS showed Resident 1 admitted to the facility on [DATE], had diagnoses including fractures and liver disease. The MDS showed Resident 1 had no PU's, was assessed at risk for PU's, and had surgical wounds that required care and application of dressings.Review of a 12/16/2025 care plan showed Resident 1 had self-care deficits due to fractures to the right and left humerus (long bone in upper arm, extending from shoulder to elbow) that required surgical repair and could not bear weight to both upper extremities. The care plan showed Resident 1 was totally dependent on staff for bathing, bed mobility, dressing, eating, hygiene, toileting, and transfers. Review of Resident 1's comprehensive care plan showed no skin or wound care plan or interventions implemented by facility staff.Review of a 12/16/2025 admission collection tool showed Resident 1 admitted to the facility with two surgical wounds and bruising. The admission collection tool showed Resident 1 had no PU's upon admission to the facility. Review of a 12/17/2025 Braden assessment showed Resident 1 was assessed at moderate risk for PU's. The assessment showed Resident 1 had limited sensory perception, occasionally moist skin, chairfast (walking severely limited or non-existent), very limited mobility, and a potential problem with friction and shearing of skin. No other Braden assessments were documented for Resident 1.Review of a skin and wound evaluation dated 12/25/2025 and locked on 12/29/2025 showed Resident 1 was assessed with an open lesion (tissue damage) in the middle of the left elbow that was acquired at the facility. The assessment showed staff left the exact date, who staged the wound, the actual stage of the new wound, and whether the dietician was notified blank with no documentation. Review of a skin and wound evaluation dated 12/25/2025 and locked on 12/29/2025 showed Resident 1 was assessed with a open lesion to the middle of the right elbow that was acquired in the facility. The assessment showed staff left the exact date, who staged the wound, the actual stage of the new wound, and whether the dietician was notified blank with no documentation.Review of Resident 1's progress notes dated 12/20/2025- 12/29/2025 showed no documentation from staff for the two newly acquired PU's, what was done in response to the new wounds, and if the director of nursing and/or dietician was notified.Review of the December 2025 Treatment Administration Record (TAR) showed staff implemented and documented dressing changes to Resident 1's right and left elbow that started on 12/30/2025, five days after the wounds were first documented.Review of a 12/31/2025 wound provider note showed Resident 1's left elbow wound was assessed as a Stage 3 PU (Stage 3-full thickness skin injury extending into the subcutaneous fat tissue). The assessment showed Resident 1's right elbow was assessed by the wound provider as an unstageable PU (severe, full thickness wound with base obscured and inability to determine wound depth). The wound provider recommended an evaluation of proper off-loading equipment for Resident 1.Review of a 12/31/2025 skin/wound evaluation for Resident 1's right elbow showed incomplete documentation of the wound assessment, that included no assessment of the wound bed, peri-wound, exudate, wound pain and treatment. The assessment showed two different measurements of the PU. Facility staff documented wrong wound measurements that did not match the wound providers assessment of the right elbow PU. Review of Resident 1's 12/31/2025 skin/wound evaluation for the left elbow showed similar findings with incomplete documentation of the evaluation. Review of a 01/09/2026 progress note showed Resident 1 was seen by the wound provider, their right elbow had deteriorated and bone was now exposed in the wound. The progress note showed concerns for OM (Osteomyelitis- an infection of the bone), and a bone biopsy was obtained from the right elbow. Review of a 01/13/2026 provider note showed Resident 1's right elbow PU was positive for an infection with bacteria that was resistant to most common antibiotics and caused hard to treat infections. During an observation and interview on 01/21/2026 at 2:21 PM Resident 1 was observed in bed with elbow protectors to both elbows and stated they had no wounds on their elbows when they were admitted to the facility. Resident 1 stated both elbows were sore, painful, and three days ago staff brought elbow protectors which have helped but it took a long time for staff to take care of their elbows.In an interview on 02/26/2026 at 11:12 AM Staff B (Director of Nursing) stated Resident 1 was at risk for PU's due to bi-lateral arm fractures, limited mobility and potential nutritional problems. Staff B would expect staff to assess Resident 1's PU risk using the Braden scale weekly for four weeks after admission, quarterly, as needed with new skin issues, and acknowledged only one Braden assessment was completed for Resident 1. Staff B would expect a skin/wound care plan in place to include interventions for wound prevention, updated with current wounds, and interventions implemented to promote healing of wounds. Staff B stated in response to a new facility acquired PU they would expect staff to write a progress note, initiate an investigation, notify the provider, dietician, resident representative, implement interventions and acknowledged staff did not respond as they would expect. Staff B would expect skin/wound evaluations to be thoroughly completed and match the wound providers assessment of the wound.<Resident 2>Review of a 01/14/2026 Quarterly MDS showed Resident 2 was cognitively intact, able to make own decisions, and had no behaviors. The MDS showed Resident 2 had diagnoses including history of brain bleed, diabetes, and anxiety. The MDS showed Resident 2 had no PU's, was at risk for developing PU's, and had a pressure reducing mattress on their bed. The MDS showed Resident 2 was dependent on staff for bathing, required maximum assistance with dressing, hygiene, bed mobility, and transfers.Review of a 01/05/2026 Braden assessment showed Resident 2 was assessed at high risk for PU's. The assessment showed Resident 2 had slightly limited sensory perception, was constantly moist, bedfast (confined to bed), completely immobile, and problems with friction and shearing when moving in bed.Review of a 09/25/2025 revised skin care plan showed Resident 2 had a right gluteal fold shearing wound and was at high risk for skin breakdown. The care plan directed staff to avoid friction and shearing, encourage and assist with repositioning, and monitor/document the location, size, and treatment of skin injuries.Review of a 07/29/2025 progress note showed Staff E (Registered Nurse, RN) documented Resident 2 had skin breakdown to the posterior thoracic(mid-back) fold. The progress noted showed Staff E documented no change in condition, continue to monitor, apply barrier cream, and notify the provider for any changes in the wound. The note did not indicate if the provider was informed of the new wound, what type of wound, and measurements of wound. Additional notes showed Staff E documented on Resident 2's back wound on 09/06/2025, 09/07/2025, 09/08/2025, 09/12/2025, 09/17/2025, on 10/16/2025 staff E described Resident 2's back wound as open and fleshy, 10/24/2025, 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025, 11/03/2025, 11/05/2025, 11/06/2025, 11/25/2025, and 12/01/2025. The progress notes do not indicate if the provider was informed and if the wound was assessed.Review of Resident 2's skin/wound evaluations showed no evaluations completed for Resident 2's back wound.Review of a 01/05/2026 hospital transfer orders showed wound care recommendations for Resident 2's four wounds that were present on admission to the hospital on [DATE]. The four wounds included a right gluteal fold PU, left posterior leg full thickness wound, upper left back partial thickness wound, and the left labia with a partial thickness wound.Review of a 01/05/2026 nursing re-admission assessment showed Staff H (Registered Nurse, RN) did not document the skin integrity and left the skin integrity section of the re-admission assessment blank.Review of Resident 2's physician orders showed a 01/06/2026 order for treatment for the right gluteal wound. No other wound treatment orders were observed for the three other wounds.In an observation and interview on 01/21/2026 at 3:02 PM Resident 2 was observed in bed on an air mattress. Resident 2 stated they had a wound to their right buttocks, it hurt, and they had to ask staff to change the dressing and to help with turning in bed. Resident 2 stated they did not have wound care done today and staff told them their wound was healing but it was painful.During an observation and interview on 02/03/2026 at 5:05 PM with Resident 2 and Staff B present in the room. Resident 2 agreed to have their skin checked, no dressing was observed on an open area to their right gluteal fold. Staff B stated Resident 2 should have a dressing covering the wound. Resident 2 stated they informed staff that they needed a new dressing to their buttocks. Resident 2 stated the wound hurt, the brief being used was too little and made the sore worse. Resident 2 stated they used a size 5X brief and was currently in a 3X brief. Resident 2's brief was observed sitting in area of the gluteal fold where the wound was present. Resident 2's back was observed with a dressing dated 01/05/2026, twenty-nine days prior. The dressing was observed soiled, was removed, a strong odor was present, and no open areas were observed on Resident 2's back. Resident 2's left leg and labia were observed with no open wounds. Staff B stated they were not sure how staff missed the dressing on Resident 2's back if the staff were completing showers, skin checks, and assisting with the resident with upper and lower body.In an interview on 02/26/2026 at 11:15 AM Staff B when asked how shearing was being reduced if that was the cause of Resident 2's gluteal wound and Staff B stated Resident 2 was being followed by an outside wound provider, on an air mattress, using ointment to reduce shearing, using a draw sheet and staff were assisting with bed mobility to reduce shearing to Resident 2's skin. Staff B stated they could consider using an underpaid with no brief for Resident 2 to reduce shearing of the skin. Staff B stated when a new wound was found they would expect staff to inform the provider, obtain a treatment order, implement provider orders, document a thorough wound assessment to include measurements, pain, and notifications. Staff B stated they would expect staff to change dressings as ordered, to thoroughly assess the skin during skin assessments, bathing, and resident care.<Resident 3>Review of a 11/14/2025 Quarterly MDS showed Resident 3 was cognitively intact, had a decision maker, no behaviors, and no speech. The MDS showed Resident 3 had diagnoses including progressive neurological conditions, diabetes, depression, and schizophrenia. The MDS showed Resident 3 did not have a PU, was at risk for PU's, and had a pressure-reducing device for the bed. The MDS showed Resident 3 was dependent on staff for oral hygiene, toileting, bathing, dressing, bed mobility, and transfers.Review of a 02/09/2024 physician order directed staff to apply a thick layer of barrier cream after each incontinent episode and as needed.Review of a 10/15/2024 Braden assessment showed Resident 3 was assessed at moderate risk for PU's. The assessment showed Resident 3 had slightly limited sensory perception, was constantly moist, chairfast, limited mobility, and a potential problem with friction and shear when moved in bed. No other Braden assessments were documented in Resident 3's record after 10/15/2024.Review of a 09/18/2025 revised skin care plan showed Resident 3 had a sacral PU that was resolved and was high risk for skin breakdown. The care plan directed staff to offload and reposition the resident every 2-3 hours while in bed and follow facility policies and protocols for the prevention and treatment of skin breakdown.Review of Resident 2's weekly skin evaluations showed staff did not complete and/or document the results of the skin evaluations on 10/14/2025, 10/21/2025, 10/28/2025, 11/11/2025, 11/25/2025, 12/01/2025, 12/08/2025, 12/22/2025, 12/30/2025, 01/05/2026, and 01/12/2026.Review of a 01/14/2026 wound provider note showed Resident 3 was seen for a new Stage 4 (severe full thickness wound extending to the muscle and the bone) sacral (tailbone) PU and a new Stage 3 PU to their right buttocks.Review of Resident 3's medical record from 10/30/2025-01/13/2026 showed no progress notes on the date the two PU's were discovered, who was notified, and what staff did in response to the two new PU's. Review of Resident 3's medical record showed no skin/wound evaluations completed by staff to determine when the wound developed and was identified by facility staff.Observations on 01/21/2026 at 2:32 PM showed Resident 3 could not answer questions and was in bed on their back on an air mattress. Staff J (Registered Nurse, RN) was present in the room and at 2:33 PM stated Resident 3 had a stage 1 PU to their sacrum (tailbone area) , the resident was repositioned every few hours but it made it hard because Resident 3 received tube-feeding (nutritional formula given directly into the stomach) and the head of the bed had to be elevated to prevent choking.In an interview on 02/26/2026 at 11:22 AM Staff B stated they would expect staff to complete a Braden skin assessment quarterly, update the skin care plan with current PU, complete and document skin and wound assessments. Staff B stated Resident 3 had physician orders for barrier cream after each incontinent episode, did not know how staff did not identify the PU's to Resident 3's bottom until it was a stage 3 & stage 4 PU, and would expect the staff to be able to identify skin breakdown. Staff B stated when a new PU was identified staff should complete a progress note, an incident report, inform the provider, resident representative, obtain and implement treatment orders, and update the care plan. REFERENCE: WAC 388-97-1060(1)(b)(3)(b).

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident 1) reviewed for sexual abuse. Resident 1 experienced psychological harm, applying the reasonable person approach (how a reasonable person would respond under the same circumstances), when they were inappropriately touched on their breast by Resident 2. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. The facility has corrected the above deficiency prior to the abbreviated survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of the facility Abuse, Neglect and Exploitation policy, dated 2023, showed the facility would provide protection for the health, welfare and rights of each resident by developing and implementing policies that prohibit abuse. The facility would keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This included freedom from verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion. The policy showed sexual abuse, defined as non-consensual sexual contact of any type with a resident. <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 08/07/2024, showed Resident 1 was not able to make their own decisions due to severely impaired cognition, needs known, and was rarely or never understood by others. The MDS showed Resident 1 had short and long term memory problems, was not able to recall the current season, location of their room, where they were, and staff faces and names. The MDS showed Resident 1 had no behaviors and diagnoses including a history of a stroke (brain bleed), Alzheimer's disease, aphasia (a communication disorder caused by damage to the brain that controls language, expression, and comprehension), depression, and schizophrenia (a mental health disorder that affects how people think, feel, and behave). The MDS showed Resident 1 used a wheelchair, and required staff assistance for wheelchair mobility, transfers, and hygiene care needs. Review of Resident 1's Activities of Daily Living (ADL) and communication problem care plan (CP), revised 07/23/2024, showed Resident 1 preferred female caregivers. The CP directed staff to anticipate Resident 1's needs and ensure a safe environment as Resident 1 was not able to communicate effectively. Review of an impaired cognition CP, revised 07/23/2024, showed Resident 1 had an impaired thought process due to dementia and directed staff to cue, re-orient, and supervise as needed. Review of a Nursing Progress Note (NPN), dated 08/09/2024, showed Resident 1 was placed on alert charting to monitor for signs and symptoms of distress from being touched inappropriately. Review of a facility investigation, dated 08/09/2024, showed Resident 1 was sitting in their wheelchair in the hallway when Resident 2 was observed rubbing and touching Resident 1's breast. Staff D (Licensed Practical Nurse) separated the residents and staff redirected Resident 2 away from Resident 1. During an observation and interview on 08/16/2024 at 4:00 PM, Resident 1 was observed sitting on the edge of their bed. Resident 1 stated doing good, but was unable to answer questions related to the incident with Resident 2. <Resident 2> Review of a quarterly MDS, dated [DATE], showed Resident 2 was not able to make their own decisions, needs known, and was rarely or never understood by others. The MDS showed Resident 2 had physical behavioral symptoms that were directed at others and other behavioral symptoms that were not directed at others, the behaviors occurred one to three times during a seven day look back period. The MDS showed the behaviors significantly interfered with Resident 2's care and participation in activities and social interactions, significantly intruded on the privacy and activity of others, and disrupted the care and living environment. The MDS showed Resident 2 had diagnoses including non-traumatic brain dysfunction, dementia, and a cognitive communication deficit (trouble reasoning and making decisions while communicating). The MDS showed Resident 2 ambulated independently with a walker and required staff assistance with bathing and personal hygiene. Review of Resident 2's medical record showed a NPN, dated 04/19/2023, the NPN showed a staff member saw Resident 2 touching a female resident's breast. The staff asked Resident 2 to stop and separated both residents. A NPN, dated 04/19/2023, showed Staff D, (Social Services Director) followed up with Resident 2 who denied touching another resident's breast. The NPN showed the SW identified through resident interviews another female resident who was inappropriately touched on the breast by Resident 2. Review of a NPN, dated 08/09/2024, showed staff witnessed Resident 2 ambulating with their walker, and was found Resident 2 rubbing and touching the breast of Resident 1. Review of Resident 2's behavior CP, dated 10/24/2023, showed Resident 2 had sexually inappropriate behaviors that included touching female residents, exposing their genitals and masturbation. The CP directed staff to re-direct Resident 2 to their room for privacy when observed masturbating in public, monitor for behaviors, re-direct or remove Resident 2 from situations, and intervene as necessary to protect the rights and safety of other residents. Review of a NPN, dated 08/09/2024, showed Resident 2 was observed by a Staff D walking over to Resident 1, asked if they could touch Resident 1's breast, and proceeded to rub Resident 1's breast. The staff member stopped Resident 2 and reported the incident to Staff B (Director of Nursing Services). Review of a facility investigation, dated 08/09/2024, showed Resident 2 was re-directed to their room after being observed by Staff D rubbing Resident 1's breast. The investigations showed both Resident 1 and Resident 2 had dementia, and Resident 2 did not recall touching Resident 1's breast. In an interview of 08/16/2024 at 3:45 PM, Staff B stated Resident 2 had a history of sexually inappropriateness, was not aggressive, and did not recall the incident with Resident 1. Staff B stated both Resident 1 and Resident 2 had dementia and were not able to recall the incident. Staff B stated Resident 2 needed increased supervision and should be kept away from female residents. In an observation and interview on 08/16/2024 at 3:55 PM, Resident 2 was observed sitting in a chair in the hallway next to the nursing station. Resident 2 was asked about the incident but did not recall what happened. When asked if Resident 2 was touched inappropriately, they responded, not yet, darn it. I wish they would. Resident 2 asked repeatedly for a kiss during the interview. During an interview on 08/16/2024 at 4:05 PM, Staff C (Nursing Assistant Certified), stated Resident 2 made sexual statements to the staff, either asking for a kiss or asking they lay in the bed with the resident. Staff C stated Resident 2 could be difficult to re-direct at times and was reminded the behavior was inappropriate. Staff C stated it was not okay for another resident to touch another resident's breast as it would be considered sexual abuse. The facility corrected the failed practice prior to the investigation by having only male caregivers work with resident 2 to decrease and remove the triggers or stimulation from females .This was past non-compliance and is no longer outstanding. REFERENCE: WAC 388-97-0640(1).

