Every finding on record at Avalon Care Center Federal Way, L.L.C.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a sanitary environment to help prevent the transmission of communicable diseases. The facility failed to follow precautions signs for 3 of 4 residents (Residents 52, 78, & 7) for Transmission-Based Precautions (TBP) and 2 of 2 residents (Residents 67 & 12) for Enhanced Barrier Precautions (EBP) as posted outside resident's rooms and failed to follow hand hygiene (HH) practice for 2 of 3 residents (Residents 8 & 12) during medication administration. These failures to wear PPE (Personal Protective Equipment - gown, gloves and goggles) as instructed on the signs outside resident's rooms and poor hand hygiene practice placed residents at risk for facility acquired or healthcare-associated infections and related complications. Findings included . <Facility Policy>According to a facility policy titled, Infection Prevention and Control Program (IPCP), revised 06/08/2022, the IPCP would maintain a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. The policy showed the program would provide guidance to staff on EBP and TBP to be followed, PPE use, and HH practices. The policy showed resident room assignments would be made while taking into consideration resident diagnoses and risk factors such as not placing residents with active contagious infections in a room with residents who are at greater risk of contracting an infection. This policy showed when a resident had an infection or was potentially infectious, the infection would be tracked, and interventions would be implemented to minimize the additional risks to the residents. The policy showed the facility would monitor for proper HH, use of PPE and TBP, and proper infection prevention techniques were used during direct care including medication administration. <TBP> <Resident 52> According to the 10/24/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 52 admitted to the facility with wound infection. The MDS showed Resident received Antibiotic medications every day during the assessment period. The MDS showed Resident 52 had an indwelling catheter (a flexible tube inserted into the bladder to drain urine) in the bladder and was assessed to require one person assistance from staff for their toileting hygiene during the assessment period. Observations on 11/17/2025 at 9:12 AM and on 11/18/2025 at 1:00 PM showed a Contact Precaution sign was posted outside Resident 52's room and instructed all staff to perform Hand Hygiene and to wear PPE before entering the room. The observations showed an isolation cart filled with PPEs and placed outside Resident 52's room. In an interview on 11/17/2025 at 10:09 AM, Staff S (Licensed Practical Nurse) stated Resident 52 was on contact precautions because the resident had a wound on their back and staff had to wear PPEs before they entered the room and remove PPEs inside the room before they leave the resident's room. Staff S stated staff had to sanitize their hands before they entered the room and before they left the resident's room. Observation on 11/17/2025 at 11:10 AM showed Staff R (Certified Nursing Assistant) entered Resident 52's room without any PPEs. Resident 52 was sitting in a chair. Staff R talked to the resident, came outside the room to fill ice water pitcher and talked to the floor nurse in the hallway, filled the water pitcher and went inside the room again without any PPEs. Observation on 11/17/2025 at 12:45 PM showed Staff R went inside Resident 52's room to deliver lunch tray without any PPE. In an interview on 11/17/2025 at 1:00 PM, Staff R stated they did not have to wear gowns or gloves unless they provide direct care to residents. Staff R stated they had to follow the instructions on the sign posted outside Resident 52's room for Contact Precautions. Staff R read the directions on the posted sign and stated they should wear PPEs before they entered the room, but they did not. In an interview on 11/20/2025 at 10:12 AM, Staff Q (Infection Preventionist) stated all staff should follow the directions on the sign posted outside residents' rooms to prevent spreading infections. Staff Q stated staff should wear PPEs before they enter the rooms on Contact Precautions, but they did not. <Resident 78> Observations on 11/17/2025 at 10:15 AM showed a sign on Resident 78's door indicating the resident was on contact precautions. The sign gave directions to staff to wear a gown and gloves prior to entering the resident's room. Staff J (Unit Manager) and Staff P (Registered Nurse) were in the room at the resident's bedside assisting with resident equipment, without a gown or gloves on. At 10:21 AM Staff J and Staff P exited the room, Staff P went to their medication cart, and returned to the resident's bedside, again without wearing a gown or gloves. Record review showed Resident 78 was on contact precautions for a contagious infection that was resistant to many antibiotics and difficult to treat. <Resident 7> Observations on 11/17/2025 at 10:37 AM showed a sign on Resident 7's door indicating the resident was on contact precautions. The sign gave directions to staff to put on a gown and gloves prior to entering Resident 7's room. Staff were observed entering Resident 7's room without putting on a gown or gloves. Record review showed Resident 7 was on contact precautions for a contagious infection that was resistant to many antibiotics and difficult to treat. In an interview on 11/20/2025 at 2:19 PM, Staff Q stated it was their expectation staff follow the directions indicated on the signs posted at the resident doors. Staff Q stated to help reduce the spread of infections, staff should put on a gown and gloves prior to entering the room when a resident was on contact precautions. <EBP> <Resident 67> Observation on 11/0/2025 at 8:14 AM showed an EBP sign posted on the outside of Resident 67's room door. The EBP sign directed staff to wear a gown and gloves for high contact resident care activities that included providing device care for intravenous (IV - medication provided through a needle inserted into a vein) therapy. Observed Staff M provide IV treatment for Resident 67 and did not wear a gown. <Resident 12> Observation on 11/20/2025 at 9:05 AM showed an EBP sign posted on the outside of Resident 12's room. The EBP sign directed staff to wear a gown and gloves for high contact resident care activities that included providing device care for a feeding tube. Observation on 11/20/2025 at 9:05 AM, Staff M (Registered Nurse) administered medications through a feeding tube for Resident 12. Staff M set up the resident's medications on a tray in Resident 12's room and stated they forgot a cleansing wipe from their medication cart outside of the room in the hallway. Staff M was observed to leave the room with their gown on and did not perform hand hygiene when leaving the room. Staff M came back into the resident's room wearing the same gown and did not perform hand hygiene before putting on new gloves. During an interview on 11/20/2025 at 8:14 AM Staff M read the directions on the EBP sign on Resident 67 and 12's doors and stated they did not know they had to wear a gown while providing direct care to residents. Staff M stated it was important to follow the directions on the sign outside of the room to prevent transmission of diseases and for infection control. .<Hand Hygiene> <Resident 8> Observation on 11/19/2025 at 8:29 AM showed Staff G (Registered Nurse) prepared medications to administer to Resident 8 without performing hand hygiene. Observation on 11/19/2025 at 8:44 AM showed Staff G paused medication preparation for Resident 8, put on gloves, and provided a topical treatment and dressing to Resident 8's roommate. Staff G removed their gloves and resumed medication preparation for Resident 8 without performing hand hygiene. Observation on 11/19/2025 at 8:56 AM showed Staff G performed hand hygiene, obtained additional supplies from the medication cart, then entered Resident 8's room. Staff G returned to the hallway four times to retrieve additional medications and supplies from the medication cart and returned to Resident 8's room each time without performing hand hygiene. Staff G put on gloves prior to administering injections without performing hand hygiene and did not perform hand hygiene after removing gloves. In an interview on 11/20/2025 at 10:23 AM, Staff B (Director of Nursing) stated they expected nurses to perform hand hygiene before going into a resident room, after leaving the room, and after each medication pass. REFERENCE: WAC 388-97-1320 (1)(a), (2)(b). .

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 6 of 32 medications for 3 of 4 residents (Resident 8, 119, & 120) observed during medication pass resulted in a medication error rate of 18.75%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication.Findings included .<Facility Policy>Review of the facility's General Dose Preparation and Medication Administration policy revised on 11/15/2024 showed staff would verify the medication name and dose for accuracy on the Medication Administration Record (MAR) prior to administering medications. <Resident 8> <Vitamin D3 (a supplement)> Observation of medication pass on 11/19/2025 at 8:26 AM showed Staff G (Registered Nurse) administer one 5,000-unit capsule of Vitamin D3 to Resident 8. Record review of Resident 8's physician's orders showed a 09/24/2025 order for Vitamin D3 with directions to administer one 50,000-unit capsule every morning, not the 5,000 units as administered by Staff G. <Pain-relieving patch> Observation of medication pass on 11/19/2025 at 8:26 AM showed Staff G prepare medications for Resident 8, including a pain-relieving patch. Staff G went to Resident 8's room and administered the medications, except for the pain-relieving patch. Staff G did not offer or administer the pain-relieving patch. In an interview on 11/19/2025 at 9:28 AM, Resident 8 stated Staff G did not offer or administer the pain-relieving patch. In an interview on 11/19/2025 at 9:29 AM, Staff G confirmed they forgot to give Resident 8 their pain-relieving patch and stated they would bring it to Resident 8 at that time. In an interview on 11/20/2025 at 10:23 AM, Staff B (Director of Nursing) stated there were several mistakes that resulted in medication errors. Staff B confirmed that Staff G did not follow the physician's order during medication administration. <Resident 119> Observation of medication pass on 11/19/2025 at 8:27 AM showed Staff N (Registered Nurse) prepare and administer multiple medications to Resident 119, including two pain patches. Staff N applied one to the right knee and a second one to just below the right knee. Staff N was holding a third pain patch and stated to Resident 119, Do you want this patch too? Resident 119 stated, it's ok. Staff N did not apply the third patch. Review of Resident 119's November 2025 Medication Administration Record showed the pain patch order gave directions for staff to apply three patches, not two as administered, and apply to the left lower leg, not the right knee as administered. Staff N signed this order as administered as directed on 11/19/2025 with no documentation to support why the ordered dose was not provided or indicate why the location was changed. In an interview on 11/21/2025 at 1:22 PM, Staff J (Unit Manager) stated it was their expectation physician orders be followed as directed. <Resident 120> Observation of medication pass on 11/19/2025 at 8:35 AM, showed Staff K (Licensed Practical Nurse) prepared to administer Resident 120's morning medications. Staff K administered: 1. Eye drops Ophthalmic solution one drop in both eyes. 2. Supplement- 200 milligram (mg) tablet. 3. 4% pain patch to Resident 120's right hip area. Review of Resident 120's November 2025 Physician Orders on 11/19/2025 at 9:28 AM showed a physician order for: 1. Eye drops- one drop to the left eye four times a day related to an incision. 2. A supplement- 220 mg daily. 3. Pain External Patch Apply to right hip topically one time daily for pain. There was no dosage for the pain patch in the orders. In an interview on 11/19/2025 at 10:00 AM, Staff K reviewed Resident 120's physician orders and stated the eye drops should be administered only in left eye for the incision. Staff K stated the facility did not have Supplement in the 220 mg dose available so they administered 200 mg only. Staff K stated they should clarify the pain patch order with the provider for the dosage, but they did not. Staff K stated they should have checked the orders prior to administering the medications and/or consult the provider for clarification. In an interview on 11/21/2025 at 10:47 AM, Staff B stated they expected staff to verify the correct resident's name, medication name, dosage amount, and the correct time the medication should be given. Staff B stated staff should read the order before administering medication to ensure they were administering the correct medications. REFERENCE: WAC 388-97-1060(3)(k)(ii).

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice for 5 (Residents 11, 82, 69, 13, & 7) of 25 residents reviewed. The nursing staff's failure to clarify and/or follow Physician Orders (PO) and follow medication parameters placed residents at risk for unmet care needs, risk for medication errors, delayed treatment, and potential negative outcomes. Findings included .<Facility Policy>Review of the facility's 12/01/2007 General Dose Preparation and Medication Administration policy, showed prior to administration of medication the facility staff would take all measures required each time a medication was administered; the correct medication, correct dose and correct rate was provided. The policy showed staff would verify the medication name and dose were correct when compared to the medication order on the Medication Administration Record (MAR). <Clarifying physician orders> <Resident 11> According to the 09/11/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 11 had diagnoses including brain dysfunction, anxiety and memory impairment. The assessment showed Resident 11 received hospice (end of life care) services. Review of the 06/11/2025 impaired thought processes Care Plan (CP), showed staff were to monitor side effects and effectiveness of medications used to treat their condition. Review of a 08/19/2025 Hospice physician order, showed an antianxiety medication order for 0.25 milligrams/milliliters (mg/ml) by mouth every two hours as needed or to take 0.5 mg with an end date of six months for end-of-life symptom management. Review of a 10/31/2025 physician order showed Resident 11 was discharged from hospice services on 11/03/2025. Review of the November 2025 Medication Administration Record (MAR) showed Resident 11 received an antianxiety medication on 11/04/2025, 11/13/2025, 11/15/2025 and 11/16/2025 after hospice services were discontinued. In an interview on 11/21/2025 at 12:49 PM, Staff B (Director of Nursing) stated the antianxiety medication order should have been discontinued when Resident 11 was discharged from hospice services. Staff B stated staff should have clarified the anxiety medication order, but they did not. <Resident 82> According to a 10/31/2025 Quarterly MDS, Resident 82 had multiple medically complex diagnoses including heart failure, depression, and chronic pain and required pain medication during the assessment period. Review of Resident 82's November 2025 MAR showed a 07/14/2025 physician order for staff to check Resident 82's blood pressure every six hours and to notify the provider of abnormal blood pressure. There were no parameters for staff to know when to notify the provider of abnormal blood pressure. Review of Resident 82's November 2025 MAR showed a physician order directing staff to monitor Resident 82's behaviors, provide interventions and record behavior code, number of episodes, interventions, and outcome. The MAR showed staff documented Resident 82 had behaviors but did not indicate which behaviors the resident demonstrated or what interventions were provided. In an interview on 11/19/2025 at 9:29 AM, Staff K (Licensed Practical Nurse) stated there were no directions in the order to notify the provider of abnormal blood pressure. Staff K stated behavior monitor order was not clear where to document the behavior and interventions. In an interview on 11/21/2025 at 10:51 AM, Staff B stated it was their expectation of nursing staff to follow the physician orders. Staff B stated if the physician orders were not clear, staff should clarify the order with a provider. Staff B reviewed Resident 82's physician orders and stated orders needed to be clarified with the provider. <Resident 69> According to a 10/14/2025 admission MDS, Resident 69 had multiple medically complex diagnoses including fractures and required the use of narcotic pain medications during the assessment period. Review of Resident 69's November 2025 MAR showed a 10/28/2025 order directing staff to administer a narcotic pain medication to Resident 69 every eight hours as needed for a pain level of six to 10 on a pain scale. A second 10/28/2025 order showed staff were to administer a non-narcotic pain medication every eight hours as needed for a pain level of one to six on the pain scale. Both medications gave directions to staff to administer the medication for a pain level of 6. In an interview on 11/21/2025 at 1:22 PM, Staff J (Unit Manager) stated the orders needed to be clarified. <Following Orders> <Resident 13> Observations on 11/19/2025 at 9:54 AM of Staff G (Registered Nurse) providing care to Resident 13 which included applying pain patches. Staff G applied one pain patch to each of Resident 13's shoulders. According to Resident 13's November 2025 MAR, staff should apply one pain patch to Resident 13's chest area only. There was no order to apply pain patch on Resident 13's shoulders. In an interview on 11/21/2025 at 12:23 PM, Staff F (Unit Manager) stated it was their expectation nursing staff follow physician orders as directed, but they did not. <Medications Given Outside of Parameters> <Resident 11> According to the 09/11/2025 Quarterly MDS, Resident 11 received pain medications during the assessment period. Review of a 11/13/2025 physician order, showed a five mg pain medication to be given to Resident 11 every eight hours as needed for pain. Review of the November 2025 MAR showed Resident 11 received pain medication on 11/15/2025. The MAR showed the nurse provided the pain medication after documenting Resident 11's pain level was at zero on a pain scale of zero to 10 (zero meaning no pain and 10 meaning the highest level of pain). In an interview on 11/21/2025 at 12:49 PM, Staff B stated the pain medication should not have been given to Resident 11 if the resident's pain level was at a zero before giving the medication. Staff B stated staff should follow the physician orders. <Resident 7> According to a 10/24/2025 admission MDS, Resident 7 had multiple medically complex diagnoses including high Blood Pressure (BP) and pain and required the use of narcotic pain medications during the assessment period. Review of Resident 7's November 2025 MAR showed a 10/24/2025 order for narcotic pain medication with directions to staff to administer every four hours as needed for a pain level of six to 10 on the pain scale. This order was administered outside of parameters on 11/08/2025 and 11/10/2025. A second 10/28/2025 order showed staff were to administer a non-narcotic pain medication every six hours as needed for a pain level of one to five on the scale. Staff administered this order outside of parameters on 11/06/2025 and 11/07/2025. Review of Resident 7's November 2025 MAR showed the resident was receiving a medication for high BP with directions to staff to hold the dose for SBP [Systolic BP - a measure of the pressure in your arteries when your heart beats] or pulse less than 55. This MAR showed staff did not hold the medication as directed when it was outside of the parameters on 11/07/2025. In an interview on 11/212025 at 12:23 PM, Staff F (Unit Manager) stated parameters were in place for a reason and it was their expectation the ordered parameters be followed by staff when administering medications. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

