Every finding on record at Avalon Health & Rehabilitation Center - Pasco

Based on interview and record review, the facility failed to monitor the bowel record to effectively treat and prevent bowel related complications for 1 of 4 residents (Resident 1) reviewed for bowel care and management. Additionally, the facility failed to transcribe and implement a physician order for a urinalysis (a simple test that checks the urine for infections) for 1 of 3 residents (Resident 1) reviewed for urinary tract infections. This failure placed the residents at risk for constipation (having fewer than three bowel movements a week or passing hard, dry, and difficult-to-pass stools), fecal impaction (a large, hard mass of dry stool stuck in the rectum or lower colon that cannot be pushed out naturally), worsening infections, and pain.Findings included. Record review of a policy titled, Bowel Program, dated 12/02/2020, showed the nurse would assess the resident's bowel movements daily. Residents that had inadequate bowl function (the absence of regular bowel movements in excess of three days) would be assessed by the nurse. The assessment would include a physical assessment of the GI system and sign/symptoms of constipation, impaction or obstruction, and a resident/staff interview. When needed, a bowl protocol would be implemented as established by physician's orders that included administration of stool softeners, laxatives/bowel stimulants, and an enema. After completion of the bowel protocol, if the resident had not had a bowel movement, the physician would be notified. Record review of a protocol titled, Bowel Care Protocol, undated, showed if a resident did not have a bowel movement in three days, administer bisacodyl (an over the counter bowel stimulant used to treat occasional constipation) 10 milligrams [(mg) a unit of measurement] every 24 hours, or, Miralax (a medication used to treat occasional constipation) 17 grams (a unit of measurement) mixed in a beverage of choice, every 24 hours as needed, or, Milk of Magnesia (a liquid medication used to treat occasional constipation) 30 cubic centimeters (cc - a unit of measurement for liquid volume equal to one milliliter) every 24 hours as needed. If no bowel movement in four days, administer one enema (a liquid medication introduced into the rectum and lower colon through the anus to stimulate a bowel movement to relieve severe or stubborn constipation when other laxatives don't work) every 24 hours as needed, or, administer one Dulcolax suppository (a small cone-shaped medication inserted into the rectum to help soften stool and cause a bowel movement) every 24 hours as needed. If no bowel movement in five days or more, begin every shift bowel assessment and notify the provider. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a urinary tract infection (an infection that happens when bacteria enter and grow anywhere in the urinary system), protein-calorie malnutrition (a condition that happens when your body does not get enough protein or total calories from food that causes extreme weight loss, severe muscle and fat wasting, fluid swelling and a weak immune system that leads to frequent infections), and anxiety (the body's response to stress or danger that causes feelings of tension, worried thoughts, and physical changes). The 06/25/2026 comprehensive assessment showed Resident 1 required substantial assistance of one staff member for activities of daily living (activities related to personal care). The assessment also showed Resident 1 had a severely impaired cognition. Bowel Care and ManagementRecord review of Resident 1's June 2026 bowel elimination record showed they had no documented bowel movement for eight days (06/11/2026, 06/12/2026, 06/13/2026, 06/14/2026, 06/15/2026, 06/16/2026, 06/17/2026, and 06/18/2026). Record review of Resident 1's June 2026 Medication Administration Record (MAR) showed they received a Dulcolax suppository on 06/16/2026, after six days with no documented bowel movement. The MAR showed the results of the medication were unknown. Additional review of the MAR showed Resident 1 was administered Milk of Magnesia on 06/19/2026 with results (small bowel movement). Record review of Resident 1's July 2026 bowel elimination record showed they had no documented bowel movements for six days (07/05/2026, 07/06/2026, 07/07/2026, 07/08/2026, 07/09/2026, and 07/10/2026). Resident 1 had three bowel movements on 07/11/2026, then five days (07/12/2026, 07/13/2026, 07/14/2026, 07/15/2026, and 07/16/2026) without a bowel movement. The record showed they had a large bowel movement on the night shift of 07/17/2026. Resident 1 had no bowel movement for the next five days (07/18/2026, 07/19/2026, 07/20/2026, 07/21/2026, and 07/22/2026). Resident 1 had a bowel movement on the next two days, then no documented bowel movement for the following five days (07/25/2026, 07/26/2026, 07/27/2026, 07/28/2026, and 07/29/2026. For the month of July 2026, Resident 1 had a bowel movement seven out of 31 days. Record review of Resident 1's July 2026 MAR showed they