Based on observation, interview, and record review the facility failed to provide consistent supervision and ensure a safe environment that was free from dangerous accident hazards for 6 of 14 residents (Resident 1, 4, 8, 3, 9 & 5) reviewed for smoking. The failure to: timely and accurately assess resident's ability to safely smoke; secure smoking paraphernalia; implement, and enforce the facility smoking policy when Resident 1 was found smoking in the facility and a common area repeatedly, including near a resident who required and was wearing oxygen, placed all residents at risk for serious adverse outcomes with the potential for fire and an explosion and/or serious bodily injury, and constituted an Immediate Jeopardy (IJ). On 04/18/2024 an IJ was identified in F-689 and the provider was informed. The IJ was determined to begin on 04/13/2024. The facility removed the immediacy that was confirmed with an on-site visit by ensuring all residents were accurately assessed to smoke, educated all residents who smoked on the facility smoking policy, consequences for not abiding to the policy, and secured all smoking paraphernalia. Findings included . Review of the facility's undated policy titled, Smoking Policy, showed the facility would provide a safe environment while ensuring resident safety as it related to the residents who smoked. The policy showed smoking was prohibited in all areas of the facility except the designated smoking area. The policy showed residents who wished to smoke would be assessed to determine if they were safe to smoke by using the resident safe smoking assessment, all safe smoking measures would be documented on the resident's Care Plan (CP), and communicated to staff. Review of the facility's undated policy titled, Accidents and Supervision showed the resident environment would remain free of accident hazards and each resident would receive adequate supervision to prevent accidents. All facility staff would be involved in the observation and identification of potential hazards in the environment. The policy showed the facility would use specific interventions to reduce the risk from hazards in the environment that included; communicating the interventions to all relevant staff, provide training, document, and ensure interventions were put into place. The interventions would be monitored and modified to ensure interventions were implemented correctly, consistently, and evaluated for effectiveness. Review of the facility, Smoking Tobacco and Marijuana Notice and Agreement, that was part of the resident admission agreement, showed residents are permitted to smoke cigarettes, marijuana, and the use of any/all tobacco products, as well as electronic cigarettes and vaping devices in certain designated outdoor areas of the facility. The smoking agreement showed the resident must be assessed first to safely smoke, assessed to safely go outside independently, and the assessment would verify if the resident was capable of maintaining their own smoking supplies, if not deemed safe to maintain their smoking supplies the resident would agree to have smoking supplies stored at the nurse station. The agreement showed if a resident failed to adhere to the policy, they may be issued a 30-day discharge notification. <Resident 1> Review of the 01/11/2024 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE], was not able to make their own decisions, and had a decision maker to assist with decisions. The MDS showed Resident 1 had medically complex conditions and diagnoses including a traumatic brain injury, pneumonia (respiratory infection) that required intermittent oxygen use, adult failure to thrive, altered mental status, and restlessness with agitation. The MDS showed Resident 1 used a wheelchair to ambulate, had behaviors of delusions (misconceptions or beliefs), was prescribed an antipsychotic (used to treat mental disorders) medication and, an antidepressant (used to treat depression). Review of an admission assessment, dated 11/16/2023, showed Resident 1 had a history of smoking one pack of cigarettes daily for [AGE] years and smoked marijuana. Review of a Nursing Progress Note (NPN), dated 03/07/2024 at 4:16 PM, showed Staff C (Registered Nurse, RN) documented another staff member found Resident 1 smoking marijuana in their room, the room smelled of marijuana but Resident 1 denied smoking in their room. The NPN showed Resident 1's roommate requested to be out of the room, and Staff C notified the Physician, Director of Nursing (DON), and the Resident Care Manager (RCM) of Resident 1's incident. A NPN on 03/07/2024 at 5:28 PM showed Staff C found a lighter and marijuana on Resident 1 who gave Staff C the lighter but refused to provide staff with the marijuana, instead put it in their mouth when staff tried to confiscate the marijuana. Staff C documented they informed Staff B (DON) of the incident and placed Resident 1 on alert monitoring. Review of a NPN, dated 03/08/2024, showed Staff E (RN) documented Resident 1's roommate stated they witnessed Resident 1 smoking in the room and when staff asked Resident 1, they denied smoking in their room. Review of a NPN, dated 03/16/2024, showed Staff D (Licensed Practical Nurse, LPN) was called to Resident 1's room because smoke was observed coming from the room and found Resident 1 smoking marijuana in the bathroom. Staff D explained the fire risks related to smoking indoors and Resident 1 refused to give Staff D the lighter but did relinquish the marijuana to staff. Staff D documented they informed Staff A (Administrator) and the Physician. Review of a NPN, dated 03/17/2024 11:49 AM, showed Staff C found Resident 1 smoking in their room and initially refused to give up their lighter. Staff C documented they informed their supervisor of Resident 1's behavior. An additional note on 03/17/2024 at 1:15 PM showed Staff C asked Resident 1 who provided the cigarette. Resident 1 stated, Resident 3 gave it to them. Staff C asked Resident 3 why they gave Resident 1 a cigarette and Resident 3 replied, they said they wanted to smoke. Review of a NPN, dated 03/28/2024 at 12:12 PM, showed Staff E documented they smelled smoke coming from Resident 1's room. Resident 1 was asked if they were smoking. Resident 1 denied smoking in their room but gave Staff E their lighter. Review of a NPN, dated 03/29/2024 at 7:56 PM, showed Staff C was notified that Resident 1 and their roommate were seen smoking in the atrium (common area) of the facility. Staff C documented they informed Staff A, Staff B, and the facility Social Worker (SW). Review of a smoking assessment, dated 04/10/2024, showed Resident 1 indicated: they wished to smoke; was assessed as cognitively intact to smoke independently; had a history of smoking in their room and other areas of the facility; and a history of non-compliant behavior regarding the smoking policy. The assessment showed the recommendations based on the data gathered was the resident denies smoking, according to the RN there have been reports of the resident and roommate smoking in room unwitnessed. There were no adjustments made to Resident 1's Care Plan (CP) to reflect the resident's smoking. Review of a NPN, dated 04/12/2024, showed Staff F (RN) documented they caught Resident 1 smoking a cigarette in their bathroom. Staff F documented they reminded Resident 1 not to smoke inside the building due to fire hazards and other residents using oxygen. Review of a NPN, dated 04/13/2024 at 9:31 AM, showed Staff G (Administrative Assistant) documented they found Resident 1 smoking a cigarette in the atrium. When Staff G told Resident 1 they could not smoke in the atrium, Resident 1 responded, I'm not. Staff G observed a lit cigarette Resident 1 had dropped on the ground. Resident 1 apologized to Staff G, and Staff G educated Resident 1 about the dangers of smoking with other residents using oxygen nearby. Staff G stated they informed Staff A and Staff B that Resident 1 was found smoking in the atrium. An additional note on 04/13/2024, four minutes later at 9:35 AM, Staff G found Resident 1 smoking again in the atrium area with another resident, possibly Resident 2 who was actively receiving oxygen from an oxygen tank with a nasal cannula delivering oxygen to their nose. Staff G stated the charge nurse was aware and went and removed the lighter from Resident 1. During an interview on 04/17/2024 at 2:07 PM Staff A (Administrator) stated that another resident might be sharing their cigarettes with Resident 1 because they had no way to get cigarettes. Staff A stated residents were allowed to keep cigarettes on them but lighters were stored in a locked box in the resident's room. In an interview on 04/17/2024 at 3:20 PM Staff J (Infection Preventionist/RN) stated they did not see Resident 1 smoking in the atrium but Resident 1's roommate (Resident 5) was seen sneaking out to smoke in the atrium. Staff J stated Resident 5 had a Collateral Contact (CC) bringing them cigarettes and when staff tried to remove the cigarettes or lighter, Resident 5 would become combative with staff. During an interview on 04/17/2024 at 3:32 PM Staff I (LPN) stated when a resident smoked their lighter and cigarettes should be kept secured on the nurse's cart but it was hard to regulate because the residents could sign out and return with more smoking supplies than staff knew about. In an interview on 04/17/2024 at 3:55 PM Staff H (Certified Nursing Assistant, CNA) stated the facility did not store resident cigarettes or lighters. During an interview on 04/17/2024 at 4:20 PM Staff C stated Resident 1 did not have access to get cigarettes from outside the facility, they were not sure where Resident 1 obtained cigarettes, but last week Staff C smelled smoke coming from Resident 1's room. Staff C could not be sure if it was Resident 1 or their roommate (Resident 5) smoking. In a follow up interview on 04/18/2024 at 5:25 PM Staff C stated they were not sure where Resident 1 obtained marijuana or smoking supplies. Staff C stated Resident 1 continued to ask staff to go outside to smoke. During an interview on 04/17/2024 at 5:45 PM Staff A stated the smoking agreement was in the admission paperwork that informed residents upon admission of the smoking policies. Review of the admission smoking agreement showed the smoking assessment would determine if the resident was able to maintain their own smoking supplies. Review of the smoking assessment showed no area to address where or if a resident could maintain their own smoking supplies. Staff A stated the admission smoking agreement was not correct, residents were not allowed to smoke marijuana in the smoking area, and the facility needed to change the smoking admission agreement. Staff A stated the admission agreement paperwork was not always completed timely and the residents were not always informed of the smoking policies in a timely manner. Staff A stated after Resident 1 was found smoking in the facility numerous times the Interdisciplinary Team (IDT) had conversations about Resident 1's non-compliance with smoking and discussed a plan. Staff A was asked to provide that documentation, as Resident 1's medical record did not show any IDT notes discussing the resident's non-compliance with the smoking policy, and no documents were provided. During an interview on 04/18/2024 at 5:15 PM Staff A stated they believed the other resident who was wearing oxygen when Resident 1 was in the atrium smoking was possibly Resident 2 who worked with Physical Therapy (PT) and would walk through the atrium when exercising with PT. Staff A stated the stated the staff that witnessed Resident 1 smoking in the atrium did not get a good look at the other resident but could see their oxygen tank on the back of the wheelchair and the nasal cannula around the resident's ears and was connected to the oxygen tank. In an interview on 04/18/2024 at 5:32 PM Staff I stated they have never seen lock boxes in rooms of residents who smoked. In an observation and interview on 04/18/2024 at 5:31 PM Resident 1 was observed sitting on their bed and stated yes, they smoked. Resident 1 stated facility staff told them they had to smoke outside and off the facility property. Resident 1 stated they never smoked in the facility and asked if they could go buy cigarettes or have someone buy them cigarettes as they reached and pulled cash out of their shirt pocket. During an interview and observation on 04/18/2024 at 5:35 PM Resident 6's room was observed with a window that looked out into the atrium. Resident 6 stated they observed Resident 1 smoking in the atrium three or four times. Resident 6 stated they observed Resident 1 with another resident one time but was not sure if the resident had oxygen on, and stated they could not always see who was out in the atrium smoking but could smell the smoke. Review of a smoking assessment, dated 04/19/2024, showed staff assessed Resident 1 as not safe to smoke independently. Review of a Smoking Cessation CP, dated 04/19/2024, showed Resident 1 is on a smoking cessation medication due to being assessed as not safe to smoke and the charge nurse should be notified immediately if Resident 1 violates the smoking policy. In an interview on 05/02/2024 at 2:45 PM Staff B stated smoking assessment should be completed upon admission if the resident was identified as a smoker, should be re-assessed every 90 days, and a CP in place to ensure safe smoking. <Resident 4> Review of the Admission MDS, dated [DATE] showed Resident 4 was admitted to the facility on [DATE], had some impairments with their decision making ability, and had verbal behaviors directed towards others. The MDS showed Resident 4 had medically complex conditions including chronic obstructive lung disease, end stage renal disease that required dialysis (process of removing excess toxins when kidneys no longer work), depression, and tobacco use. The MDS showed Resident 4 was dependent on staff for transfers and used an electric wheelchair to move around the facility. Review of an admission assessment, dated 01/30/2024, showed Resident 4 was assessed as a current smoker and used alcohol. Review of a smoking assessment, dated 01/30/2024, showed Resident 4 wished to smoke, was assessed to be cognitively intact to smoke, had no disease or medical conditions that disqualified them from smoking per the assessment, and was assessed as able to safely smoke independently. The smoking assessment showed when a resident had certain medical conditions, such as neuropathy, the resident may not smoke at that time. Review of Resident 4's Physicians Orders (PO) showed Resident 4 was prescribed a medication for neuropathy. Review of an Active Smoker CP, dated 01/31/2024, showed Resident 4 was instructed about the facility policies on smoking locations, times, and safety concerns. Review of a NPN, dated 02/04/2024, showed Staff K was informed that staff could not enter Resident 4's room because their motorized wheelchair was blocking the door. Staff K documented they observed Resident 4 unresponsive with irregular breathing. Emergency responders were able to gain access into Resident 4's room and while working on Resident 4, a crack pipe, lighter, used foil pieces, used cut straws, a baggie with what appeared to be crack, and six tablets of a narcotic 30 milligram medication were found. Staff K documented Resident 4 transferred to the hospital, informed Staff A of the incident, and requested instructions on what to do with the drug paraphernalia. Review of a signed behavior contract between the facility and Resident 4, dated 02/09/2024, showed Resident 4 would; refrain from the possession or use of illicit drugs and paraphernalia while residing in the facility, if there was concern about paraphernalia Resident 4 would agree to their belongings and room being searched, no smoking in the community, and no smoking in the with oxygen on. The behavior contract showed if Resident 4 failed to meet these expectations it would result in an immediate termination of the relationship between the facility and Resident 4. Review of a NPN, dated 02/26/2024, showed staff observed Resident 4 in the front lobby, with a cigarette and lighter in their hand. Resident 4 was observed with a runny nose, a white residue above their lip, and constricted eye pupils. The NPN showed Resident 4 consented to have their bag being searched, no items were found, but Resident 4's clothing and jacket pockets were not searched. The NPN did not mention if the cigarette or lighter was removed from Resident 4 at that time. Review of a NPN, dated 02/29/2024, showed Resident 4 appeared to be under the influence of a recreational substance and gave consent for staff to search their room. Upon searching Resident 4's room, an electrical heating pad, heat gun, cut pieces of aluminum foil, a cut straw, and a cigarette butt were found. The documentation showed no further interventions were indicated at this time. Review of Resident 4's NPN's showed no documentation to support the facility enforced Resident 4's behavior contract after being found with drug paraphernalia twice in three days. Observations and interviews on 04/17/2024 at 2:45 PM showed Resident 11 self-propelling in the hallway, upset, screaming, and swearing that they wanted their lighter back so they could go smoke. At this time Staff B came into the hallway and stated Resident 11 was new to the facility and was not able to safely smoke or go outside independently. Observations and interviews on 04/17/2024 at 4:50 PM showed two working lighters, one with a torch like flame sitting on Resident 4's bedside table. Resident 4 was not observed in their room or in the facility. On 04/17/2024 at 4:55 PM Staff B stated lighters should be stored in the lock box and should not be accessible to other residents because it was a safety issue, especially when Resident 11 was previously looking for a lighter earlier that day. Staff B was not able to locate a lock box or key in Resident 4's room and stated they would expect Resident 4 to have a lock box and key to secure their smoking supplies. During an interview on 04/24/2024 at 4:10 PM Staff B acknowledged the smoking assessment for Resident 4 was not marked for neuropathy although they were being treated with medication for neuropathy and stated the nursing management and administration reviewed and revised the resident smoking assessments eliminating certain medical diagnoses, such as neuropathy. Staff B stated because a resident was treated for neuropathy does not mean they are not safe to smoke. Staff B stated the smoking assessment included a visual assessment to watch the resident smoke to determine if they were safe. <Resident 8> Review of a 04/12/2024 significant change MD'S showed Resident 8 admitted to the facility on [DATE], was able to make their own decisions and needs known. The MDS showed Resident 4 had medically complex conditions including cancer, diabetes, anxiety, and bipolar disorder. The MDS showed Resident 8 used a wheelchair to ambulate and had no behaviors. Review of an Admission Assessment, dated 03/15/2024, showed Resident 8 was identified as a current smoker on admission to the facility. Review of a NPN, dated 03/16/2024 at 2:35 AM, showed Resident 8 demanded staff take them outside to smoke. Staff documented they informed Resident 8 of the facility smoking policy and that staff cannot assist in facilitating smoking. An additional NPN, dated 03/16/2024 at 6:17 PM showed Resident 8 was found smoking cigarettes in their bed. Resident 8 put their cigarette out and gave staff one pack of cigarettes, 1/2 smoked cigarette, and a lighter. Review of a smoking assessment, dated 04/04/2024, showed Resident 8 wished to smoke, was unable to access the smoking area independently, was dependent on staff for all smoking needs, and should not smoke unassisted. A second smoking assessment was completed on 04/19/2024 showed Resident 8 preferred not to smoke and was currently prescribed a smoking cessation to stop smoking. Review of a NPN, dated 04/16/2024, showed Resident 8 was heard yelling about wanting to go outside to smoke. The NPN showed staff reminded Resident 8 that it was past the smoking time. Staff were able to re-direct the resident. During an interview and observation on 04/17/2024 at 4:45 PM Resident 8 stated they were a current smoker and kept their cigarettes and lighter on their person. Resident 8 was observed with a pack of cigarettes and a lighter on them and stated they did not have a lock box with a key to store their cigarettes and stored their smoking supplies in their pocket. Observations showed no lock box in Resident 8's room to secure smoking supplies. Review of Resident 8's CP showed on 04/19/2024, a smoking cessation CP was initiated and directed staff to notify the nurse immediately if Resident 8 violated the facility smoking policy. During an interview on 04/24/2024 at 4:22 PM Staff B stated all smokers were re-assessed and Resident 8 was assessed as no longer safe to smoke independently, wished not to smoke, and was started on a smoking cessation medication. Staff B stated they would expect all residents who smoked to have a lock box and key in their room to secure smoking supplies. <Resident 3> Review of a quarterly MDS, dated [DATE], showed Resident 3 admitted to the facility on [DATE], was not able to make their own decisions, and had behaviors of wandering that put Resident 3 at significant risk of getting to a potentially dangerous place. The MDS showed Resident 3 had medically complex diagnoses including epilepsy (brain disorder that causes seizures), dementia, and nicotine dependence. Review of an admission assessment, dated 12/12/2023, showed Resident 3 was identified as a current smoker with a history of smoking for [AGE] years and currently used smokeless tobacco. Review of Resident 3's CP, initiated 12/13/2023, showed no CP in place that addressed Resident 3's smoking or a smoking assessment completed upon Resident 3's admission after being identified as a current smoker. Review of a NPN, dated 12/15/2023, showed Resident 3 went outside to smoke with their roommate and later returned to the unit. Additional NPN's dated 12/30/2023 and 12/31/2023 showed Resident 3 was reminded not to go smoke by themselves and a staff member assisted them outside to smoke a cigarette. A NPN, dated 01/02/2024 showed Resident 3 triggered the wanderguard alarm (a system to alert staff if a resident attempted to exit the facility) because they wanted to go outside to smoke. Staff C documented they were informed by staff that another resident gave Resident 3 a cigarette and Resident 3 made multiple attempts to go outside to smoke, eventually staff escorted Resident 3 outside to smoke their cigarette. Review of a Social Services Assistant (SSA) note, dated 02/04/2024, showed Staff L (SSA) spoke with Resident 3 and requested they be supervised when leaving the building to go smoke or go to the corner store. Staff L documented Resident 3 had a history of confusion and wandering. Review of a NPN, dated 02/17/2024, showed Staff D was notified by a staff member leaving the building that the wanderguard alarm was ringing and they saw Resident 3 walking down the street towards the facility. Resident 3 told Staff D they went to the corner store to have a cigarette. Review of a smoking assessment, dated 03/06/2024, showed Resident 3 preferred not to smoke, was independent with their cognition, judgement, and safety decision making. The smoking assessment showed staff documented that Resident 4 was able to smoke independently, acknowledged the smoking policy, and agreed to follow the smoking policy. Review of a NPN, dated 03/16/2024, showed Resident 3 requested to go outside to smoke but when staff brought Resident 3 outside the resident wanted to go to the corner store. A NPN, dated 04/15/2024, showed Staff M (Resident Care Manager, RN) documented a smoking assessment was completed supporting Resident 3 was assessed as not safe to smoke unassisted. Staff M requested an order for nicotine patches for Resident 3. During an observation and interview on 04/17/2024 at 4:34 PM, Resident 3 stated they were a current smoker and they usually had a lighter on them, was unable to locate one, and stated that it was probably in their room. Review of a smoking assessment, dated 04/19/2024, showed Resident 3 wished to smoke, had impaired cognition, judgement, and unsafe decision making. The assessment showed Resident 3 was deemed unsafe to smoke and smoking cessation was in progress. Review of a NPN, dated 04/20/2024, showed Staff C documented they were informed that Resident 3 got money from another resident and left the facility to go to the corner store and returned with a pack of cigarettes, a lighter, and three cans of beer. A staff member found Resident 3 smoking a cigarette in the parking garage, Resident 3 refused to give staff the cigarettes and lighter, and was difficult to re-direct. The documentation did not include any reassessment to new interventions the facility would take to ensure the resident's safety and non-compliance with smoking. Review of Resident 3's PO showed a 04/24/2024 PO for a smoking cessation medication was ordered five days after Resident 3 was deemed unsafe to smoke on 04/19/2024. In an interview on 04/25/2024 at 3:00 PM Staff B stated if a resident was assessed not safe to smoke, they should not be smoking. <Resident 9> Review of a quarterly MDS, dated [DATE], showed Resident 9 readmitted to the facility on [DATE], was able to make their own decisions, and had no behaviors. The MDS showed Resident 9 had medically complex diagnoses including chronic respiratory failure, heart failure, history of brain bleed, anxiety, schizophrenia, and post traumatic stress disorder. The MDS showed Resident 9 had impairments to both lower extremities and used an electric wheelchair to move around the facility. Review of an admission assessment, dated 01/09/2024, showed staff documented Resident 9 was a current smoker. Review of a smoking CP, initiated on 01/31/2024, showed Resident 9 had a history of smoking marijuana and used a vape pen (electronic cigarette). The CP directed staff to instruct Resident 9 on the facility smoking policy and to notify the charge nurse if the resident violated the facility smoking policy. Review of a smoking assessment, dated 03/06/2024, showed staff documented Resident 9 indicated they did not wish to smoke, they were assessed cognitively intact to smoke independently, and had diagnoses that included neuropathy that automatically disqualified them from being able to smoke at that time, per the smoking assessment directions. The smoking assessment concluded that Resident 9 continued to smoke, had plans to stop in the future, and declined smoking cessation medications. Review of a smoking assessment, dated 04/19/2024, showed staff documented Resident 9 wished to smoke, was assessed to be safe to smoke independently, and had diagnoses that included neuropathy that automatically disqualified them from being able to smoke at that time, per the smoking assessment directions. The smoking assessment concluded that Resident 9 continued to smoke at this time. Review of a smoking assessment, dated 04/24/2024, showed Resident 9 wished to smoke, was assessed as cognitively intact, able to smoke independently, and the smoking assessment no longer contained the section that reviewed conditions or medical diagnoses automatically disqualifying a resident to smoke if they had one or more of those conditions. Review of a NPN, dated 03/06/2024, showed staff spoke with the physician about Resident 9 continuing to smoke while having a PO for a nicotine patch, the physician discontinued the order for the nicotine patch. A NPN, dated 04/18/2024, showed Resident 9's lighter was removed from them and put in the nurses cart to keep secure. During an observation and interview on 04/23/2024 at 3:18 PM, Resident 9 was observed sitting on the edge of their bed and stated they had not smoked a cigarette in a week but did still use a vape pen to smoke. Review of a NPN, dated 04/24/2024, showed staff documented that Resident 9 was aware they could not keep marijuana or any smoking paraphernalia in their room, and if they did not abide by the facility smoking policy they may be subject to a 30 day discharge notice. <Resident 5> Review of the admission MDS, dated [DATE], showed Resident 5 admitted to the facility on [DATE], was not able to make their own decisions, and had no behaviors. The MDS showed Resident 5 had a non-traumatic brain dysfunction, dementia with behavioral disturbances, restlessness with agitation, and tobacco use. The MDS showed Resident 5 was able to ambulate independently with no assuasive devices. Review of an admission assessment, dated 03/21/2024, showed Resident 5 was assessed as a previous smoker. Review of a smoking assessment, dated 03/21/2024, showed Resident 5 did not wish to smoke, was not cognitively independent to safely smoke. The assessment concluded that an order for smoking cessation medications were ordered. Review of Resident 5's history of tobacco use CP, dated 04/15/2024, directed staff to monitor for non adherence to the smoking policies and report to the provider with each occurrence. Review of a NPN, dated 03/29/2024 at 4:08 PM, showed Resident 5's Collateral Contact (CC) requested staff look at Resident 5's belongings and staff found a lighter on Resident 5, who was not willing to have their smoking items secured. An additional NPN, dated 03/29/2024 at 4:45 PM showed Staff C was informed that Resident 5 had a lighter in their hand, refused to give Staff C the lighter, and Staff C informed Staff B. Staff C documented they were notified after an hour that Resident 5 was smoking in the atrium with their roommate (Resident 1), and Resident 5 gave Staff C the cigarettes but refused to give them the lighter. A NPN, dated 03/30/2024 showed Resident 5's CC came to the facility and staff were able to obtain and secure the lighter in the nurses cart. Review of a NPN, dated 04/09/2024, showed Staff K documented at 7:45 PM Resident 5 was observed smoking a cigarette in the atrium, was educated not to smoke in that location, put their cigarette out, and refused to relinquish their lighter to staff. Staff K re-attempted to obtain the lighter but Resident 5 became aggressive and refused to give up their lighter. Staff K documented they informed Staff A, Staff G, and Staff B of the incident. Resident 5 continued on 15 minute checks for safety. Review of a NPN, dated 04/14/2024 at 11:00 PM, Resident 5 was observed pacing the hallway with clenched fists and stated I want out, just out!. Staff K asked Resident 5 if they had cigarettes and Resident 5 stated, you can't have mine. Staff K escorted Resident 5 outside and the resident pulled out a cigarette lit their cigarette with their lighter. The NPN did not indicate if staff removed or attempted to remove Resident 5's smoking supplies from them as they were not assessed to be able safely to smoke independently. During an interview on 04/17/2024 at 3:20 PM Staff J stated Resident 5 was new to the facility and was sneaking out to the atrium to smoke. Staff J stated there was no clear directions from management on how to manage Resident 5's non-compliant behaviors. In an observation and interview on 04/17/2024 at 4:22 PM, Resident 5 stated yes they were a smoker, kept their cigarettes in their pocket as they pointed at their pocket and a shape of a small box was observed. Resident 5 stated they had a lighter but it was almost empty. No lock box was observed in Resident 5's room. In an observation and interview on 04/18/2024 at 5:30 PM, Resident 5 was observed in their room, was unable to answer questions due to increased confusion, and pulled out a Ziploc baggie from their pocket that contained three cigar [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 2 residents (Residents 16 & 15) reviewed for resident-to-resident incidents. This failed practice resulted in psychological harm, applying the reasonable person approach (a reasonable person in this situation would be upset, angry, and feel violated), for Resident 16 who experienced inappropriate sexual touching by Resident 14, and for Resident 15 who was inappropriately slapped by Resident 14. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. Findings included . Review of the facility Abuse, Neglect, and Exploitation policy, undated, showed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy showed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The policy showed examples to protect residents included; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, and increased supervision of the alleged victim and residents. The policy showed abuse prevention would include establishing a safe environment that supported, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. <Resident 16> Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/30/2023, showed Resident 16 was not able to make their own decision, and was assessed as rarely or never understood by others. The MDS showed Resident 16 had behaviors of wandering that occurred daily that placed the resident at significant risk of getting to a unsafe place and significantly intruded on the privacy and activities of others. The MDS assessed the wandering behaviors as worse when compared to prior assessments. The MDS showed Resident 16 had medically complex conditions including fracture, seizure disorder, anxiety, and depression. Review of an impaired cognition Care Plan (CP), revised 09/15/2023, showed Resident 16 had an impaired thought process due to being developmentally delayed (progression through developmental stages slows, stops, or reverses) and the goal was Resident 16 would develop skills to cope with their mental decline and to maintain the residents safety. Review of an elopement risk CP, revised 11/23/2023, directed staff to monitor Resident 16's location every 30 minutes and distract the resident from wandering with activities. Review of a Nursing Progress Note (NPN), dated 02/07/2024 at 5:15 PM, showed Resident 16 was touched inappropriately in the breast area by another resident (Resident 14) in the hallway by the main nurses station, the residents were immediately separated, and Resident 14 was placed on 15-minute checks. The NPN showed Resident 16 was interviewed and acknowledged the incident occurred. Review of Resident 16's medical record showed no documentation the facility completed an assessment of Resident 16's skin after the incident. Review of a facility investigation, dated 02/09/2024, showed Resident 14 was observed by Staff L (Licensed Practical Nurse, LPN) putting their hands up Resident 16's shirt and touching their breasts. Review of a witness statement, dated 02/07/2024, showed Staff L was able to separate the two residents and re-direct Resident 14. The investigation concluded that Resident 14's behaviors were a result of their progressing diagnoses and they were not aware that the behaviors were inappropriate. The investigation showed that Resident 16 stated they were okay, Resident 14 continued on 15 minute checks, and both residents were at their baseline without signs of psychological harm. In an interview and observation on 02/14/2024 at 2:37 PM, Resident 16 was observed self propelling their wheelchair near the main nurses station. Resident 16 had a hard time focusing on questions and when asked if they were touched inappropriately, Resident 16 could not provide any information on the incident. <Resident 15> Review of a Quarterly MDS, dated [DATE], showed Resident 15 was able to make their own decisions and needs known. The MDS showed Resident 15 had diagnoses including history of a brain bleed, dementia, anxiety, and depression. Review of a social services note, dated 02/07/2024 at 6:51 PM, showed Staff F (Social Services Assistant) documented that resident was tapped on the behind while passing another resident (Resident 14) and the resident wants the behavior addressed. Review of facility investigation documents, dated 02/08/2024, showed Staff A (Administrator) documented the facility actions as; Resident 15 was safe, both residents placed on alert monitoring, and possible medication increase for Resident 14. Review of a investigation document, dated 02/12/2024, showed Staff A documented Resident 15 sustained no injuries and exhibited no psychological harm, and Resident 14 was placed on 15 minute checks. Review of Resident 15's medical record, dated 02/06/2024-02/13/2024, showed one NPN documentation entry for monitoring Resident 15 for psychological abuse, no other NPN were found that showed Resident 15 was monitored for psychological harm as indicated in the investigation documents. Review of Resident 15's record showed no documentation to support the facility assessed Resident 15's skin for injury after being slapped on the buttocks by Resident 14. During an interview and observation on 02/14/2024 at 2:45 PM, Resident 15 was observed in bed and stated that they were standing in line with a Certified Nursing Assistant (CNA) when Resident 14 slapped their buttocks really hard, and it hurt. Resident 15 stated that facility staff told them not to tell their significant other (Resident 17) because they would be upset. Resident 15 stated they were embarrassed, it hurt, and the resident (Resident 14) slapped the CNA's buttocks as well. Resident 15 stated no one from the facility came down to talk to them, interview them, or check or ask to see the skin on their buttocks for injury. Resident 15 stated that they heard from other residents that Resident 14 had hit other residents before, I hope they are gone, and no one here at the facility is doing anything about Resident 14. In an interview on 02/14/2024 at 2:51 PM, Resident 17 stated, I think I was more mad then them (Resident 15), I almost went down there to punch them (Resident 14), but I didn't. During an interview on 02/14/2024 at 3:45 PM, Staff F stated they interviewed Resident 15 after overhearing Resident 15 telling Resident 17 what happened in the hallway. Staff F stated, Resident 15 stated they stepped out of their room, the hall was crowded, and when they passed by Resident 14, they reached out and felt their buttocks. Resident 15 stated they told Resident 14 don't do that and what if I did that to you. Resident 15 told Staff F they wanted this behavior addressed. When asked what was done with this information, Staff F stated they documented in Resident 15's record and informed the clinical team. Staff F stated the process was to direct reports to the administrator to make the report to the state agency and stated it was late when the allegation occurred. Staff F stated they were a mandated reporter and the allegation should have but was not reported immediately. <Resident 14> Review of a Quarterly MDS, dated [DATE], showed Resident 14 had a non-English language preference and required an interpreter to communicate with healthcare staff. The MDS showed Resident 14 could not make their own decisions, could rarely understand or be understood by others, and had no behaviors. The MDS showed Resident 14 had medically complex conditions including dementia without behavioral disturbances, traumatic brain injury, anxiety, depression and a cognitive communication deficit. Review of a dementia CP, revised on 01/11/2024, showed Resident 14 had a history of sexual gestures towards female residents. The CP directed staff to offer the resident activities they preferred and monitor for changes in the resident's behavior or mood. Review of a wandering CP, dated 04/03/2023, directed staff to re-direct the resident to activities of interest and place a stop sign at the entrance of the resident's room. Review of a NPN, dated 02/07/2024, showed Resident 14 had touched another resident (Resident 16) inappropriately, the residents were immediately separated and Resident 14 was placed on 15 minute checks. Review of a NPN, dated 02/10/2024 showed Resident 14 continued to roam around the facility. A NPN, dated 02/12/2024, showed Resident 14 was found sleeping in another residents bed. Review of a NPN, dated 02/13/2024 showed Resident 14 was found in another residents room trying to use the toilet and staff assisted the resident to their own room. Review of Resident 14's medical record showed no documentation that Resident 14's behaviors of wandering or inappropriate sexual touching were being monitored consistently by facility staff. In an observation and attempted interview on 02/14/2024 at 2:40 PM, showed Resident 14 asleep in their wheelchair sitting near the nurses station. On 02/14/2024 at 3:00 PM, 3:10 PM, and 3:30 PM Resident 14 remained in the same spot, sleeping with their eyes closed. At 3:30 PM attempted to interview Resident 14 but they did not respond. During an interview on 02/14/2024 at 3:15 PM, Staff M (Registered Nurse) stated they were familiar with Resident 14 and took care of them often. Staff M stated Resident 14 needed an interpreter when communicating with staff and Resident 14's representative would be called to communicate or assist in re-directing Resident 14. Staff M stated Resident 14 was hard to direct at times, after explaining to the resident they would stop their behavior but then continue with the behavior. When asked how do staff complete 15 minute checks on Resident 14, Staff M stated it was not easy to do, especially during medication pass. On 02/14/2024 at 3:32 Staff M stated Resident 14 would sometimes not respond or open their eyes when they were sleeping, had a hard time sleeping at night, and recently had a medication increased to help with their behaviors. In an interview on 02/14/024 at 4:45 PM, Staff A stated they would expect an allegation of inappropriate sexual touching to be reported immediately to them and the required entities in a timely manner. Staff A stated the purpose of a investigation was to rule out harm and put a plan in place to prevent reoccurrence. Staff A stated Resident 14 was being followed by a mental health provider and was currently being monitored for medication changes related to Resident 14's behaviors. REFERENCE: WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to provide adequate supervision for 3 of 3 residents (Resident 1, 2 & 3) reviewed for accidents. The facility failed to provide supervision to Resident 1, who resided on the second floor with a wander guard in place, when they eloped from the first floor of the facility unnoticed, and experienced harm when they fell from their wheelchair and sustained a head injury, an abrasion to the head, and required an evaluation at a local hospital. The facility failed to implement fall prevention measures after Resident 1 experienced harm from a fall and after that fall , experienced a suspected fall that caused a leg fracture and a laceration to their forehead that required suture repair. Additionally, the facility failed to implement their elopement policies and procedures for 2 residents (Resident 2 & 3) who eloped and went missing from the facility, this failure resulted in the facility taking no action for 17 hours for Resident 2 and almost 10 hours for Resident 3. These failures placed Resident 2 & 3 at serious risk for harm and injury, and placed all residents at risk for accidents, and avoidable injury. Findings included . Review of the facility's, Wandering and Elopement policy, revised 03/2019, showed residents who were identified at risk for wandering or elopement would have a care plan (CP) that would include strategies and interventions to maintain the resident's safety. When a resident was found missing from the facility, staff would initiate the elopement/missing resident emergency procedure and determine if they resident is out of the building on a leave or pass. If the resident was not out of the facility on a leave or pass the facility staff would initiate a search of the building and premises. If the resident was not located the Administrator, Director of Nursing Services (DNS), the resident's legal representative, the physician, and law enforcement would be notified. If the resident returned to the facility, the facility staff would examine the resident for injuries, inform the physician of the findings and condition of the resident, notify the legal representative, complete an incident report and document all relevant information in the resident's medical record. Review of the facility's, Safety and Supervision of Residents policy, revised 07/2017, showed the facility would take an individualized, person-centered approach to safety, and accident hazards for individual residents. The interdisciplinary team would analyze information obtained from assessments and observations of the resident to identify any specific accident hazards or risks for individual residents. The policy showed resident supervision was a core component of the systems approach to safety and the type and frequency of supervision was determined by the individual resident's assessed needs and identified hazards in the environment. <Resident 1> Review of a 09/01/2023 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was not able to make their own decisions, could usually understand and be understood by others. The MDS showed Resident 1 had medically complex conditions that included a neurological disorder that affected movement and muscle tone, seizure disorder, and muscle weakness. The MDS showed Resident 1 was assessed to require one-person physical assistance and supervision with moving to and from locations in the building, had no impairments to their upper extremities, and used a wheelchair for mobility. Review of Section E, Behaviors, showed Resident 1 did not exhibit behaviors of wandering and behaviors were assessed to have remained the same. Review of a Wander Risk CP, dated 05/23/2023, showed Resident 1 had increased wandering behaviors and made statements of wanting to go home. The CP directed staff to monitor Resident 1's location every 60 minutes, invite and encourage the resident to engage in activities, and distract the resident from wandering by offering diversions, activities, television, food, or conversation. Review of a Fall Risk CP, revised 08/31/2023, showed Resident 1 was high risk for falls. The CP directed staff to anticipate Resident 1's needs and offer toileting before and after meals, before bed, and as needed. A new 11/12/2023 intervention showed a tilt in space wheelchair was added to aide in positioning and decrease fall risk. Review of an Elopement Screen, dated 07/13/2023, showed Resident 1 was assessed as a five, indicating Resident 1 was high risk for an elopement due to diagnoses, a history of wandering, and a history of exit seeking. Review of a Fall Assessment, dated 11/04/2023, showed Resident 1 was assessed at high risk for falls due to a history of falls, weakness, and overestimating their own ability to ambulate. Review of a 07/13/2023 Nursing Progress Note (NPN) showed Resident 1 was witnessed by facility staff trying to exit the lobby door, Resident 1 stated they had an appointment and needed to go, or stated they wanted to go home. The facility staff documented the medical director ordered a wander guard (bracelet that alarms when the resident is close to exit doors to alert staff) for the resident's safety. Review of a 07/20/2023 and 07/27/2023 physician encounter note showed the Medical Director documented Resident 1 frequently wandered and agreed with Resident 1 being fitted for a wander guard for their safety. Review of a 07/28/2023 Psychiatric physician encounter note showed Resident 1 was assessed with poor safety awareness, wandering, and anxiety, and would be appropriate for a wander guard. Review of a 08/02/2023 Physician Order (PO) showed a PO to place a wander guard on Resident 1 and directed staff to place the wander guard on Resident 1's left side of the wheelchair, and to check placement and functioning of the wander guard twice daily. Staff were directed to inform appropriate personnel if the wander guard was not functioning. Review of a 11/07/2023 NPN showed Staff C (Licensed Practical Nurse, LPN) was called down to the front lobby at 11:10 AM and observed Resident 1 laying on the ground outside in front of the facility. Emergency Medical Service personnel were observed assisting Resident 1 when they stated another visitor observed the resident fall out of their wheelchair and notified the front desk. Staff C documented Resident 1 stated they were trying to leave the facility when asked what happened. Resident 1 sustained an abrasion to the right side of their forehead and was sent to the ER to be evaluated for a head injury. Review of a 11/07/2023 hospital After Visit Summary (AVS) showed Resident 1 was seen for a mechanical fall from their wheelchair and a facial abrasion. The AVS instructed Resident 1 to return to the emergency room of worsening or new concerning symptoms of dizziness, fever, bad headache, and repeated vomiting. Resident 1 was prescribed antibiotics for a urinary tract infection and discharged back to the facility. Observations on 11/08/2023 at 3:15 PM showed a visitor waiting at the reception area with no staff present. After a few minutes staff who were just feet away having a meeting acknowledged visitors waiting at the reception area. Observations of the front lobby and first floor showed no wander guard censors and a keypad used to enter a code to exit the front door. Observations showed the front lobby door was not armed and visitors could enter and exit the facility without entering a code. In an interview on 11/08/2023 at 3:20 PM Staff D (Registered Nurse, RN) stated there was supposed to be a staff member at the reception desk, but they left to use the bathroom. In an interview on 11/08/2023 at 3:30 PM Staff B (Director of Nursing Services) stated there was not a wander guard censor on the front door and on 11/07/2023 Resident 1 was last seen at 10:40 AM on the second floor near the elevator doors but was re-directed to the nurse's station. Staff B stated they reviewed the security cameras, and it showed Resident 1 followed two emergency medical service personnel out the front door at 11:01 AM. Staff B stated they were notified at 11:10 AM of Resident 1 being found outside of the facility, falling out of their wheelchair, and hit their head. During an interview and observation on 11/08/2023 at 5:05 PM Resident 1 stated yesterday I wasn't feeling good. My head hurt when I fell down and it hurts now in the back (of the head). I feel really dizzy now; my head feels funny. Resident 1 was observed in bed and an abrasion was observed to the right side of their forehead. Review of a 11/10/2023 NPN showed staff documented the resident had to be brought back upstairs once because they were wanting to leave. Review of a 11/11/2023 at 10:58 PM NPN showed Staff E (Licensed Practical Nurse, LPN) documented they were notified by staff that Resident 1 was observed with an injury to their forehead, assessed the injury as a laceration 5 centimeters (cm) long by 0.5 cm deep, and applied a pressure dressing to stop the bleeding. Resident 1 was not able to tell Staff E how they obtained the injury to their forehead. Staff E documented that Resident 1 was last toileted at 9:30 PM by staff and was transferred to a local hospital to be evaluated for a fall with head injury. Review of a 11/11/2023 hospital AVS showed Resident 1 was found with a fracture to the right leg and a laceration to their forehead was repaired with stitches. Resident 1 was diagnosed with dizziness, fall, closed head injury, closed fracture of the right leg, and a laceration to the forehead. Review of a 11/11/2023 facility investigation showed at 9:30 PM staff assisted Resident 1 to the bathroom and then to bed, at 9:47 PM a staff member found Resident 1 sitting up in their bed, near the head of the bed, with a bleeding injury above the left eyebrow and redness to their right cheek. Staff B documented that hospital visit notes showed Resident 1 complained of feeling dizzy before the fall and drops of blood were observed on the bathroom floor. The investigation showed staff who assisted Resident 1 on 11/11/2023 to the bathroom, prior to the suspected fall asked another staff member to help assist them because Resident 1, who normally required one staff for transfers, was not the same when transferring after the fall on 11/07/2023. The investigation showed Resident 1 reported to the social services director that they fell , hospital reports showed Resident 1 complained of feeling dizzy before the fall, and Staff B concluded that an unwitnessed fall likely happened. Review of Resident 1's medical record showed Resident 1 had experienced falls on 05/12/2023, 06/27/2023, 10/13/2023, and on 11/04/2023 that were all unwitnessed and Resident 1 was found at the bedside. Resident 1 experienced additional falls on 11/07/2023, and the most recent fall on 11/11/2023. Review of Resident 1's medical record showed the facility performed a fall assessment after each of Resident 1's falls that showed staff assessed Resident 1 to be high risk for falling. The fall assessment instructions showed; fall risk is based on fall risk factors and is more than a total score, determine fall risk factors and target interventions to reduce risks. Review of Resident 1's fall risk CP, revised 08/31/2023, showed no documentation of new fall prevention interventions added to the CP after Resident 1's fall on 05/12/2023 and 06/27/2023. The CP showed a new intervention added a month later, on 07/21/2023 that directed staff to provide re-direction as needed for safety during episodes of confusions and behaviors and allow resident to express their feelings and thought process for support when agitation is expressed. The CP showed no documentation to support new fall prevention measures care planned or implemented after Resident 1 fell on [DATE], 11/04/2023, 11/07/2023, until the 11/11/2023 fall when staff added a new intervention on 11/12/2023 for Resident 1 to use a tilt in space wheelchair (wheelchair reclines back) to aide in positioning and decrease fall risk, although Resident 1's falls usually occurred at the bedside, except the 11/7/2023 fall outside the facility, and the 11/11/2023 fall that was suspected to occur during a transfer with facility staff. In an interview on 11/21/2023 at 10:15 AM, Staff B stated that after a resident fell , the interdisciplinary team would review and determine the root cause of the fall and discuss and implement interventions to prevent further falls. Staff B reviewed Resident 1's fall CP and stated there should be updated interventions and acknowledged that a fall mat was added on 10/30/2023 but no new interventions were added after Resident 1's falls on 11/04/2023, 11/07/2023, and 11/11/2023. When asked about a PO for a tilt in space wheelchair, Staff B stated Resident 1 had been using a tilt in space for a while and had updated the PO as part of an audit, not a new intervention. <Resident 2> Review of a 07/16/2023 Admission MDS showed Resident 2 was able to make their own decisions, needs known, and was able to understand and be understood by others. The MDS showed Resident 2 had diagnoses that included heart disease, history of a stroke (brain bleed), weakness, and history of substance abuse disorder. Facility staff assessed Resident 2 with no behaviors and the resident required one person staff assistance to move to and from locations in the facility. Review of a facility Elopement Screen, dated 07/10/2023, showed Resident 2 was assessed at a three, indicating a moderate elopement risk due to their ability to ambulate and being aware enough to deactivate exit alarms. Review of a 07/10/2023 PO showed resident may leave the center with an escort. Review of an Activities of Daily Living (ADL) CP, revised 10/02/2023, showed Resident 2 was able to transfer and ambulate independently. Review of an Incident progress note, dated 10/13/2023 at 11:21 AM, showed staff documented what happened as Resident 2 was missing. The note showed the writer was informed by the previous night nurse that Resident 2 was not in their room when the night nurse went to administer medications and has not returned. The note showed the DNS was notified of the incident. Review of the October 2023 Medication Administration Record (MAR) showed staff documented that Resident 2 received medications scheduled at 2:00 PM and staff documented a 9 for medications due at 6:00 PM and 8:00 PM. Review of the MAR chart codes showed 9 indicated other/see progress notes. Review of Resident 2's medical record showed no documentation from staff in progress notes on why Resident 2 did not receive their medications on 10/12/2023 at 6:00 and 8:00 PM. During an interview on 10/17/2023 at 12:18 PM Staff G (Previous Administrator) stated Resident 2 did not return to the facility and after a few days the facility considered the resident an Against Medical Advice (AMA) discharge. Staff G stated they attempted to reach the resident but did not make contact, Staff G did eventually get a hold of a case manager and a collateral contact (CC), who informed Staff G Resident 2 was with family. Resident 2 did show back up to the facility and was sent back to the hospital to be evaluated. Staff G stated Resident 2 had recently tested positive for Covid-19 (a contagious respiratory illness), had finished isolation precautions, and was not sure if Resident 2 would be returning to the facility. <Resident 3> Review of a 10/12/2023 Admission MDS showed Resident 3 was able to make their own decisions, needs known, and was able to understand and be understood by others. The MDS showed Resident 3 had diagnoses that included a disease that altered the brain's function, high blood pressure, alcoholic cirrhosis of the liver (alcohol induced liver disease), anxiety, and a dependence on alcohol. Resident 3 was assessed with no behaviors. Review of a 10/06/2023 ADL CP showed Resident 3 required one person staff assistance for ambulation and limited assistance for transfers. The CP showed goals that Resident 3 would have needs met and safety maintained. Review of a facility Elopement screen, dated 10/06/2023, showed Resident 3 was assessed at a three, indicating a moderate elopement risk due to their ability to ambulate and being aware enough to deactivate exit alarms. Review of a 10/13/2023 NPN at 11:33 PM showed Staff F (LPN) documented during shift change report they were informed that Resident 3 was not in the building and staff did not know Resident 3's whereabouts. The NPN showed Resident 3 received their 11:00 AM medications and did not receive their 1:00 PM scheduled medications. Staff F notified the administrator, attempted to make contact with Resident 3 and listed contacts. Staff F spoke with Resident 3's collateral contact who wanted to be updated when the resident was found. Staff F filed a missing person report with the local police, this occurred almost 10 hours after the resident was not found in the building to receive their 1:00 PM medications. Review of a 10/14/2023 social services note at 10:36 AM showed staff documented, the resident was seen leaving the facility with roommate the afternoon of 10/13/2023. The documentation did not show who witnessed Resident 3 leave the facility, if other staff were aware of where Resident 3 was going, the time they planned to return, or if Resident 3 signed out of the facility. An additional note was added on 10/14/2023 at 1:27 PM showed staff spoke with Resident 3 who would not be returning to the facility, if the resident returned to the facility staff were directed to send the resident to the hospital because Resident 3 was not cognitively intact (has sufficient judgement, planning, organizing, and self-control to manage the normal demands in the environment). Review of a 10/14/2023 at 8:20 PM NPN showed the facility was contacted by a local hospital requesting medication information on Resident 3, as they were at the hospital. Facility staff faxed over Resident 3's medications and documents as requested by hospital staff. During an interview on 10/17/2023 at 12:18 PM Staff G stated Resident 3 left the facility with an older gentleman and spoke with a CC that stated Resident 3 was with family. Staff G stated the facility received a call from a local hospital requesting medical documents for Resident 3, but Staff G was not sure why Resident 3 was being admitted to the hospital. Staff G stated the facility considered Resident 3 to be an AMA discharge and was not sure if Resident 3 would be readmitted back to the facility. In an interview on 10/17/2023 at 1:15 PM Staff G stated the facility did not do an investigation on Resident 2 and Resident 3 leaving the facility because they were considered AMA discharges and the facility made reports to adult protective services. During an interview on 11/08/2023 at 3:45 PM Staff A (Administrator) stated an AMA discharge would be when the facility was aware the resident wanted to leave, and staff would explain the risks and benefits of leaving AMA. Staff A stated they would expect staff to respond immediately and follow the facility procedure of a missing resident and not wait a prolonged period of time. Staff A stated the facility took this seriously, would expect an investigation to be completed, and they would look into the incidents. No additional documents were provided to support the facility reviewed the incidents. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review the facility failed to ensure residents received wound care consistent with professional standards of practice that prevented skin breakdown and the development and/or worsening of Pressure Ulcers (PUs) for 5 of 6 (Residents 55, 65, 32, 53 & 24) residents reviewed for treatment and services for PUs. Three residents (Residents 55, 65, & 32) experienced harm when the facility failed to identify, consistently assess, monitor changes in skin condition, and implement preventative measures and interventions timely, follow Physician Orders (PO) for treatment, and complete weekly documentation of PU progress to promote healing and prevent new or avoidable PUs from developing or existing PU from worsening. These failed practices placed additional residents at risk for worsening of skin integrity, potential for developing PUs, and infections. Findings included . <Facility Policy> Review of the facility's undated 2022 Pressure Injury Prevention and Management policy, the facility was committed to the prevention of avoidable PUs and would provide treatment and services to heal PUs. This policy defined avoidable as a resident developing a PU and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with resident needs, goals, and professional standards of practice; monitor and evaluate the effectiveness of interventions, or revise interventions as needed. According to the National Pressure Injury Advisory Panel (NPIAP) PU staging definitions include: a Stage 4 PU was a wound with full thickness skin and tissue loss with exposed connective tissue, muscle, tendon, ligaments, cartilage, or bone; a Stage 3 PU with full thickness loss of skin, in which fat was visible on the ulcer and rolled wound edges were present; an Unstageable PU was defined as a full thickness skin and tissue loss where the base of the wound was obscured by slough (dead skin cells) and/or eschar (dead tissue) where until sufficient slough and/or eschar could be removed to expose the base of the wound, the true depth, and therefore stage, could not be determined; Deep Tissue Injury (DTI) was intact or non-intact skin with localized area of persistent non blanchable deep red, maroon or purple discoloration. Pain and temperature change often preceded skin color changes. <Resident 55> According to the 07/07/2023 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 55 was admitted on [DATE] and had multiple medically complex diagnoses that included an impairment in motor or sensory function of their lower legs, malnutrition, and a Stage 4 PU on their sacrum (the triangular area located below the waist and above the tailbone). The MDS showed Resident 55 was at high risk for new PU development and required extensive assistance for bed mobility, toileting, and transfers. A review of the Resident 55's records showed the resident's wounds were assessed by an outside wound provider on 08/30/2023 for the sacrum PU and left lower leg PU. No additional assessments by the wound provider were found in the records. Review of Resident 55's record showed the resident was transferred to the hospital on 08/31/2023 for a condition change and readmitted to the facility on [DATE]. Review of the 09/13/2023 readmission skin assessment showed Resident 55 readmitted with PUs to their sacrum and to their left lower leg. A Braden scale (a tool that identified the risk for forming PUs) was completed on 09/13/2023 with a score of 13, showing Resident 55 was at moderate risk for developing PUs. Review of a 09/13/2023 revised Skin Integrity Care Plan (CP) showed Resident 55 had a Stage 4 sacrum PU, right heel with a DTI, and a PU to their left outer lower leg. Interventions included instructions for staff to follow wound care as ordered, monitor and document the location, size, and treatment of the skin injury, and to report any abnormalities to the provider. The interventions directed the staff to complete the weekly treatment documentation with wound measurements, and any other observations noted. Review of the weekly skin check assessment for 09/18/2023 -09/25/2023 showed no new skin issues were observed by staff during that period. Observations on 09/19/2023 at 10:28 AM and 2:07 PM, 09/20/2023 at 9:37 AM and 2:18 PM, 09/21/2023 at 8:51 AM, 10:01 AM, 12:37 PM, and 1:50 PM showed Resident 55 lying in bed on their back. In an interview on 09/21/2023 at 2:05 PM, Resident 55 stated they had a big wound on their bottom, and one on their left lower leg. Resident 55 stated they were unable to reposition themselves in bed and that staff assisted them with repositioning in bed once or twice a day. Resident 55 stated staff were busy helping other residents. Resident 55 stated staff used to get them up in the wheelchair but they have stayed in bed since they returned from the hospital. In an interview on 09/21/2023 at 2:08 PM, Staff R (Certified Nursing Assistant - CNA) stated they tried to reposition Resident 55 in bed at times and Resident 55 refused to be on their side. Staff R stated they did not document the refusals. An observation on 09/22/2023 at 2:25 PM showed Staff O (Licensed Practical Nurse - LPN) and Staff P (LPN) providing wound care to Resident 55. Resident 55's sacral wound was covered with a bordered gauze dressing. Staff O removed the dressing, assessed the wound which measured 10 x 11 x 0.2 centimeters (cm). The wound had mild drainage and no odor. At this time, Staff O and Staff P observed two new open wounds on Resident 55's right buttock that measured 3.5 x 1.5 x 0.1cm and 1.0 x 1.0 x 0.1cm with light bloody drainage, no odor, and no dressings in place. In an interview on 09/22/2023 at 2:48 PM, Staff O and Staff P stated they were not aware of these two wounds on Resident 55's right buttock. Staff O stated there was no documentation or treatment orders for these open wounds in Resident 55's record. Staff O stated the facility process for new skin issues was for CNAs report to the nurse, and for the nurse to assess the skin, make appropriate notifications, and investigate the origin of the wound. Staff O stated they were unaware of the open wounds on Resident 55's right buttock area. Review of Resident 55's POs dated 09/13/2023 showed orders for staff to to cleanse the sacrum PU with normal saline, apply a medicated dressing to the wound bed and cover with a foam dressing daily, and as needed, and cleanse the left lower leg with normal saline, apply a medicated dressing, and change daily and as needed. In an interview on 09/22/2023 at 2:53 PM, Staff O stated staff did not follow the PO to cover the sacrum PU with the foam dressing as ordered, and instead applied a different dressing. Staff O stated the foam dressing was not available in the facility for a few days and they notified their supervisor. In an interview on 09/22/2023 at 2:43 PM, Staff Q (Registered Nurse - RN) stated they were not aware of Resident 55's wound status because a wound nurse provided the daily wound care. Staff Q stated a CNA told them about the right buttock PUs last week, but they were busy and did not get time to look at Resident 55's right buttock PUs. Staff Q stated they reported the newly identified PU to the wound nurse. The wound nurse was not available for interview throughout the survey. In an interview on 09/26/2023 at 10:34 AM, Staff R stated they took care of Resident 55 since their readmission on 09/13/2023. Staff R stated Resident 55 admitted with a big wound on their sacrum and small wounds on their right buttock. Staff R stated they reported that these wounds were getting bigger to a nurse and that nurse responded they would inform the wound nurse. In an interview on 09/26/2023 at 10:47 AM, Staff S (LPN) stated they knew Resident 55 had a sacral PU. Staff S stated the prior week one of the CNAs reported to them about the right buttock PUs but they misunderstood and thought the CNA was discussing the sacral wound. Staff S stated they did not evaluate the wounds. Staff S stated they were busy and passed the information on to the wound nurse who was assigned to assess the PUs and provide daily wound care. In an interview on 09/26/2023 at 12:02 PM, Staff B (Director of Nursing) stated they expected staff to provide wound care as ordered by the provider. Staff B confirmed the facility was out of the ordered treatment supply for Resident 55's wounds temporarily. Staff B stated they found out about Resident 55's right buttock wounds on 09/22/2023 and interviewed CNAs because CNAs provided personal care to Resident 55 every shift. Staff B stated staff should have repositioned Resident 55 every two to three hours while in bed, and if the resident refused, staff should have documented the refusal. Staff B reviewed Resident 55's record and was unable to find documentation about Resident 55's refusal of care. Staff B stated the facility missed to identify and assess the PUs, initiate interventions and treatment to resolve the wounds, and prevent reoccurrences. Staff B stated the nursing staff should have assessed the PUs when CNAs reported to them, but did not. On 09/28/2023 at 9:22 AM, Staff B stated nurses were expected to identify, and assess changes in skin condition, notify the provider to obtain orders for treatment, and complete weekly documentation of wound status. Staff B acknowledged the nurses did not follow these instructions and this resulted in Resident 55's new open wounds on their right buttock. 46471 <Resident 65> According to the 07/23/2023 Admission MDS, Resident 65 admitted to the facility on [DATE] and was assessed to have clear speech with moderate memory impairment due to a brain injury. The MDS showed Resident 65 had multiple diagnoses including kidney failure and was dependent on dialysis (a treatment that cleaned the blood), a medical condition characterized by elevated levels of blood sugar in the body, and weakness to one side of the body from their brain injury. Review of the 07/17/2023 Admission Nursing Evaluation form showed Resident 65 was identified to have two skin issues: A right ankle scar, and a right heel PU. The Braden scale skin assessment completed by the admission nurse the same day assessed Resident 65 to be at risk for skin breakdown because of their complex medical conditions, bowel and bladder incontinence, and limited mobility. Review of a 07/17/2023 nursing progress note showed Resident 65 had dry/flaking scar tissue observed to their sacral area. The progress note did not identify any open area on Resident 65's tailbone or upper buttocks area. Review of a 07/19/2023 facility incident report showed Resident 65 was identified with a PU and was categorized as a Stage 3 (full-thickness loss of the skin that extended to the fat tissue) wound, two days after Resident 65's facility admitted on 07/17/2023. Review of the July 2023 Treatment Administration Record (TAR) showed a 07/20/2023 order to cleanse Resident 65's sacral PU with normal saline (a sterile solution used for cleaning wounds) and to apply skin protectant as needed. The TAR showed no documentation to demonstrate the treatments were performed from 07/20/2023 until 07/26/2023; (seven days). Review of the 07/21/2023 skin CP showed Resident 65 had actual skin impairments including the identified stage 3 PU to their sacral area. A CP intervention listed showed an air mattress was implemented for Resident 65 on 08/07/2023, 19 days after their Stage 3 PU was identified. Observation on 09/19/2023 at 12:10 PM, showed Resident 65 wearing a foam boot to their right lower leg/foot. At the same date and time, Resident 65 stated they have a sore on their bottom. When asked if treatments were being provided for the sore on their bottom, Resident 65 stated, .sometimes, not every day though . Observation on 09/25/2023 at 11:18 AM of Resident 65's Stage 3 PU with Staff H (Resident Care Manager) and Staff N (LPN) during wound care treatment showed exposed fat tissue and macerated (softened skin from being soaked) wound edges. The old dressing showed a moderate amount of serosanguinous (mixed blood and body fluids) drainage. In an interview on 09/27/2023 at 11:18 AM, Staff B stated Resident 65's Stage 3 PU was identified during the facility's skin sweep. Staff B stated they expected the nursing staff to assess and identify skin issues during admission, and to implement preventative measures timely to avoid development of and/or worsening skin condition. Staff B stated a skin breakdown could occur almost instantly, within a matter of hours especially for residents with multiple risk factors. Staff B reviewed Resident 65's records and stated there were no documentation to support the existence of the sacral Stage 3 PU prior to Resident 65's facility admission on 07/17/2023. 42203 <Resident 32> According to the 08/06/2023 Quarterly MDS, Resident 32 had medically complex conditions including heart failure, peripheral vascular disease, diabetes, a bone infection, and an amputated right leg. The MDS showed Resident 32 was at risk for PU but had no current PU. Resident 32's POs included: a 05/02/2023 PO to cleanse Resident 32's heel with normal saline; a 05/10/2023 order to check Resident 32's skin weekly for new skin impairments. Review of the May 2023 TAR showed nurses did not cleanse Resident 32's left heel on four of 29 opportunities. Review of the June 2023 TAR showed nurses did not cleanse Resident 32's left heel on two of 30 opportunities. Review of the July 2023 Tar showed nurses did not cleanse Resident 32's left heel on three of 31 opportunities. Review of the August 2023 TAR showed nurses did not cleanse Resident 32's left heel on five of 27 opportunities prior to discovery of a DTI/unstageable PU on 08/28/2023. Review of the weekly skin checks showed Resident 32's weekly skin check was not documented as completed on 08/25/2023 (for the week of 08/21/2023 - 08/25/2023) as ordered and scheduled. Review of a 05/02/2023 nursing progress note showed Resident 32 was observed with a non-blanchable area (an indicator of a potential skin impairment) to their left heel. The note showed staff applied skin prep (a skin treatment) to the area. There were no other progress notes between 05/02/2023 and 08/28/2023 documenting Resident 32's left heel. Review of an 08/28/2023 nursing progress note showed Resident 32 had a DTI on their left foot. The note showed the wound was intact and directed staff to continue to float heel. The note did not show how the wound developed. An 08/30/2023 wound consult with an outside wound provider showed Resident 32 had two wounds on their left lower leg: The wound to their left foot, and a wound on the left heel. The documentation showed the foot wound was a diabetic foot wound, and not caused by pressure. The documentation described the left heel wound as an unstageable PU (a PU whose depth and condition could not be assessed due to the presence of eschar - a type of scab that prevents assessment of the wound base). The consult recommended to relieve pressure from the heel by repositioning/offloading (a positioning technique that reduced the risk of ongoing pressure to an area at risk for pressure), and to apply lotion to all areas of dry skin. Record review showed Resident took a leave of absence from the facility beginning on 09/14/2023. Resident 32 returned to the facility on the evening of 09/20/2023 and discharged to the community on 09/21/2023. The wound was not observed by the surveyor. Review of the 05/02/2023 Potential for Impairment to Skin Integrity related to Diagnosis of Diabetes CP showed Resident 32's diabetic foot ulcer was noted in this CP. There was no documentation of the left heel unstageable PU. No CP was developed to address Resident 32's risk for pressure injury documented in the MDS, and the CP did not include instructions on how to care for the left heel wound, and did not include the suggested interventions listed in the 8/30/2023 wound consult. In an interview on 09/26/2023 at 2:43 PM Staff H, stated the purpose of weekly skin checks was to ensure resident skin remained intact. Staff reviewed Resident 32's CP and stated the interventions identified by the wound specialist were not on the CP. Staff H stated the interventions should have been but were not added. 46479 <Resident 53> According to a 06/13/2023 Admission MDS, Resident 53 had no memory impairment and had limited range of motion on one side of their body. This assessment showed Resident 53 was at risk for developing PUs but did not have PUs upon admission. Review of a 07/19/2023 incident report showed Resident 53 was identified to have a PU on their buttock, right ankle, and left elbow. The incident report showed interventions implemented were a referral to a contracted wound specialist, nutritional supplements to promote wound healing, and regular position changes for pressure reduction. Review of a 07/26/2023 assessment from the contracted wound specialist showed recommendations to always use pillows to float Resident 53's heels and left elbow. This assessment showed Resident 53 should be repositioned for pressure relief. This assessment showed Resident 53's left elbow PU should have a new bandage applied daily. A 09/10/2023 PO showed Resident 53 was to have a specialty air mattress in place. An 08/07/2023 Air Mattress CP showed Resident 53 used an air mattress to promote wound healing. The CP directed staff to notify maintenance or the RCM if the air mattress malfunctioned. A 09/20/2023 Registered Dietician (RD) note recommended Resident 53 start a liquid protein supplement to promote healing of Resident 53's PU. Review of Resident 53's records on 09/27/2023 showed the RD recommendation was not implemented. Facility staff were not providing the protein supplement to promote healing to Resident 53's PUs. Observation on 09/21/2023 at 9:04 AM showed Resident 53 lying on their side, no pillows were under their feet or under their left elbow. Resident 53 was not lying on an air mattress. Observations on 09/22/2023 at 8:40 AM and 09/25/2023 at 8:08 AM showed Resident 53 on their back, no pillows were under their feet or left elbow and an air mattress was not in place. In an observation and interview on 09/25/2023 at 12:19 PM, Resident 53 was on their back, not on an air mattress as ordered. There were no pillows under Resident 53's feet or left elbow. There was no bandage covering Resident 53's PU to the left elbow. At that time, Staff H confirmed Resident 53 should have pillows under their feet and left elbow. Staff H confirmed Resident 53 should have a dressing on their left elbow and an air mattress in place as ordered. In an interview on 09/27/2023 at 10:21 AM, Staff B stated Resident 53 often removed the pillows from under their feet and elbows. Staff B stated these refusals of care should be documented, care planed, and a risk versus benefits should be in place, but there was not. Staff B stated it was their expectation the RD recommendations for the protein supplement should be implemented by the following day of the recommendation. Staff B stated an air mattress should be in place as ordered over two weeks prior, for Resident 53 but was not. 48010 <Resident 24> According to the 05/15/2023 Quarterly MDS Resident 24 made their own decisions and required extensive assistance of two people to meet their daily care needs. Resident 24 had a progressive neurological condition that resulted in the need for artificial nutrition through a surgically implanted tube going directly into the stomach, and a Stage 4 PU to the coccyx (tailbone). Review of the 04/22/2021 CP showed treatments were to be administered as ordered and assessed including measuring the wound weekly. Review of the 08/04/2023 PO showed Resident 24 was to receive daily dressings to their coccyx, which included a brown medicated paste to the wound bed. Observation and interview on 09/21/2023 at 12:15 PM showed a wound to the coccyx. The wound was covered with a dry dressing but the medicine that was ordered was not observed. Staff H stated they did not see the wound had medicine in it. Staff H stated the medicine should be there, not administering the medicine as prescribed could lead to worsening of the wound. Review of the weekly skin assessments showed Resident 24's wound was not assessed on 04/26/2023, 5/3/2023, 5/10/2023, 5/17/2023, 5/24/2023, 6/21/2023, 7/12/2023, 08/10/2023, and 08/16/2023. Review of Resident 24's TAR showed no treatment was administered on 07/15/2023, 08/04/2023, 08/13/2023, 08/15/2023, 08/18/2023, and 09/07/2023. In an interview on 09/27/2023 at 9:32 AM, Staff B stated they expected wounds to be assessed weekly. Staff B stated wound nurses were recently hired to meet the facility needs but when they could not provide treatments or assess, then direct care staff should deliver wound care. Staff B stated not providing care to the coccyx PU could result in worsening wounds. Refer to F610- Investigate/Prevent/Correct Alleged Violation. REFERENCE: WAC 388-97-1060(3)(b). .