Based on observation, interview, and record review, the facility failed to assess the gastrostomy tube (surgically placed tube through the abdominal wall into the stomach to provide nutrition) placement prior to initiating an enteral feeding (feeding through a tube), provide formula timely as scheduled, and failed to follow the physician orders for 1 of 1 residents (Resident 13) reviewed for tube feeding management. This failure placed residents at risk for alteration in nutrition, dehydration, and decreased quality of life.Findings included .<Facility Policy>Review of a 06/2018 facility, Tube Feeding Management/Restore Eating Skills policy showed staff were instructed to collaborate with the dietician for the appropriate method of formula (liquid nutrition) infusion using gravity flow or an infusion pump (device to deliver formula). The policy instructed collaboration of the dietician and nursing staff to validate the administration of formula and water and ensure the rate and volume of infusion followed the physician orders. This policy instructed staff to verify the potency and function of the feeding tube by checking the stomach residual volume (food, liquid, or material from a previous feeding left in the stomach at the start of the next feeding) or asking alert residents about symptoms that indicate a feeding is not well tolerated.<Resident 13>According to a 08/29/2025 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 13 had multiple medically complex diagnoses including difficulty with swallowing and required the use of a feeding tube for greater than 50 percent of their total calories received.Review of Resident 13's November 2025 Medication Administration Record (MAR) showed a 05/10/2025 order for 150 milliliters (ml) of water to be administered via feeding tube every four hours. Review of Resident 13's November 2025 Treatment Administration Record (TAR) showed a 05/11/2025 order to check the enteral tube placement and residual volume before feeding and water flushes and an 11/05/2025 order for enteral nutrition formula to be administered five times a day at 12:00 AM, 7:00 AM, 11:00 AM, 5:00 PM, and 9:00 PMObservations on 11/19/2025 at 9:54 AM showed Staff G (Registered Nurse) prepared and administered 160 ml of water into the feeding tube, rather than the 150 ml as directed on the orders from the November 2025 MAR. Staff G did not check tube placement or residual prior to administering Resident 13's water flush or formula as directed in the orders on the November 2025 TAR. Staff G did not ask Resident 13 if they were having any symptoms of not tolerating the feedings. Staff G then administered 237 ml of the enteral nutrition formula at 10:15 AM, three hours after the 7:00 AM scheduled dose. When asked if Staff G had provided any previous enteral nutrition formula during the shift, Staff G stated, no, this was their first time administering the formula for the day.In an interview on 11/19/2025 at 10:44 AM, Staff G stated it was very important to follow the tube feeding orders and stated they accidently overcounted the water flush amount. Staff G stated they should have, but did not, follow the orders and check the placement and residual prior to starting the water flush and formula. Staff G stated the formula was scheduled for 7:00 AM, but they did not have enough time to administer it until three hours later at 10:15 AM.In an interview on 11/21/2025 at 12:23 PM, Staff F (Unit Manager) stated it was their expectation staff follow the physician orders as directed and administer the tube feeding water flushes amount as ordered, check placement and residual prior to administering, and provide the tube feedings as scheduled to prevent complications.REFERENCE: WAC 388-97-1060(3)(f).

Based on observation, interview, and record review the facility failed to provide restorative/functional maintenance services for 2 of 4 residents (Residents 5 & 70) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility.Findings included .<Facility Policy>According to a revised June 2018 facility Quality of Care Restorative Nursing Programs policy, the facility would assist residents to obtain and maintain their highest practicable functional levels to prevent unnecessary declines and to provide an active and healthy living environment.<Resident 5>According to a10/9/2025 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 5 had slight memory impairment, muscle weakness, and functional limitation in ROM to both legs.Review of a revised 10/09/2023 limited physical mobility Care Plan (CP) showed staff were to provide gentle range of motion daily as tolerated. Review of the November 2025 caregiver task records showed no documentation staff provided range of motion activities with Resident 5.In an interview on 11/18/2025 at 8:53 AM, Resident 5 stated they needed assistance with mobility because of recent falls and thought someone would provide exercises to them in their room. Resident 5 stated staff did not discuss ROM exercises with them in over a month and they did not hear anything further since.Observations on 11/19/2025 at 8:53 AM, showed Resident 5 lying in bed attempting to sit up to talk but was unable to. Resident 5 then rested on their right elbow and stated they should go to an exercise class to help them get stronger. Resident 5 stated they could not recall a time when someone helped them with ROM exercises in their room. <Resident 70>According to a 10/17/2025 Quarterly MDS, Resident 70 had no memory impairment. The MDS showed Resident 70 had multiple diagnoses including generalized muscle weakness, paralysis and was dependent on staff for mobility. Review of the revised 07/28/2025 Activities of Daily Living self-performance deficit CP, showed Resident 70 required assistance from staff daily with active ROM while providing dressing and grooming assistance of upper arms. Review of the November 2025 caregiver task sheets showed staff were to provide Resident 70 with active ROM daily while providing personal hygiene care. There was no documentation provided by the facility to show staff completed ROM with Resident 70.In an interview on 11/18/2025 at 9:20 AM, Resident 70 stated they wanted therapy to help them get stronger and wondered if it was a cost issue for why they were not receiving help with exercises. In an interview on 11/21/2025 at 10:19 AM, Resident 70 stated their legs and arms were weak, and they would like help with exercises. Resident 70 stated because of their limited mobility it was difficult to get to the activity room for exercises and staff did not offer them exercises in their room.In an interview on 01/21/2025 at 12:41 PM, Staff B (Director of Nursing) stated the facility did not have designated staff to provide restorative and ROM exercises with residents. Staff B stated the facility was setting up a functional maintenance program to track residents' functional abilities, and this was not in place yet. Staff B stated they expected the Certified Nursing Assistants (CNA) to provide ROM with residents as stated in the CP and to document the assistance provided. Staff B stated they were not aware the CNAs did not currently provide active ROM for residents but stated they should be. REFERENCE: WAC 388-97-1060 (3)(d).

Based on observation, interview, and record review the facility failed to ensure activity programs met the needs of each resident for 2 of 3 residents (Resident 15 & 69) reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life.Findings included .<Facility Policy>According to the facility's 11/2017 Quality of Life Activities policy, the facility would implement an ongoing activities program to support resident in their choice of activities. The programs would be based on the comprehensive assessment, care plan and the preferences of each resident to support their physical, mental, psychosocial well-being and independence. <Resident 15> According to the 10/08/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 15 had a mood disorder, respiratory failure and weakness. The MDS showed it was very important for Resident 15 to do their favorite activities that included books, newspapers and participation in religious services. The MDS showed it was important to keep up with the news, to listen to music and to go outside weather permitting. Review of the 10/07/2025 Adjustment to Placement Care Plan (CP) showed Resident 15 expressed no interest in scheduled activities, staff were to provide leisure material, and assist with setting the channel on the television. Review of Resident 15's November 2025 activity participation record showed documentation once on 11/15/2025 with no further documentation for the month of November. In an interview on 11/17/2025 at 9:22 AM, Resident 15 stated they needed someone to push them around so they could go to activities. Observations on 11/19/2025 at 8:51 AM, 11/20/25 at 8:04 AM, and 11/20/2025 at 1:53 PM showed Resident 15 lying down in bed, the room was dark with no lights on, and the television was off. In an interview on 11/20/2025 at 2:07 PM, Staff H (Recreation Director) stated they provided a survey to residents on what they like to do, and their team helped residents with their interests. Staff H stated Resident 15 did not like to do activities and preferred to stay in their room. Staff H stated they were not aware if the television was put on for the resident and the recreation staff provided one-on-one activities ongoing and brought Resident 15 writing pads. Staff H stated they did not document activities but should. In an interview on 11/21/2025 at 1:13 PM, Staff B (Director of Nursing) stated their expectation was facility staff would follow the care plan for activities and document when the care was provided. Staff B stated it was important for staff to assist residents to get up out of bed to attend an activity or to escort residents to activities to increase participation. <Resident 69> According to a 10/14/2025 admission MDS, Resident 69 had no memory impairment, was understood, and understood others. This MDS showed Resident 69 had no rejection of care and that it was very important to the resident to have books, newspapers, and magazines to read, do their favorite activities, and participate in religious services or practices. Review of a revised 10/13/2025 adjustment to facility CP showed Resident 69 was adjusting to the facility, would like to know what activities were scheduled, and liked to observe. This CP showed directions to staff to post the activity calendar in the room, invite them to activities and encourage participation, and provide leisure materials as the resident enjoyed magazines. In an interview on 11/17/2025 at 10:46 AM, Resident 69 stated they would get up more if there was something to do. Resident 69 stated staff got them up and then left them sitting there with nothing to do. Resident 69 stated, I just stare at this black television, I spend all morning looking for something to do. Observations at this time showed Resident 69 lying in bed, with no reading materials nearby, no music, and the television was off. Observations on 11/20/2025 at 2:50 PM showed no activity schedule nearby, no reading materials, no magazines, no music, and the television was off. There was an activity schedule posted near the door entrance of the room which Resident 69 was unable to view. In an interview at this time, Resident 69 stated they were lonely. In an interview on 11/20/2025 at 3:00 PM, Staff H (Recreation Director) stated they interview residents when they are admitted , to find out what they like to do and how staff could help them with their activity interests. Staff H stated they used the information to individualize the resident CPs, and staff should document when activities are provided or offered. Staff H stated it was their expectation that refusals be documented so they can re-evaluate a resident's current interests. Review of October 2025 activity documentation showed staff documented only three of 23 days where one to one activity participation occurred; only one of 23 days when group activity participation was offered; and only four of 23 days independent activities occurred. Review of November 2025 activity documentation showed staff documented only two of 18 days where one to one activity participation occurred and only five of 18 days when independent activities occurred. In an interview on 11/21/2025 at 2:19 PM, Staff H stated the activity participation, offers, and/or refusals were not always documented by staff when provided for Resident 69 and stated they needed to be documented, otherwise, it did not happen. REFERENCE: WAC 388-97-0940 (1).

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 3 (Residents 70, 17 & 52) of 5 sample residents and 1 supplemental (Resident 69) resident reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with bathing, nail care, and shaving, placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life.Findings included .<Facility Policy>According to the facility's 11/2017 Quality of Life- Activities of Daily Living policy, if a resident was unable to carry out ADL's they would receive the necessary services to maintain grooming and personal hygiene.<Resident 70> According to the 10/17/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 70 had diabetes, muscular dysfunction and weakness. The assessment showed Resident 70 had no behavior of refusing care during the assessment period and had no memory impairment. The 07/22/2025 ADL self-care performance deficit Care Plan (CP) showed Resident 70 needed substantial assistance with bathing and staff to provide nail trim and clipping on shower days. Review of the November 2025 Kardex (caregiver task sheet), showed Resident 70 shower days scheduled every Wednesday and Saturdays and as needed. Observations on 11/18/2025 at 9:40 AM, 11/19/2025 at 1:20 PM and 11/21/2025 at 10:58 AM showed Resident 70 had nails that extended half an inch past their nail bed with brown debris and dry skin underneath their nails. In an interview on 11/21/2025 at 10:58 AM, Resident 70 stated they usually trim their own nails. Resident 70 stated they wanted the nurses to follow up after they clip their own nails as they were diabetic and this had only occurred a few days ago. <Bathing> Review of the November 2025 bathing task record for Resident 70, showed staff documented a bed bath was provided on 11/1/2025, 11/8/2025, 11/12/2025, 11/14/2025 and 11/21/2025. No documentation was found in the record to show Resident 70 refused a bath. In an interview on 11/21/2025 at 10:58 AM Resident 70 stated they did not receive a bed bath. Resident 70 stated a few days ago a bed bath was offered and they refused it because their room was too cold at the time. Resident 70 stated staff did not come back since then to offer them another one. In an interview on 01/21/2025 at 12:41 PM, Staff B (Director of Nursing) stated they expected ADL's to be completed and for staff to document refusals, especially for diabetic residents. Staff B stated if a resident refused an ADL service, staff should reapproach the resident and document that they made another attempt. <Resident 69> According to an admission MDS, Resident 69 had clear speech, was understood, able to understand others, and had no memory impairment. This MDS showed Resident 69 was dependent on staff for personal hygiene and had no rejection of care during the assessment period. Observations on 11/17/2025 at 10:46 AM showed Resident 69 with long, uneven fingernails to both hands. In an interview at this time, Resident 69 stated, they are a little long. Resident 69 stated they were unable to clip them currently, and stated staff had not trimmed them since admission. Review of Resident 69's November 2025 Medication Administration Records showed an order for staff to complete nail care weekly. This order was signed as completed by staff on 11/17/2025. Observations on 11/21/2025 at 9:44 AM showed Resident 69's fingernails remained long, uneven, and untrimmed. In an interview at this time, Resident 69 stated, I keep waiting for them to be done. In an interview and observation on 11/28/2025 at 12:28 PM, Staff L (Licensed Practical Nurse) assessed Resident 69's fingernails and stated they were long and needed to be trimmed. Staff L stated nail care should be done on shower days and as needed. <Resident 17> According to the 08/21/2025 Annual MDS, Resident 17 admitted to the facility on [DATE] with a compression fracture to lower back and right shoulder pain. The MDS showed Resident 17 required moderate one person assistance from staff with personal hygiene, showers and toileting during the assessment period. Review of a 12/22/2023 revised ADL Self Care Performance Deficit Care Plan (CP) showed Resident 17 had a history of right shoulder pain and lower back pain. The CP showed Resident 17 needed one person assistance with personal hygiene and oral care. Observation on 11/17/2025 at 12:19 PM and on 11/18/2025 at 11:02 AM, and on 11/19/2025 at 9:03 AM showed Resident 17 lying in their bed, in a hospital gown, with long facial hair and long fingernails with black debris under their fingernails. <Resident 52> According to the 10/24/2025 admission MDS, Resident 52 admitted to the facility on [DATE] with a wound infection and weakness. The MDS showed Resident 52 required one person assistance from staff with personal hygiene, toileting and showers and Resident 52 had no rejection of care during the assessment period. Review of a 10/20/2025 ADL Self Care Performance Deficit related to wound infection CP, showed Resident 52 required one person assistance with personal hygiene and toileting. The CP directed staff to provide nail care to Resident 52 on Wednesdays/Saturdays. Review of Resident 52's November 2025 Physician Orders directed staff to provide nail care weekly to Resident 52. Observation on 11/17/2025 at 11:32 AM, on 11/18/2025 at 10:24 AM, and on 11/20/2025 at 7:37 AM showed Resident 52 in their room, nicely dressed up, and had long fingernails with black debris underneath fingernails. Resident 52 stated they needed assistance from staff to clip their fingernails. In an interview on 11/20/2025 at 1:09 PM, Staff F (Unit Manager) stated staff should provide ADLs to all dependent residents including personal hygiene, shaving and clip resident's nails weekly and as needed. In an interview on 11/21/2025 at 10:47 AM, Staff B (Director of Nursing) stated they expected staff to provide ADLs to all residents including oral care, shaving, dressing, and nail care as residents allowed, but did not. Staff B stated if residents refuse care, staff should document refusals in resident's record and notify social services. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review, the facility failed to ensure residents' ability to communicate was maintained for 2 of 3 sampled residents (Resident 13 & 69) when reviewed for communication. This failure placed the residents at risk of inability to communicate needs, social isolation, feelings of worthlessness, and diminished quality of life.Findings included .<Facility Policy>Review of an 11/2017 facility, Resident Rights policy showed health information and services would be provided in ways that were easy for the resident and/or representative to understand. The facility would offer language assistance services to residents who had limited English proficiency, provide qualified sign language interpreters, or auxiliary (additional support) aids if hearing was impaired.<Resident 13>According to an 08/29/2025 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 13's preferred language was Spanish and the resident needed or wanted an interpreter to communicate with a doctor or health care staff.Review of a revised 09/11/2025 communication Care Plan (CP) showed Resident 13 had a communication problem which included a language barrier. Interventions identified showed Resident 13 preferred to communicate in Spanish.In an interview on 11/18/2025 at 10:20 AM, Resident 13 indicated they were having a hard time understanding and preferred to communicate in Spanish. Observations at this time showed Resident 13 making hand gestures and no signage or directions for interpreter services available in the resident's room.In an interview with an interpreter on 11/18/2025 at 10:34 AM, Resident 13 stated they did not have any concerns with their hearing ability and indicated they like and do better with understanding and communicating in Spanish.In an interview on 11/21/2025 at 11:02 AM, Staff V (Certified Nursing Assistant - CNA) stated it was hard to communicate with Resident 13, they tried their best, and were usually able to figure out what the resident needed. Staff V stated Resident 13 would point to things and staff were eventually able to figure out what they wanted. When asked if an interpreter was used to communicate with Resident 13, Staff V stated the resident was able to understand English, the only problem was the resident could not let staff know exactly what they were saying. Staff V stated, we have to connect the sentences in order to figure it out.In an interview on 11/21/2025 at 12:23 PM, Staff F (Unit Manager) stated a sign was usually posted in the resident's room with directions to staff on how to reach interpreter services. Staff F stated it was their expectation staff communicate with residents in the residents' preferred language and utilize an interpreter as needed.<Resident 69>According to an 10/14/2025 admission MDS, Resident 69 had clear speech, no memory impairment, and had minimal difficulty with hearing with the use of a hearing aid or other hearing appliance.Review of a 10/10/2025 Inventory of Resident Personal Items form showed Resident 69 had one hearing aid on admission.Review of a revised 10/17/2025 communication CP showed Resident 69 had a potential communication problem related to minimal difficulty hearing. This CP did not identify Resident 69 had a hearing aid or a need for other hearing devices.In an interview on 11/17/2025 at 10:46 AM, Resident 69 said they were having difficulty hearing and kept asking for sentences to be repeated during the interview. When asked if Resident 69 had hearing aids, Resident 69 stated they did, but they were broken. Observations at this time showed no hearing aids on or hearing device headphones in Resident 69's room.In an interview on 11/20/2025 at 10:36 AM, Resident 69 indicated they did not hear good at all and stated, hopefully I will get my hearing fixed, then I will be happy. Resident 69 stated their right hearing aid was broken before they were admitted to the facility, and the left hearing aid broke a couple weeks ago. Resident 69 stated staff used a hearing device headphone once when they first got to the facility and it was never offered again by staff. Resident 69 stated they were unsure why they did not have a hearing device headphone to use but felt one would help. Resident 69 stated, it's a real nuisance for me and for them [staff] when I cannot hear them [staff] and have to keep asking them what? over and over.In an interview on 11/21/2025 at 12:35 PM, Staff X (CNA) stated Resident 69 was hard of hearing and did not have hearing aids or hearing devices. Staff X stated they would stay close to the resident and talk louder so they could hear them.In an interview on 11/21/2025 at 1:22 PM, Staff J (Unit Manager) stated they were unaware of any residents on their unit with hearing aids or currently using hearing device headphones. Staff J stated they had several devices available in their office. Staff J stated they would expect staff to assist Resident 69 to use a hearing device, if they were having difficulty with hearing.REFERENCE: WAC 388-97-1060(2)(a)(v)(3)(a).

Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR - a mental health screening required prior to nursing home admission) evaluation was incorporated into the Care Plan (CP) for 1 of 5 residents (Resident 13) reviewed for PASRR. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of life. Findings included .<Resident 13>According to a 08/29/2025 Significant Change Minimum Data Set (an assessment tool), Resident 13 had multiple medically complex diagnoses and was currently considered by the state Level II PASRR process to have a Serious Mental Illness (SMI). This MDS showed Resident 13 received antipsychotic and antidepressant medications during the assessment period.Review of an updated 06/05/2025 Level 1 PASRR showed staff identified Resident 13 had an SMI and required a Level II evaluation. On 07/21/2025 the Level II evaluation was completed with recommendations provided to the facility for Resident 13's plan of care.Review of Resident 13's comprehensive CP on 11/17/2025, four months after the evaluation was completed, showed staff did not have the Level II recommendations incorporated into the resident's CP as required.In an interview on 11/21/2025 at 10:10 AM, Staff I (Social Services Director) stated it was their expectation staff incorporate Level II recommendations into resident CPs once obtained. Staff I stated it was important to incorporate the recommendations provided to ensure the goals, interventions and mental health needs of the residents were being addressed and they could be successful. Staff I reviewed Resident 13's records and stated the 07/21/2025 Level II recommendations should be but were not incorporated into the resident's plan of care.REFERENCE: WAC 388-97-1915 (4).

Based on observation, interview, and record review, the facility failed to implement pharmacy recommendations for 2 of 6 residents (Residents 8 & 69) reviewed for pharmacy recommendations. These failures placed residents at risk of medication errors and adverse health outcomes.Findings included .<Facility Policy>Record review of the facility's November 2017 Pharmacy Services Medication Regimen Review policy showed a pharmacist conducted medication regimen reviews at least monthly to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities. The facility was to act upon reported irregularities in order to minimize adverse consequences that might be associated with medications.<Resident 8> According to a 09/26/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 8 had recent major orthopedic surgery and required active care during their admission to the facility related to the surgery. Observations during medication pass on 11/19/2025 at 8:26 AM showed Staff G (Registered Nurse) administered one 5,000-unit capsule of Vitamin D3 (a supplement that helps the body absorb calcium to build and maintain strong bones) to Resident 8. Review of Resident 8's physician's orders showed a 09/24/2025 order for Vitamin D3 one 50,000-unit capsule every morning. Review of a 10/17/2025 pharmacy Consultation Report showed Resident 8's current order for Vitamin D3 50,000-units daily was above the recommended dose of 1,000-units to 5,000-units daily, depending on Vitamin D levels in their blood. The pharmacy recommendation included obtaining a blood test to determine Resident 8's vitamin D level. If the results showed a level of less than 30, the facility was to start Vitamin D3 50,000-units weekly or if results showed a level greater than 30, start Vitamin D3 2,000-units daily. Resident 8's physician accepted the recommendations, ordered they be implemented as written, and signed the order on 10/20/2025. Review of a 10/24/2025 Lab Results Report showed Resident 8's Vitamin D level was 47. Review of Resident 8's September 2025, October 2025 and November 2025 Medication Administration Records (MAR) showed Resident 8 continued to receive Vitamin D3 50,000-units daily from 09/24/2025 through 11/19/2025. In an interview on 11/20/2025 at 10:23 AM, Staff B (Director of Nursing) stated the facility obtained a blood test for Resident 8 but did not implement the signed physician's order to change the Vitamin D3 dose based on the blood test results. Staff B stated the Vitamin D3 dose should have been changed to 2,000-units daily when blood test results were received. <Resident 69> According to a 10/14/2025 admission MDS, Resident 69 had multiple medically complex diagnoses including fractures and a disease that causes bones to become weak and brittle. Review of Resident 69's records showed a 10/10/2025 Consultant Pharmacist Medication review with documentation to, See report for any noted irregularities and/or recommendations. This report was not found in Resident 69's records. In an interview on 11/21/2025 at 1:38 PM, Staff B stated they were previously unaware they needed to obtain the completed reports from the pharmacy website instead of automatically receiving the reports. Staff B logged in to the website and printed the report with recommendations for Resident 69 from 10/10/2025, over one month previously. The report showed recommendations to administer Resident 69's calcium and iron supplements separately from many medications for proper absorption. Review of Resident 69's November 2025 MAR showed the calcium and iron supplements were still scheduled to be administered at the same time as the resident's other medications. In an interview on 11/21/2025 at 1:38 PM, Staff B stated it was their expectation the pharmacy recommendations be obtained timely, acted on, and be available in the resident records. Staff B stated Resident 69's 10/10/2025 pharmacy recommendations needed to be addressed. REFERENCE: WAC 388-97-1300(4)(c).

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 2 medication storage rooms (West Station Medication Room) and 1 of 3 medication carts (West Two Medication Cart) reviewed for medication storage. This failure placed residents at risk for medication errors or receiving expired medications.Findings included .<Facility Policy>According to the facility's November 2017 Pharmacy Services Labeling and Storage of Drugs and Biologicals policy, all medications would be labeled with an expiration date. The policy showed multi-dose vials would be dated with an open date and discarded within 28 days after opening, unless the manufacturer specified a shorter or longer date for that opened vial. <West Station Medication Room>Observation on 11/18/2025 at 9:17 AM of the [NAME] Station medication storage room showed a bottle of medication used to treat itching with an expiration date of 10/25/2025, and nine bags of IV (intravenous - injected directly into a patient's bloodstream) medications with an expiration date of 10/13/2025.In an interview on 11/18/2025 at 9:17 AM, Staff D (Unit Manager) confirmed the medication used to treat itching was expired and should have been discarded. Staff D stated the IV medications were discontinued on 10/03/2025 and should have been discarded or returned to the pharmacy at that time.<West 2 Medication Cart>Observation on 11/18/2025 at 12:25 PM of the [NAME] 2 medication cart showed three opened multi-dose injectable medications used to treat a blood sugar disorder with no open dates, and one that had an open date that was smeared and illegible.In an interview on 11/18/2025 at 12:25 PM, Staff E (Licensed Practical Nurse) stated the multi-dose injectable medications were to be discarded 28 days after opening. Staff E stated they would need to know the open date in order to know when to discard the medications.In an interview on 11/20/2025 at 10:23 AM, Staff B (Director of Nursing) stated if multi-dose injectable medications were not labeled with the open date, they would discard them. Staff B confirmed that expired medications should be discarded.REFERENCE: WAC 388-97-1300(2).

Based on observation, interview, and record review, the facility failed to update and/or revise Care Plans (CP) as needed for 3 of 25 sample residents (Residents 91, 2 & 69) whose CPs were reviewed. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.Findings included . <Resident 91> According to the 11/01/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 91 admitted to the facility on [DATE] with medically complex conditions including recent abdominal surgery. The MDS showed Resident 91 was able to transfer and walk 10 feet with supervision or touching assistance, did not use a wheelchair, did not use bed rails, and required a pressure-reducing device for their chair. Review of a 10/29/2025 physical mobility Care Plan (CP) showed Resident 91 required supervision or touching assistance by staff to walk and bilateral mobility bars (bed rails on both sides of bed) to increase mobility were initiated on 11/09/2025. Review of a revised 10/29/2025 risk for falls CP showed staff were to encourage Resident 91 to use mobility aids, such as a walker or cane, when ambulating or transferring. Review of a revised 11/03/2025 potential for pressure ulcer development CP showed Resident 91 required a pressure-reducing device on their chair. Record review on 11/18/2025 showed Resident 91's CP had no documentation regarding the use of a wheelchair. Observation on 11/17/2025 at 10:17 AM showed Resident 91 sat in a wheelchair and self-propelled out of their room into the hallway. Resident 91 said they needed to get outside to get some fresh air, asked staff if it was raining outside, then self-propelled to exit the building. Observation and interview on 11/18/2025 at 10:08 AM showed Resident 91 sat in a wheelchair in their bedroom. Resident 91 grimaced and stated they needed to get up from the wheelchair because their bottom was sore. Resident 91 transferred independently to their bed. Observation showed no cushion or pressure-reducing device in the wheelchair. Resident 91 stated the facility had some wheelchair cushions, but not enough or not the right size for their wheelchair. Resident 91 stated they used to have a wheelchair cushion, but it did not fit correctly and was uncomfortable. Observation and interview on 11/18/2025 at 10:08 AM showed a padded mobility bar partially raised on the right side of Resident 91's bed, with a small fan clamped to the center of the rail. A padded mobility bar was in the down position below the left side of the bed. Resident 91 said they only used one of the mobility bars to hold their fan, they never used them for mobility, and they did not need them to turn in bed or to transfer. Observation on 11/19/2025 at 10:38 AM and 11/20/2025 at 8:17 AM showed Resident 91 lying in their bed with the right-side mobility bar partially up with a fan clamped in the center, and the left-side mobility bar in the down position. In an interview on 11/21/2025 at 10:41 AM, Staff J (Unit Manager) stated Resident 91 requested and needed mobility bars when they were first admitted , their mobility improved not long after they admitted , and they no longer needed the mobility bars for mobility. Staff J confirmed the CP should have been updated at the time the mobility bars were no longer needed. Staff J stated the therapy department gave Resident 91 a wheelchair when they were admitted and Resident 91 preferred to use the wheelchair for long distances. Staff J confirmed Resident 91's use of a wheelchair should be included in their CP, but it was not. Staff J stated Resident 91 was no longer at risk for pressure ulcer development due to improved mobility and did not require a pressure-relieving device in their wheelchair. Staff J confirmed the CP should have been updated to show the potential for pressure ulcer development was resolved, but it was not. <Resident 2> According to a 10/03/2025 admission MDS, Resident 2 had a history of falls and had a fall since admission to the facility. This MDS showed Resident 2 had a functional limitation in range of motion to both lower legs, required substantial assistance from staff for transferring from the bed to chair, and used a walker and wheelchair. In an interview on 11/18/2025 at 9:30 AM, Resident 2 stated they had a fall since admission in their room. Observations at this time showed Resident 2 lying in bed with their wheelchair nearby. Review of a 10/02/2025 facility incident report showed Resident 2 was found on the floor between their bed and their chair and the resident reported they fell trying to get back into bed. This report showed staff revised the CP to include an intervention for a Call Don't Fall sign to be in Resident 2's room as a visual reminder to request staff assistance. Review of a revised 11/02/2025 risk for falls CP showed Resident 2 was at risk for falls due to confusion, deconditioning, and gait/balance problems. The goal established was for Resident 2 to be free of falls through the next review date. This CP was not updated or revised to include the new fall intervention identified by staff to help prevent further falls. Observations on 11/21/2025 at 7:45 AM showed no fall interventions signs in Resident 2's room. In an interview on 11/21/2025 at 1:22 PM, Staff J stated the Call Don't Fall sign was previously in Resident 2's room, but their room had been packed up, and staff forgot to put the sign back up upon the resident's return. Staff J stated the fall intervention sign should be in place and the CP needed to be updated and revised. According to a 10/03/2025 admission MDS, Resident 2 had obvious or likely tooth decay or broken teeth. Review of a 10/06/2025 Dental Care Area Assessment showed staff documented Resident 2 had broken teeth and staff would proceed to CP. Review of Resident 2's comprehensive CP showed staff only identified the resident was at risk for oral/dental problems but did not indicate Resident 2 had actual broken teeth. In an interview on 11/21/2025 at 1:22 PM, Staff J stated it was their expectation CPs be updated and revised to reflect the current conditions of the resident. <Resident 69> According to a 10/14/2025 admission MDS, Resident 69 had multiple medically complex diagnoses including a chronic digestive disorder. Review of a revised 10/09/2025 digestive disorder CP showed interventions to staff to provide small frequent meals rather than three large ones to avoid overeating. Observations on 11/19/2025 at 8:23 AM, 11/19/2025 at 12:35 PM, and 11/20/2025 at 7:33 AM showed Resident 69 was provided the regular portion meals, rather than the small frequent meals as identified on the resident's CP. In an interview on 11/21/2025 at 1:30 PM, Staff O (Dining Services Manager) stated Resident 69 did not receive small frequent meals but instead received three regular meals a day. In an interview on 11/21/2025 at 1:22 PM, Staff J stated it was their expectation CPs be updated and revised to reflect the current conditions of the resident. REFERENCE: WAC 388-97-1020(2)(c)(d).

Based on observation, interview, and record review the facility failed to assess and obtain consent prior to implementing bed rails for 2 (Residents 1 & 2) of 3 sample residents reviewed for bed rails. The failure to assess and obtain consent prior to implementing bed rails resulted in Resident 1 sustaining a cut to their eyebrow and placed Resident 2 at risk for injury. These failures placed all residents at risk for injury and other negative health outcomes. Findings included . <Resident 1> According to the 10/30/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 1 had diagnoses including an acute condition affecting their brain function that could cause confusion, memory loss, and personality changes. The MDS showed Resident 1 had severe memory impairment. The MDS showed Resident 1 had severely impaired vision and did not use bed rails during the assessment period. The 10/31/24 discharge MDS showed the resident was discharged from the facility and not available for observation or interview. Review of Resident 1's evaluation and documentation tabs in their clinical record showed no assessments indicating Resident 1 was assessed for safe use of bed rails. Resident 1's record showed no consent or risk and benefit documentation for use of the bed rails. Review of Resident 1's 10/25/2024 comprehensive care plan showed no care plan indicating the resident utilized bed rails. Review of an 11/01/2024 nurse progress note showed a care giver providing one-to-one supervision reported to the nurse Resident 1 hit their head on the bed handrail, resulting in a cut above the left eyebrow . In an interview on 11/05/2024 at 2:12 PM, Staff C (Registered Nurse) stated they recalled Resident 1 having bed rails on their bed. Staff C stated unit managers completed assessments and consents for bed rails. In an interview on 11/05/2024 at 2:20 PM, Staff B (Unit Manager) reviewed Resident 1's record and confirmed the resident did not have an assessment or consent for the bed rails. In an interview on 11/05/2024 at 3:20 PM, Staff A (Administrator) stated Resident 1 was moved to a private room as they required one-on-one supervision. Staff A stated the bed rails were accidentally left on the bed in the private room from the previous tenant. Staff A stated they expected assessments and consents to be obtained for bed rails prior to implementation. <Resident 2> According to the 11/04/2024 Admission MDS, Resident 2 had no memory impairment. This MDS showed Resident 2 had a fall prior to their admission to the facility and did not have impairment to their range of motion but required substantial/maximal assistance with bed mobility. The MDS showed Resident 2 did not use bed rails. Review of Resident 2's 10/31/2024 comprehensive care plan showed no care plan indicating the resident utilized bed rails. Observation on 11/05/2024 at 1:00 PM showed Resident 2 lying in bed. Resident 2's bed had bilateral bed rails installed. Review of Resident 2's evaluation and document tabs in their record showed no assessments indicating Resident 2 was evaluated for safe use of bed rails. Resident 2's record showed no consent or risk and benefit documentation of the bed rails. In an interview on 11/05/2024 at 3:20 PM, Staff A stated it was their expectation assessments and consents were obtained prior to the use of bed rails. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of Antibiotics (ABO), reduce the risk of unnecessary ABO use, and decrease the development of an ABO resistance for 6 of 6 sample residents (Resident 204, 80, 77, 64, 47, & 3) reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of ABO's. Findings included . <Facility Policy> According to a facility policy titled, Infection Prevention and Control ABO Stewardship, revised 03/2019, the program would validate that antibiotics were prescribed for the correct indication, the correct dose, the correct route and the correct duration. The policy showed the program would implement a data gathering system and analyze the collected data to ensure unnecessary ABO prescribing did not take place. The policy showed the facility would monitor the use of ABO's using the McGeer's (a set of signs and symptoms that verify active infection) and Loeb's (tool used to assess antibiotic appropriateness) criteria as a guide for protocols for prescribing ABO's. This policy showed when a resident was admitted on an ABO regimen, the facility would review for appropriateness of the ABO. The policy titled, Antibiotic Stewardship Program, revised 04/2022, showed documentation related to the ASP, including meeting minutes, tracking information, and logs would be maintained in a binder to facilitate comparisons and review. The policy showed within 48 -72 hours following initiation of an ABO, an ABO Time-Out Checklist would be completed and reviewed with the prescriber. Record review on 07/22/2024 showed incomplete and inaccurate antibiotic line listing for the facility's ASP. Review of the ASP showed no documentation of a positive McGeer's or Loeb's criteria to meet the need of ABO use for Residents 204, 80, 77, 64, 47, or 3. The facility was unable to provide accurate and complete ABO line listing documentation from the last survey to the current survey. <Residents 204> Review of Resident 204's records showed two ABO's that were not documented on the ASP line listing and had no documentation of McGeer's or Loeb's data. <Residents 80> Review of Resident 80's records showed they had completed an ABO without any documentation of symptoms that met McGeer's or Loeb's criteria. <Residents 77> Review of Resident 77's records showed they had completed an ABO without any documentation of symptoms that met McGeer's or Loeb's criteria. <Residents 64> Review of Resident 64's order summary showed they were admitted on an ABO for colitis (inflammation of the colon), but review of hospital history and physical showed the colitis was resolved and Resident 64 was placed on the ABO for Pneumonia (inflammation of the lungs). Review of Resident 64's hospital records showed a chest X-ray which was clear of pneumonia. <Residents 47> Review of Resident 47's records showed they had completed an ABO without any assessment or ABO time-out. <Residents 3> Review of Resident 3's records showed they had completed an ABO without any assessment or ABO time-out. In an interview on 07/22/24 at 8:09 AM Staff C (Infection Preventionist) stated they did not maintain an ASP binder with meeting minutes, tracking information, and logs for comparison and review. Staff C stated they did not have the ASP up to date and did not have residents who are on ABO's, or were on an ABO, logged for July 2024. Staff C stated they had three job titles, Assistant Director of Nursing, Staff Development Coordinator, and Infection Preventionist, which made it difficult to keep up with their workload. Staff C stated they did not complete a McGeer's or Loeb's assessment on any resident that used to be or was currently taking an ABO. Staff C stated the facility had a software with a question . meets McGeer's or Loeb's criteria? Yes or no, but the software did not document the data that qualified the resident to take an ABO. Staff C stated it was important to complete a McGeer's & Loeb's assessment to ensure the resident was receiving the correct ABO and to ensure the ABO was necessary. REFERENCE: WAC 388-97-1060(3)(k)(i),-1320(2)(a-c).

Based on observation, interview, and record review the facility failed to provide restorative/rehabilitative treatment/services for 7 of 8 residents (Residents 47, 20, 40, 41, 61, 32, & 59) reviewed for limited Range of Motion (ROM) and mobility to ensure the residents maintained and/or improved their highest level of functioning. This failure placed residents at risk of further decline in ROM, loss of function, and/or permanent immobility. Findings included . <Facility Policy> According to a facility policy titled, Quality of Care Restorative Nursing Programs, revised 06/2018, showed Restorative Nursing Programs (RNP) would be developed and/or formalized by a supervising nurse. <Resident 47> According to a 05/31/2024 Quarterly Minimum Data Set (MDS- an assessment tool), Resident 47 had functional limitation in ROM to both arms and both legs. The assessment showed Resident 47 did not have any memory impairment. The MDS showed Resident 47 had medically complex conditions which included, but were not limited to, depression, generalized muscle weakness, difficulty in walking, and fibromyalgia (chronic disorder characterized by pain, stiffness, and tenderness). Review of a 02/23/2024 Activity of Daily Living (ADL) Care Plan (CP), Resident 47 required substantial/maximal assistance from staff with bathing/showering, bed mobility, dressing, and toilet use. The CP showed Resident 47 required two staff maximal assistance with a mechanical lift machine for transfers. In an interview on 07/16/2024 at 11:56 AM Resident 47 stated they were unable to raise either arm up to shoulder level and unable to bend both of their knees to a 90-degree angle. Resident 47 stated they were informed by therapy they can't work with therapy, and they could not have restorative nursing services until they were approved for Medicaid insurance. In an interview on 07/24/2024 at 9:52 AM Staff G (Unit Manager - UM) stated Resident 47 was assessed to have limited ROM to both arms and both legs. Staff G stated Resident 47 should have started a RNP to prevent ADL decline, but they were not. Staff G stated they did not assess residents for RNP's and believed therapy was responsible for these recommendations. Staff G stated it was important when a resident with limited ROM finished working with therapy to continue exercises with a RNP, so they did not become contracted or develop a decrease in their ROM and mobility. <Resident 20> According to a 05/06/2024 Annual MDS, Resident 20 had no memory impairment. The MDS showed Resident 20 was [AGE] years old and originally admitted on ,d+[DATE] with a rehospitalization in December 2023 and April 2024. The assessment showed Resident 20 had diagnoses of, but not limited to, generalized muscle weakness, and difficulty in walking. Review of a 06/10/2024 nursing admission assessment/evaluation showed Resident 20 required assistance from one staff with walking daily. In an interview and observation on 07/17/2024 at 10:06 AM Resident 20 stated their right shoulder had limited ROM. Resident 20 demonstrated the inability to raise their right arm on its own by using their left hand to lift their right arm up and stated they could not even raise their right arm up to shoulder height anymore. Resident 20 stated when staff gave me the power chair, they stopped physical therapy and walking with me. Resident 20 stated walking was the one thing they really looked forward to, but staff had not been walking with them anymore. In an interview on 07/19/2024 at 10:07 AM, Staff B (Director of Nursing) stated the RNPs were removed by the higher-ups. Staff B stated the facility did not have any dedicated staff to provide RNPs to residents and was told the RNPs would be incorporated/performed by all Certified Nursing Assistants (CNA) during the provision of ADL care. Review of Resident 20's records on 07/24/2024 there was no assessment of their right arm/shoulder in the resident's chart showing the decrease in their ROM. A daily task for staff to document they assisted Resident 20 with walking 10 feet every shift showed activity did not occur for the months of October, November, December in 2023, and January, February, March, April, May, June and July 2024. In an interview on 07/24/2024 at 10:14 AM Staff G stated Resident 20 had limited ROM to their right shoulder. Staff G stated staff were to assist Resident 20 with walking daily and they should be on a RNP to prevent a decline in their level of function and ROM, but they were not. Staff G stated there was no documentation staff assisted Resident 20 with daily walking. 45720 <Resident 40> According to a 06/13/2024 Quarterly MDS, Resident 40 was understood and could understand others in conversations and had intact cognition. The MDS showed Resident 40 had functional limitation in ROM to both legs, used a wheelchair for mobility, was dependent on staff assistance with rolling side to side, bathing, and chair/bed-to-chair transfers. The MDS showed Resident 40 had no rejection of care and did not receive a RNP during the assessment period. The revised 12/28/2023 limited physical mobility CP directed staff to provide a Nursing Rehab/Restorative: Active Assist ROM program for Resident 40 three to six days per week and a Nursing Rehab/Restorative: Mobility program three times per week. During an interview on 07/16/2024 at 8:50 AM Resident 16 stated staff assisted them to get out of bed about once a week. Resident 40 stated staff don't assist them with any exercises. During an interview on 07/23/2024 at 11:19 AM Staff P (Unit Manager) stated this facility does not have a RNP, the CNAs are expected to provide this service when a resident needs it. Staff P reviewed Resident 40's revised 12/28/2023 limited physical mobility CP and stated it directs staff to provide Resident 40 with restorative exercises. Staff P reviewed Resident 40's task documentation for July 2024 and stated there were no tasks listed for staff to sign off on, therefore Resident 40 did not receive these interventions. 45941 <Resident 41> According to the 06/12/2024 Admission 5 Day MDS, Resident 41 admitted to the facility on [DATE], cognitively intact and had a diagnosis of below the right knee amputation. The assessment showed Resident 41 had impairment on both upper and lower extremities with functional limitation in ROM and was required maximal assistance for bed mobility rolling from back to left and right side, toileting, and shower. Resident 41 had no rejection of care during the assessment period. Review of the 06/07/2024 ADL CP showed Resident 41 required two staff members for repositioning in bed and for locomotion. Observations on 07/16/2024 at 10:13 AM and 12:55 PM, on 07/17/2024 at 9:10 AM, and 07/18/2024 at 12:23 PM showed Resident 41 lying in their bed on their back. In an interview on 07/18/2024 at 12:23 PM, Resident 41 stated they had only one leg and they need two staff members to get them out of bed and even to reposition in bed. Resident 41 stated they worked with therapy till end of June 2024 and after that Resident 41 did not receive any exercise. In an interview on 07/23/2024 at 11:26 AM, Staff B stated the facility did not have any dedicated RNPs to residents and was told the RNPs would be performed by all CNAs during care and sometimes activity department would perform exercise program with a group of residents. Review of Resident 41's record showed a daily task for staff to document they assisted Resident 41 with walking 10 feet every shift and staff documented activity did not occur every day. In an interview on 07/23/2024 at 1:10 PM, Staff T (Rehab Director) stated Resident 41 received rehab services from 06/06/2024 thru 06/30/2024 until insurance covered the services. Staff T stated Resident 41 had limited ROM and would benefit from more therapy or RNP to prevent a decline in their level of function and ROM, but the facility did not have RNP. <Resident 61> According to the 05/20/2024 Admission 5 Day MDS, Resident 61 admitted to the facility on [DATE], had limited ROM on right arm and required maximal assistance with personal hygiene, bed mobility, and toileting. The MDS showed Resident 61 had no behavior of refusing care during the assessment period. Review of the 05/16/2024 ADL CP showed Resident 61 was dependent on staff for ADLs and locomotion. Observations on 07/16/2024 at 9:40 AM, 07/17/2024 at 11:59 AM, 07/18/2024 at 2:45 PM showed Resident 61 was lying in their bed and was trying to get out of bed. In an interview on 07/23/2024 at 11:14 AM, Staff B stated the facility did not have any dedicated RNPs to residents and was told the RNPs would be performed by all CNAs during care. Staff B stated CNAs were assisting Resident 61 with ADLs and feeding all meals. Review of Resident 61's record showed a daily task for staff to document they assisted Resident 61 with walking 10 feet every shift and staff documented activity did not occur every day. In an interview on 07/23/2024 at 1:10 PM, Staff T stated Resident 61 was non weight bearing status on right their arm. Staff T stated Resident 61 had limited ROM and would benefit from a RNP to prevent a decline in their level of functioning and ROM, but the facility did not have a RNP. 46479 <Resident 32> According to the 06/26/2024 Quarterly MDS, Resident 32 had clear speech, was understood and could understand others in conversation, and had some impairment with their thinking/processing abilities. The MDS showed Resident 32 had limited ROM to one side of their upper extremities and to both lower extremities. The MDS showed Resident 32 did not receive restorative nursing services during the assessment period. In an interview on 07/17/2024 at 9:22 AM, Resident 32 stated they used to have a RNP but it stopped a while ago and the resident was unsure why the program ended. Review of Resident 32's .limited physical mobility . CP showed a 07/10/2022 revised intervention directing staff to assist the resident in completed upper and lower extremity ROM exercises five to seven times per week. Review of Resident 32's May 2024, June 2024, and July 2024 task report, showed staff did not offer or provide Resident 32 their RNP as care planned. <Resident 59> According to the 05/29/2024 Annual MDS, Resident 59 was understood and able to understand others in conversation. This MDS showed Resident 59 had severely impaired thinking/processing abilities. This MDS showed Resident 59 had limited ROM to one side of their upper body and one side of their lower body. The MDS showed Resident 59 did not receive RNP services for their limited ROM during the assessment period. Observation on 07/17/2024 at 8:48 AM showed Resident 59 lying in bed on their left side toward the wall. A palm protector was observed in Resident 59's left hand Review of Resident 59's limited physical mobility CP revised 11/29/2023, showed Resident 59 had generalized weakness related to a stroke and weakness to one side of their body. This CP showed a goal for Resident 59 to remain free of complications related to their immobility including contractures. Resident 59's ADL - self-care performance deficit . CP showed Resident 59 was totally dependent on staff for turning/repositioning in bed, dressing, bathing, toilet use, transfers, and personal hygiene. This CP had no directions to staff regarding the palm protector and did not indicate Resident 59 was receiving a RNP despite have limited ROM. In an interview on 07/24/2024 at 10:43 AM, Staff B stated the CNAs were expected to provide walking assistance for resident who could walk. Staff B stated other activities such as encouraging a resident to brush their hair was considered active ROM. Staff B stated the CNAs were not documenting these activities. Staff B stated they did not have a list of residents who had formal RNPs in place. Staff B stated they expected CNAs to be trained to perform RNP tasks but they were not trained. REFERENCE: WAC 388-97-1060 (3)(d).

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. The facility failed to ensure staff: consistently performed Hand Hygiene (HH) before and after resident care/contact; apply/remove Personal Protective Equipment (PPE) in accordance with the Transmission Based Precaution (TBP- implement precautions based on the means of transmission in order to prevent or control infection) signs posted outside of resident rooms; and implement interventions to prevent Legionnaires disease (a serious severe respiratory infection caused by inhalation of bacteria growing in the water system) within the facility. The facility was unable to provide documentation of completed McGeer's or Loeb's infection surveillance criteria forms for each resident with an infection who received, or was currently on, an antibiotic. These failures placed all residents and staff at risk for contracting and/or spreading infections, possible future antibiotic resistance, and a decreased quality of life. Findings included . <Facility Policies> According to a facility policy titled, Infection Prevention and Control Program (IPCP), revised 06/08/2022, the IPCP would utilize a system for prevention, identifying, reporting, investigating, and controlling infections, and communicable disease. The policy showed the program would provide infection surveillance to assist in identification of infections and communicable diseases before they can spread. The policy showed the program would provide guidance to staff on TBP to be followed, PPE use, and HH practices. The policy showed resident room assignments would be made while taking into consideration resident diagnoses and risk factors such as not placing residents with active contagious infections in a room with residents who are at greater risk of contracting an infection. This policy showed when a resident had an infection or was potentially infectious, the infection would be tracked, and interventions would be implemented to minimize the additional risks to the residents. The policy showed the facility would monitor for proper HH, use of PPE and TBP, and proper infection prevention techniques were used during wound care. According to an undated facility policy titled, Legionnaires' Disease, the maintenance director would keep logs to assure that routine preventative measures were being done for the prevention of Legionnaires Disease. According to a facility policy titled, Infection Prevention and Control Antibiotic Stewardship, revised 03/2019, the facility would utilize McGeer's and Loeb's criteria for infections and antibiotic use. <Legionella Prevention> Record review on 07/19/2024 showed no documentation of Legionella prevention. In an interview on 07/19/2024 at 8:44 AM Staff L (Maintenance Director) stated they did not know where Legionella was at higher risk of development and did not have monitoring or prevention techniques for Legionella in place. In an interview on 07/22/2024 at 8:57 AM Staff C (Infection Preventionist) stated they were not involved with the facilities Legionella prevention process. <Hand Hygiene> During an observation and interview on 07/18/2024 at 12:19 PM, Staff K (Certified Nursing Assistant - CNA) entered room [ROOM NUMBER] to bring the resident their lunch. Staff K was observed, without gloves, to move the over the bed table to the resident, assisted the resident to sit up, and set their meal tray up for them. Staff K exited room [ROOM NUMBER] without performing HH, collected room [ROOM NUMBER] lunch tray from the meal cart and proceeded to room [ROOM NUMBER]. Staff K setup 216-1 lunch tray for the resident and the resident requested fresh ice water, so Staff K collected the water pitcher and exited room [ROOM NUMBER] to collect fresh ice water for the resident at the ice machine without performing HH. Staff K then collected room [ROOM NUMBER]'s lunch tray from the meal cart and brought to room [ROOM NUMBER] without gloves or performing HH, cleared and moved the over the bed table over the resident, and setup their meal tray. Staff K collected dirty cups and glasses from room [ROOM NUMBER] and exited the room without performing HH. Staff K stated they only had to perform HH if they contacted a resident or provided care, otherwise they did not have to perform HH. In an interview on 07/19/2024 at 1:28 PM both Staff B (Director of Nursing) and Staff C stated they expected staff to perform HH before entering a room or exiting a room, between dirty and clean cares, before and after glove change, before and after resident contact, and between passing meals to residents. <Resident 41> Observation on 07/18/2024 at 9:26 AM showed Resident 41 had a bowel movement and Staff G (Unit Manager) was holding Resident 41 on their side and Staff X (CNA) was providing incontinency care to Resident 41 in their bed. Staff X was wearing gloves on both hands during providing the care. Staff X removed the dirty brief and cleaned the resident, removed one glove from their right hand and still had another glove on right hand (was wearing double gloves on right hand), did not wash their hands, grabbed the clean brief with the same gloves and put on the resident, grabbed the clean linens and fixed Resident 41's bed, put dirty linens in a bag, removed their gloves, washed their hands and left the room with the soiled linens in a bag. In an interview on 07/18/2024 at 9:39 AM, Staff X stated they were wearing double gloves on right hand because Resident 41 had Bowel movement everywhere in their bed. Staff X stated after they cleaned the resident, they removed the dirty glove from right hand and continued with changing the clean brief and linens in Resident 41's bed. Staff X stated they should have removed the dirty gloves and washed their hands between dirty to clean care, but they forgot to do so. In an interview on 07/18/2024 at 1:33 PM, Staff B stated they expected staff not to wear double gloves during any care and to perform HH before entering a room or exiting a room, between dirty and clean cares, before and after glove change. <Transmission Based Precautions> <room [ROOM NUMBER]> Observation on 07/16/2024 at 1:36 PM showed room [ROOM NUMBER] door had two signs posted: one for Enteric Barrier Precautions (EBP) for bed one and another Contact Precaution sign for bed two. Contact Precaution sign was directed staff to wear gown and gloves before entering the room. Observations on 07/17/2024 at 9:57 AM showed Staff Y (Licensed Practical Nurse - LPN) went to room [ROOM NUMBER] to administer medications to the resident. Staff Y was not wearing the gown while administering medications to the resident inside the room. In an interview on 07/17/2024 at 10:00 AM, Staff Y stated they should have followed the sign posted outside the door to wear gown and gloves, but they forgot to do so. In an interview on 07/18/2024 at 8:42 AM, Staff B stated they expected staff to follow the sign posted outside the door. <room [ROOM NUMBER]> Observation on 07/16/2024 at 11:30 AM showed room [ROOM NUMBER] door had sign posted for Contact Enteric Precautions with instructions for the staff to follow: Prior to entering the room- wash or gel hands, use soap and water upon leaving the room. Wear gown and gloves. In an interview on 07/16/2024 at 11:36 AM, Staff E (LPN) stated Resident in room [ROOM NUMBER] had C-Diff (Clostridium Difficile- contagious bacterial infection of the colon) infection and staff had to follow the sign posted on the door. Observation on 07/16/2024 at 12:05 PM showed Staff S (CNA) was delivering lunch hall trays in resident's rooms. Staff S went to deliver tray in room [ROOM NUMBER], did not wear gloves or gown when entered the room, delivered the meal tray, came outside the room, and sanitized their hands. In an interview on 07/16/2024 at 12:08 PM, Staff S stated they only had to wear gown and gloves if they contacted a resident or provided care, otherwise they did not have to wear PPE. In an interview on 07/18/2024 at 8:38 AM, Staff B stated their expectation from staff is to follow the sign posted outside the door and to wear PPE as instructed on the sign, but they did not. <McGeer's/Loeb's Infection Surveillance Criteria> In an interview on 07/19/2024 at 1:59 PM Staff B and Staff C stated they used the McGeer's and Loeb's criteria for their antibiotic stewardship/surveillance program. Review of ABO stewardship records on 07/22/2024 showed no McGeer's or Loeb assessment documentation for a sample of six residents that had taken or were currently on antibiotics. In an interview on 07/22/2024 at 8:09 AM Staff C stated the McGeer's and Loeb's criteria was documented in different software. Staff C stated it does not have the McGeer's or Loeb's documentation of the assessments and only showed a box to check yes /no if they met the criteria. Staff C stated they did not have documentation to support they completed the McGeer's or Loeb's assessment on any of the residents, so they did not have the symptoms documented that supported they met these criterions. Refer to F812 - Food Procurement, Store/Prepare/Serve - Sanitary Refer to F881 - Antibiotic Stewardship REFERENCE: WAC 388-97-1320(1)(c)(2)(b). 45720 45941