Based on observation, interview, and record review the facility failed to implement care for 2 of 2 (Residents 24 & 37) residents reviewed for Tube Feeding (TF) management including: (1) timely action re: Resident Dietician (RD) recommendation to change the type of TF formula, (2) the administration TF rate consistent with and that followed the practitioner's orders; (3) the periodic evaluation of the amount of TF being administered for consistency with the practitioner's orders, (4) the maintenance of TF pumps consistent with manufacturer's instructions to ensure proper TF delivery, and (5) the implementation of proper resident positioning during TF administration to prevent the risk of aspiration (inhaling food contents into lungs). Resident 24 experienced harm when the facility failed to assess their nutritional needs, and placed residents at risk for developing TF complications and a decreased quality of life. Finding included . <Facility Policy> The undated Appropriate Use of Feeding Tubes facility policy showed any decision regarding the use of a feeding tube was based on the resident's clinical condition and residents who were fed by enteral (a way of delivering nutrition directly to the stomach) means received the appropriate treatment including the prevention of complications such as aspiration. The policy outlined Interdisciplinary Team (IDT) involvement, with the support and guidance of the physician, would ensure the ongoing review, evaluation, and decision-making regarding the initiation, continuation, or discontinuation of a feeding tube. The policy incorporated the plan of care to address the use of feeding tubes including strategies to prevent complications. <Resident 24> The 05/15/2023 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 24 made their own decisions and required extensive assistance of two people to meet their daily needs. The MDS showed Resident 24 had a progressive neurological condition with the need for artificial nutrition through a surgically implanted tube directly into the stomach. Review of the 04/22/2021 Care Plan (CP) showed interventions that instructed staff to record intake on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), provide/serve diet as ordered, monitor intake and record the percentage consumed, and provide and maintain good oral hygiene. Review of the weight summary report showed Resident 24 weighed 172 Pounds (LB) on 03/17/2023 and on 09/13/2023 Resident 24 weighed 158 LB for a 7.06% weight loss in one month. Observation on 09/19/2023 at 9:05 AM showed Resident 24 lying in bed resting while receiving TF from a feeding pump. The pump was running at 85 milliliters per hour (ML/HR). The bag containing the formula had the rate written as 90 ML/HR. Resident 24 was noted to have a white film on their tongue and there were no oral care supplies observed in the room. Additional observations of the feeding pump running at 85 ML/HR and no oral care supplies were noted on 09/20/2023 at 8:54 AM, and on 09/21/2023 at 11:42 AM. A 09/12/2023 Physicians Order (PO) showed the pump should be set to 90 ML/HR. Observation and record review on 09/21/2023 at 12:15 PM showed Resident 24 had a wound to the coccyx (tailbone). Review of the 08/30/2023 RD note showed Resident 24's weights were decreasing. The note indicated maintaining a stable weight was desired and recommended increasing the TF pump rate by 5 ML/HR to total 90 ML/HR and recommended a multivitamin and protein powder supplement for Resident 24's wound healing. Review of the 09/08/2023 RD note showed the recommendation on 08/30/2023 was not carried out, and a recommendation to increase the tube feed pump by 5 ML per hour to total 90 MLs was made. In an observation and interview on 09/21/2023 at 12:15 PM Staff H (Resident Care Manager - RCM) confirmed Resident 24 had a white film on their tongue. Staff H stated the film was likely due to poor oral care. In an observation and interview on 09/22/2023 at 8:01 AM, Staff X (License Practical Nurse - LPN) confirmed the pump running at 85 ML/HR. Staff X stated the rate should be 90 ML/HR and adjusted the pump as ordered. Review of the September 2023 MAR and TAR showed intake were not being monitored. In an interview on 09/27/2023 at 9:27 AM, Staff B (Director of Nursing) stated they expected ample oral care supplies to be readily available to encourage oral care. Staff B stated they expected oral care to be offered by staff in the morning and evening daily. Staff B stated not doing so could result in oral yeast infections. Staff B stated they expected all physician's orders to be followed as they were written, and that not following the prescribed tube feeding rate could result in unintended weight loss and delayed wound healing. <Resident 37> According to the 07/26/2023 Admission MDS, Resident 37 had multiple medical conditions including memory impairment, heart failure, and difficulty swallowing. The MDS showed Resident 37 was provided nutrition via a TF inserted through their stomach. The 07/20/2023 TF CP showed Resident 37 was not to receive anything by mouth because of swallowing difficulty. The CP outlined an intervention to keep Resident 37's Head of Bed (HOB) elevated at least 30 to 45 degrees during and 30 minutes after their TF. The CP instructed the nursing staff to provide good oral care and maintain Resident 37's oral health. On 09/19/2023 at 10:09 AM, Resident 37 was observed asleep, lying flat on the bed while their tube feeding was infusing, their mouth was open to show multiple, diffuse whitish spots over their tongue. The nutrition bag was not dated to determine when the TF was initiated. A hand-written note was observed taped on top of the pole holding the feeding pump that read TF on at 1pm, off at 9am daily (20-hours run). On 09/19/2023 at 10:16 AM, Staff U (Resident Care Manager) validated the TF was ongoing and that Resident 37 was lying flat in bed. Staff U stated they expected the nursing staff to elevate the HOB when the TF was on. Staff U acknowledged the TF bag did not have a date, time, or staff initial and stated they expected the nurse who initiated the process to label the bag with the items identified as lacking. Staff U read the note taped on top of the pole and stated, .the TF should be stopped by this time. Staff U reviewed Resident 37's TF order in the MAR to validate the times as written on the note. The 09/11/2023 TF order in the MAR did not indicate the time(s) as to when to start and end the TF. Staff U stated, .from my assumption, the intention was for the nurse to start the TF at 1 PM and end at 9 AM of the following day. Staff U stated the PO was not clear because there were no start and end times written for Resident 37's TF order. Staff U stated the hand-written note/directions found taped on the pole did not constitute a PO. Review of the 2023 September MAR showed Resident 37's TF PO was changed on 09/19/2023. The revised PO instructed nursing staff to administer a total of 1600 ML in 20 hours, to start the TF at 4:00 PM and end at 12:00 PM the following day. Observation on 09/20/2023 at 11:05 AM showed Resident 37's TF bag was empty, the TF tubing had multiple air pockets, and the feeding pump showed feed error on the monitor. There was no audible sound heard to alert the staff of the feeding pump malfunction. At 11:36 AM, Staff N (LPN) was alerted that more than half an hour passed since the feeding bag was observed empty. Staff N stated Resident 37's TF should be continuous until 12:00 PM as ordered, and a physician notification was warranted to make up for the time when Resident 37 did not receive any TF. In as observation and interview on 09/20/2023 at 11:58 AM, observed a new TF bag was hung at 11:45 AM by Staff N. The feeding pump showed 2190 ML. as the total amount administered at that time, 590 ML over the prescribed daily total TF amount as ordered. Staff B stated they expected the nursing staff to administer the TF amount as ordered, to document the amount in the MAR, and to clear the feeding pump when a new bag was stated in order to get an accurate reading for the benefit of the interdisciplinary team including the physician and RD. Staff B stated the feeding pump's alarm settings, noted the audible sound was muted, and stated, .that was probably why the nurse was not alerted when the feeding bag became empty. Review of Resident 37's 08/02/2023 Nutrition Assessment form showed the RD recommended a change of feeding formula that considered Resident 37's diabetes. A 08/30/2023 nutrition/dietary progress note completed by the same RD showed they re-recommended the feeding formula change, and again as noted on their 09/02/2023 follow-up progress note. The 2023 September MAR showed the feeding formula was changed on 09/11/2023, one month and nine days after the RD's initial recommendation date on 08/02/2023. The 09/02/2023 nutrition/dietary progress note showed Resident 37's last recorded weight was on 08/11/2023. A 07/28/2023 PO showed an order to obtain Resident 37's weight every Friday. Review of Resident 37's weights summary report showed there was no recorded weight between 08/11/2023 and 09/08/2023. The 2023 August TAR showed staff did not obtain Resident 37's weight on 08/04/2023, 08/18/2023, and 08/25/2023 as ordered. In an interview on 09/26/2023 at 1:44 PM, Staff B stated they expected the nursing staff to notify the physician within 24 hours of receiving an RD recommendation, most importantly for residents on TF. Staff B stated Resident 37's weights should have but were not obtained as ordered. Staff B stated the delay in action to address the RD's recommendation to change the feeding formula was unacceptable, .it should have been done sooner than that. Refer to F686- Treatment/Services to Prevent/Heal Pressure Ulcers. Refer to F692- Nutrition/Hydration Status Maintenance. REFERENCE: WAC 388-97-1060 (3)(f). 48010