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 7 of 7 residents (Residents 94, 31, 1, 20, 26, 23, & 59) reviewed for hospitalization s. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> A facility policy titled, Admission, Transfer, and Discharge - Notice Requirements Before Transfer/Discharge, dated 07/2018, showed a notice of transfer must be provided to the resident/representative when an emergency transfer to an acute care facility is ordered. <Resident 94> Review of Resident 94's 05/10/2024 Discharge Minimum Data Set (MDS- an assessment tool) showed the resident was transferred to an acute care hospital on 05/08/2024. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 94 and/or their representative regarding their discharge. <Resident 31> Review of Resident 31's Electronic Health Record (EHR) on 07/20/2024 showed a progress note the resident was transferred to the hospital on 05/27/2024 and 06/04/2024. Review of Resident 31's 06/10/2024 Discharge MDS showed the resident was transferred to an acute care hospital on 06/04/2024. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 31 and/or their representative regarding their discharge for 05/27/2024 or 06/04/2024. <Resident 1> Review of Resident 1's 06/07/2024 Discharge MDS showed the resident was transferred to an acute care hospital on 05/28/2024. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 1 and/or their representative regarding their discharge. <Resident 20> Review of Resident 20's 12/23/2023 Discharge MDS showed the resident was transferred to an acute care hospital on 12/11/2023. Review of Resident 20's 05/03/2024 Discharge MDS showed the resident was transferred to an acute care hospital on 04/28/2024. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 20 and/or their representative regarding their discharges on 12/11/2023 or 04/28/2024. <Resident 26> According to 09/10/2023 Discharge MDS, Resident 26 discharged to an acute care hospital on 09/07/2023 with a return anticipated. Record review on 07/20/2024 showed no documentation staff provided the required written notification to Resident 26 and/or their representative regarding their discharge on 09/07/2023. 46479 <Resident 23> Review of Resident 23's 09/17/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 09/17/2023. Review of Resident 23's 09/28/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 09/27/2023. Review of Resident 23's 01/24/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on 01/24/2024. Review of Resident 23's records on 07/16/2024 at 1:44 PM showed no documentation staff provided written notifications to Resident 23 regarding their rights related to their 09/17/2023, 09/27/2023, or 01/24/2024 discharges as required. <Resident 59> Review of Resident 59's 07/12/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 07/12/2023. Review of Resident 59's 07/25/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 07/25/2023. Review of Resident 59's 10/27/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 10/27/2023. Review of Resident 59's 11/20/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 11/20/2023. Review of Resident 59's 12/04/2023 Discharge MDS showed Resident 23 discharged to an acute care hospital on 12/04/2023. Review of Resident 59's 02/07/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on 02/07/2024. Review of Resident 59's 03/01/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on 03/01/2024. Review of Resident 59's 04/29/2024 Discharge MDS showed Resident 23 discharged to an acute care hospital on 04/29/2024. Review of Resident 59's records on 07/23/2024 at 8:34 AM showed no documentation staff provided written notifications to Resident 59 or their representative regarding their rights related to their 07/12/2023, 07/25/2023, 10/27/2023, 11/20/2023, 12/04/2023, 02/07/2024, 03/01/2024, or 04/29/2024 discharges as required. In an interview on 07/23/2024 at 9:22 AM Staff A (Administrator) stated they did not have a process for written transfer notifications, so they were not being provided to any of the residents transferred to the hospitals. Staff A stated it was important to provide a written transfer notification to ensure the resident or resident representative was informed of the reason for transfer and to ensure the transfer was in alignment with the resident's stated goals for care and preferences. REFERENCE: WAC 388-97-0120 (2)(a-d).

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, and served under sanitary conditions. Facility staff failed to: consistently perform hand hygiene when preparing resident meal trays; label food items and discard expired food items from unit refrigerators; keep the kitchen dishwasher machine free from grime and debris build up; and maintain accurate documentation for the dishwasher temperature and chlorine chemical logs. These failures contributed to an unsanitary kitchen environment, placed residents at risk for food borne illness, and/or contaminated food. Findings included . <Facility Policy> Review of the facility's Food and Nutrition Services - Food Safety policy dated ,d+[DATE], showed facility staff would use good hygienic practices when handling food. This policy showed facility staff would follow manufacturer's guidelines based on the type of dishwasher used to sanitize dishware and chemical solutions would be checked for concentration levels at least once per shift. Review of the facility's Food's Brought by Family/Visitors policy revised ,d+[DATE] showed perishable foods would be stored in the refrigerator and the container would be labeled with the resident's name and use by date. The policy showed the nursing staff were responsible for discarding perishable foods on or before the use by date. <Meal Tray Service> Observation on [DATE] at 11:59 AM showed kitchen staff plating resident meals for the day's lunch service. Staff U (Dietary Aide) was placing drinks, desserts, and silverware rolled in napkins on the resident trays. Staff U was observed to have their hairnet placed behind their ears leaving hair around their eyes and forehead not contained within the hairnet. Staff U was observed to use their gloved hands to wipe their hair out of their eyes and wipe sweat away from their face using the back of their gloved hand and/or the thumb side of their hand on five occasions throughout the plating of resident meals. Staff U did not remove their gloves and perform hand hygiene during the meal service and continued wearing the contaminated gloves while touching resident drink cups, dessert plates, and rolled napkins containing silverware. During the lunch service observation on [DATE] at 12:22 PM, Staff V (Dietary Manager) was assisting with the plating of the lunch meal. Staff V wiped their face with their forearm and then rested their forearm on a large, uncovered bin of lettuce. Staff V's watch band was resting in the bin of lettuce. Staff V then used their gloved hands to adjust their shirt, walked away from the tray line, obtained a large stack of trays, and continued assisting with putting toppings like cheese and lettuce on plated lunch meals. Staff V did not change their gloves or perform hand hygiene after touching their face or shirt. <Dishwashing Machine> Observation on [DATE] at 8:40 AM of the facility's dishwasher machine showed the machine was a low temperature dishwasher machine. A sign near the machine, above the dish sink showed the dishwasher temperature should be between ,d+[DATE] degrees Fahrenheit (F) and the chemical test strips should have a result of ,d+[DATE] Parts Per Million (PPM) of chlorine (chemical used to ensure proper sanitization of dishes washed in a low temperature dishwasher machine). The sign instructed staff to dip the chlorine test strip on droplets of water leftover on dishes after a dishwashing cycle was completed. Observation of the top of the dishwasher machine at that time showed a large amount of rust colored debris, crumbs, and grime build-up. Observation on [DATE] at 8:49 AM showed Staff W (Cook) and Staff V running a test cycle on the dishwasher machine. Staff W placed dishware in the dishwasher machine, took a chemical test strip and placed it on a dish, closed the dishwasher, and ran a cycle. When the cycle was complete, the chemical test strip was washed off the dish and down into the drain. Staff W and Staff V repeated the same process again and the chemical test strip was washed away in the machine by the end of the cycle. On the third attempt, the instructions on the sign on the wall were pointed out the the kitchen staff. At that time, staff performed the chemical test strip per the instructions. Staff V's test strips remained unchanged, indicating the chlorine chemical was ineffective. In an interview at that time, Staff V stated they were having issues with their test strips and needed to obtain new ones. Observation on [DATE] at 9:03 AM of a cycle of the dishwasher machine showed the machines temperature during the wash cycle was 150 degrees F and the rinse cycle was 157 degrees F. Review of the facility's [DATE] Dish Machine Log showed on 74 dishwashing cycles, the facility staff documented the dishwasher temperature was above 140 degrees F temperature for the low temperature machine. This same log showed staff documented the PPM of chlorine was greater than the indicated ,d+[DATE] PPM range on 30 occasions. The bottom of the Dish Machine Log showed directions to staff that a low temperature dishwasher machine's wash and rinse cycle should be between ,d+[DATE] degrees F. There was a spot on the form reading: Manufacturer's Recommended PPM with a blank area to be filled in. This was left blank. In an interview on [DATE] at 8:50 AM, Staff V confirmed the discrepancies on the Dish Machine Log. Staff V confirmed the dishwasher temperature was high during the test cycle and the machine needed to be checked. <Unit Refrigerators/Freezers> Observation on [DATE] at 5:26 AM of the [NAME] Hall unit refrigerator/freezer showed a sign on the door directing staff that the refrigerator was for resident items only. The sign showed the food items must have a name, date, room number, and the item must be tossed after three days. Observation of the freezer showed a coffee mug containing an opened, unlabeled ice cream sandwich with a bite taken out of it. The back of the freezer contained an unlabeled and undated plastic cup with a slice of cake and a spoon. The freezer contained one ice cream cake dated [DATE] and another ice cream cake dated ,d+[DATE]. Observation on [DATE] at 5:43 AM showed the East Hall unit refrigerator/freezer contained three yogurts with a handwritten date of ,d+[DATE], a piece of cake unlabeled and undated, and three meals in food storage containers and/or fast-food bags without resident names or dates. The refrigerator contained a grocery bag with three food containers. The bag had a resident name but no date. The refrigerator also contained an undated pizza box and a grocery bag that had two chicken breasts, a package of four yogurts, and two bags of store-bought hard-boiled eggs. The bag was unlabeled and undated. In an interview on [DATE] at 11:53 AM, Staff A (Administrator) stated it was their expectation staff changed gloves and performed hand hygiene after touching their face. Staff A stated they expected staff disposed of food in unit refrigerators after three days. REFERENCE: WAC [DATE](3), -2980.

Based on observation, interview, and record review, the facility failed to ensure Care Plans (CPs) were accurately reviewed and revised to reflect current resident status and needs as required for 5 (Residents 41, 61, 6, 68, & 32) of 20 residents reviewed for CP's. This failure left residents at risk for unmet care needs and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's Quality of Care policy, revised 08/2018, showed the resident's CP would reflect person-centered care and include resident choices, preferences, goals, concerns, and needs. The CP would describe the care and services staff would provide to the resident so the resident could attain or maintain their highest practicable physical, mental, and psychosocial well-being. <Resident 41> According to the 06/12/2024 Admission 5 Day Minimum Data Set (MDS - an assessment tool), Resident 41 admitted to the facility on [DATE] with two pressure ulcers (PUs). Resident required maximal assistance with bed mobility and toileting needs. Review of Resident 41's record showed Resident 41 had PUs on right buttock and left buttock. Review of the 06/11/2024 Skin CP showed Resident had a coccyx PU and was at risk for new PU development. Nursing interventions included Resident 41 preferred to be repositioned with two staff members. Observations on 07/18/2024 at 9:39 AM during wound care showed Resident 41 had PU on right buttock and left buttock. There was no PU on Resident 41's coccyx area. In an interview on 07/18/2024 at 10:22 AM, Resident 41 stated staff did not offer or assist the resident to reposition in bed. In an interview on 07/18/2024 at 10:45 AM, Staff G (Unit Manager - UM) stated Resident 41 had PUs on their right and left buttock. In an interview on 07/22/2024 at 10:02 AM. Staff B (Director of Nursing) stated they knew the facility had a CP issue. Staff B stated Resident 41 did not have a PU on coccyx area and the CP is inaccurate. Staff B stated nursing staff should have reviewed the CPs and updated according to the resident's status, but they did not. <Resident 61> According to the 05/20/2024 Admission 5 Day MDS, Resident 61 admitted to the facility on [DATE] and had moderately impaired memory. Review of the 05/16/2024 Medication CP showed Resident 61 received Intravenous (IV- needle inserted into a vein to provide medication or fluids) medications and nursing interventions included instructions for nursing staff to monitor IV dressing site every shift. Review of the July 2024 medication administration record showed Resident 61 received no IV medication. Observation on 07/18/2024 at 9:21 AM showed no IV insertion site or dressing on Resident 61's body. In an interview on 07/18/2024 at 11:21 AM, Staff E (Licensed Practical Nurse) reviewed Resident 61's record and stated Resident 61 had no IV medication orders. In an interview on 07/22/2024 at 10:02 AM, Staff B stated the CP was not accurate. Staff B stated nursing staff should have reviewed the CPs and updated according to the resident's status, but they did not. 45720 <Resident 6> According to the 06/07/2024 Quarterly MDS Resident 6 was independent with lying to sitting on side of bed, sit to stand, chair-to-bed/bed-to-chair transfer, toilet transfer, and walked ten feet. This MDS showed Resident 6 had intact cognition. During an interview on 07/16/2024 at 9:07 AM Resident 6 stated they transferred from their bed to their wheelchair or walker and back to their bed independently. Review of Resident 6's Potential for Alteration in Activities of Daily Living CP on 07/18/2024 at 8:46 AM showed the CP had contradicting information. One intervention stated the resident required supervision or partial assistance of one staff for transferring. Another intervention stated Resident 6 was able to transfer on their own. Review of Resident 6's bedside Kardex on 07/18/2024 at 9:00 AM showed Resident 6 required substantial to maximal assistance by one staff to turn and reposition in bed, was independent with bed mobility, was able to transfer on their own, and required supervision or partial assistance of one staff for transferring. During an observation on 07/18/2024 12:16 PM Resident 6 went from lying in bed to sitting on the edge of their bed independently. During an interview on 07/23/2024 at 11:21 AM Staff P (UM) stated Certified Nursing Assistants used the CP and Kardex for information on what care to provide for each resident. Staff P stated it was important to update or revise CPs to ensure proper care was provided to the residents. During an interview on 07/23/2024 at 11:28 AM Staff P stated Resident 6 was mostly independent with bed mobility and transfers. Staff P stated the CP and Kardex should be revised to reflect Resident 6's current care needs. 46479 <Resident 68> Review of the 05/29/2024 Quarterly MDS showed Resident 68 had severe impairment to their thinking abilities. This MDS showed Resident 68 was receiving hospice (end of life care) and had a life expectancy of less than six months. Review of Resident 68's Comprehensive CP on 07/23/2024 at 1:30 PM showed the CP was not revised to include goals or interventions related to Resident 68's hospice services. There were no instructions to staff indicating what care and services hospice staff provided to Resident 68. There were no instructions to staff regarding what measures to implement for Resident 68's comfort or directions for coordination between hospice and the facility. In an interview on 07/23/2024 at 1:35 PM, Staff B stated it was important for CPs to be updated and revised to ensure staff were providing the correct care for residents. Staff B reviewed Resident 68's CP and confirmed it needed to be updated to reflect Resident 68's hospice status. <Resident 32> Review of the 06/26/2024 Quarterly MDS showed Resident 32 had one fall since their admission to the facility. This MDS showed Resident 32 had no behaviors or rejection of care during the assessment period. Review of Resident 32's 07/02/2024 revised Fall CP showed an intervention directing staff to keep Resident 32's bed in a low position. Observations on 07/17/2024 at 9:18 AM and 07/22/2024 at 9:29 AM showed Resident 32 lying in bed. Resident 32's bed was not in the low position. In an observation and interview on 07/23/2024 at 2:03 PM, Resident 32 was lying in bed with the bed not in the low position. At that time, Resident 32 stated they did not like their bed in the low position because it affected their sleep. At that time, Resident 32 grabbed their bed controller and demonstrated how they could independently raise their bed up and down. In an interview on 07/23/2024 at 1:17 PM, Staff B stated Resident 32's bed should be in the lowest position, but the resident was able to position their bed independently. Staff B stated the CP should be updated to identify Resident 32's non-compliance with their plan of care, but the CP was not. REFERENCE: WAC 388-97-1020(5)(b).

Based on interview and record review, the facility failed to inform residents or their assigned representatives in advance of the risks and benefits associated with psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), and obtain resident consent prior to implementing the proposed treatments/therapies for 2 of 5 residents (Residents 61 & 34) reviewed for unnecessary medications. The failure of facility staff to obtain consent for psychotropic medications prior to administration detracted from the residents' and/or their representative's ability to exercise their right to make an informed decision about proposed treatments, and prevented the residents and their representative from exercising their right to decline the treatments/therapies. Findings included . <Facility Policy> The facility's revised 10/04/2022 Psychotropic Medication policy showed residents who used psychotropic drugs would be educated on the risks and benefits of psychotropic drug use. <Resident 61> According to the 05/20/2024 Admission 5 Day Minimum Data Set (MDS - an assessment tool) Resident 61 had moderately impaired cognition (impaired memory and problem solving) and had diagnoses of schizophrenia (mental disorder affects a person's ability to think, feel and behave), anxiety, and depression. The MDS showed Resident 61 regularly used Antipsychotic (AP), Antianxiety (AA), and Antidepressant (AD) medications. Review of Resident 61's records showed no consent was obtained for the psychotropic medications prior to implementing the medications. In an interview on 07/23/2024 at 11:07 AM Staff B (Director of Nursing) stated they expected staff to explain risk and benefits for psychotropic medications to residents or their representative prior to implementing the treatments. Staff B reviewed Resident 61's record and stated there was no documentation for consent at the time of order for the psychotropic medications for Resident 61. Staff B stated staff should obtain consent prior to implementing the medications for Resident 61, but they did not. 45720 <Resident 34> According to 04/15/2024 Admission MDS, Resident 34 had a diagnosis of dementia with agitation. The MDS showed Resident 34 received AP medication. Review of Resident 34's records showed a court order that appointed full guardianship and full conservator for Resident 34 on December 21, 2023. Review of Resident 34's record showed AP Medication Informed Consent, was consented to by Resident 34's family member over the telephone on 4/9/2024. Review of Resident 34's record did not show documentation that the risks and benefits of the medication were discussed, either verbally or written, with the resident or their representative/legal guardian, prior to the resident receiving the medication. During an interview on 07/24/2024 10:08 AM, Staff Q (Social Services Assistant- SSA) and Staff R (SSA) stated if a resident had a guardian, the guardian needed to consent to and be informed of risks and benefits for AP medications. REFERENCE: WAC 388-97-0260(1)(a)(b)(i)(ii)(iii).

Based on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 1) reviewed for Pressure Ulcers (PU) received care and services, in accordance with professional standards of practice, to promote healing of existing PUs and prevent the development of avoidable PUs. The facility failed to accurately assess the resident's clinical condition, identify factors that increased the risk for skin breakdown, ensure the development and implementation of a resident specific plan of care, provide ongoing assessment of existing PUs, and to ensure provision of care as ordered by a Physician. These failures placed the resident at risk for unidentified deterioration of existing wounds, and caused harm to Resident 1, when the resident developed an avoidable, full thickness PU to their occiput (back of head). Findings included . According to the facility's 08/2018 Quality of Care Skin Integrity policy, the facility would, based on the resident's assessment, provide care consistent with professional standards of practice to prevent and heal PUs. If the resident had an identified PU, a weekly evaluation of the PU would be documented, to include: Location and staging; measurements, including the depth and any undermining or tunneling; exudate, if present (type, color, odor, amount); wound bed status; description of wound edges and surrounding tissue. The comprehensive assessment will provide the basis for defining approaches to address residents at risk for developing PUs. The facility will evaluate resident specific risk factors and changes in the resident's condition that may impact the development of PU. Residents identified as at risk for development of PUs will have individualized interventions implemented. RESIDENT 1 According to the 02/18/2021 Admission Evaluation Resident 1 was assessed to have Deep Tissue Injuries (DTI) to both heels and a PU on the left neck. The assessment did not include staging of the PU on the neck, wound descriptions, or measurements. Record review showed Resident 1 was admitted to the facility on [DATE], status post [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 02/25/2021 Admission Minimum Data Set (MDS, an assessment tool), the resident required aftercare for spinal surgery, was cognitively intact with clear comprehension, required extensive assistance with bed mobility, transfers, toileting and hygiene, and was assessed at risk for PUs, but had no current or healed PUs. Resident 1's PU Care Area Assessment (CAA) indicated a history of, but no current, PUs to the heels and neck. Staff assessed Resident 1 was at risk for PUs, due to incontinence of bowel and bladder and decreased bed mobility. The CAA did not identify Resident 1 wore a CTO or address the potential risks it presented to Resident 1's skin integrity. Review of Resident 1's 02/18/2021 Care Plan (CP) showed no Actual PU or Actual alteration in skin integrity CP had been developed. A 02/18/2021 Potential for alteration skin integrity CP, identified Resident 1's risk factors as incontinence of bowel and bladder, and decreased bed mobility. Interventions included: keep skin clean and dry; Heel protector boots; avoid scratching; and keep hands and body parts from excessive moisture. There was no mention of the three PUs identified on admit, Resident 1's use of a CTO, the potential risks it presented, or instruction to staff on how to manage it or mitigate the risks for skin breakdown. Review of the February and March 2021 Treatment Administration Records (TAR) on 03/23/2021 showed facility nurses continued to sign they were monitoring the pressure area to Resident 1's left neck, for signs and symptoms of infection twice a day, and that they cleansed the DTIs to Resident 1's bilateral heels with normal saline and applied skin prep daily. In an interview on 03/26/2021 at 11:57 AM, Staff J, Admission Nurse, stated while performing her admission assessment, she observed the DTIs to Resident 1's bilateral heels, and the PU to left neck. Record review on 03/26/2021, showed no indication facility staff had assessed any of the three identified PUs since the day of admission, greater than five weeks prior. In an interview on 03/26/2021 at 1:25 PM, Staff B, Director of Nursing, acknowledged Resident 1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if there was any indication Resident 1's PUs were assessed weekly, or at all, in the past five weeks Staff B stated, No. Record review showed a 03/15/2021 neurosurgery consult that indicated when they removed Resident 1's CTO, an eschar (dead tissue) covered PU on the right occiput was obscured. Resident 1's CTO was discontinued at that time. During an interview on 03/19/2021 at 2:00 PM, Resident 1 reported that facility staff never removed her CTO. She indicated on two occasions, staff loosened the bottom of the CTO to provide a bed bath, but the cervical collar was never loosened or removed. When asked how staff performed her skin check, Resident 1 stated that staff did not do skin checks. According to the February and March 2021 TARs, from 02/18/2021-03/15/2021, facility nurses signed three times a day that the CTO was to remain in place at all times, except for skin checks. Head to toe skin checks were documented as performed on 02/19/2021, 02/26/2021, 03/05/2021, and 03/12/2021. The 02/26/2021, 03/05/2021, and 03/12/2021 skin checks were performed by Staff G, Registered Nurse, who documented a 9 (other/ see progress notes.) Record review showed no progress notes were present that addressed Resident 1's skin checks. In an interview on 04/14/2021 at 6:18 AM, Staff G stated she did not remove Resident 1's CTO as ordered, when performing her skin checks because she didn't know how, and explained that is why she documented 9. A 03/26/2021 skin and wound evaluation, assessed the wound to Resident 1's occiput as an unstageable (depth hidden by dead tissue) PU, with obscured full skin and tissue loss. The National Pressure Injury Advisory Panel states an unstageable PU, with obscured full-thickness skin and tissue loss, is either a Stage 3 PU (full thickness- with fat tissue is visible, but not muscle, tendon, ligament, bone) or Stage 4 PU (full thickness- with exposed muscle, bone, tendon, ligament, fascia). During a telephone interview on 04/06/2021 at 1:10 PM, Staff B, Director of Nursing, acknowledged that the facility failed to remove Resident 1's CTO, and cleanse or visualize the skin under her cervical collar for 26 consecutive days. Reference: WAC 388-97-1060(3)(b).

Based on interview and record review, the facility failed to ensure Physician's orders (POs) were accurately and timely processed, transcribed, and implemented for two (#1 & 3) of three residents reviewed. The facility's trendable pattern of failed or delayed implementation, inaccurate transcription, and/or failure to follow POs, resulted in significant medication errors, and caused harm to Resident #3. Findings included . Refer to CFR 483.25, F-692, Nutrition/Hydration Status Maintenance, 483.21(b)(3)(i), F-658, Services Provided Meet Professional Standards RESIDENT #3 Resident #3 admitted to the facility on [DATE]. According to the 06/13/2020, Admission Minimum Data Set (MDS, an assessment tool), the resident had moderate cognitive impairment, [DIAGNOSES REDACTED]. According to the facility's 06/06/2020 admission assessment, and provider notes dated 06/08/2020, and 06/12/2020, Resident #3 had no [MEDICAL CONDITION]. A 06//22/2020 provider note indicated Resident #3 was seen due to .Shortness of breath (SOB) .(Resident) reports of shortness of breath which occurred over the weekend .chest x-ray ordered and revealed [MEDICAL CONDITION] congestion . no [MEDICAL CONDITION] .patient started on [MEDICATION NAME] (a diuretic) . The conclusion of the 06/22/2020 chest x-ray, was Modest left basilar (lower) infiltrate (small areas of collection in the lung tissue, due to various causes) and mild congestion. There were no adverse findings to the right upper, mid or lower lobes. Review of the June 2020 PO's showed a 06/11/2020 order to obtain weekly weights (wts), and a 06/22/2020 order to start [MEDICATION NAME] 20 mg (milligrams) daily, for three days for shortness of breath. According to the June 2020 Medication Administration Record [REDACTED]. On 06/25/2020 Resident #3 was re-assessed by the provider who documented No further reports of shortness of breath, however, (had) occasional oxygen desaturation requiring oxygen via nasal canula. The resident was also assessed with [REDACTED]. Subsequently, the provider directed staff to Continue [MEDICATION NAME]. However, record review showed the 06/25/2020 continue [MEDICATION NAME] order was never carried out. During an interview on 07/30/2020 at 4:37 PM, Staff A, Administrator, and Staff F, Resident Care Manager, acknowledged there was a 06/25/2020 order to continue [MEDICATION NAME]. When asked if the order had been carried out and implemented, both Staff A and Staff F stated, No. According to a 06/26/2020 nurses note Resident #3 was now assessed to have left leg [MEDICAL CONDITION] .from the upper (thigh) at +2 pitting to the top of the foot +3 pitting . In an interview on 07/30/2020 at 4:40 PM, when asked if he 2-3+ [MEDICAL CONDITION] to the resident's left leg from foot to thigh was worse than previously assessed Staff A and Staff F stated, yes. On 06/29/2020 Resident #3 was again seen by the provider who assessed .occasional oxygen desaturation, requiring oxygen via nasal canula (and) left leg [MEDICAL CONDITION] . Facility staff were directed to Continue [MEDICATION NAME] and repeat chest x-ray given continued intermittent oxygen desaturation. Record review revealed the resident was on alert for a new [MEDICATION NAME] order, and the facility nurses were documenting daily that Resident #3 had no adverse side effects. Yet no one identified that they had not been administering the [MEDICATION NAME] since 06/24/2020. The 06/29/2020 chest x-ray showed Mild bilateral (both sides) lung base infiltrates and a mild right upper lung infiltrate. There is a small left pleural effusion (fluid in the chest space but outside the lung). A small right pleural effusion cannot be ruled out. The report noted there was .worsening of the right upper lung and right lung base compared to 06/22/2020. The 06/22/2020 chest x-ray showed no adverse findings to the right lung, nor was there a right to left pleural effusion. Review of Resident #3's weekly wts showed the following: 06/11/2020- 158 lbs ; 06/18/2020- 157.6 lbs; 06/25/2020 no wt was recorded; and on 06/29/2020 and 06/30/20 the resident weighed 181 lbs, revealing a 23 lbs wt gain in 11 days. Review of the June 2020 MAR indicated [REDACTED] According to 07/02/2020 nurse's notes: at 10:58 AM the resident was identified with a 4 lbs wt gain in 24 hours (now 184 lbs), and had 2 + [MEDICAL CONDITION] to both lower extremities; at 11:20 AM the nurse documented the resident was given an additional dose of 20 mg [MEDICATION NAME]; and at 11:35 AM nursing received a new order to start [MEDICATION NAME] 40 mg twice daily (quadrupling the previous dose). Review of the July 2020 MAR indicated [REDACTED]. Additionally, the new order for [MEDICATION NAME] 40 mg twice daily, that was received by 11:35 AM on 07/02/2020, was to start on 07/03/2020 at 6:00 AM. This resulted in the 07/02/2020 afternoon dose of [MEDICATION NAME] 40 mg not being administered. During an interview on 07/31/2020 at 3:16 PM, when asked if there was any indication Resident #3 received the additional dose of [MEDICATION NAME] 20 mg on the morning of 07/02/2020 as ordered, Staff B stated, No. When asked when the [MEDICATION NAME] 40 mg order should have been implemented Staff B indicated Resident #3 should have received 40 mg of [MEDICATION NAME] that evening (07/02/2020). When asked if that occurred Staff B stated, No. A 07/02/2020 8:15 PM nurses note indicated Resident #3 had a unwitnessed fall in his room. Upon assessment it was identified the resident had: right hip pain 10/10 (a pain scale which 10 is the most severe pain and 0 being no pain), but range of motion was intact; an irregular pulse of 149; and a 2.5 inch laceration to the back of his head. The resident was subsequently transported to the emergency room for evaluation. Review of the 07/02/2020 fall investigation showed the facility concluded It is reasonable to believe fall occurred due to acute change in medical status pertaining to the [MEDICAL CONDITION] congestion and weakness. Facility staffs' recurrent failure to carry out, accurately transcribe, and administer Resident #3's [MEDICATION NAME] as ordered, resulted in increased fluid retention, increased LE [MEDICAL CONDITION], significant weight gain, worsening lung/respiratory function (required supplemental oxygen), and ultimately (according to the facility fall investigation) contributed to Resident #3's fall, which resulted in a [MEDICAL CONDITION] and hospitalization . RESIDENT #1 Resident #1 admitted to the facility on [DATE]. According to the 05/15/2020, Quarterly MDS, the resident was assessed with [REDACTED]. This MDS indicated the resident required diuretic medications on all days of the assessment period. Record review showed Resident #1 was followed by Pulse Heart Institute (PHI), a Cardiac Care Clinic. [MEDICATION NAME] (a cardiac medication) According to Physician Orders (POs) dated 02/26/2020, staff were directed to administer [MEDICATION NAME] daily and to hold for (systolic blood pressure less than) 100 or pulse (less than) 60. According to the April and May 2020 Medication Administration Records (MARs), staff assessed the resident with a pulse of less than 60 on 04/02/2020, 04/03/2020, 04/10/2020, 04/11/2020, 04/12/2020, 04/20/2020, 05/09/2020, and 05/29/2020, but administered the medication despite instructions to hold the medication. Administration of cardiac medication outside physician ordered parameters placed this resident at risk for falls and medical complications. During an interview on 06/19/2020 at 12:46 PM, Staff B, Director of Nursing, stated nursing staff should have held the medication as directed and failure to do so constituted a medication error. According to PHI consult documents dated 04/15/2020, staff were directed to, Please decrease to Metroprolol (a cardiac medication) to 12.5 mg once daily. Patient has been bradycardic on last few visits and virtual visit. Review of April 2020 MARS showed that while staff initiated this order on 04/16/2020, nursing staff failed to administer this medication on 04/16/2020. During an interview on 06/19/2020 at 12:46 PM Staff B acknowledged the medication should have been administered on 04/16/2020, but was not. [MEDICATION NAME] (a diuretic) According to PHI consult documents dated and timed 04/15/2020 at 9:49 AM, staff were directed to, Increase [MEDICATION NAME] to 60 mg in the morning and 30 mg in the afternoon. Dosing times are 60 mg PO (orally) [MEDICATION NAME] at (7:00 AM) and 30 mg PO [MEDICATION NAME] at (2:00 PM). Please give the 60 mg PO [MEDICATION NAME] this afternoon at (2:00 PM) then switch to the 60 mg in the morning and 30 mg in the afternoon for the next three days. We will follow up on Friday (04/17/2020) to assess if patient has had weight loss and/or improvement to symptoms at which time we will decide diuretic dose going forward . The PHI consult included directions Take 60 mg in the morning and 30 mg in the afternoon the next three days. Decrease to 40 mg BID (twice a day) unless otherwise directed. Despite receiving the PHI order recommendations at 9:49 AM, according to the April 2020 MAR, nursing staff failed to implement the 60 mg of [MEDICATION NAME] at 2:00 PM as directed on 04/15/2020. According to the MAR, on 04/16/2020, nursing staff administered 60 mg at 3:50 PM, contrary to the PHI directions of 30 mg at 2:00 PM. Record review showed no physician order was obtained to administer 60 mg on the evening 04/16/2020. In an interview on 06/19/2020 at 3:20 PM, when asked why Resident #1 was administered 60 mg of [MEDICATION NAME] on the evening of 04/16/2020, when the order was for 30 mg Staff B explained .because the 60 mg was not administered on the evening of 04/15/2020 as ordered, Staff C, Resident Care Manager, likely scheduled it for 04/16/2020 to make it up. When asked if an order was obtained to do that Staff B stated, No. Review of the April 2020 MAR indicated [REDACTED]. Review of Resident #1's orders showed the resident was to receive [MEDICATION NAME] 60 mg at 7:00 AM and 30 mg at 2:00 PM. There was no order found to administer an additional 60 mg at 5:28 AM. During an interview on 06/19/2020 at 12:47 PM, when asked why the resident was administered an additional 60 mg of [MEDICATION NAME] at 5:28 AM, Staff B, indicated it resulted from a data entry error. When asked if the resident had an order for [REDACTED]. Additionally, review of the April 2020 MAR indicated [REDACTED]. In an interview on 06/26/2020 at 11:41 AM, Staff B explained that the order on the front page of the 04/15/2020 consult directed staff to administer [MEDICATION NAME] 60 mg at 7:00 AM and 30 mg at 2:00 PM times three days. Thus, the order for [MEDICATION NAME] was completed and the weekend nurses did not have further instructions. When asked to read the instruction on the back of the consult Staff B confirmed that it directed staff to see the end of the after visit summary for complete medication list. The medication list stated, Take 60 mg ([MEDICATION NAME]) in the morning and 30 mg in the afternoon the next three days. Decrease to 40 mg BID unless otherwise directed. Staff B then confirmed facility staff missed those instructions, which subsequently resulted in further medication errors. In an interview 06/19/2020 at 2:55 PM, when asked if the facility had a system by which they audited consults, order input, or the MAR indicated [REDACTED].not unless there is a complaint. REFERENCE: WAC 388-97-1060(3)(k)(ii).