Based on observation, interview, and record review the facility failed to implement physician orders (PO) timely, assess, measure, and document the wound characteristics consistently, implement preventative measures, and develop and implement a care plan (CP) that directed staff how to manage wounds for 4 (Resident 1, 2, 3 & 4) of 4 residents reviewed for wounds. These failures caused harm to Resident 1 who required a surgical toe amputation and three intravenous (IV) antibiotic treatments for the toe bone infection, caused harm to Resident 2 who developed maggots in their wound, and caused harm to Resident 3 and 4 who had delayed healing to wounds and placed all residents at risk for new wounds, deterioration of existing wounds, risk for decline in medical status, risk of infection, pain and diminished quality of life. Findings included . Review of the undated facility Skin Care policy, to ensure effective healing of resident wounds, licensed nurses would perform wound assessments according to the wound assessment schedule and an IDT (Intra Disciplinary Team) would meet regularly as a skin committee to review wound assessments and recommend changes to the resident's CP. Wounds included pressure ulcers (PU), lacerations, skin tears, abrasions, or other skin issues considered to be at risk for poor healing by the Director of Nursing (DNS) or the skin committee. Not all skin issues would be followed by the skin committee or be included on the wound assessment schedule if the DNS or skin committee determined the skin issues would likely heal without worsening. Skin ulcers caused by vascular disease such as venous, arterial, and stasis ulcers, were not included in the facility's skin care policy that was provided by facility staff. For resident's identified at risk for PU's, facility staff would use preventative measures and implement a two hour positioning schedule and complete an assessment for appropriate pressure reducing devices. When a PU developed, staff would complete an incident report, notify the provider and family, provide appropriate treatment, notify the Resident Care Manager (RCM) who would complete a PU assessment, update the resident's CP, and complete weekly PU assessments until the wound was resolved. If the PU/wound showed no improvement within 14 days, staff would contact the provider for a new treatment. <Resident 1> According to the 06/04/2023 Quarterly Minimum Data Set (MDS) an assessment tool) showed Resident 1 admitted to the facility on [DATE], had impaired decision making, and diagnoses including a brain bleed, chronic kidney disease, and diabetes with a history of toe amputations. The MDS showed Resident 1 was assessed to require extensive assistance of one staff member for bed mobility, dressing, eating, toilet use, and personal hygiene. Review of section M, skin conditions, showed Resident 1 had no PU's, and no other types of ulcers or wounds. The MDS showed Resident 1 was at risk for developing PU's, had a nutrition or hydration intervention to manage skin problems, received applications of dressings to their feet, and did not receive PU care. Review of an admission assessment, dated 02/28/2023, showed Resident 1's skin was assessed with no PU's. Review of Resident 1's diabetes CP, dated 02/28/2023, directed staff to check the resident's body for breaks in skin and treat promptly as ordered by the physician. Resident 1's clinical record showed no CP in place for the resident's skin integrity risk related to their diabetes diagnosis and history of toe amputations or directions to staff on how to manage and prevent Resident 1's risks of skin breakdown. Review of a Braden Scale (a tool used to assess risk for development of PU), dated 02/28/2023, showed Resident 1's Braden Score (determined by six subscales and added together to get a score between 9 and 23, less than 9 very high risk, 10-12 high risk, 13-14 moderate risk, and 15-18 at risk) was a 15, indicating Resident 1 was at risk for PU development. Review of a Nursing Progress Note (NPN), dated 04/27/2023, showed Resident 1 was working with physical therapy when a a blackened and bleeding area was observed to the tip of the big left toe. Review of a physician encounter note, dated 04/27/2023, showed Resident 1 was seen for a wound on the tip of the left toe, staff were instructed to use measures to prevent further skin breakdown by tenting bed garments (keeps the weight of bed garments off the toes), wound care to include damp debridement and cleaning of wound, followed by a non-stick dressing to be changed every other day until Resident 1 was seen by an outside wound provider. The provider referred the resident to an outside wound provider for the left foot wound. The physician directed staff to notify them immediately if redness, odor, pus drainage (indicative of an infection), or concerning appearance of the wound or abnormal vital signs in the resident. Review of physicians orders (PO) showed a 04/27/2023 PO that directed staff to cleanse the left toe wound and cover with a dressing. Review of a physician encounter note, dated 04/28/2023, showed Resident 1's wound was assessed with redness, pus drainage, and odors. The physician directed staff to obtain a specimen of the wound drainage, ordered a lab draw and started Resident 1 on an antibiotic to treat the wound infection to the left toe. A 04/28/2023 PO showed Resident 1 was started on an antibiotic three times a day for seven days for the wound. Review of a NPN, dated 04/29/2023, showed staff documented Resident 1's wound specimen was obtained and ready for the lab to pick up. Review of wound culture (determines which bacteria is present in wound) results, dated 05/17/2023, showed the lab specimen was collected on 05/11/2023, thirteen days after the physician ordered the wound drainage specimen to be sent for culture. The wound culture results showed three different types of bacteria, one being a multi-drug resistant organism (resistant to many antibiotics), and the results could not determine if the lab specimen was contaminated. In an interview on 07/07/2023 at 12:45 PM, Staff A (Administrator) was asked why the delay in collecting the wound drainage for culture and was not able to provide answers. The Director of Nursing (DNS) was not available for an interview and other facility staff were not able to provide answers on why there was a delay in collecting the wound drainage for culture. Review of a physician encounter note, dated 05/22/2023, showed Resident 1 was seen by the physician for follow up on wound culture results, five days after the facility received the results. The physician encounter note showed Resident 1 would be started on two antibiotics to treat the wound infection of the left toe. The note showed the physician continued to wait for the outside wound provider notes, would refer Resident 1 to a podiatrist for possible amputation of the left toe, and directed staff that any suspected treatment failure should prompt a review for the need for emergency evaluation, hospitalization , and continued urgency for a podiatry consultation. Review of Resident 1's clinical record showed no wound provider notes that documented Resident 1 was seen or assessed by the wound provider after the physician ordered on 04/27/2023. A 05/11/2023 PO showed the physician ordered Resident 1 to consult with the outside wound provider, fourteen days after the original PO was made. Review of Resident 1's clinical record showed no outside wound provider notes that documented Resident 1 was seen by an outside wound provider after the physician ordered on 05/11/2023. Review of a physician encounter note, dated 05/26/2023, showed Resident 1 was seen by the physician for a right heel PU of the deep tissue and directed staff to continue wound care with the outside wound provider and schedule a podiatry consult. Review of Resident 1's clinical record showed no PO for a treatment for the right heel PU on 05/26/2023 or thereafter. Review of a skin and wound evaluation, dated 06/01/2023, showed Resident 1 was assessed with a facility acquired, unstageable (unable to determine extent of wound) pressure ulcer to the right heel, unknown how long the wound was present, and the wound measured 3.6 cm (centimeters) by 2 cm. The assessment showed facility staff assessed the wound with no signs of infection, no pain, and no progress with the right heel wound. A skin and wound evaluation, dated 06/01/2023 showed facility staff documented measurements of 3.9 cm by 0.8 cm, all other areas of the assessment were left blank and did not indicate the type of wound, location, where acquired, how long it was present, description of wound characteristics, pain presence, treatments, or progress. Review of a NPN, dated 06/09/2023, showed staff documented the podiatry referral was made, eighteen days after the referral request was first made by the physician on 05/22/2023. Resident 1's podiatry appointment was made for 06/19/2023, twenty-eight days after the referral was first made by the physician. Review of a facility skin and wound evaluation, dated 06/15/2023, showed facility staff documented Resident 1 had a open lesion (ulcer or sore) located on the left foot, first digit that was acquired at the facility on 04/27/2023. The wound measured 2.7 cm by 2.1 cm, and facility staff documented the wound improved. The assessment showed facility staff left descriptions of wound characteristics, pain, treatments, and notifications blank. This was the first wound assessment found for Resident 1's wound to the left great toe, seven weeks after it was discovered by facility staff on 04/27/2023. Review of a NPN, dated 06/19/2023, showed Resident 1 was sent to the hospital per Collateral Contact's (CC) request and concern for the left toe wound. Review of a hospital encounter note, dated 06/19/2023, showed Resident 1 presented at the hospital with a open wound with bone exposed to the left great toe. Drainage and a foul odor were observed by the physician. The note showed Resident 1 was seen by a podiatrist that same day [06/19/2023] who recommended Resident 1 go to the hospital for osteomyelitis (bone infection) of the left great toe. Resident 1 was admitted to the hospital for osetomyelitis to the left great toe. During an interview on 07/05/2023 at 3:11 PM Resident 1's collateral contact (CC) stated the resident admitted to the facility with no wounds on the left foot big toe, previously had four toes on the left foot amputated, and the resident's podiatrist informed the CC Resident 1's feet should be assessed every other day and the podiatrist should be notified immediately for any new sores or open areas. The CC stated the podiatrist really wanted to save the big toe because it helped with Resident 1's balance. CC stated they received a call from facility staff that Resident 1 had a slight infection and needed to see a podiatrist. The CC went to the podiatrist appointment and when the bandage was removed from Resident 1's left foot big toe, three bones were observed protruding from the wound. The toe was swollen, red, and infected. The podiatrist immediately sent Resident 1 to the hospital to be evaluated. Resident 1 had the left big toe amputated, a central line (used for IV therapy) placed, and required antibiotic therapy for the next six to eight weeks for the left toe infection. CC stated when they asked to see the wound, facility staff would tell the CC the dressing was just changed, or the doctor just looked at the wound and therefore did not see the toe wound prior to the podiatrist appointment and stated if they would have known they could have taken Resident 1 to the podiatrist sooner. Observations of pictures of Resident 1's left big toe on 07/05/2023 at 4:08 PM showed pictures taken at the podiatrist appointment on 06/19/2023 and Resident 1's left big toe was observed red, swollen, and slightly falling over to the left with two large open areas and three separate bones protruding through the open areas. A second picture showed Resident 1's right heel with a large area covered in dry dark tissue. During an interview on 07/07/2023 at 12:36 PM Staff A stated that after reviewing Resident 1's CC concerns about Resident 1's wounds it was identified that we have a problem with wounds. Staff A stated Resident 1 had no wounds upon admission to the facility and the wound to the left big toe was identified by facility staff on 04/27/2023. When asked why it took twenty eight days for Resident 1 to be seen by a podiatrist, Staff A stated that the current medical director puts PO's in their progress notes and facility staff can't be expected to review every physician progress note for PO's. When asked when were the bones identified as being exposed through the skin, Staff A was not able to answer, Staff B (DNS) was not available for an interview, and other facility staff were not able to provide answers or did not recall Resident 1. <Resident 2> According to the 05/23/2023 Admission MDS, Resident 2 admitted to the facility on [DATE], was able to make their own decisions and needs known, and had diagnoses including cardiogenic shock (heart is unable to pump as much blood as the body needs), heart failure, peripheral vascular disease (a circulatory condition with narrowed blood vessels and reduced blood flow to the limbs), and history of blood clots. The MDS assessed Resident 2's skin with no PU's, at risk for developing PU's, had no other ulcers, wounds or skin problems, but received applications of dressings to the feet. Review of a nursing admission assessment, dated 05/16/2023, showed facility staff assessed Resident 2 with dark hardened tissue to the left toes, scattered dark scabs to the right toes, and dry scabs to the left lower leg. The assessment did not document the measurements of the wounds. Review of a Braden scale, dated 05/16/2023, showed Resident 2's braden scale score was 18, indicating at risk for PU development. Review of a skin integrity CP, dated 05/17/2023, showed Resident 2 had the potential for impairment to their skin integrity due to ischemia (restriction of blood supply) to the lower extremities. Interventions directed facility staff to monitor and document the skin injury and include the size and treatment. The physician would be contacted if abnormalities, failure to heal, or any signs or symptoms of infection were observed in the wound. The CP did not show Resident 2 had actual impairments to their skin that required treatments. Review of a provider note, dated 05/24/2023 showed Resident 2 had a non-pressure, chronic ulcer of the right foot and recommended meticulous wound care. Review of a NPN, dated 06/09/2023, showed Resident 2 requested wound dressings be changed to both feet. Review of a NPN, dated 06/12/2023, showed facility staff documented when changing Resident 2's wound dressings to the left foot, maggots (fly larva) were observed coming out of the wound, indicating a source (fly) landed on the residents wound, laid eggs that developed into maggots Resident 2 was sent to the hospital for further evaluation, as maggots were not a current treatment for wound care and non-medical maggots carry multiple bacteria that can lead to infection. Review of a NPN, dated 06/20/2023, showed Resident 2 readmitted to the facility on [DATE] with a left foot wound infection that required three different antibiotics to treat the wound infection. Resident 2's right foot was noted with scattered scabbing and all left toes with wounds with eschar (dark, dry, dead skin). Review of a facility skin and wound evaluation, dated 06/22/2023, showed facility staff documented wound measurements of 8.1 cm by 4.1 cm, but did not indicate the type of wound, location of the wound, where acquired or how long it was present, wound characteristics, pain, treatments, progress of wound, or who was notified of the presence of the wound. Review of Resident 2's clinical record showed one facility skin and wound evaluation [completed on 06/22/2023] , thirty seven days after their admission on 05/16/2023, indicating the facility did not monitor wounds or perform wound assessments which led to an infection and maggots in Resident 2's wound. In an interview on 06/23/2023 at 2:50 PM Staff B (DNS) stated it was a difficult question to answer when asked how maggots got into Resident 2's wound. Staff B stated they could not find a cause of the maggots and Resident 2 would refuse dressing changes at times and no flies were observed in the resident's room. Review of the May 2023 and June 2023 Treatment Administration Record (TAR) showed Resident 2 had not refused any treatments and facility staff documented treatments as completed. In an interview and observation on 06/23/2023 at 3:45 PM, Resident 2 stated that a couple flies landed on their left foot but there wasn't too many in their room. Resident 2 was observed sitting in bed and dressings were observed to both feet. In an interview on 07/07/2023 at 12:40 PM Staff A stated the facility had problems with wounds and Resident 2's toes were gangrenous (decaying due to lack of blood flow) and in bad shape. <Resident 3> According to the 04/13/2023 Admission MDS Resident 3 admitted to the facility on [DATE], was able to make their own decisions and needs known, had diagnoses including heart failure, diabetes, and a chronic ulcer of the right foot, right ankle, and an open wound on the left foot. The MDS assessed Resident 3's skin with a PU, was at risk for developing PU's, had two unhealed and unstageable PU's that required PU care and application of dressings to the feet. Review of a nursing admission assessment, dated 04/07/2023, showed Resident 3's skin was assessed with wounds to both feet, on heel and sole. The assessment did not show what type of wound, site of each wound, and measurements of the wounds. Review of a Braden scale, dated 04/07/2023, showed Resident 3's braden scale score was an 18, indicating Resident 3 was at risk for PU's. Review of a 04/11/2023 PO directed staff to refer Resident 3 to an outside wound provider. Review of a skin integrity CP, revised 04/20/2023, showed Resident 3 had an actual impairment to their skin integrity that consisted of an unstageable PU to their left heel and an unstageable PU to their right inner ankle. Interventions directed staff to document weekly wound measurements of each area of skin breakdown with length, depth, type of tissue, drainage, and any other notable changes in the wound. Staff would identify causative factors, eliminate if possible, and would have Resident 3 followed by an outside wound provider. Review of an outside wound provider assessment, dated 04/18/2023, showed Resident 3 was assessed with a right inner ankle arterial ulcer that measured 1 cm x 1 cm x 0.3 cm and a unstageable left heel PU that measured 6.5 cm x 4.5 cm. The wound provider recommended treatments, pain medication prior to wound treatments and to offload pressure to prevent worsening of wounds. Review of an outside wound provider assessment, dated 05/03/2023, showed Resident 3 had their right inner ankle wound assessed but no measurements were documented. Resident 3's left heel PU measured 6 cm x 4 cm and the wound provider recommended treatments, pain medications to wound treatments and to offload pressure to prevent worsening of wounds. Review of an outside wound provider assessment, dated 05/17/2023, showed Resident 3 had their right inner ankle wound measured at 1 cm x 1 cm x 0.3 cm and their left heel PU measured 6 cm x 4 cm. The outside wound provider documented a surgical debridement procedure of the right inner ankle wound occurred. Review of an outside wound provider assessment, dated 05/31/2023, showed Resident 3 had their right inner ankle wound measured at 1.4 cm x 1 cm x 0.5 cm and their left heel wound measured 4.6 cm x 3.2 cm. The wound provider documented that the right inner ankle wound deteriorated with palpable (can feel) bony presence, osteomyelitis was suspected, and recommended Resident 3 obtain an urgent appointment with an infectious disease (ID) provider or a podiatrist, and nursing was to monitor the surrounding skin for any spreading redness to the right inner ankle wound. Review of Resident 3's clinical record showed no PO's from 05/31/2023 with the wound care provider's urgent recommendation to have Resident 3 assessed by a ID provider or a podiatrist. Review of NPN's from 04/24/2023- 06/23/203, showed no indication the facility staff made an appointment for Resident 3 to be seen by a ID provider or a podiatrist or documentation from an infectious disease or podiatry consult, which delayed care that Resident 3 was assessed to require by the outside wound provider. Review of a skin and wound evaluation, dated 06/14/2023, showed Resident 3 had a PU that was from a medical device, to the left heel that was unstageable. The evaluation showed the PU was present on admission, progress had deteriorated, and measured 5.1 cm by 3.3 cm, which indicated the PU became larger since it was last measured on 05/31/2023. The evaluation did not assess the wound characteristics, pain, treatments, and notifications, as they were left blank. A skin and wound evaluation, dated 06/14/2023, showed Resident 3 had a PU that was from a medical device to the right inner ankle that was unstageable. The evaluation showed the PU was present on admission, the PU was stable, and measured 1.4 cm x 1.2 cm. The evaluation did not assess the wound characteristics, pain, treatments, and notifications, as they were left blank. There was no documentation to show what medical device had caused the PU to the left heel and how to avoid worsening of the wound related to the use of a medical device. Review of Resident 3's clinical record showed no documentation that facility staff or the outside wound provider assessed Resident 3's wound during the week of 04/24/2023-04/28/2023, 05/08/2023-05/12/2023, 06/05/2023-06/06/2023, and 06/19/2023-06/23/2023, indicating the facility did not monitor wounds or perform wound assessments. In an observation and interview on 06/23/2023 at 5:10 PM Resident 3 was observed in bed, a dressing was observed to their left heel that was saturated in a green and brown substance and a dressing observed to the right ankle with no drainage. Resident 3 stated Look at my slippers, I just bought them and they are wet with that brown green drainage, it's everywhere, on the bed, it's even on my pillow. It has been draining this green stuff since I first got here. Some of the other residents complained that it smelled and didn't want to look at it when it didn't have a dressing on it. During an interview on 07/07/2023 at 12:45 PM Staff A stated the facility had a problem with wounds, there was a breakdown in communication between physicians and facility staff, and PO's were not carried out as expected. The Director of Nursing (DNS) was not available for an interview and other facility staff were not able to provide answers on why Resident 3 was not seen by an ID doctor or a podiatrist after the outside wound care provider recommended an urgent consult for the resident's wounds. <Resident 4> According to the 05/22/2023 Quarterly MDS, Resident 4 admitted to the facility on [DATE], was able to make their own decisions and needs known, and had diagnoses including a neurological condition, malnutrition, muscle wasting, and weakness. The MDS assessed Resident 4's skin with no PU's, at risk for PU's, no other ulcers, wounds or skin conditions, but did receive application of dressings to their feet. Review of a admission assessment, dated 11/14/2022, showed staff documented Resident 4 had no wounds. Review of a Braden assessment, dated 02/16/2023, showed Resident 4's braden scale score was a 16, indicating Resident 4 was at risk for PU's. Review of a skin CP, revised 03/17/2023, showed Resident 4 had an actual impairment to their skin integrity related to a chronic ulcer of the left foot second toe. Interventions directed staff to monitor and document the location, size, and treatment of skin injury weekly and when abnormalities were observed in the wounds facility staff would contact the provider. Review of an outside wound provider assessment, dated 04/26/2023, showed Resident 4 was seen for the chronic ulcer to the left foot second toe. The assessment showed the ulcer continued to drain pus but no infection was noted. The assessment referred Resident 4 to a podiatrist for a nail tear on the left foot second toe. The wound provider recommended treatments to the toe three times a week and as needed. A outside wound provider assessment, dated 05/03/2023, showed similar findings of continued pus drainage and referred Resident for to a podiatrist for the second toenail tear. Review of a wound provider assessment, dated 05/17/2023, showed Resident 4 was not able to be seen by a podiatrist due to insurance reasons, the facility would have the in-house podiatrist see Resident 4, and the resident would be seen monthly by the outside provider. The assessment showed Resident 4's chronic ulcer on the left foot second toe measured 0.5 cm by 0.5 cm and a depth of 0.2 cm. The assessment showed the ulcer was not expected to heal until the resident was seen by the podiatrist for the nail tear. The outside wound care provider placed orders for dressing changes to the chronic ulcer three times a week. Review of Resident 4's clinical record on 06/27/2023, showed after 05/17/2023 facility staff did not assess or document the resident's ulcer weekly to include the type, size, location, wound characteristics, and notifications of abnormal findings as the CP directed. Review of PO's showed on 04/26/2023 the wound provider treatment orders were carried out and did not change for two months on 06/23/2023. Due to the lack of facility wound documentation it is unclear if the ulcer improved or became worse after receiving the same treatment for an extended duration. Review of the June 2023 MAR showed staff did not document the left foot second toe wound and left the documentation blank on 06/12/2023, 06/19/2023, and 06/23/2023. In an interview and observation on 06/23/2023 at 4:15 PM Resident 4 stated that a podiatrist showed up today [06/23/2023] without notice and performed a procedure on their second toe. Resident 4's left foot second toe was observed wrapped in a bloodsoaked gauze and secured with tape. Review of Resident 4's clinical record showed no documentation that the resident was seen by the podiatrist or documentation about the toenail removal procedure and the outcome to Resident 4's second toe. In an interview on 07/07/2023 at 12:26 PM Staff A (Administrator) was not able to answer why it took nearly two months for Resident 4 to be seen by the in-house podiatrist and stated the previous medical director documented their orders in progress notes and did not communicate orders to the facility staff which ultimately delayed care and treatment to Residents 1, 2, 3 & 4. Staff A stated there was a breakdown in communication between providers and facility staff but would expect PO's to be carried out timely, wounds measured and documented weekly, and the provider to be notified of any abnormal findings with a wound. The Director of Nursing (DNS) was not available for an interview and other facility staff were not able to provide answers on why it took two months for Resident 4 to be seen by a podiatrist. REFERENCE: WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to identify a change in condition as an emergency that required urgent transfer to an acute care facility for 1 (Resident 1) of 3 residents reviewed for hospitalization . This failure resulted in actual harm due to delay in emergency care for Resident 1, who developed septic shock (a life-threatening condition). Findings included . Review of a 06/20/2022 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility with medically complex conditions on 06/14/2022. This MDS showed Resident 1's cognition was intact. Review of 07/23/2022 vital signs showed that at 3:00 PM, staff measured Resident 1's blood pressure (BP) at 158/61 (normal range is 120/80), a temperature of 97.9 degrees (normal range is 97.7 to 99.5), and a heart rate (HR) of 96 beats per minute (bpm). Review of a 07/23/2022 Communication Form showed Staff B, Registered Nurse (RN), notified the physician at 5:00 PM, two hours later, that Resident 1 experienced, Decreased consciousness (sleepy, lethargic) and fever. This form communicated to the physician that Resident 1, needs more assistance with ADLs [Activities of Daily Living]) and their mobility decreased. The form showed a BP reading of 95/49, a temperature of 102.1, and a HR of 112 bpm. The Communication Form showed Staff B did not document a response to the question on the form specifically directed to an RN, What do you think is going on with the resident? RN. I think the problem may be (e.g. [for example] cardiac, infection, respiratory, dehydration). Review of the medical record showed a 07/23/2022 progress note written by Staff B at 9:39 PM that stated, Sent [Resident 1] to the hospital after patient experienced a fever (tested negative for covid [a highly contagious infectious disease]), being lethargic and decreased consciousness. Review of a 07/23/2022 facility transfer form showed that at 8:00 PM, Staff B informed the emergency room staff of Resident 1's clinical status. Review of a Census List showed Resident 1 finally discharged from the facility at 8:21 PM, a period of 3.5 hours from the acute change in condition identified by Staff B at 5:00 PM. Review of a 07/25/2022 Hospital History and Physical (H&P) summary showed Resident 1 arrived at the hospital with low blood pressure and altered mental status, somnolence, and weakness. The H&P showed Resident 1 experienced severe [CONDITION(S)] and septic shock. A 07/28/2022 Hospital Discharge Summary showed Resident 1 stayed at the hospital for five days. According to the Centers for Disease Control, [CONDITION(S)] is the body's extreme response to an infection. It is a life-threatening medical emergency. [CONDITION(S)] happens when a current infection triggers a chain reaction throughout the body and, without timely treatment, can lead to tissue damage, organ failure, and death. [CONDITION(S)] symptoms include fever, difficulty breathing, low blood pressure, fast heart rate, and mental confusion. According to the [CONDITION(S)] Alliance (a national leading [CONDITION(S)] organization), Septic shock is the final, most severe form of [CONDITION(S)] and also the most difficult to treat, and It is essential that treatment begin as early as possible. The chances of [CONDITION(S)] progressing to severe [CONDITION(S)] and septic shock, causing death, rises by 4% to 9% for every hour treatment is delayed. On 08/19/2022 at 1:43 PM, Staff B stated that they took Resident 1's vital signs and acknowledged the acute change in values. Staff B stated that when they identified the change in condition, they notified the Weekend Nurse Manager, and the physician ordered Staff B to send Resident 1 to the hospital. Staff B stated that it took the medical transport two or three hours to get to the facility and transfer Resident 1 to the hospital. Staff B stated, We waited that long. I didn't ask the reason [for the delay]. We didn't call 911, we called Tri-Med [non-emergency] ambulance. Staff B stated that the non-emergency ambulance that was called for transport would arrive on average, maybe within 30 minutes or less than an hour. Staff B stated that 911's arrival to the facility would be, within minutes. They're not gonna' take a long time. Staff B stated that the Weekend Nurse Manager instructed Staff B to call the non-emergency transport, instead of 911. On 08/19/2022 at 1:43 PM, Staff B stated that no additional vital signs were taken between 5:00 PM and 8:00 PM. Staff B stated, I was aware it was kind of alarming but [I] did not see any other changes aside from the temperature. Staff B acknowledged that their assessment of Resident 1's vital signs and change in alertness were, signs of shock, and a medical emergency that required activation of the 911 system. On 08/12/2022 at 1:02 PM, Resident 1 stated, It was weird. Something happened. I started shaking and woke up at [the hospital] with all these things in my arm. My roommate here said, 'You were shaking and went out of it.' The above findings were shared with Staff A, Director of Nursing, on 08/19/2022 at 2:34 PM. Staff A acknowledged Resident 2 displayed signs of, [CONDITION(S)] or infection. Staff A acknowledged [CONDITION(S)] is a medical emergency and the staff should call 911 for immediate treatment. Reference WAC 388-97-1060 (1).