Based on observation, interview, and record review, the facility failed to ensure residents received the care and services they were assessed to require, in accordance with professional standards of practice, and, the comprehensive person-centered care plan. The facility failed to ensure two (#s 1 & 3) of three residents reviewed received services related to [MEDICAL CONDITION] monitoring and management, and two (#s 1 & 2) of three residents reviewed received services related to non pressure skin issues. These failures resulted in harm to Resident #1 and placed other residents at risk for a decline in medical status and quality of life related to unmet care needs. Findings included . Refer to CFR: 483.21(b)(3)(i), F-658, Services Provided Meet Professional Standards 483.25, F-692, Nutrition/Hydration Status Maintenance 483.45(f)(2), F-760, Residents are free of Significant Med Errors RESIDENT #1 Resident #1 admitted to the facility on [DATE]. According to the 05/15/2020, Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had multiple medically complex [DIAGNOSES REDACTED]. The record review showed Resident #1 had a 01/08/2020 order for [MEDICATION NAME] (a diuretic) 30 mg (milligrams) twice daily for [MEDICAL CONDITION], and was followed by Pulse Heart Institute (PHI), a Cardiac Care Clinic, for [MEDICAL CONDITION] management. The resident also had a 03/19/2020 order to obtain wts every every Monday and Thursday, and notify the MD (Doctor) of a wt gain of three or more pounds (lbs). According to a 03/28/2020 [MEDICAL CONDITION] care plan (CP), staff were directed to monitor, document and report signs and symptoms of [MEDICAL CONDITION] including: dependant [MEDICAL CONDITION] of legs and feet; periorbital (around the eyes) [MEDICAL CONDITION]; SOB (shortness of breath) upon exertion; orthopnea (SOB when lying flat); distended neck veins; and wt gain unrelated to intake. In a telephone interview on 06/17/2020 at 12:27 PM, when what the facility's process or method was for [MEDICAL CONDITION] monitoring, Staff B, Director of Nursing, explained that [MEDICAL CONDITION] assessments should include, type of [MEDICAL CONDITION], brawny (non-pitting) versus pitting. If [MEDICAL CONDITION] was present, nurses should assess the degree of [MEDICAL CONDITION] (0-4+) and indicated nurses would document these assessments in their progress notes During an interview on 06/19/2020 at 12:00 PM, for clarification, Staff B was asked if 2+ pitting pedal (foot/ankle) [MEDICAL CONDITION], had the same clinical significance as 2+ [MEDICAL CONDITION] that extended from the foot up to the mid thigh? Staff B stated, No and indicated nurses should also document the extent of the [MEDICAL CONDITION], acknowledging that failure of nurses to document the extent, could detract from their ability to determine if the [MEDICAL CONDITION] was improving or worsening. According to a 02/25/2020 PHI consult Resident #1 had 0 [MEDICAL CONDITION]. A 04/02/2020 provider note stated the resident had +2 [MEDICAL CONDITION] to bilateral lower extremities (LEs). Review of the weight summary flowsheet for the two weeks preceding 04/02/2020, showed the following: 3/19/2020, 273 lbs (pounds); 03/26/2020, 272.5 lbs; and on 04/02/2020, 285 lbs. (12.5 lbs wt gain in seven days.) Review of the progress notes showed no indication staff identified the significant wt gain or notified the Physician as ordered until 04/05/2020, three days later. The 04/05/2020 nurses note acknowledged Resident #1's 12.5 lbs wt gain in one week, and indicated the ARNP (Advanced Registered Nurse Practitioner) was notified, and a reweigh would be obtained. The note did not include an assessment of the resident, her [MEDICAL CONDITION], or fluid volume status. On 04/06/2020 the resident was re-weighed at 282.2 lbs, confirming the resident had a 10 lbs wt gain. A 04/07/2020 progress note confirmed the 10 lb wt gain and stated, Increased wt due to pre-existing +2 [MEDICAL CONDITION] on bilateral lower extremities. ARNP notified. No explanation was provided as to how the resident gained 10 lbs in just over a week, if the [MEDICAL CONDITION] was pre-existing. Again, there was no indication staff assessed the resident, or her [MEDICAL CONDITION]. The resident's progress notes were reviewed up to 04/15/2020. There was no further mention of the resident's wt gain, or indication staff were assessing/monitoring her [MEDICAL CONDITION]. On 04/15/2020 Resident #1 had a telehealth consult with PHI. Per the consult Resident #1 reported Over the last month she had increases in swelling to her bilateral LEs (lower extremities) despite wearing TED (compression) hose, and that (her legs) were so swollen and tight, they hurt. The PHI practitioner concluded Resident #1 was .volume overloaded with increase (sic) swelling of bilateral LE and wt gain of 20 lbs (from prior visit on 02/25/2020, which PHI had a documented wt of 260 lbs). PHI recommended: 1) Daily wts for the next week, if wt gain > (greater than) 3 lbs in one day or 5 pounds in 3 days, please call our office immediately. 2) Increase [MEDICATION NAME] to 60 mg in the AM and 30 mg in the PM for three days, then give [MEDICATION NAME] 40 mg twice daily, unless otherwise directed. Review of the April 2020 MAR indicated [REDACTED]. The order for daily wts was not initiated until 04/20/2020, five days later. Additionally, the parameters directing staff when to notify the PHI clinic of wt gain, were not transcribed. In an interview on 06/26/2020 at 11:41 AM, Staff B acknowledged the six [MEDICATION NAME] medication errors and indicated they were due to data entry errors. According to Staff B, the delay in implementation of of the daily wts was because the nurse understood Daily wts for the next week to mean, start them the next week. When asked how staff would know when to notify the MD, in absence of the ordered parameters Staff B stated, they wouldn't. A 04/15/2020 acute CP directed staff to Assess and Document [MEDICAL CONDITION] on all shifts. Review of the progress notes showed staff failed to assess and document Resident #1's [MEDICAL CONDITION] on all shifts, as she was assessed to require. On the shifts the resident's [MEDICAL CONDITION] was assessed, staff only documented e.g. continues with 2+ [MEDICAL CONDITION] to bilateral lower extremities. The extent of the [MEDICAL CONDITION] was not assessed. During an interview on 06/19/2020 at 12:00 PM, Staff B acknowledged the nurses failed to asses and document the resident's [MEDICAL CONDITION] all shifts and consistently failed to document the extent of [MEDICAL CONDITION]. Staff G, Regional Nurse Consultant, explained the facility had moved away from assessing [MEDICAL CONDITION] to determine fluid volume status related to [MEDICAL CONDITION], due to inconsistencies in how nurses graded the [MEDICAL CONDITION]. Staff G indicated the facility was now utilizing weights, as they were more accurate. However, Staff G did acknowledge that both the comprehensive and acute CPs directed staff to assess and monitor the residents [MEDICAL CONDITION]. Review of the daily wts from 04/20/2020 through 04/30/2020, showed the facility only obtained the wts on six of the 11 days. During an interview on 06/19/2020 at 12:00 PM, when asked if the resident was being weighed at the frequency she was assessed to require Staff B stated, No and acknowledged that could result in a delay in identification of wt gain. Review of the May 2020 Medication Administration Record [REDACTED]. A review of Resident #1's May 2020 wts showed, on 05/04/2020 the resident weighed -279.6 lbs. The next wt was obtained was 05/07/2020 at 285 lbs, showing a 5 lbs wt gain. Record review showed no indication facility staff identified the wt gain, or notified the doctor as ordered. On 05/13/2020 Resident #1's [MEDICATION NAME] was decreased to 40 mg daily secondary to a critical BUN (Blood, Urea, Nitrogen) level of 74. On 05/18/2020 Resident #1 weighed- 284 lbs. The next wt obtained on 05/21/2020 was 291 lbs, showing a 7 lb wt gain in three days, and a 12 lb wt gain since 05/04/2020. Again, record review showed no indication staff identified the wt gain, notified the doctor as ordered, assessed the resident, or considered the correlation of the decreased [MEDICATION NAME] and subsequent increased wt. During an interview on 06/23/2020 at 12:30 PM, when asked if there was any indication staff identified the above wt gains, assessed the resident, and notified the doctor, Staff B stated, No. On 06/02/2020 Resident #1 was seen by PHI via telehealth. According to the encounter note the resident reported .an increase in [MEDICAL CONDITION] to her bilateral LEs. She is quite miserable with her lower extremity swelling .experiences some orthopnea when lying flat .she was (also) noted to be experiencing hypervolemia (fluid overload) back in April at this visit .(Resident #1) is in need of IV (intravenous) diuretics and perhaps direct admit. PHI subsequently ordered an additional 40 mg of [MEDICATION NAME] to be given 06/02/2020, and scheduled an in person appointment for 06/03/2020. Review of Resident #1's progress notes from 05/27/2020 to 06/02/2020 (the 7 days preceding the 06/02/2020 PHI consult) revealed no indication any nurse assessed the resident's [MEDICAL CONDITION], fluid volume status, or identified the resident's weight gain until after the PHI appointment. A 06/02/2020 4:12 PM, nurses note stated, .Cont(inues) with BLE (bilateral LE) [MEDICAL CONDITION]. The nurse did not grade or evaluate the extent of the [MEDICAL CONDITION]. On 06/03/2020 Resident #1 was seen at PHI. They assessed the resident with Significant wt gain .increase in swelling and bloating .her legs are openly weeping, [MEDICAL CONDITION] to above the knees, JVD (Jugular Vein Distension) is elevated to the ear .gets short of breath with talking. Right (lung) base crackles noted. Both legs are weeping with blisters .wounds present. According to the 06/03/2020 Report of Consultation the resident was [MEDICATION NAME] with 100 mg of IV [MEDICATION NAME], and returned to the facility with recommendations for a two liter per day fluid restriction, and to increase [MEDICATION NAME] to 40 mg twice daily. Review of the June 2020 Treatment Administration Record (TAR) showed upon return Staff D, Licensed Practical Nurse, conducted Resident #1's weekly head to toe skin check. According to the documentation the resident had no new wounds, her skin was warm, pink, and dry to touch. Staff D did not identify the weeping legs, [MEDICAL CONDITION] to above the knees, blisters, or wounds, that the PHI clinic noted to the resident's LEs just hours before. In a telephone interview on 06/11/2020 at 7:14 PM, when asked if her legs were still swollen Resident #1 stated, Yes .they're terrible, they're so tight they hurt. When asked if she was familiar with the term weeping Resident #1 said, yes and indicated both legs were still weeping and then volunteered I have sores .one behind my left knee, down on my left leg, and I think on my right leg, but I'm not sure. Resident #1 indicated her legs had been that way for a couple of weeks or so, maybe a little more. Record review showed no indication staff had identified any weeping or wounds to Resident #1's LEs. According to the June 2020 TAR, Resident #1 skin checks were performed on 06/10/2020 and 06/17/2020 by Staff D. On each occasion Staff D assessed the resident had no new wounds, and the resident's skin was pink, dry and intact. Additionally, staff were signing daily, that they applied TED (compression) hose to Resident #1's LEs, which indicated Resident #1's legs were observed daily. In a telephone interview on 06/18/2020 at 1:18 PM, Resident #1 stated that her legs were still swollen, weeping, painful and that her wounds were still present. When asked if she was sure the wounds were still present Resident #1 stated, Yeah .I am looking at it, and indicated it was on her left LE. When asked how she was tolerating the placement of her TED hose Resident #1 laughed and stated, I haven't worn them in three weeks or more. When asked why the resident stated, They don't bring them anymore . On 06/19/2020 at 1:55 PM, Staff E, Resident Care Manager, was requested to perform a skin check on Resident #1. Upon entering the room Resident #1 was observed reclined in her electric wheelchair, with no TED hose or socks on and her lower extremities exposed. Two weeping ulcers were clearly visible. Staff E assessed the upper wound to the left shin to be 2 cm (centimeters) x 2 cm x 0.1 cm, with heavy serous (straw colored fluid) drainage, and a yellow wound base. The lower ulcer was assessed to be 0.5 cm x 0.5 cm x 0.1 cm, with heavy serous drainage and a yellow wound base. Staff E confirmed Resident #1's LEs were weeping, and noted a path of fluid from the mid shin ulcers, around the back of the calf that ended at the resident's achilles . where multiple drops of serous fluid were hanging and dripping onto the wheelchair. While performing the skin check Resident #1 stated the nurses and the aides were aware of the weeping and the wounds. When asked what nurse specifically was aware of the wounds Resident #1 stated, (Staff D) .she does my checks .she did one last night after we got off the phone, she wanted to know what we talked about. After exiting the residents room Staff E acknowledged he had not seen TED hose on her awhile. On 06/24/2020 Staff A, Administrator, provided statements from the four nurses who had documented from 6/01/2020 through 06/19/2020 that they applied Resident #1's TED hose. Each nurse acknowledged that Resident#1 had not been wearing the TED hose. During an interview on 06/23/2020 at approximately 3:20 PM, Staff D stated that she was the primary evening shift nurse for Resident #1 and confirmed she performed the resident's skin checks on 06/03/2020, 06/10/2020, 06/17/2020 and assessed there were no new wounds, and the skin was pink, dry and intact. Staff D was then informed; on 06/03/2020 the PHI clinic had identified weeping [MEDICAL CONDITION], blisters, and wounds to Resident #1's LEs just hours before she performed a skin check; on 06/11/2020, and 06/18/2020 Resident #1 reported via telephone that her legs were weeping and she still had wounds (both one day after her documented skin checks); and that today the weeping and wounds were validated. Staff D was asked if she actually performed the skin checks. Staff D stated, I guess so. When asked if she had ever falsely signed for a skin check that she did not do Staff D stated. Yes later elaborating I am busy, so I click (sign of as complete) through stuff and go back later and fix it. Facility staffs' pattern of failure to: consistently monitor, accurately assess, and document resident #1's [MEDICAL CONDITION]; apply TED hose to manage [MEDICAL CONDITION] as the resident was assessed to require; consistently obtain, evaluate, address and report wt variances to the physician as ordered; and failure to perform skin checks as ordered, resulted in delayed identification, intervention, and treatment of [REDACTED]. These failures resulted in harm to Resident #1. RESIDENT #3 Resident #3 admitted to the facility on [DATE]. According to the 06/13/2020, admission MDS assessment, the resident had moderate cognitive impairment, [DIAGNOSES REDACTED]. According to the facility's 06/06/2020 admission assessment, and provider notes dated 06/08/2020, and 06/12/2020, Resident #3 had no [MEDICAL CONDITION]. Record review revealed the following nurse's notes: 06/22/2020 12:56 AM .left leg swelling noted. There was no indication where the swelling was located (upper leg/lower leg) or the type (pitting/non-pitting) or extent of the swelling; 06/23/2020 left leg with [MEDICAL CONDITION] .[MEDICAL CONDITION] remains plus 3 The note did not indicate the extent of the [MEDICAL CONDITION].; 06/29/2020 4:15 PM .increased swelling to the left lower leg from upper thigh to toes . The assessment failed to grade the [MEDICAL CONDITION] or identify the type; and 07/02/2020 10:58 AM .BLE (bilateral LE) [MEDICAL CONDITION] 2+ . Again, the assessment failed to identify the extent of the [MEDICAL CONDITION]. During an interview on 06/19/2020 at 12:00 PM, Staff B was asked if 2+ pitting pedal (foot/ankle) [MEDICAL CONDITION], had the same clinical significance as 2+ [MEDICAL CONDITION] that extended from the foot up to the mid thigh? Staff B stated, No and stated nurses should also document the extent of the [MEDICAL CONDITION], acknowledging that failure of nurses to document the extent, could detract from their ability to determine if the [MEDICAL CONDITION] was improving or worsening. RESIDENT #2 Resident #2 admitted to the facility on [DATE]. Review of the May 2020, physician's orders [REDACTED]. According to the May and June 2020 TAR the resident received the treatment daily from 05/15/2020 through 06/18/2020 (34 days). Record review showed no indication that staff obtain initial measurements, assessed the wound base, amount and type of drainage, or determine what type of wound it was. Additionally, there was no indication the facility assessed or monitored wound weekly after identification. In an interview on 07/08//2020 at 12:03 PM, when asked how Resident #2 acquired a wound to her left inner thigh, Staff B reviewed the resident's record and stated I don't know. When asked if there was any indication that the facility obtained initial measurements, and assessed the wound characteristics. Staff B stated, No. When asked if the facility staff measured and assessed the wound weekly to determine if it was improving or declining Staff B stated, No. REFERENCE: WAC 388-97-1060 (1)