Based on interview and record review the facility failed to recognize, assess, and treat pain for 1 (Resident 23) of 5 residents reviewed for pain management. Failure to consider administration of pain medication prior to care and services that were clearly and repeatedly identified by staff to cause pain, caused Resident 23 to experience untreated pain, and for a reasonable person would result in fear and emotional distress. Findings included . Resident 23 According to the 11/02/2021 Admission Minimum Data Set (MDS- an assessment tool), Resident 23 had moderate cognitive impairment, was understood and able to understand conversation, had no rejection of care, and had one sided paralysis. This MDS showed the resident required extensive two-person physical assistance for bed mobility and transfers, received a regularly scheduled pain regime, and as needed pain medication. According to the Bowel and Bladder Care Area Assessment associated with this MDS, pain was a modifiable factor contributing to urinary incontinence. According to a 10/26/2021 Pain assessment the resident reported having occasional pain or hurting in the past five days which limited day-to-day activities because of pain. In an interview on 01/04/2022 at 10:23 AM Resident 23 indicated they previously worked with therapies, but stopped participation related to issues with knee pain. Resident 23 stated they recently received injections in their knees due to excruciating pain because of bone-on-bone issues in their knees. They elaborated they had no pain when lying in bed without movement, but movement or standing caused unbearable pain and that staff disregarded the significance of the pain. Occupational Therapy (OT) notes dated 10/28/2021 showed the resident Reported pain in her butt 10/10 while lying in bed, R [right] shoulder pain 8/10 while lying in bed . patient did not tolerate ROM [range of motion] to left shoulder. Attempted sit > stand [an exercise going from a sitting to a standing position] several times . R[ight] knee brace not used as part was missing. Patient unable to come to full stand with maximum Assist Physical Therapy (PT) notes dated 10/29/2021 showed staff tried the [bike exercises] patient having too much pain in [their] legs . and patient sitting in wc [wheelchair] had c/o [complained of] pain in left thigh. Review of November 2021 MARs (Medication Administration Records) showed Resident had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to these MARs, nursing staff documented three times a day for each day the resident experienced no pain. According to PT notes dated 11/04/2021 at 8:36 AM, attempt to stand multiple times patient having too much pain in right knee . Review of November 2021 MARs showed the resident was not offered pain medication prior to this therapy session. PT notes dated 11/05/2021 at 12:44 PM showed, patient is stating that [their] bottom hurts and did not want to get out of bed .with encouragement patient sat EOB [Edge of Bed]. Review of November 2021 MARs showed staff did not offer or provide as needed pain medication on this day. Physical Therapy notes dated 11/08/2021 showed, patient stated [they] had fallen a couple days ago, did not want to get out of bed .patient refused to do any therapy .and began to get verbally abusive . There was no indication facility staff assessed the reason behind the resident's refusal and did not rule out pain as a rationale for refusal. Review of November 2021 MARs showed staff did not offer or provide as needed pain medication on this day. November 2021 MARs showed on 11/09/2021 Resident 23 received Tylenol at 11:16 AM. Therapy notes dated 11/09/2021 at 6:26 PM showed patient received Tylenol for R[ight] knee pain, however, refuses to continue despite several attempts, talked with DON [Director of Nursing] about pain and [patient's] request for cortisone shot in knee. There was no documentation to show how soon after the Tylenol administration that therapy was provided, or that staff considered the resident's continued refusal to participate was related to the Tylenol being ineffective. There was no indication facility staff acted on the resident's request for cortisone treatments. PT notes dated 11/10/2021 showed attempted standing pt [patient] unable secondary to c/o R knee pain, Tylenol on board and R knee brace donned without effectiveness. OT notes dated 11/10/2021 showed pt limited by R knee pain . Review of November 2021 MARs showed staff did not offer or provide as needed pain medication on this day. Physical Therapy notes dated 11/11/2021 at 2:54 PM showed staff applied, SWD (Short Wave Diathermy- a therapeutic treatment most commonly prescribed for muscle and joint conditions. It uses a high-frequency electric current to stimulate heat generation within body tissues), to the lateral R knee secondary to pt c/o pain limiting effort and ability. While staff provided the billable service of SWD, staff failed to consider or offer pain medication. PT notes dated 11/12/2021 showed staff provided SWD to work on decreasing R knee inflammation prior to performing lower extremity activities including Range of Motion. No pain medication was offered or provided. Therapy notes dated 11/15/2021 showed diathermy was provided to the resident's right knee, to improve decreased pain in right knee. PT notes dated 11/16/2021 at 4:48 PM showed the SWD was provided and staff attempted to see pt, pt reply's with excuses not to get out of bed .Pt continues to come up with excuses not to get OOB, educated pt on importance of participation and OOB activity to continue to progress. Facility staff failed to rule out pain as a cause for refusals and did not offer or provide pain medication prior to therapy. Physical Therapy staff documented on 11/18/2021 that SWD was provided to assist with pain management allowing for improved effort and ability to perform therapy. Staff further documented with attempts to walk the resident again resistant to therapy. Record review showed no as needed pain medications were offered or provided despite documented need for pain management. PT notes on 11/19/2021 showed SWD services to decrease pain were provided in conjunction with working on foot placement related to transfers. Record review showed no as needed pain medication was offered or provided. PT notes dated 11/22/2021 showed, pt c/o pain with R knee with all standing. Similar PT notes dated 11/23/2021 showed staff had to provide, .multiple rest secondary to c/o R knee pain without resistance . and low standing time up to 25 [feet] at best secondary to c/o R knee pain despite bio-freeze (a topical [MEDICATION(S)] gel for sore muscles and joints). OT notes dated 11/23/2021 showed Pt demonstrated fear of pain/falling. While the November 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further OT notes dated 11/24/2021 showed, .pt demo fear of falling with movement with R knee pain impacting performance . Review of 11/24/2021 MARs showed the resident received as needed Tylenol only at 3:07 AM, not in conjunction with or prior to any Therapy. PT staff documented on 11/30/2021, pt states 2/10 pain without movement, 9/10 with movement and Manual stretching to [Left Lower Extremity], limited Rand of Motion d/t [due to] tightness and c/o pain despite Tylenol on board. Pt resistive and non-compliant with therapy session. Contrary to the therapy note, review of November 2021 MARs showed Resident received as needed Tylenol once on 11/30/2021 at 1:20 AM, and received no other as needed pain medication this day. Physical Therapy notes dated 12/01/2021 showed, Pt .continuously refuses standing and stand pivot transfers and often is verbally abusive. Many attempts to decrease pain have been attempted such as SWD, bio-freeze and soft knee brace donned prior to movement to no avail. Record review showed no indication facility staff considered providing pain medication prior to therapy sessions based on the identified pain the resident experienced with movement and standing. According to a Risks/Benefits form dated 12/02/2021 staff advised the resident of the risks associated for Refusing to get out of bed and refusing therapy. Staff documented multiple risks of not getting out of bed including, may contribute to increased pain, especially in lower back and multiple benefits which included, May contribute to less general pain. Staff did not identify the reason for refusing to get out of bed or refusal of therapy or consider pain as the reasons for refusals. Therapy notes dated 12/03/2021 showed Pt refuses all therapy even pain relief but failed to identify what pain relief was offered. Provider notes by the Advanced Registered Nurse Practitioner [ARNP] dated 12/02/2021 showed, Seen at bedside, she feels sad, depressed and she hurts. Her knees hurt most. Is interested in starting [MEDICATION(S)] patches to bilateral knees . Physical therapy notes that she has some difficulty with knee pain and recommend a steroid injection. In an interview on 01/07/2022 at 12:17 PM, Staff B (Director of Nursing) acknowledged Resident 23 refused therapy related to complaints of pain stating the resident had bone on bone in the knees. Staff B stated the plan was for Resident 23 to get (Steroid) injections to both knees, then start therapy back up two weeks after the injections. Record review showed no plan to premedicate the resident for pain prior to therapy and no interventions regarding pain which would increase the resident's participation in therapy. According to Staff B, of the 23 days of therapy reviewed Resident 23 received no as needed pain medication on 18 days. In an interview on 01/10/2022 at 11:56 AM Staff B indicated the facility was aware that standing and movement caused the resident pain. After reviewing therapy notes and MARs, Staff B indicated therapy continued to have the resident perform movement, standing and stand to pivot exercises without benefit of pain medication. At this time, Staff B confirmed staff should have, but did not, objectively reassess the resident's pain after identifying on 11/04/2021 that the resident experienced pain during therapy until 12/02/2021 when the Risk versus Benefit of refusing therapy and transfers was completed. When asked why there was a three-week delay from the PT note on 11/09/2021 to when the Provider ordered steroid injection on 12/02/2021, Staff B replied, I thought I told the ARNP, but there is no note . In the interview on 01/10/2022 at 12:05 PM, Staff B stated the standard of practice for residents identified to experience pain with therapy was, .to do a pain assessment, and premedicate, reassess to see the effectiveness and refer to the doctor. Staff B elaborated the resident should be on alert charting regarding the pain. In an interview on 01/10/2022 at 10:50 AM, Staff AA (Therapy Director) stated if a resident experiences pain, therapy staff normally offer pain medication 30 minutes prior to therapy and schedule it with the nurses. At this time Staff AA confirmed staff should have, but did not provide pain mediation prior to therapy interventions which were known to cause pain, stating, I need to do an Inservice REFERENCE: WAC 388-97-1060(1).

Based on observation, interview and record review, the facility failed to operationalize all components of the infection prevention and control program, ensure residents were protected from COVID-19 (Coronavirus - a contagious disease). The facility did not have a system in place to ensure staff followed Infection Control (IC) practices to prevent exposure to or the spread of COVID-19, to include: (1) The facility failed to provide N95 mask fit testing and ensure the mask's proper use for 9 (A, B, D, E, F, G, H, I and J) of 10 staff who worked in the Isolation Unit and the COVID-19 Unit. (2) The facility failed to provide training to staff for the appropriate use of N95 respirators. (3) The facility failed to use or adequately wear required PPE (Personal Protective Equipment) during an outbreak. (4) The facility failed to screen 2 of 2 Surveyors upon entry in the facility, and were allowed access to residential areas. (5) The facility failed to conduct a root-cause analysis and identify where a breech in IC practices occurred, in order to remedy actual or potential areas of concern, and prevent further COVID-19 transmission to the residents. These failures caused 15 residents to become infected with COVID-19, to include 5 transfers to the hospital, and 1 death, and increased the elkhound of serious illness or death to unvaccinated residents during an outbreak constructing an immediate jeopardy. On 06/22/2021 at 12:30 PM, the facility was notified of an Immediate Jeopardy related to Infection Control. Findings included . Refer to CFR 483.70(e)(1)-(3) - Facility Assessment CFR 483.80(b)(1)-(4)(c) - Infection Preventionist Qualifications/Role FAILURE TO ADEQUATELY USE N95/FIT TESTING Review of the Washington State Department of Health Contingency Strategies for PPE Use During COVID-19 Pandemic, updated 04/29/2021, showed that Health Care Professionals in close contact with residents presumed or confirmed COVID-19 positive, and in close contact with new admissions, readmissions, or potentially exposed persons, should wear N95 respirators, eye protection, gown, and gloves. In addition, it showed that staff who have not passed the N95 respirator fit testing, or have not yet been fit tested , should not be offered use of an N95 respirator until fit testing can occur and/or risk is mitigated and an N95 is no longer needed. Review of a facility guideline dated 06/03/2020 stated, PPE should be used when caring for patients with confirmed or suspected COVID-19 infections. PPE must remain in place and worn correctly for the duration of work in potentially contaminated areas. Put on . N95 face piece, respirator or higher (use a facemask if a respirator is not available). Respirator straps should be placed on the crown of head (top strap) and base of neck (bottom strap). On 06/16/2021 at 10:30 AM, Staff D, Registered Nurse (RN), was observed wearing a make-up stained N95 mask, with the lower strap missing. When asked how long the staff was using the same mask, Staff D said, Two days. When asked if she was working with the same residents both days, Staff D said, No, I worked the COVID area yesterday, and today on Medicare When asked if she was fit tested for the N95 mask she was wearing, Staff D said, No. Use of PPE from a COVID Unit to a non-COVID Unit placed the residents and other staff at risk of becoming infected with COVID-19. On 06/16/2021 at 11:30 AM, Staff A, Administrator, was observed wearing an N95 mask, with the edge of the mask tucked in. On 06/16/2021 at 11:32 AM, Staff G, Housekeeping, was observed entering a resident's room in the South Hall [Yellow Zone - Isolation Unit] without PPE, and stated she was cleaning the resident's room. When asked how often she cleaned the rooms, Staff G said, Every three to four hours. On 06/16/2021 at 12:28 PM, Staff H, RN, was observed wearing an N95 mask, and no face shield. When asked if he was trained on how to wear PPE, Staff H said, Not in this facility. When asked if he was fit tested for the N95 mask he was wearing, Staff H said, No. On 06/16/2021 at 1:30 PM, Staff I, RN, was observed wearing an N95 mask with both straps missing, and a surgical mask over the N95 to hold it in place. Staff I said, The straps are too tight, I use the surgical mask to hold on the N95. When asked if she had training on how to use PPE, Staff I said, No. When asked if she was fit tested to use the N95 mask, staff I said, No. An observation in the Red Zone (Covid- Unit) on 06/16/2021 at 3:00 PM showed, Staff E, Licensed Practical Nurse (LPN), and Staff F, Certified Nursing Assistant (CNA), both wearing an N95 mask and face shield. When asked if they were trained on how to use the PPE, and if they were fit tested for the N95 mask they were wearing, Staff E and F said, No. An observation on 06/22/2021 around 5:00 AM showed Staff K, CNA, wore an N95 mask with its edge folded in. On 06/16/2021 at 11:30 AM, Staff B, Director of Nursing, was observed wearing an N95 mask with the lower strap dangling under the chin, not around the base of the neck. In addition, Staff B was wearing a face shield that was flipped upwards, diminishing its intended use to provide protection to the eyes. In an interview on 06/16/2021 at 2:35 PM, when asked if she was trained on how to use an N95 respirator, Staff B said, Yes. When asked why the N95 strap was not secured, Staff B stated, I have not been trained like that. I have lost hair on the back of my neck, and mine shouldn't be like that. When asked if staff were trained on how to use PPE, Staff B said, We use most agency staff and we have started training them. When asked about her expectation on staff wearing PPE in Isolation and COVID-19 units, Staff B stated that, All staff must wear one fitted N95 and with both straps on the head. Review of infection control records provided by Staff B showed only two of 39 staff who worked in the COVID Unit from 06/14/2021 to 06/21/2021 were fitted for an N95 mask. The above findings were shared with Staff A, Administrator, on 06/22/2021 at 11:20 AM. Staff A confirmed that the staff who worked in the COVID Unit were not fit tested for an N95 mask before working in the COVID Unit. Staff A stated that the expectation was that all staff should be fit tested and trained on how to use PPE before working in the COVID-19 Unit. FAILURE TO USE FACE SHIELDS Observations on 06/22/2021 between 4:30 AM to 5:30 AM showed five (Staff J, K (CNA), L (CNA), M (LPN), and N (CNA)) of nine staff did not wear a face shield; Staff M and N worked in the COVID Unit. All of the staff acknowledged they should be wearing a face shield during an active outbreak status in the facility. FAILURE TO SCREEN STAFF AND VISITORS Review of the COVID Unit Employee Screening Log showed the facility failed to adequately screen staff working in the COVID Unit for eight (06/14/2021 to 06/21/2021) of eight days reviewed. In an interview on 06/22/2021 at 9:30 AM, Staff C, Scheduling Coordinator, confirmed the number of staff who worked each day, in a 24-hour period, in the COVID Unit between 06/14/2021 to 06/21/2021: Four staff worked on 06/14/2021. Review of the COVID Screening Log showed only 1 staff was screened. Four staff worked on 06/15/2021, and review of the COVID Screening Log showed no staff was screened. Five staff worked on 06/16/2021, one staff did not have her temperature screened, and review of the COVID Screening Log showed only four staff were screened. Seven staff worked on 06/17/2021, and review of the COVID Screening Log showed only two staff were screened. Eight people worked on 06/18/2021, and review of the COVID Screening Log showed only two staff were screened. Five people worked on 06/19/2021, and review of the COVID Screening Log showed only three staff were screened. Six people worked on 06/20/2021, and review of the COVID Screening Log showed only one staff was screened. Seven people worked on 06/21/2021, and review of the COVID Screening Log showed only two staff were screened. On 06/22/2021 at 4:27 AM, Staff J, LPN, allowed two Surveyors entry in the facility. Staff J summarily turned her back to the Surveyors once they identified themselves and went towards the elevator while texting on her cell phone. The Surveyors followed Staff J into the elevator and asked Staff J if the elevator had a limit capacity for the number of people inside it at one time, to which Staff J replied, I think it has a weight limit of 4,600 pounds. From entry into the facility to point of exit at 5:27 AM, the Surveyors interviewed a total of 9 staff, who did not identify the Surveyors had not been screened, or asked them if they had been screened. Prior to exit, when asked how staff was screened, Staff M stated, You ask. That's how you know if they've been screened. You ask them, 'Can I assist you with screening?' The Surveyors returned to the building entry at 5:20 AM on 06/22/2021. Staff J answered the door again and allowed the Surveyors entry. When Staff J was asked to describe the screening process for visitors, Staff J stated, They get screened every day. On night shift the nurse comes down and screens before their shift. We do a rapid nasal test and have their temperatures taken. Staff J identified that when staff was screened using the front entry, the screening machine would print a sticker identifying the staff had been screened for COVID-19 symptoms and their temperatures taken. No identifying sticker was observed on Staff J. Staff J acknowledged she did not screen the two Surveyors and should have, prior to allowing them access to residential areas. In an interview on 06/22/2021 around 11:00 AM, when asked to describe the screening process in the facility, Staff B stated, It's on and off. It's based on an honor system. FAILURE TO EDUCATE In an interview on 06/16/2021 at 2:35 PM, when asked how staff were trained about COVID-19 infection and prevention, Staff B stated that she started doing in-services after the outbreak. FAILURE TO CONDUCT A ROOT CAUSE ANALYSIS Review of an undated COVID Outbreak Summary showed, the facility identified 15 residents and three staff tested positive for COVID-19 between 06/13/2021 and 06/22/2021. Review of the summary showed the facility did not conduct a root cause analysis to show how COVID-19 spread between the residents and the staff, or that the facility evaluated potential breeches in Infection Control practices or processes in place like visitors and staff screening, appropriate use of PPE, fit testing of staff, ongoing monitoring for compliance of Infection Control practices, staff education, and a trained/credentialed Infection Preventionist. In an interview on 06/16/2021 at 2:45 PM, Staff B stated that she had not determined the root cause of the COVID-19 outbreak in the facility. In an interview on 06/23/2021 at 1:30 PM, when asked about the source of the COVID-19 outbreak, the Local Health Jurisdiction contact stated, We are not sure. We have not received a line listing from the facility. We are suspecting the three agency [staff] who tested positive for COVID-19. In an interview on 06/23/2021 at 10:30 AM, Staff A confirmed a total of 15 out of 60 residents and 3 staff, had contracted COVID-19 since 06/13/2021. This resulted in the hospitalization of five residents. One resident has since passed away. Reference WAC 388-97-1320 (1)(a).

Based on interview and record review the facility failed to ensure resident supervision, thorough accident investigations to determine the circumstances of resident accidents and implementation of measures to prevent reoccurrence for one (#1) of three residents reviewed for falls, for whom fall precautions were not implemented and one (#4) of four residents reviewed for injuries, for whom staff failed to provide adequate supervision to prevent injury. Failure to implement interventions, including adequate supervision and assistive devices, consistent with Resident #1's needs, goals, and care plan in order to reduce the risk of an accident, contributed to a pattern of repeated falls which caused Resident #1 to sustain a fall with a fracture, which constituted harm. Failure to provide adequate supervision during a mechanical transfer caused Resident #4 to sustain a fracture, which constituted harm. Findings included . Refer to CFR 483.412(c)(2)-(4), F-610, Investigate/Protect Resident During Investigation CFR 483.25(b)(1)(i)(ii), F-686, Treatment/Services to Prevent Pressure Ulcers RESIDENT #1 Review of facility incident logs showed Resident #1 demonstrated a pattern of eight falls starting on 01/03/2020, culminating in a fall with significant injury on 06/19/2020. Resident #1 was admitted to the facility on [DATE] and according to the 01/03/2020 Admission Minimum Data Set (MDS, an assessment tool), had [DIAGNOSES REDACTED]. Staff determined, according to this MDS, Resident #1 had no history of falls prior to admission and experienced one fall since admission. According to the 03/27/2020 and 06/16/2020 Quarterly MDSs, the resident was assessed with [REDACTED]. The 03/27/2020 MDS indicated Resident #1 sustained two or more non injury falls and the 06/16/2020 MDS reflected one non injury fall and one fall with injury. Review of facility Investigative documents showed Resident #1 sustained a fall on 01/03/2020 while attempting to ambulate to the bathroom. Record review showed no staff were present to assist or supervise the resident's ambulation. According to facility investigative documents, Resident #1 sustained a second fall on 03/19/2020 when the resident was found on the floor in the bathroom. According to Care Plan documents dated 03/19/2020, staff were directed to, Ensure that the resident is wearing appropriate footwear nonskid socks or shoes when ambulating or mobilizing in w/c (wheelchair). Nonskid socks while in bed. Facility investigative documents dated 03/30/2020 showed a third fall when the resident was found on the floor, lying on his left side, on the left side of the bed. The investigation did not address the resident's footwear or if the care planned interventions regarding footwear were implemented. Staff identified the intervention of, Placed on 15 minute checks around the clock to increase supervision to decrease fall risk and help prevent future occurrence. Facility investigative documents dated 04/19/2020 showed Resident #1 sustained a fourth fall. Record review showed the 15 minute checks were last done on 04/08/2020. There was no assessment which supported why the 15 minute checks were no longer required or why the resident no longer required increased supervision to decrease fall risk. Subsequent investigative documents showed that on 04/22/2020 the resident sustained [REDACTED]. Per CNA resident did not have a gait belt on . According to care plan documents dated 12/30/2019, The resident required (extensive assist by (1) staff to move between surfaces as necessary using a FWW (Front Wheeled Walker) with SBA (Stand By Assist). In-service documents associated with the 04/22/2020 fall investigation summarized, When assisting a resident with ambulation (Stand by Assist) you must use a gait belt to help decrease fall risk. The investigation failed to address why nursing staff did not utilize a gait belt for a resident who was assessed to require SBA. While the CP was amended on 04/24/2020 specifying transfers with SBA should be done, with gait belt, there was no documentation to support why staff attempted the SBA transfer without the use of a gait belt. Failure to ensure use of a gait belt for a resident who was assessed to require SBA, did not provide a safe level of supervision or assistance. According to facility investigative documents the resident was identified with a sixth fall, from bed on 05/07/2020. Review of the resident record and investigative documents did not address whether the resident's CP was implemented regarding the use of non-skid socks while in bed. In an interview on 07/14/2020 at 11:10 AM, Staff B indicated that facility staff did not, but should have considered alternate interventions to prevent recurrence such as a perimeter mattress or mats at bedside. Record review showed Resident #1 sustained a seventh fall while attempting to transfer from the wheelchair to the bed on 06/13/2020. Review of investigative documents showed staff did not consider increased supervision to prevent further falls. Resident #1 experienced an eighth fall according to facility investigative documents dated 06/19/2020. Staff documented the resident fell from bed and, Resident was not wearing pants or socks . A witness statement dated 06/19/2020 indicated, while I was walking towards residents room I saw resident tried to stood (sic) up (at the edge of bed was dangling) and fell on his face. The resident was subsequently identified with a fractured left upper arm. Failure to implement identified measures to reduce the risk of falls, including nonskid socks, contributed to a fall with significant injury, which constituted harm. In an interview on 07/14/2020 at 10:35 AM, Staff B, Director of Nursing, indicated staff were expected to implement care plans. RESIDENT #4 Resident #4 admitted to the facility on [DATE]. According to the 12/09/2019 Significant Change MDS the resident was assessed to require Hospice services. The 03/10/2020 Quarterly MDS, showed the resident no longer required Hospice services. The 06/08/2020 Quarterly MDS showed the resident had [DIAGNOSES REDACTED]. Staff assessed the resident with severe cognitive impairment and, rarely/never understood. According to CP documents dated 08/28/2018, the resident required a (Broda - a speciality wheelchair that prevents skin breakdown for residents that need a high level of positioning or special adaptation due to positional challenges) tilt-n-space w/c (wheelchair) for trunk control, proper body alignment and off-loading pressure to coccyx. An additional intervention dated 10/08/2019 directed staff, Tilt and space/Broda chair: Specialty Pressure Reducing Air Mattress with bolsters (a device to provide physical perimeter of mattress edge) * mattress provided by hospice. Care Plan documents dated 09/29/2015 showed Resident #4, requires mechanical lift/hoyer lift with two staff assistance with transfers. Record review showed the resident was discharged from Hospice services on 03/14/2020 and that Hospice staff picked up the Broda wheelchair and Specialty Pressure Reducing Air Mattress with Bolsters on 06/22/2020. In an interview with Staff D, Hospice Nurse Staff Manager on 08/05/2020 at 3:15 PM confirmed that all hospice Durable Medical Equipment (specialty mattress with bolsters and Broda wheelchair) was picked up from the facility on 06/22/2020 and was no longer available to the resident. Record review showed no indication facility staff acknowledged hospice retrieved the Broda wheelchair or assessed the resident's wheelchair needs at that time. There was no indication in the record that facility staff re-assessed the resident required any chair other than the Broda wheelchair, which the care plan continued to reflect the resident required. In an interview on 08/06/2020 at 9:56 AM, Staff B indicated the resident was provided with a non-Broda wheelchair to replace the Broda which Hospice retrieved. Staff B stated that therapy staff provided Resident #4 with a replacement wheelchair that previously was ordered for another resident. Record review revealed no assessment that this wheelchair was appropriate for Resident #4. Staff B & C, Interim Administrator, at this time confirmed the record should, but did not contain information to show staff evaluated and analyzed potential hazards and risks associated with the replacement wheelchair. According to facility investigative documents the resident was identified on the morning of 07/22/2020 with, .a bruise purple and yellow in color on residents left ankle foot area with noted swelling. Resident unable to give description. The resident was subsequently identified with a, fracture involving lateral malleolus (outer ankle). Immediate actions taken included, staff in-service completed to position extremities to prevent them from being injured/bumped on w/c when lifted/lowered in Hoyer, and to make sure foot pedal are up prior to transferring the resident . A subsequent evaluation by the Physical Therapy Assistant dated 07/30/2020, after the fracture, showed, It was recommended that the Broda is a better and safer fit at this time d/t (due to) extended foot recliner and improved back rest that improves pt's comfort and functional fit. According to investigative documents dated 07/24/2020, The resident was evaluated while up in her w/c, and noted with her legs resting on the calf support system, however her feet were noted under the foot pedals. There was a pillow placed under the resident calves in attempt to support her legs. The foot pedal was noted to be situated directly above the point of impact of the bruising .Likely cause of the bruising is the resident's ankle bumped the foot pedal while being raised up in the hoyer (a mechanical lift). According to the CNA, Certified Nursing Aide, Mechanical lift transfer competency, Staff ensure wheelchair footplates are in the up position and, if able, swung away from the front of the chair. In an interview on 08/05/2020 at 2:25 PM, Staff A and B indicated mechanical transfers required two staff, one to operate the mechanical lift and one to help guide the resident to prevent injury. Record review showed multiple CNAs were identified as providing care for Resident #4 in the days prior to the transfer resulting in a fracture. In an interview on 08/06/2020 at 10:15 AM, Staff B confirmed that none of the CNAs identified had completed a CNA competency for a mechanical lift transfer. Facility staff failed to ensure adequate supervision, including competency and training of the staff, consistent with a resident's needs, goals, care plan in order to eliminate or reduce the risk of an accident. In an interview on 08/05/2020 at 2:25 PM, administrative staff were asked if direct care staff had performed the mechanical transfer properly, would Resident #4 have sustained the ankle fracture. Administrative staff (Staff B, C & E, Clinical Operations Staff) indicated, I believe they (CNAs) lifted and she (Resident #4) shifted and the foot got caught under (the foot pedal)and the CNA didn't see prior to lifting (the resident with the lift), I think they followed the procedure but didn't look under the blanket and we were not able to determine which CNA did it because I do not think the CNA realized they did it (caused the left ankle fracture). Administrative staff at this time confirmed that the resident's left ankle fracture was the result of a hoyer lift transfer. Failure to ensure adequate supervision during a mechanical transfer caused Resident #4, who was dependent on staff for transfers, to sustain a fracture. REFERENCE WAC 388-97-1060(3)(g).

Based on observation, interview and record review the facility failed, for one of seven residents (Resident #1) reviewed for accident hazards and supervision, to supervise direct-care staffs' implementation of care planned interventions to prevent falls. This failure resulted in Resident #1 falling from bed and hitting her head. Findings included: Resident #1 was admitted to the facility with a terminal [DIAGNOSES REDACTED]. Resident #1 was cognitively aware but frail and able to make her own decisions according to this assessment. The facility further assessed Resident #1 for falls on 03/20/18 with a score of eight. Instruction to staff on this assessment was, All residents have the potential of falling .if the .score is greater than 45, the resident is considered as having High Potential for falls .If the total .score is below 45 the resident may still have a low to moderate risk of falling. The interdisciplinary team .determines if other interventions are needed. Based on the facility's assessment of the resident, the facility developed a 12/11/17 care plan that was still being implemented and that instructed direct-care staff to employ two staff each time the resident required turning or personal care. Resident #1 was observed on 04/06/18 at 9:10 a.m. in bed with a large 4.5 centimeter sutured laceration over the right eye that exhibited a degree of swelling. Resident #1 presented with lethargy and was difficult to understand. Resident #1 said she was feeling better. According to the facility's 04/04/18 evidence of investigation, Staff C provided care and services to Resident #1 without the benefit of a second staff. Staff documented on the investigation Resident #1 fell out of bed, hit her head and extremities, causing a laceration to the head and multiple skin tears to the extremities. Review of the 04/04/18 hospital emergency room report revealed the laceration to the head was so significant that sutures were required. Staff A, the Administrator, and Staff B, the Director of Nursing, said in an interview on 04/06/18 at 9:30 a.m., that Staff C did not follow the care plan for the provision of care and attempted to provide care by herself without the required second staff. Staff A and B said Resident #1 fell out of bed hitting her head and suffering the [MEDICAL CONDITION] and extremity skin tears. Staff C was not available for interview. WAC 388-97-1060(3)(g)

Based on interview and record review it was determined the facility failed for one of 11 residents (Resident #1), reviewed for antibiotic medication error, to ensure medication was administered according to physician's orders [REDACTED].#1's hospitalization and placed the resident at risk for systemic infection and further loss of limb. Findings included: Refer to CFR 483.20(k)(3)(i), F281, Services meet standards According to the 10/18/16 Minimum Data Set (MDS) assessment, Resident #1 admitted to the facility on [DATE] with kidney disease and following surgical repair and amputation of a gangrenous right foot and toes. This MDS identified the resident was able to make his own decisions and required limited to extensive assistance with activities of daily living. Resident #1 was discharged from the facility, reviewed as a closed record and not available for interview. According to 10/10/16 hospital discharge orders, Resident #1 was to receive, for a pseudomonas infection, the antibiotic [MEDICATION NAME] HCL ([MEDICATION NAME]) 2GM (grams) Recon Sln (reconstituted solution) as directed twice daily start date: 10/10/16 End date: 11/17/16. A 10/10/16 hospital physician's note indicated this preferred medication was not available to hospital staff due to a shortage nationwide. The medication [MEDICATION NAME] was substituted while Resident #1 was hospitalized . The facility received a 09/27/16 memo from their Omnicare Pharmaceutical provider indicating this same issue with the lack of available [MEDICATION NAME]. According to Staff C, interviewed on 10/28/16 at 2:30 p.m., Staff D, notified the hospital physician of the lack of available [MEDICATION NAME] and received an order for [REDACTED]. Staff C entered a discontinuation date of 10/17/16 into the computer record. According to the Medication Administration Record, [REDACTED]. This was only four days of an antibiotic for an infection that posed grave danger to a resident with a compromised immune system, [MEDICAL CONDITION] and known pseudomonas wound infection. According to manufacturer's guidelines, [MEDICATION NAME] should be administered for at least two days after the signs and symptoms of infection have disappeared. There was no indication any facility or consulting physician determined or documented Resident #1's infection disappeared. October 24, 2016 clinic and hospital physician notes included, .at high risk for potential non-healing sequalae due to macro & microvascular disease from diabetes . ischemic changes . (surgical) site that has gangrenous ischemic changes . features focal to the (surgical) site. According to these notes, Resident #1 was to be referred for hospitalization , renewed antibiotic therapy, hyperbaric therapy and further surgical debridment. The facility failed to administer the antibiotic for the scheduled and ordered six week therapy period resulting in hospitalization and more extensive treatment of [REDACTED].