Based on observation, interview and record review it was determined the facility failed to prevent, identify, monitor and/or timely implement preventative measures for three (Resident #1, 2, and 3) of four residents reviewed for pressure ulcers. Failure to implement the interventions identified as required for Resident #1 caused harm as evidenced by the development of two unstageable pressure ulcers. Failure to ensure accurate monitoring of skin placed Resident #2 at risk for delayed identification of new skin issues. Failure to consistently reposition Resident #3 placed the resident at risk to develop pressure ulcers. Findings include: RESIDENT #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 06/11/15 Minimum Data Set (MDS) assessment, the resident was identified as at risk for, but having no Pressure Ulcers (PUs). This MDS revealed the resident required extensive two person assistance with toileting, personal hygiene and bed mobility and that the resident was transferred from bed only once or twice in the seven day look back period. This resident was discharged and reviewed as a closed record and was thus unavailable for observation. Record review revealed the resident discharged from the facility to an Adult Family Home (AFH) on 07/17/15. Transportation documents revealed Resident #1 left the nursing home at 11:23 a.m. and arrived at the AFH at 12:31 p.m. Review of AFH documents revealed Resident #1 was identified at 6:00 a.m. on 07/18/15, less than 24 hours after discharge from the nursing home, with wounds to the right buttock (measuring 3.1 centimeters (cms) by 2.6 cms) and left heel (measuring 4.5 cms by 2.6 cm). The left heel wound was described as black, round and hard. A Home Health nurse evaluation, dated 07/20/15, described the buttock wound as 4.2 cm x 2.0 cm x 0.2 cm with a wound bed of slough and the heel wound as 4.5 cm x 2.6 cm with a wound bed of eschar (dead tissue). These wounds would be considered unstageable due to coverage of the wound bed by slough and / or eschar. The Nursing Home Admission assessment, dated 06/04/15, revealed staff identified Resident #1 with redness to the resident's groin and abdominal folds, but no other wounds or pressure ulcers. Resident #1 was identified on 07/09/15 by the facility with rapid weight loss. Review of weekly skin assessments for Resident #1 revealed that no weekly skin assessments were performed by the facility between 06/26/15 and 07/10/15. This was confirmed by Medical Records staff on 07/31/15. In an interview on 08/03/15, Staff D (Shower Aide) indicated she had not provided showers to Resident #1 and the staff who had no longer worked at the facility. In an interview on 08/03/15 at 1:05 p.m. when questioned regarding Resident #1's skin status, Staff C (Resident Care Manager) stated, Nobody said there was a wound. Staff C elaborated that on the day of discharge (07/17/15), the resident was refusing showers- he didn't want anyone touching him and we were unable to do the head to toe skin assessment. he wouldn't let us. Staff C stated the resident had been identified with soft area on a heel. Staff C was unable to elaborate which heel but indicated it was discussed at a care conference and that booties were ordered for mushy heels. After searching the resident's progress notes, Staff C was unable to locate any mention of his skin condition or the intervention of booties. Staff C was able to provide a weekly update information for Utilization Call form (not part of the resident's record) which indicated on 06/25/15 staff identified, mushy on left heel and heel protectors (soft) heels. While an Interdisciplinary weight review form dated 06/25/15 also indicated the resident had a Left mushy heel, the weekly head to toe skin assessment dated [DATE] indicated, skin is warm, clean, dry, intact and without issue. There was no mention of any wound or the mushy heel identified the previous day. Similar notes were written on 07/10/15 and 07/17/15, the date of discharge, which indicated, Pt's skin is warm, clean, dry and intact. no issues. Staff C later provided a Care Conference form dated 07/02/15 which identified there continued to be Skin Concerns of Lower Extremity (sic) [MEDICAL CONDITION] (feet) spot on foot (heel). There was no description of where this area was located, its appearance, what the spot was or any interventions to deal with this identified Concern. When asked how staff would know to apply the booties or heel protectors, Staff C stated, it's on the aide directive sheets. Review of the Aide Directive sheets, dated 06/04/15, revealed staff were directed to place fall mats at bedside and the resident required total extensive assistance of two staff but there were no directions to staff regarding positioning, floating heels or any type of adaptive equipment. In an interview on 08/04/15 at 10:38 a.m. Staff B stated that Staff C did put the boots on the Aide directive sheet, but that Aide directive sheet wasn't kept after discharge. Staff B stated only the aide directive sheet in the chart was kept, and that one wasn't updated. When asked to provide evidence any intervention had been implemented for the heels, Staff C provided a receipt for heel protector pillows dated 07/07/15, almost two weeks after the mushy left heel was first identified. In an interview on 08/04/15 at 10:38 a.m., Staff B indicated she would expect interventions to be implemented at the time skin issues were identified. When asked when the heel protectors were implemented, Staff B replied, I don't know when. When asked why the heel protectors weren't ordered until 07/07/15 when the mushy heel were identified on on 06/25/15, Staff B stated, I don't have an answer for that. Care Plan documents dated 06/08/15 revealed a problem of, Potential for Impaired skin integrity related to impaired mobility, incontinence and included a standard intervention of encourage resident to float heels and the use of heel protectors when in bed but there were no additional interventions after staff's 06/25/15 identification of mushy heels. In an interview on 08/03/15 at 10:30 a.m., the resident's family member indicated she saw both the foot and buttock wound on 07/18/15. She described the buttock wound as, It's bigger than a quarter, it had a dried scab on one side of it and puss like white puffy stuff on the surface. The family member reported, It's a pretty big scab on the back of the heel, pretty dried up, the size of a lime. She elaborated, I knew about the thing on his heel, he had it (at the facility). I put his socks on (while he was at the facility). no they never told me about it. they knew something was up with his feet, they elevated them on pillows. The family member indicated the spot on the heel did not appear any bigger on 07/18/15 than it had when she had observed it in the facility. Photographs, time stamped as taken on 07/18/15 at 2:55 p.m., provided by the resident's family member confirmed the presence of an unstageable (wound bed obscured by slough/dead tissue) ulcer to the right buttock. In an interview on 08/03/15 at 1:25 p.m., Staff F (Nursing Assistant) indicated she had cared for Resident #1. Staff F stated, he's not easy, especially when it's time to change him. we had to do everything for him. Staff F indicated she noticed a small open area on the resident's buttock and reported it to Staff E (Licensed Nurse) stating, I work two days, one day it was red then the next day it was open. Review of Activity of Daily Living documents revealed Staff F provided care for Resident #1 on 07/06/15 and 07/07/15. Staff F indicated after reporting the issue to Staff E she was given a treatment to apply to Resident #1's buttock stating, I am the one putting cream on it. Staff E stated the cream was called, Renew. Staff E also described a red and hard spot on the resident's foot. Record review revealed no mention of an open area on the buttock. In an interview on 08/03/15 at 1:45 p.m. Staff E was asked about Staff F's report of skin issues replying, I don't remember it was so long ago. Staff F indicated if she had identified any skin issue it would be documented in the record. RESIDENT #2 Resident #2 admitted to the facility on [DATE] and, according to the 04/30/15 MDS, was assessed to have two unstageable (covered by slough and /or eschar) pressure ulcers. Resident #2 was reviewed as a closed record. Review of wound assessment forms revealed staff identified and measured wounds to the resident's right foot weekly from 05/13/15 through 06/17/15. However, according to weekly head to toe skin assessments dated 06/09/15 and 06/16/15, nursing staff documented the resident's, skin is intact. In an interview on 07/31/15 Staff B was unable to explain why staff would document the skin was intact when a pressure ulcer was being monitored. RESIDENT #3 In an interview on 07/31/15 at 8:50 a.m., Staff C identified multiple residents who were considered to be at risk for pressure ulcers, including Resident #3, who was a long term resident. According to the 06/10/15 MDS, Resident #3 was assessed to require extensive two person assist with bed mobility and transfers and was assessed to be at risk for the development of PUs. Observations on 07/31/15 at 9:05 a.m., 9:15 a.m., 9:35 a.m. and 10:25 a.m. revealed Resident #3 sitting in a wheelchair, tilted back slightly next to the bed in her room. The resident was noted to wear hand splints. Observations at 11:00 a.m. and 11:06 a.m. revealed the resident in the same position, with pillow cases rolled in her palms. In an interview at 11:04 a.m. Staff H (Licensed Nurse) stated, We turn everybody every two hours. In an interview at 11:04 a.m. when asked how frequently residents are repositioned, Staff G (Nursing Assistant) stated, It is standard, every two hours. Failure to reposition Resident #3 placed the resident at risk for the development of PUs.

Based on observation, interview, and record review the facility failed to supervise direct care staff in the administration of hot packs to one of four Residents (#1) reviewed for implementation of care and services. This failure caused Resident #1 to experience second degree burns to the left lateral/posterior buttock area and placed the resident at risk for infection. Findings included: According to the 10/25/13 Minimum Data Set, Resident #1 had impaired decision-making, continuously experienced disorganized or incoherent thinking, required two person extensive assistance for activities of daily living including bed mobility and toileting, had a [DIAGNOSES REDACTED]. According to the facility's 11/08/13 evidence of investigation, Resident #1 asked Staff C, a Licensed Nurse, for hot packs to relieve pain in the area of a stage four pressure ulcer. Staff C instructed Staff D and E, Nursing Assistants, to administer the hot packs to Resident #1. According to a statement dated 11/13/13, when Staff D and E asked Staff C for assistance, Staff C explained how the hot pack functioned and expected Staff D and E to administer the hot packs to Resident #1's buttocks. Staff documented in the investigation Staff C did not instruct Staff D or E how the instant hot packs should be administered or that they should be removed after 20 minutes. According to Staff B (Director of Nursing), Staff D and E applied the instant hot packs directly to Resident #1's skin at approximately 2:30 a.m. on 11/08/13. Ten and one half hours later that day (1:00 p.m.) staff observed Resident #1 with blisters to the left lateral/posterior thigh/buttocks and hot packs "twisted" up in the linens. Clearly the hot packs were applied for greater than the prescribed 20 minutes. According to Staff B, interviewed on 11/19/13 at 1:15 p.m., there was a physician's orders [REDACTED]. Staff B said Resident #1 had decreased sensation as the result of a stroke and suffered from [DIAGNOSES REDACTED] on the side affected by the burns. According to physician's orders [REDACTED]. DO NOT APPLY DIRECTLY TO SKIN." Facility staff did not follow the 20 minute direction, and applied the hot packs directly to the resident's skin, in direct conflict with Physician ordered direction. According to the fifth edition of Nurses' Guide to Clinical Procedures, physician prescribed treatments are to be administered as written and by Nursing Staff. According to investigation documents dated 11/08/13, staff were aware the resident sustained [REDACTED]. The Advanced Registered Nurse Practitioner (ARNP) note dated 11/26/13 indicated second degree burn wound is slow to heal as a result of multiple factors. Weekly skin round documents dated 11/13/13, five days after identification of the burns, indicated Resident #1 was monitored for two second degree burns to the left thigh measuring "5x3 (centimeters- cms)" and "4 x2 (cms)." According to wound tracking documents dated 11/19/13, staff assessed the first burn as, "5.0 x 3.0(cm)" with a 0.2 cm depth, having moderate serosanguinous drainage and 80% granulation. The second burn was assessed as 4 x 2 cm with a 0.1 cm depth., also having moderate drainage and 80% granulation. Resident #1 was observed on 11/19/13 at 1:55 p.m. receiving personal care following toileting. The resident said of the incident, "(They) laid it (instant hot pack) right on the skin, if you don't lay it (instant hot pack) on the skin it will be all right." Two open wounds were observed on the resident's left later/posterior buttock area. Staff H, interviewed on 11/19/13 at 1:55 p.m., described the wounds as "second degree burns." According to investigative documents dated 11/13/13, "physician orders [REDACTED]." Staff C failed to recognize the administration of hot packs as a potential hazard to a resident with decreased cognition and decreased skin sensation and paralysis to the left side. Further, once delegating this task, Staff C did not provide direct care staff necessary supervision in the administration and removal of the hot packs. At no time during the application of these hot packs did staff monitor their effectiveness. These failures resulted in Resident #1 sustaining multiple second degree burns.

Based on observation, interview and record review the facility failed to ensure one of nine sample residents (# 110) at risk for skin breakdown did not develope wounds. Failure to thoroughly assess, identify and monitor the resident's skin condition resulted in harm for Resident #110 who developed a necrotic wound. Findings include but are not limited to: RESIDENT #110 Resident #110 was admitted to the facility with care needs related to diabetes and [MEDICAL CONDITION]. According to the 5/2/10 Minimum Data Set (MDS), staff assessed the resident received treatment for [REDACTED]. This MDS reflected the resident was dependent on staff for bed mobility, bathing and dressing and was bedfast all or most of the time. According to Care Plans dated 12/30/1899 (sic), the resident had "Potential for Pressure ulcers related to History of PU (pressure ulcer)/impaired tactile sense/bed mobility/bedfast . . . [DIAGNOSES REDACTED]. . ." This care plan identified the resident had [DIAGNOSES REDACTED]. Review of Social Service notes dated 5/26/10 reflected, "Requested Podiatrist last week. Will ensure res(ident) is on list to be seen." As of 7/23/10, two months after the initial request, there was no indication in the record the resident was seen by podiatry. In an interview in the morning of 7/23/10, Staff N confirmed the resident was not seen by podiatry. Observation on 7/23/10 at 10:30 a.m. revealed Staff O remove the resident's left sock. Black/brown tissue was noted along the base of his left great toe with a reddened area on the medial aspect of the nail bed. Upon observation of the foot, Staff O stated "He needs to see the Podiatrist." When Staff O touched the toe, the resident grimaced and cried out, "Ouch." When asked to describe the left great toe, Staff O indicated this was outside the scope of her practice. According to the "Admission and Weekly Skin Integrity Action Tool" (the document on which Licensed Nurses document weekly head to toe skin assessments) dated 7/23/10 "evening", the resident's skin was assessed to be "intact". In an interview on 7/27/10 at 8:22 a.m., Staff B was asked why the "Skin Integrity Tool" for the evening of 7/23/10 indicated no skin issues contrary to what had been identified by the surveyor, Staff B did not respond. The physician, who was requested to assess the resident's toe, documented on 7/24/10, "Left great toe with area of necrosis (death of tissue resulting from irreversible damage) (at) base of nail . . . painful to touch." The physician wrote a referral to ". . . Podiatry related to possible debridement (surgical removal of foreign matter and dead tissue from a wound)." When asked in an interview on 7/27/10 at 8:22 a.m. if any staff could have identified the left toe wound prior to identification by survey staff on 7/23/10, Staff B replied, "there are many eyes that could have seen it (the necrotic tissue)."