Based on observation, interview and record review it was determined the facility failed to ensure one (#28) of one sampled residents reviewed for significant weight loss maintained acceptable nutritional status and did not experience significant unintentional body weight loss. Failure to consistently monitor weights and assess and respond to continue identified weight loss resulted in an unplanned, avoidable significant weight loss of 35 pounds (26.4%) in two months. Additionally, the facility failed to ensure a system by which staff monitored supplement intake for Resident #47 and consistently obtained accurate and timely weights and/or assessed weight changes for seven (#s 35, 107, 87, 78, 138, 7 & 142) of nine residents reviewed who admitted in the previous six months. Findings include: FACILITY POLICY According to the facility policy on "Resident Weight Monitoring", residents should "have a weight every week for four weeks to evaluate their weight..." and "It is the responsibility of the LN (licensed nurse) or RCM (Resident Care Manager) to evaluate the weight and if the weight is either an increase or decrease of 3 pounds in one day or 5 pounds in one week a re-weight is to be obtained. If the weight continues to fall into this category then the RCM/LN should evaluate the potential reasons for the change in weight." This policy further directed staff, "For significant weight loss or gains (greater than 5% in 90 days or greater than 10% in 180 days) a referral to the Nutrition At Risk Committee (NAR) should be made to ensure interventions are in place" and "The resident's attending physician should be notified of a resident's significant weight loss/gain." RESIDENT #28 Resident #28 admitted to the facility on [DATE]. According to the 08/27/14 Minimum Data Set assessment (MDS), she weighed 134 pounds (lbs) and required extensive, two person physical assistance for bed mobility, transfers and setup help with eating. This MDS identified the resident experienced a weight (wt) loss of 5% or more in the last month and was not on a physician-prescribed weight-loss program. The Nutrition Care Area Assessment indicated the resident experienced a wt loss and "See RD (Registered Dietitian) evaluation. Resident has lost 6.7% x 1 month r/t (related to) poor appetite and intake... Her appetite is poor at times. We will offer meal substitutions and health shakes when intake is less than 50%. We will also follow RD recommendations. (Resident) will be encouraged to eat and assistance provided as needed. Weights will be monitored per facility protocol. We will proceed to care plan to address (resident's) nutritional status and potential for additional weight loss." Review of the resident's weight record revealed an admission weight of 134 lbs on 08/20/14. The next weight, obtained on 08/26/14, was 125 lbs, a loss of nine lbs (6.7%) in six days. Record review on 10/15/14 revealed no weight had been obtained since 09/17/14 (127 lbs) and a more recent wt was requested. Staff obtained a wt of 102 lbs on 10/15/14, a loss of 25 lbs (19.7%) in less than 30 days. Facility staff failed to obtain a re-weigh per their policy or notify the family or physician of the significant weight loss. There was no evidence of a re-weigh or any further nutritional interventions until survey staff requested an additional wt on 10/21/14. At that time facility staff determined the resident weighed 98.6 lbs, an additional 28.4 lb wt loss in a month (22.3% ) and a 35 lb (26.4%) wt loss since admission. Review of September meal monitors revealed staff documented the resident consumed 50% or less of 46 of 61 meals served and took no nutritional supplements for any of those meals. An 08/26/14 RD note assessed the resident was nutritionally at "high risk" and indicated, "has [MEDICAL CONDITION] in her lower extremities and with its resolution, weight decrease is expected." Record review revealed no other indication the resident had [MEDICAL CONDITION]. The 08/26/14 RD note further directed staff to provide the resident with "Nephro (a nutritional supplement) one can at (bedtime)...". Review of Medication Administration Records (MARs) revealed staff did not implement the recommendation until 10/02/14. In an interview on 10/22/14, Staff C (RCM) was unable to explain why the RD recommendation was not implemented for over five weeks after it was made. Review of the 10/14 MAR indicated [REDACTED]. In an interview on 10/21/14 at 10:17 a.m., Staff K (RD) was asked how she determined the amount of Nephro Resident #28 consumed. She stated, "I have to look at the med sheets...". After review of the October MARs, Staff K indicated the documentation for the Nephro was "sporadic", as was the amount of intake. Staff K additionally stated, "For a resident who is nutritionally at risk, who has demonstrated a wt loss I would expect the wts do be done weekly...". Staff K indicated there had been difficulty obtaining timely resident wts from the facility. A 09/17/14 MDS identified the resident weighed 127 lbs and similarly assessed the resident experienced, "a weight loss of 5% or more in the last month" and that the resident was "not on a physician prescribed weight-loss regime." Record review revealed a continued absence of response to this identified weight loss. Review of the resident's Care Plan (CP) on 10/17/14 revealed no identified or planned weight loss and no terminal [DIAGNOSES REDACTED]. Record review revealed no evidence facility staff assessed the resident's food preferences in an attempt to increase Resident #28's intake. According to Staff D (RCM), in an interview on 10/22/14 at 11:20 a.m., "They have a new admission dietary assessment, food preference form ..." which was to be completed for each resident on admission. After reviewing Resident #28's record, Staff D stated, "No, I don't see it in (Resident #28's) chart." In an interview on 10/22/14 at 11:42 a.m. Staff J (Dietary Service Manager) stated, "The new admission assessment form is in the record... (the RD) has been helping me, I've been cooking a lot lately." When informed there was no such assessment in the resident's record, Staff J indicated it might be in a file. Upon reviewing her files Staff J stated, "I don't see it (Resident #28's dietary assessment for preferences), I can't say for sure that it was done...". In an interview on 10/22/14 at 10:25 a.m., Staff C stated, "Medical records gives me a wt report to know who needs a re-weigh." Staff C indicated she had only worked at the facility for three weeks and was not sure why the resident wasn't re-weighed on 08/26/14 when the first weight loss was identified. Staff C further stated she had spoken with the physician who indicated that [MEDICATION NAME] (an appetite stimulant) would be started as the potential benefit of [MEDICATION NAME] would outweigh any risk. Record review revealed facility staff, on 10/02/14, reviewed Resident #28 in a "Skin at Risk" committee, but failed to recognize or provide monitoring or interventions for the resident's weight loss. According to physician's orders [REDACTED]. All of these medications had sedation as a primary side effect. A progress note (untimed) for 10/12/14 indicated the resident "naps on and off. Hardly ate lunch...". A progress note, dated 10/13/14 at 6:00 a.m., indicated the resident was "sleeping whole shift..." with the 10:45 a.m. note reflecting the resident "remains in bed this am sleeping at this time." On 10/15/14 at 5:00 p.m. staff documented the resident was "still drowsy." In an interview on 10/17/14 at 5:29 a.m. Staff X (Licensed Nurse), stated she made a call to the doctor that morning because, "the resident had [MEDICATION NAME] due at 4:00 a.m., I usually get it for her around 3:30 a.m. but she seemed really tired so I waited until 5:00 a.m. and she seems tired still... she had this a couple of days ago where they had to hold her [MEDICATION NAME] for a shift or two...". Observation on 10/15/14 at 1:39 p.m. revealed the resident lying in bed sleeping. Similar observations were made on 10/17/14 at 5:04 a.m., 7:32 a.m., 9:56 a.m., 11:04 a.m., and 12:04 p.m. Observation on 10/20/14 at 8:23 a.m. revealed Resident #28 lying on her right side sleeping. Her breakfast tray was untouched on the overbed table. At 9:15 a.m., the resident was observed up in her wheelchair and Staff F was setting the resident up for breakfast. Staff F was not observed to offer to heat the meal which had been sitting out for almost an hour. By 9:46 a.m. the resident had consumed a bite of yogurt, a few bites of egg and eaten some pineapple. No oatmeal had been consumed. The resident's denture plate was noted in a cup near the sink. At 2:57 p.m. the resident was observed lying in bed. The resident's daughter was at the bedside attempting to get the resident to consume some soup, which she had brought from home. Observation on 10/21/14 at 7:57 a.m. revealed the soup from the previous evening still sitting on the overbed table. At 9:09 a.m. Resident #28 was in her wheelchair eating breakfast from an overbed table. The resident was not wearing her dentures. At 10:12 a.m. the resident was lying in bed sleeping. At 2:37 p.m. the resident was lying on her right side, sleeping. Observation on 10/22/14 at 8:32 a.m. revealed Resident #28 sitting on the edge of her bed, listing to the right with her elbow on the mattress. Only the resident's toes were touching the ground. The breakfast tray was on the overbed table in front of her and the resident was attempting to eat with her left hand while holding herself upright with her right elbow. When asked by survey staff to intervene, Staff C stated, "she can't eat the way she is (positioned)...". Failure to provide assistance with meal set up and positioning prevented the resident from independently eating. Observation of the lunch meal on 10/22/14 revealed the resident consumed approximately 10% of her meal. In an interview at 1:22 p.m., Staff I (Nursing Assistant) stated, "she ate 25%, four bites of fish, a couple of bites of cottage cheese, a bite of potato and a bite of fruit cocktail." Failure to ensure staff accurately documented the amount of food the resident consumed detracted from the facility's ability to accurately assess her intake. In an interview on 10/22/14 at 9:09 a.m. Staff G (Nursing Assistant) stated, "I've had her a couple of times... she asks for coffee a lot, that's basically it. She is cooperative for the most part, lately she's been pretty out of it, not wanting to eat... I've gone in there and I haven't seen her touch it (food), and I've gotten her tray and noticed that she didn't eat or if she did it was only a bite. I'd ask her if she wanted more and she'd just wave me away, I'll ask her if I can get her anything else or do anything for her and tell the nurse she didn't touch her food." In an interview on 10/22/14 at 9:20 a.m. Staff I indicated the resident had been more sleepy recently. Observation on 10/23/14 at 8:14 a.m. revealed Resident #28 lying in bed on her right side. The resident was awake and stated "I am hungry, help me up." When asked at that time what her favorite food was she stated, "poached eggs and cream of wheat...". When the resident's tray arrived the breakfast included 2% milk and oatmeal. When asked if she would rather have cream of wheat, the resident replied, "yes." In an interview on 10/22/14 at 9:58 a.m., Staff B (Director of Nursing) stated it was the facility expectation that staff obtain newly admitted resident's weights, "once weekly for four weeks." Staff B indicated a re-weigh was expected if any weight deviated from the previous weight by three or more pounds. When asked why staff hadn't obtained weights for Resident #28 according to facility policy and practice, Staff B stated "We're working on the weight system." Staff B further explained that in the event of an identified wt loss, "The first thing is to do a re-weight. In Nutrition At Risk committee, we would look at labs, look at her intake, then refer to the RD. One thing too we would want to look at is their overall health status, review medications, that is a big part of it. Are there some that effect appetite? Contact the physician asking for labwork. We'd be doing interventions like health shakes, would it help? If she has a wound Ajuven (a high protein supplement)... nutritionally enhanced meals, they put whole milk in foods, butter on veggies and fortified cereals. A lot of times too we ask (the DSM) to do another likes list to see if there is something she (the resident) really wants, maybe there is something the family could bring in, like soup. Keeping family in the loop like that, multivitamins, protein, [MEDICATION NAME] sometimes for an appetite stimulant." Staff B was unable to explain why the facility failed to: obtain weights and re-weighs according to facility policy; refer Resident #28 to the NAR committee; request or review laboratory tests that might reflect the resident's nutritional adequacy; review the resident's overall health status; review the resident for the sedating effects of the medications she received; provide nutritionally enhanced meals; assess the resident's food preferences or timely implement RD recommendations. Failure to assess the reasons for the weight loss and implement any interventions caused the resident to experience a significant, avoidable weight loss. RESIDENT #47 Review of a NAR committee note, dated 09/18/14, revealed the resident's "nutrition is poor...". In an undated follow up note the committee recommended to "add health shake to each meal...". A PO, dated 10/09/14, reflected an order for [REDACTED]. Review of the October 2014 MAR indicated [REDACTED]. There was no record that identified how much, if any, of the health shakes were consumed. In addition, there was no record on the MAR indicated [REDACTED]. On 10/21/14 at 2:30 p.m., Staff K was asked how many health shakes this resident should receive each day. She stated "one at each meal and hs (at bedtime)." Staff K stated she expected staff to record the actual intake of each of the four supplements. She indicated some of the consumption records were located on the meal monitor. Review of the October 2014 meal monitor revealed staff were to record the percentage of the meal consumed as well as the amount of fluid intake. However, there was not a separate column for supplements, meaning there was no way to determine how much of the supplement the resident consumed. On 10/23/14 at 8:46 a.m., Staff D was asked how many health shakes Resident #47 was to receive per day. She stated this resident should get three health shakes per day, not the four Staff K had stated. Staff D stated staff "should be putting the amount consumed." Staff D thought the amount was being tracked on the meal monitors. After review of the meal monitors, Staff D was asked how the facility determined how much of the supplement the resident consumed. Staff D stated the meal monitors "don't distinguish between the water and the health shake" and that the total of fluid intake included both together. Failure to ensure a system by which the facility clearly knew how much of a supplement was to be offered and how much was consumed placed this resident at risk for further decline in her nutritional status. RESIDENT #s 35 & 107 Resident #35 admitted to the facility on [DATE] with multiple health needs. According to the 05/02/14 MDS, facility staff entered "000" for the weight, indicating no weight had been obtained. Similar findings were noted for Resident #107 who admitted on [DATE] and whose 07/05/14 MDS reflected a height of "0" and a weight of "000", indicating facility staff failed to obtain a baseline weight which would allow staff to establish nutritional goals and adequacy. In an interview on 10/23/14 at 8:06 a.m., Staff L (MDS coordinator) confirmed the absence of height (ht) and/or weight for Resident #s 35 or 107. Staff L was unable to explain the absence of height and wts stating, "that was before me, I am not sure who was doing the MDSs." Staff L indicated it was nursing staff's responsibility to ensure wts were done. RESIDENT #s 87, 78 & 138 Similar findings were identified for Resident #87 who admitted on [DATE] but for whom staff documented "000" on the 05/27 and 06/03/14 MDS assessments. Similar findings were identified for the closed record of Resident #78 who admitted on [DATE] but for whom staff documented "000" on the 06/27 and 07/04/14 MDS assessments. Similar findings were identified for Resident #138 who admitted on [DATE] but for whom the 08/22/14 MDS assessed a weight of "000". RESIDENT #s 7 & 142 Record review revealed Resident #7 originally admitted to the facility on [DATE] and according to the 09/07/14 MDS was assessed to weigh 145 lbs and have a ht of "00". Failure to assess the resident's ht detracted from staff's ability to determine nutritional status. The resident discharged to the hospital for a [MEDICAL CONDITION] and readmitted to the facility on [DATE] with a wt of 143 lbs. According to wt documents, Resident #7 was assessed to weigh 133 lbs on 10/10/14, a loss of 10 lbs (7%) in less than 30 days. There was no re-weight or assessment of the resident's nutritional status. The wt record reflected the resident was 196.4 lbs on 10/15/14. There was no re-weight or assessment of the large wt discrepancy to determine if the wts were accurate or if the resident experienced an actual wt loss. Similar findings were identified for Resident #142 for whom staff documented wts reflective of wt loss without re-weights or assessment. In an interview on 10/23/14, Staff C indicated the wt deviations for Resident #7 were related to staff not documenting if the wts included the resident's splint and/or wheelchair. .

Based on observation, interview and record review, it was determined the facility failed to provide services to assist in maintaining the ability to participate in activities of daily living for one (#77) of one residents reviewed for rehabilitation who was assessed to require continued restorative nursing services. Failure to ensure a restorative program was initiated as recommended by a skilled therapist caused the resident to decline in transfer and ambulation ability. Findings include: RESIDENT #77 Resident #77 was admitted to the facility 07/31/13 for therapy following a fall with left wrist fracture. Review of the resident's progress in Physical Therapy (PT) revealed a weekly summary for the period of 09/19/13 through 09/25/13 which revealed "her functional performance has improved dramatically from the time of eval. She has improved from a min/mod assist for mobility/transfer to a stand by to min assist (variable), but she is now able to walk 150 feet indoors and tolerate over 30 minutes of exercise at nearly 2 mats. She is unable to supervise herself and will need 24 hour supervision and physical assistance. She will stay LTC (longterm care) on an RA (restorative) program." The note directed the resident would be discharged from skilled PT to an RA program. At discharge the resident was assessed as able to perform a stand pivot transfer with either contact guard or minimum assistance of one staff. The resident was able to ambulate 150 feet twice with a walker and contact guard to minimum assist and verbal cues. Additionally, on 09/30/13 the resident was discharged from Occupational Therapy (OT) as the resident reached maximum potential with all OT goals and function. Review of the resident's record revealed an 08/06/13 ADL/Mobility Deficit care plan (CP) which had not been reviewed and revised to reflect the resident's functional mobility at the time of discharge from skilled therapy. In addition, interventions included "provide therapy per physician order." The CP had not been updated to reflect the discontinuation of therapy services and the addition of a restorative nursing program. The 10/01/13 PT Discharge Summary indicated "progress was seen in each area of the plan of care but she was not able to return to full baseline levels of independent as the dementia has made it very difficult for her to access her motor planning very effectively. Will graduate from skilled PT and transfer to an RA based exercise program. DC to RA program." In an interview on 12/04/13 at 9:52 a.m. the Physical Therapist, Staff P indicated the resident was referred to a restorative program as planned. Review of the resident's record revealed no restorative flow sheets. In an interview on 12/03/13 at 2:38 p.m. a Restorative Aid, Staff N said the resident was not released to her when therapy was discontinued and Resident #77 was not on a restorative program. In an interview on 12/04/13 at 12:30 p.m. Staff M indicated he did not recall getting a referral or setting up a restorative program. Neither nursing nor rehabilitation staff were able to provide evidence the referral for restorative was completed as the resident was assessed to need. Review of the 09/25/13 Minimum Data Set assessment (MDS) revealed the resident was assessed to require extensive assistance of one staff for bed mobility. According to the 11/20/13 MDS the resident required more assistance and was assessed to require extensive assistance of two staff for bed mobility. In an interview on 12/04/13 at 1:55 p.m. Staff Q indicated after the resident was discharged from PT the resident had a decline in mobility and a decline in her ability to ambulate. In an interview on 12/04/13 at 9:52 a.m. Staff P said the resident had recently been picked up by Physical Therapy because Resident #77 experienced "disintegration of motor pattern." Staff P indicated for residents with dementia to be able to maintain motor tasks, staff needed to provide repetitive, consistent motor patterning. Review of the 11/13/13 Physical Therapy Evaluation revealed the documented reason for referral was the resident "with known dementia, has been in nursing facility since fall with fracture months ago. She was transitioned to a restorative program and long term care. Her function has been variable with her cognition." She was referred to PT "for worsening transfers". She "presents with a loss/decline... while she can move (lower extremities) on isolated movements she is patterning when attempting to integrate her legs into complex mobility tasks. Will benefit from a bout of PT to reintegrate the LEs into her daily mobility tasks." On 11/12/13 the resident was assessed by PT to require maximum assistance with transfers and was unable to ambulate. In an interview on 12/04/13 at 2:17 p.m. Staff P said at the 11/12/13 evaluation Resident #77 was unable to walk and required maximum assistance with transfers. Staff P went on to say since the resident was placed back on therapy services the resident ambulated up to 60 feet, with the longest distance of 75 feet. Failure by the facility to implement the restorative program for maintenance the resident was assessed to require caused the resident an avoidable decline from ambulation and minimal assistance with transfers to not being capable of ambulating and requiring maximum assistance with transfers. .

Based on observation, interview, and record review the facility failed to ensure two (#s 42 & 21) of three sample residents reviewed for Range of Motion and two supplemental residents (#s 54 & 39) identified by staff with decreased range of motion received appropriate treatment and services to prevent further decrease in range of motion. The facility demonstrated a system failure in communication between restorative department, therapy department, and nursing that placed all residents in the facility with decreased range of motion at risk for further decline. Findings include; RESIDENT #42 According to the 08/19/19/13 Minimum Data Set assessment (MDS), Resident #42 was admitted to the facility on [DATE] with care needs related to heart and liver disease, [MEDICAL CONDITION], and multiple infections. Staff assessed the resident as able to understand and be understood in conversation and had a BIMs score of 15, indicative of no memory impairment. The 11/11/13 MDS indicated the resident required extensive two person physical assistance for bed mobility and transfers. Both the 08/12/13 and 11/11/13 MDS indicated the resident had functional limitation in Range of Motion (ROM) and impairment of the Upper Extremity (UE) on one side. According to the nursing admission assessment dated [DATE], the resident was assessed as having a contraction of the "left UE." Care delivery guides, dated 12/03/13, documented the resident with, "L(eft) UE contracted" but no direction regarding ROM or a splint for the affected UE. In an interview on 12/02/13 at 11:14 a.m., Staff M stated Resident #42 had contractions of the "left upper extremity." According to Staff M, the resident had a restorative program for the upper extremity but "no splint." Observation on 12/02/13 at 11:00 a.m. revealed Resident #42 had what appeared to be contracted joints at the left elbow, wrist and possibly fingers. Observation on 12/04/13 at 10:58 a.m. revealed Resident #42 lying in bed on his back, slightly to the right. The resident stated in an interview at that time, "I am all locked up, I can't move my neck at all, it's gotten worse in the last few days...". The resident indicated his range of motion to his neck and left arm had declined since he was admitted to the facility (08/12/13), stating, "They only do exercises (range of motion) on my legs, they don't do my arms or neck." Occupational Therapy (OT) notes dated 08/13/13 identified a short term goal of "OT will assess pt (patient) for a UE ROM program and set it up with RA nurse." The OT evaluation dated 08/13/13 identified the right upper extremity was within functional limits for both fine and gross motor coordination and manipulation, but did not address the left upper extremity for either manipulation or range. OT notes dated 08/14/13 indicated, "Pt allowed P(assive)ROM to L UE, presents with increased tight /tone distally... Tolerated PROM all joints well no complaint (pain) or discomfort. Pt stated, "I feel tight." OT notes dated 08/20/13 indicated, "OT educated splinting vendor and pt on L UE splinting needs to (increase) pt's quality of life and (increase) ROM (decrease) contractures. OT educated PT on the importance of a splinting program for skin break down and contracture management." OT notes dated 08/21/13, "Pt reports L UE splint good fit from previous day, however is unable to have use of thumb/1st digit in pincer motion to grasp objects. Therapist reported goal of splint is to have it donned during night. Pt reports would like to have it donned during night starting today. This therapist will educate eve(ning) nurse for this splint to begin today, goal is to increase toler(ance) to 3 hours." OT notes dated 08/26/13 indicated, "Pt will be placed on a L UE splinting RA (Restorative Aide) program and a BUE (bilateral upper extremity) ROM/strength RA program." There was no documentation any nursing staff was educated in the use of the splint, or that the splint/ROM program was ever referred to nursing staff any time after the resident was assessed to require this service. According to Medication/Treatment Administration Records (MARs/TARs) for August 2013, staff were directed to, "encourage to do his AROM (Active ROM) and PROM to ble (bilateral lower extremities) & ROM to ble tid (three times a day)." This was listed as information and there was no indication staff implemented these directives. A Restorative nursing Care Plan (CP) dated 11/18/13 identified the resident with "tetraplegia (loss of movement/function to four extremities) (related to) spinal cord injury" with a goal of "will maintain current level of of ROM in (bilateral) LEs." There was no care plan (CP) or RA program which addressed the resident's identified upper left extremity contractures, where the contractures were (shoulder, elbow, wrist, fingers) or any interventions which might prevent worsening of the contractures. An Activity of Daily Living CP, dated 11/18/13, indicated the resident had "contractures poss (ible) (right) ankle" but did not address the left UE contracture. Restorative notes dated 10/06/13 indicated, "He has Left UE contracted; negative for contractures otherwise. To maintain current level of ROM res. is appropriate for gentle passive ROM bilateral lower extremities... goal res. will maintain current level of ROM in bilateral lower extremities." There was no mention of any intervention to maintain the current level of ROM in the left upper extremity, despite the presence of a contracture. In an interview at 12:21 p.m. on 12/04/13, the resident reiterated that no one encouraged him to do ROM on his UEs. The resident indicated he had no splint for the left arm, but there used to be one for the left hand. He stated "I don't know what happened to it." Resident #42 explained he had nothing for the left arm and no exercises to the UE. In an interview on 12/04/13 at 12:24 p.m., Staff M (Resident Care Manager) was asked about the upper extremity splint (from OT notes in August) and a ROM program for the UE. Staff M stated, "typically I get a referral for restorative program (from therapy), then I try to write it up...". Staff M referred to a 09/24/13 Physical therapy discharge notice which recommended a ROM program for the resident's BLE. Staff M stated, "It (PT discharge notice) didn't mention anything about the upper extremities, that's why I didn't do anything about the upper extremities." Staff M was unable to explain why staff would provide interventions to the lower extremities, but not the left upper extremity, for which a contracture was identified. Staff M elaborated that, "Nursing doesn't have anything from therapy regarding a splint or upper extremity program." When asked if Nursing would provide interventions for a contracture, Staff M said "of course we would, we do (interventions)...". Staff M was unable to explain why Resident #42 didn't have an UE RA program, In an interview on 12/04/13 at 12:50 p.m., Staff N (Restorative Aide) indicated Resident #42, "...usually participates (with restorative program), the last time I was with him he was in pain, he said he had neck pain... he has different joint pain." Staff N stated "...he doesn't get a splint, I do not do upper (extremity ROM), I do what I am instructed to do." In an interview on 12/04/13 at 12:58 p.m., Staff M indicated OT had a program/splint that should have been implemented back in August, but could not explain why it wasn't implemented. In an interview on 12/04/13 at 1:01 p.m., Resident #42 indicated his small finger (which appeared visibly contracted) on his left hand, was less "mobile" than it had been previously and his elbow "is more stiff" than it was. The resident pulled on his left forearm demonstrating an elbow contracture which prevented him from fully extending the forearm. The resident stated his neck had "...gotten worse, I can't turn my head to watch the TV anymore." The resident grimaced as he appeared to exert effort to turn his head to the right, to visualize the TV to the right of the foot of his bed and verbalized pain when attempting this movement. In a previous interview on 12/02/13 at 11:05 a.m. the resident stated, "I like the tv, that's all I want to do." In an interview on 12/04/13 at 1:10 p.m. Staff B (Director of Nursing) was asked to identify, in the record where the upper extremity contractures were located. Staff B, upon reviewing the record, was unable to find a description of the location or degree of L UE contracture, stating, "staff were aware (of the contracture), so I am not sure why we didn't do anything with it (contracture)...". Staff B was observed to perform ROM to Resident #42's left UE, and confirmed the resident's left fifth digit, wrist and elbow had limited range and were contracted. Staff B confirmed the resident's left shoulder also had limited range. In an interview on 12/04/13 at 3:08 p.m., Staff S, OT, when asked how she could tell if the contractures had gotten worse Staff S replied, "I don't know if the contractures have or haven't (gotten worse) (because there was no initial assessmentn)...". In an interview on 12/05/13, Staff S confirmed that after three months of no movement/exercise of the left UE, there would be, "...an increased likelihood of discomfort after initiating treatment." Staff S elaborated in an interview on 12/06/13 at 8:31 a.m., "the reason I put them (RA programs) into place is to prevent a decline, my skilled eyes thought it was necessary to continue those interventions, you could anticipate a decline (if program not implemented), that's why we put people on restorative programs...". In an interview on 12/06/13 at 8:37 a.m., Staff Q indicated the resident's OT RA program should have been implemented. Record review revealed an absence of objective data which would allow staff to determine the location or extent of "Upper Extremity" distal contractures. Facility staff did not identify elbow or shoulder contractures. Facility staff assessed the resident to require splinting, Restorative Aide, and upper extremity ROM/strength programs to increase ROM and decrease contractures. Facility staff failed to ensure these programs were implemented. While facility staff obtained a 04/22/13 assessment done by an outside provider prior to admission which indicated no loss of left elbow range of motion, there was no clinical assessment of the digits of the left hand or neck. An assessment of the resident's neck by this same outside provider dated 12/12/13 indicated "neck has decreased functinoal range." Resident #42, who was assessed by staff as cognitively intact, stated he had a decline in ROM and muscle function, including finger and neck. According to the 12/04/13 evaluation performed by Staff S, Resident #42 was identified with decreased ROM in the left: shoulder, elbow, wrist, thumb, and second through fifth fingers. The facility was aware of the resident's unique needs that placed him at risk for decine in ROM, identified care and services the resident required to avoid decline and failed to provide those services. RESIDENT #54 According to the 05/12/13 MDS, Resident #54 had care needs related to [MEDICAL CONDITION], stroke and hemipalegia. According to this MDS, the resident required extensive assistance for mobility and transfers. Record review revealed Resident #54 was discharged from OT on 06/20/13. According to the discharge notice, the resident was assessed to require a RA rehabilitation program for PROM to left UE prior to donning a splint. However, there was no documentation to support these services were implemented. A Nursing to Therapy communication form dated 07/19/13 indicated staff identified the "Resident is showing a change of condition in the following areas: ROM upper extremities... please set up ROM exercise RA therapy for (upper) extremities." Therapy communication to nursing dated 07/23/13 indicated, "RA program in place as of 06/20/13, please refer to RA for PROM." Nursing staff were not aware therapy had developed a program based on the resident's assessed needs and therapy was not aware nursing had not implemented the program developed for this resident. Failure to ensure Resident #54 received the treatment and services she was assessed to require placed this resident at risk for a decline in ROM. RESIDENT #21 According to the 07/08/13 MDS the resident had functional limitation in UE ROM on both sides and was assessed to require one person limited assistance to eat. According to the MDS the resident did not receive skilled therapy or a RA program for ROM, splint or brace assistance or transfer and skill practice for transfers. In an interview on 12/02/13 at 11:27 a.m. when asked if Resident #21 had contractures, Staff D said yes, arthritis in fingers and hands. Staff D said Resident #21 wore palm protectors and was on a RA program. On 12/02/13 at 10:42 a.m. and 2:16 p.m., 12/03/13 at 10:06 a.m. and 12/05/13 at 9:51 a.m. Resident #21 was observed with contractures to both hands without splints or palm protectors. Similar findings were noted on 12/04/13 at 1:24 p.m. Resident #21's hands were observed with closed fingers and no palm protectors. Bilateral palm protectors were found in the resident's bedside drawer and shown to the resident who commented, "I don't put them on." When asked if the staff did, Resident #21 replied, "No." A 09/07/12 OT discharge note indicated the resident presented with B(ilateral) hand contractures and swan neck deformities on fingers."Agreed to wear B palm protectors to decrease potential for skin breakdown and prevent further contractures. Upon discharge from skilled OT, Resident to be on RA program for PROM and palm protector don/doff wear time of up to 6 hours as tolerated". Instructions to staff included to refer back to therapy if presented with discomfort or refusal of POC (Plan of Care). Review of RA Progress Notes revealed a 09/14/12 entry which acknowledged the resident was screened by OT for contracture management, agreed to palm protectors, and planned for staff to don palm protectors when resident went to bed and remove when awake. "Res(ident) ROM to all other joints is normal. She can follow direction for AROM. Resident to benefit from AROM while in wheelchair to all joints - 10 reps, 6 days/wk. NAC's on floor to don palm protectors. Resident also at risk for BLE weakness/contractures, to maintain current level and potentially increase strength and endurance for easier transfers resident will perform static standing exercises at the parallel bars". The next RA Progress note was 10 months later on 07/08/13 which indicated the resident continued on a RA program of sit to stand in parallel bars to maintain current level ROM and Standing ability. "Resident also on program bilateral upper extremities with dowel to prevent further contractures and maintain current ROM. Resident wears bil upper extremity hand splints x 8 hours, on hs (night) off AM." The 07/01/13 RA Nursing CP indicated the resident had [DIAGNOSES REDACTED]. In addition the CP indicated the resident had arthritis contractures of hands - fingers, with interventions of bilateral upper extremity hand splints up to 8 hours on HS/off AM, and exercise with dowel. Review of the RA Flow Sheets July through December 2013 revealed staff documented the resident participated daily in sit to stand in parallel bars and exercise with dowel since 07/31/13. Review of Physician order [REDACTED].*On in AM * Remove at HS." Review of the Nursing Treatment Records revealed staff documented daily through December that staff applied the palm protectors in the morning and removed them at HS. In an interview on 12/04/13 at 1:09 p.m. Staff D agreed the staff was documenting the palm protectors were applied in the AM and removed at HS as ordered, but applied the palm protectors at HS and removed them in the AM. Further Review of the POS [REDACTED]. According to the OT evaluation the resident was assessed to require moderate assist with eating and moderate assist with standing transfers. Review of the weekly notes revealed on 09/30/13 the resident "made progress this wk (week) tolerating palm protectors for 3 hrs with no red or pain. Skilled OT is needed to cont. assessing splinting needs, increase wear time, and increase BUE PROM to increase pt's overall quality of life." A 10/01/13 Restorative Progress note indicated the resident was still on a RA Program and "continues the sit to stand at parallel bars but resident has some bad days and some good. Will offer and encourage resident to do this to maintain her standing and transfer ability." The note did not address the OT treatment, or coordinate palm protector application and indicated the palm protectors were on at night and off at AM by nursing as scheduled. According to the 10/01/13 MDS the resident was assessed with [REDACTED]. According to the MDS the resident did not receive skilled therapy or a restorative nursing program for ROM, splint or brace assistance or skill practice for transfers. The facility did not refer the resident to Physical Therapy to be screened or alter the RA program to address the decline in LE ROM. On 10/08/13 the resident was discharged from skilled OT and according to the discharge summary would "be placed on an RA program for palm protectors and BUE PROM." There was no RA progress note entry, no revision to the the Ra program, nor a change in the RA plan of care. The RA Program did not include BUE PROM or application of palm protectors as planned. In an interview on 12/04/13 at 1:09 p.m. Staff D indicated when she took over the RA program Resident #21 was already on a program, which was continued as written. Staff D said she did not get a referral from OT in October 2013. In an interview on 12/05/13 at 9:43 a.m. Staff R said the nursing assistants applied the palm protectors, and PROM was not on the RA Flow Sheets. Staff R said she had been providing Resident #21 the same RA program for the prior six to seven months when she started, and no one had said anything to her about making any changes to the program. In addition to not receiving RA Program referrals from therapy, referrals which were sent were either delayed in getting to nursing or delayed in implementation by nursing. For example, in an interview on 12/06/13 at 9:13 a.m. Staff M said for Resident #42 he received the RA referral for a LE ROM program on 09/24/13, which was implemented on 10/06/13. Similarly in an interview on 12/06/13 at 9:22 a.m. Staff D said Resident #39 was discharged from OT on 08/21/13, and the RA Program was implemented when the RA referral for UE ROM and splint program was received by nursing on 09/03/13. .

Based on observation, interview and record review the facility failed to provide adequate supervision and ensure safe interventions were implemented to prevent accidents. Failure to develop and implement assessed, resident specific interventions, caused one (Resident #1), of four resident's reviewed for falls, to experience an avoidable fall, from bed during care, resulting in injury. Findings included: Refer to CFR 483.20(k) Comprehensive Care Plans, F-279 Resident #1's 07/2012 Care Area Assessments indicated, "...(Resident) is very weak and debilitated...and needs two person assist with transfers and mobility...(and other Activities of Daily Living(ADL))."According to the most recent quarterly 3/17/13 Minimum Data Set (MDS) Resident #1 had [DIAGNOSES REDACTED]. On 4/30/13 at 6:30 a.m., Resident #1 was observed in a bed that was mid-height, not low, with no staff in attendance. On 4/30/13 at 8:06 a.m. Resident #1 said, of a recent 4/25/13 fall, "I remember (Staff G, a Certified Nursing Assistant) pulled me the wrong way...it wasn't on purpose." Resident #1 pointed to their left hand that was dressed with steri-strips and a bruise on the left ear. According to the facility's 4/25/13 evidence of investigation the resident fell out of bed because the aide caring for the resident, "...tried to pull (resident) back...(resident) roll off the bed and hit (resident's) left hand and cut it. (Resident) also hit (Resident's) left side of (resident's) head. (Resident's) ear puffe." The facility's plan of correction was to educate Staff G, "...on bed mobility - turning, repositioning when resident is one assist bed mobility..." Staff C the Residential Care Manager who developed the Care Plan (CP), said in an interview on 4/30/13 at 7:20 a.m., "(Resident #1) was a one (person bed mobility assistance) because she only needed a one (person assistance)." When asked if the MDS was used to develop the CP, Staff C said, "No I did not look at the MDS." Staff F, the MDS Coordinator, said in an interview on 4/30/13 at 7:55 a.m., "I followed the MDS instructions (to establish the number of staff required to provide assistance with ADLs). I use two person care for everyone." According to Staff B, the Director of Nursing, interviewed on 4/30/13 at 8:45 a.m., Resident #1 was, "One person (assistance with bed mobility) until the day of the fall." When asked if the MDS was correct in reflecting a required two person assistance for bed mobility Staff B said the MDS was not an assessment and it was not necessary for the facility to develop a care plan based on the MDS. When asked if two person care to Resident #1 would have prevented the fall Staff B said, "(The Resident) is now two person to provide care." Had the facility utilized the MDS to accurately develop care plans and care directives staff would have sought out direction and implemented assessed two person care as recommended by Staff F and the MDS, preventing the fall.

Based on observation, interview and record review the facility failed to ensure one of four residents (#1) assessed at risk for falls remained free from injury. Failure to implement fall precautions the resident was assessed to require, contributed to Resident #1 sustaining a fall and head trauma which required emergency room treatment and hospitalization . Findings included: Resident #1, was assessed on 3/17/12 to be at risk for falls. According to the 3/24/12 and 5/28/12 Minimum Data Sets, the resident had impaired sitting balance, was not ambulatory and had mental health issues which required administration of psychotropic medications that placed the resident at risk for falls. The facility developed a 2/6/12 care plan that instructed staff to "keep the bed in lowest position when occupied. According to the 6/01/2010 Alteration in Mobility Care Plan, staff were instructed to, "Low bed, keep in lowest position at all times, except for providing direct care." Staff C said, in an interview on 6/25/12 at 4:26 p.m., she was going to provide the resident with personal care and a brief change on 6/20/12 at 3:45 p.m. Staff C said she raised the bed to hip level and realized she forgot a clean brief. She left the resident in the raised bed and went to the closet for a new brief. The closet was at least eight feet away from the bed. While Staff C's back was turned the resident managed to get out of bed and was then observed by Staff C to briefly stand at the bedside then bend over, falling and hitting the floor, causing a head laceration. Staff C said she knew the resident was at risk for falls and had falls in the past. Staff C said she realized she should have gathered all of her supplies before initiating personal care. As a result of the incident staff were required to send the resident to the hospital where, according to 6/20/12 hospital records, the resident required sutures for a nine centimeter laceration. On 6/25/12 at 4:07 p.m. three staff were observed to provide personal care and a brief change to Resident #1. Resident #1 was observed to have a bandage on the mid-forehead and a bruise under the left eye. The resident said she recalled the fall. Staff B said, in an interview on 6/25/12 at 4:10 p.m., staff should not have left the resident in bed, unsupervised, while it was in the elevated position. Staff B said Staff C should have lowered the bed before leaving the resident and gathered supplies before initiating care.

Based on interview and record reviews it was determined that the facility failed to ensure one of three residents (#1) reviewed for medication services received care and services consistent with his needs. This failure contributed to delayed treatment for [REDACTED]. Findings include: FACILITY POLICY According to facility policy on fall prevention, "should a resident have a fall an assessment of the incident will be initiated with interventions added according to preliminary assessment of the incident..." According to the facility Diabetic Management Protocol, "residents with a [DIAGNOSES REDACTED]." Components of this assessment were: "Obtaining blood glucose (BG) readings per Physician orders, and PRN (as needed) per protocol", "documentation of timely reporting to the physician of any BG readings outside the prescribed parameters", "documentation of interventions specific for either [DIAGNOSES REDACTED]...initiated PRN per resident symptoms", documentation of the resident response to the interventions", Consideration of the resident's dietary intake, when assessing the resident's BG trends, with referral to the RD (Registered Dietician) when indicated." According to this policy, "If BG is below 60...and resident is able to swallow-HOLD INSULIN- until order obtained from MD. Give the resident 4 oz (ounces) juice)..."If next meal is more than 30 minutes away , give the resident a snack that contains protein, such as cheese, peanut butter crackers or a 2 cal/cc dietary supplement. Call the MD and tell him you have held the insulin. Ask for orders regarding insulin administration and follow-up care...Recheck the BG in 10-15 minutes." The policy further directs staff that "ABNORMALLY HIGH OR LOW BLOOD GLUCOSE READINGS ARE CONSIDERED AN EMERGENCY. NOTIFY THE PHYSICIAN BY PHONE." RESIDENT #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission physician orders [REDACTED]. Diabetic care plan documents dated 2/23/12 direct staff to "monitor for diaphoresis, decreased Level of Consciousness...confusion, Notify LN/MD immediately." Review of Medication Administration Records (MARs) for 2/12 revealed staff obtained blood sugar (BS) levels twice at day, "Day" and "NOC (nightshift)". Staff were directed to, "Notify MD if (BG less than) 70..." Additional orders directed staff to "follow house diabetic protocol, if BS (Blood Sugar less than) 70 and resident is alert offer orange juice or snack and recheck...Notify MD." According to the 2/12 MAR staff assessed the resident with a BG of 65 on nightshift of 2/22/12. There was no indication staff followed any part of the diabetic policy or POs by: 1) notifying the physician, 2) offer juice or snack, or 3) recheck BG. Review of meal monitor documents revealed the resident consumed 50% of his breakfast on 2/25/12 and refused his breakfast and lunch on 2/26/12. Staff documented the resident ate 25% of his lunch on 2/23, 24, 25/12 and refused lunch on 2/26/12. Staff documented no dinner intake for Resident #1 on 2/22 and 2/23/12. Dinner consumption was documented as 50 and 75%, respectively, for 2/24 and 2/25/12. Staff consistently assessed the resident's blood sugar below 100 on 2/22, 2/23, 2/24 and 2/25. There was no assessment of the resident's BG trends, or consideration of the resident's dietary intake. Dayshift on 2/24/12 identified the resident with a BG of 48. Record review revealed staff provided interventions as directed in the MAR and a "message (was) left" for the physician. Staff did not hold the morning insulin or obtain direction from the physician to administer the insulin, according to facility policy. Review of MARs dated 2/25/12 at 4:00 p.m. revealed, "Res(ident) refused [MEDICATION NAME]" There was no documentation to support why the insulin was refused. A "noc (night)"progress note entry on 2/25/12 indicated, "HS (evening) [MEDICATION NAME] 10 units refused, BS check at 12 MN (midnight) 87, food given..." There was no indication staff considered the resident's continued low blood sugar despite the resident's refusal of insulin. In an interview at 11:15 a.m. on 3/16/12, Staff B, the Director of Nursing, was asked when staff were expected to perform BSs for residents when the MAR indicated "NOC". Staff B indicated night shift staff obtained Resident #1's BSs "between 2:00 a.m. and 3:00 a.m.". Staff B indicated this was an error, and that blood sugars were to be obtained "before meals and at HS." Facility Event and Occurrence (E & O) documents dated 2/26/12 indicated the resident experienced a fall in his room at 6:30 a.m. and sustaining skin tears to his right hand and clavicle. Staff D, in a witness statement dated 2/26/12 documented, "Last night on my last rounds I checked on (Resident #1) and he was sideways in his bed. Today when I got here and heard he fell I noticed he was more confused than normal." There was no indication Staff D reported the noted increased in confusion to the Licensed Nurse (LN) on duty. A statement by Staff E, an LN, dated 3/08/12 indicated at the time of the fall on 2/26/12, "he (the resident) seemed confused." There was no evidence Staff E reported this confusion to either the LN caring for Resident #1 or Resident #1's physician. According to a 3/08/12 interview with Staff F "saw the resident rubbing his right side on rib area." There was no indication LN staff assessed the resident's right side. According to 3/08/12 interview statements Staff G, an Occupational Therapy (OT) assistant, requested pain medication for Resident #1 prior to therapy on the morning of 2/26/12, "as the resident had complaints of back pain." According to the conclusion of the 2/26/12 E & O staff determined, "that due to low blood sugar in AM led to confusion and self transfers." There were no progress notes or MAR entries on 2/26/12 which indicated the resident had low blood sugars. There was no assessment of the resident's condition at the time of the fall which might include blood sugars, vital signs or neuro checks. In an interview on 3/15/12 at 1:25 p.m. Staff B indicated she would expect nursing staff to obtain vital signs at the time of the fall and initiate neuro checks. There was no indication the resident was assessed with [REDACTED]." There was no indication in the record what time the BS was determined to be 39, what nurse gave the resident food, how much or what food the resident received, what time the 102 BS was obtained or that the physician was notified. In an interview on 3/13/12 at 9:45 a.m. the resident's wife indicated she reported to facility staff, prior to lunch on the morning of 2/26/12, that her husband's condition had changed, he was confused and didn't recognize her. Resident #1's wife further indicated the resident couldn't eat. This statement was supported by OTA notes dated 2/26/12 which reflected, "Pt didn't eat much of meal (lunch served at 11:30 a.m.)...Pt either really tired or showing a decline in abilitys today." Meal monitor records for 2/26/12 revealed the resident refused both breakfast and lunch. Progress notes from 2/26/12 at 5:40 p.m. indicated, "Pt lethargic...confused, does not recognize family...Dr...notified (telephone order) to send pt to hospital to eval and treat". The physician was not notified until almost 12 hours after the resident was identified with a fall and confusion. Failure to timely identify and report a change in condition resulted in delayed treatment. The resident was subsequently sent to the hospital where he was identified with [DIAGNOSES REDACTED]." Hospital records revealed the resident had a blood "glucose of 46." Hospital notes indicated, "Unfortunately, the patient did have a fall while he was there (at the nursing home), fracturing his 11th rib."

Based on observation, interview and record review the facility failed to ensure two of five sampled Residents (#1 and 3) reviewed for admission medications were free of significant medication errors. This failure resulted in significantly low blood sugars which required treatment and had the potential to cause significant harm. Findings include: Refer to CFR 483.25, F-309, Care and Services RESIDENT #1 Resident #1 was admitted to the facility on [DATE] at 4:30 p.m. with [DIAGNOSES REDACTED]. The resident was discharged from the facility and not available for observation or interview. According to hospital discharge medication directions, the resident was to receive "[MEDICATION NAME] (a blood thinning medication)... every 8 hours" and "[MEDICATION NAME] (a type of insulin) 10 units SQ (subcutaneously) daily." Review of admission physician orders [REDACTED]. In an interview on 3/15/12 at 1:25 a.m. Staff B indicated she expected the admission POs should accurately reflect the most recent discharge medication list. Staff B confirmed Resident # 1 should have received only 10 units of [MEDICATION NAME] once a day. Staff B indicated it appeared staff transcribed orders from an earlier hospital discharge record, effectively more than doubling the dose of intended insulin and resulting in significantly low blood sugars. Staff B also confirmed staff omitted, and the resident never recieved, the [MEDICATION NAME] which the resident was intended to recieve. Review of Medication Administration Records (MARs) for 2/12 revealed staff obtained blood sugar (BS) levels twice at day with the following results: Progress notes for 2/24/12 at 11:00 a.m. reflected, "Res(ident) had blood glucose reading this a.m. of 48. Late entry progress notes dated 3/04/12 indicated that on 2/26/12, "received report from noc shift that pt's BS was 39, nurse gave pt food then pts BS (increased to 102)." Similar findings were identified for Resident #3 for whom staff failed to ensure there were accurate admission orders [REDACTED].)

Based on observation, interview and record review the facility failed to promote and maintain an environment that ensured staff interactions with residents were consistently dignified, respectful and resulted in provision of goods and services for 18 of 37 sample residents. Eight of the 37 residents had specific complaints about verbal treatment. Four of seven residents who complained about staff's slow response to call lights said they had soiled themselves, attributing these problems to the constant influx of new staff. Four of four residents said they informed staff of problems with medications but no one took action to remedy the problems. Two of two residents said they had repeatedly informed kitchen staff that food was cold but food continued to be cold. Failure to treat resident's with dignity, respect and provide care and services caused residents to feel "small, worthless, and distraught" and that staff did not care. Failure to answer call lights promptly caused four residents to lose their self-esteem and dignity and placed them at risk for accidents and falls. Residents who informed staff of issues with medications and food felt, ignored, disrespected and frustrated with the lack of staff response to their requests and concerns. Findings include but are not limited to: Residents interviewed were assessed to be cognitively intact, able to make their own decisions and require assistance with activities of daily living. Residents said the constant turn over of staff created an atmosphere of mistrust. Residents felt they were not getting respect and care. Residents feared retaliation for speaking up. The resident said staff, "was threatening both emotionally and (with the use of) body language." The resident recounted an event during which decisions were about the resident and her belongings without the residents full understanding or consent. According to the resident she was asked, "What do you think this is a hotel." The resident said, "The (it) made me feel this small, (uses the first and fifth finger to approximate a half an inch.) The resident said body language indicated staff had the attitude "If you don't like it get out." The resident, still distraught about the incident, "(It) made me feel bullied, made me not want to see her." Residents said; "This used to be the best (place). Staff worry about their jobs rather than (the) care. I don't feel secure...I used to say how happy I was to be here, it was heaven... I'm angry, sad and scared...They (staff) don't know me, my care and don't treat me with the same level of respect and kindness..." This resident said he might have to look for another facility because things were so bad. One mistake and staff are gone. This resident recounted how the Administrator yelled at one of the staff (in a public place), saying that the incident, "...didn't make me feel very good. They got rid of the good aides...(we don't) get respect from nurses, (they work 12 hour shifts), (it's) hard on them and hard on us...The aides are afraid to interact with the resident's for fear of being fired." "(The administrator ) "yells." When asked who was yelled at the resident indicated "everybody." When asked how this made her feel the resident, frowned and motioned with her hand thumbs down. Another resident recalled a "Stern lady...someone with an attitude," after an event at the nurses station several days before the interview. The Administrator was "...not able to be helpful, it's her way or the highway, doesn't think about the staff or the residents..." The resident then demonstrated the Nazi salute and said, "It upsets me. It's hard." The resident indicated the administrator yelled and this made the resident feel, "Not good." "(The facility is being run) like the military. That's not going to work. Staff comes and goes out of this place...it doesn't make me feel good at all." The resident expressed his desire to tell the administrator how he actually felt but said, "I don't want to get kicked out, I have no place to go, yeah I'm afraid that would happen." "I soiled myself no later than three weeks ago." This resident said it could take as long as forty minutes for staff to answer a call light and attributed these delays to "Staff are new and getting used to (residents)." When asked how this made her feel, this resident said, I felt disgust, a grown woman can't get to the bathroom!" Residents said medications that are to be given at 8:00 p.m. are not given until 9:30 p.m. several times a week. Residents said they had discussed this with the nurse many times but to no avail. Resident s said the lack of prompt medication administration made them feel anxious, afraid and frustrated. Residents said they had repeatedly informed staff that food was cold. Resident's said that the lack of staff response to their concerns caused them to become frustrated.

Based on 17 of 38 resident interviews and review of the facility's staffing patterns the facility failed to enure sufficient and qualified staff were on duty to provide services such as but not limited to, answering call lights, toileting residents and administering medications. Failure to ensure residents received care according to their identified needs contributed to decreased quality of life, decreased sense of self worth and placed residents at risk of exacerbation of medical conditions Findings include but are not limited to: Refer to CFR 483.15(a), Dignity F-241, CFR483.25(a)(3), Dependent resident received care F-312, and WAC-288-97-1080(1)(3)(a). Residents were assessed to be able to make their own decisions, communicate their needs and require staff assistance for activities of daily living. Residents were fearful of retaliation and did not want to be identified. Review of the facility's staffing patterns from 10/6/10 through 10/20/10 revealed five days, 10/8/10, 10/9/10, 10/14/10, 10/15/10 and 10/19/10 with out sixteen hours of continuous registered nurse coverage. Evening and night shift nursing staff consisted of one registered nurse and one licensed nurse on two days, 10/6/10 and 10/7/10. On the 10/14/10 night shift there were only two Nursing Assistants to care for the entire facility resident population of approximately 60 residents. Seven resident said call lights were not answered timely. Four of these residents said they soiled themselves because staff did not attend to them promptly. Residents recounted that staff were, "...slow when I put my light on." The "...call light is a joke...(I'm) lucky if anybody shows up." The resident recounted when staff do not come, "So I get up on my own even though I'm not supposed to." When asked how this made her feel the resident said, "I don't like it here, it's not fair. The State is paying for no care." "Aides once in a while (don't) get around (to answering call lights). I told (staff) (but it hasn't) improved. This resident said the problem with call lights had been going on a long time, "...especially on the second crew, the swing shift." When asked how he was impacted by this failure the resident indicated staff were not available to assist with care needs. "(Staff) care, from time to time takes a long time to get here after (using) the call light...I have wet myself many times because we (room mate and resident) couldn't get to the bathroom." "In the last month (at least) three to four times." When asked how this made her feel, this resident said "I hate it." In an interview on 10/20/10 at 11:07 a.m., Resident #22 said "Sometimes it takes a while, (for call lights to be answered). I wet myself every day. I don't like it." Staff answer the call light but "say I got to wait." This resident said "I wish I could be changed more often." The "...call light is a joke...(I'm) lucky if anybody shows up." The resident recounted when staff do not come, "So I get up on my own even though I'm not supposed to." When asked how this made her feel the resident said, "I don't like it here, it's not fair. The State is paying for no care." Four of four residents said they either did not receive their medications or did not receive them on time. Residents said they had discussed these medication issues with staff but the issues were not resolved. One resident said she did not receive her breathing medications but staff said they were administered. Review of this resident's records revealed documentation supporting the resident's contention, breathing medications were not administered. Residents felt frustrated with staff's lack of concern over these issues. One resident said she spoke with the nurses and told them she hadn't received her breathing medication. The resident said staff said the medications were administered. The resident insisted the medications for breathing were not administered. Review of this residents's record revealed three dates when there was no documentation to support breathing medications were administered. The resident expressed anger and resentment at staff not administering the medication and not believing her when she brought it to their attention.

Based on observation, interview and record review facility administration failed to use resources effectively and efficiently and ensure sufficient, qualified staff provided 17 of 38 resident's with necessary and required goods and services. Failure to provide sufficient and qualified staff caused residents to receive less than necessary care and to become frustrated with this lack of care. Findings include but are not limited to: Seventeen of 38 residents interviewed had complaints about the lack of care and staff behavior. Residents were concerned about the changes that had taken place in the facility and were fearful of retaliation and did not want to be identified. Refer to: CFR 483.15(a), Dignity F-241: The facility failed to promote and maintain an environment that ensured staff interactions with residents were consistently dignified, respectful and resulted in provision of goods and services. Corporate Staff, interviewed on 10/19/10 and 10/21/10 said they were aware of the issues with staff behavior as early as March of 2010. CFR 483.30(a)(1)&(2), F-353 Staffing: The facility failed to enure sufficient and qualified staff were on duty to provide services such as but not limited to, answering call lights, toileting residents and administering medications, contributing to resident's decreased quality of life, decreased sense of self worth and placed residents at risk of exacerbation of medical conditions WAC-388-97-1080(1)(3(a): The facility failed to ensure 16 hours of Registered Nurse coverage for five of 14 days in October 2010 preventing prompt care and treatment and placing residents at risk for health related decline.