received a Dulcolax suppository on 07/11/2026 (day 7 of no bowel movement), 07/17/2026 (day six of no bowel movement), 07/22/2026 (day 5 of no bowel movement), and 07/30/2026 (day six of no bowel movement), despite the protocol to initiate bowel medications after three days of no bowel movement. Record review of Resident 1's August 2026 bowel elimination record showed they did not have a documented bowel movement for four days (08/08/2026, 08/09/2026, 08/10/2026, and 08/11/2026). Resident 1 had no documentation of a bowel movement on the day shift of 08/12/2026 and had been transferred to the hospital for evaluation of their change in condition. Record review of Resident 1's August 2026 MAR showed they did not receive any medication for their bowels on 08/11/2026, day four of no bowel movement. During an interview on 08/14/2026 at 12:53 PM, Resident 1's Representative (RR) stated on August 12, 2026, Resident 1 had been transferred to the hospital because they had not been eating or drinking adequately. They stated the resident had a medical imaging test that showed they had a 7.6 centimeter (a unit of measurement) rectal stool ball (a large, hard mass of dried stool stuck in the rectum that cannot be pushed out naturally, caused by severe constipation). During an interview on 08/25/2026 at 1:54 PM, Staff B, Registered Nurse, stated they ran a report in the electronic medical record every morning that identified which residents had not had bowel movements for more than three days and would start the bowel protocol on day four. They stated the system would also alert the licensed nurses if there was no documented bowel movement past day three. Staff B stated on day four, they would speak to the resident regarding their lack of bowel movement and complete an assessment that included listening to bowel tones (gurgling, clicking, or rumbling noises made by the intestines that indicate the digestive system is active and healthy) and would feel the abdomen for tenderness or rigidity. Staff B stated they provided care for Resident 1starting in July 2026. They stated the resident was not eating anything, and their abdomen was flat with hypoactive (reduced or absent bowel tones indicating the intestines are not functioning properly) bowel tones. Staff B stated the lack of eating and hypoactive bowel tones was the only way I knew the resident to be since assuming their care in July. During an interview on 08/25/2026 at 2:27 PM, Staff C, Resident Care Manager, stated they reviewed the list of residents without bowel movements each morning and provided that list to the floor nurses. They stated if the resident had more than five days without a bowel movement, the nurses were required to do an assessment shift that included listening to bowel tones, and feeling the abdomen for pain, tenderness, and firmness. They also reviewed how much the resident was eating. Staff C stated Resident 1 should have had a daily medication to regulate their bowels since they were often on the bowel list. Staff C stated it was unacceptable that Resident 1 went many days without a bowel movement or medication to treat the condition. UrinalysisRecord review of the medical record showed a Physician's Telephone Orders dated 07/30/2026 to obtain a urine culture and fax the results to the outside urology providers office. Record review of nursing progress notes (PN) dated 08/03/2026 showed the facility received orders to complete a urinalysis with culture and sensitivity and fax the results to the outside urology provider. Further review of the PNs showed the urine sample was collected on 08/04/2026, with results received on 08/08/2026. The provider was notified and an antibiotic medication was ordered. During an interview on 08/25/2026 at 2:27 PM, Staff C stated the order for the urinalysis came from the outside urology providers office. They stated they did not enter the order when the resident returned from the appointment. The order was placed on a stack of papers and was overlooked until 08/03/2026 when they entered the order. Staff C stated not entering the providers' order was their fault, as they had received the order on Thursday 07/30/2026 and did not enter it until 08/03/2026. Staff C stated the urine sample was collected on 08/04/2026 and the facility received the culture results on 08/08/2026. The provider was notified and antibiotics were initiated. During an interview on 08/25/2026 at 4:10 PM, Staff A, Director of Nursing, stated they were aware of the issues with the bowel protocol. They stated they had provided recent education to the nursing assistants for accurate documentation. They had educated the licensed nurses to review the clinical alerts in the electronic medical record, and the management team had a process in place to review the clinical alerts in their morning meetings. Staff A stated they agreed that there was a potential delay in care related to the transcription and collection of the urine sample. They stated the nurses did not follow the processes for bowel management and physician order transcription and implementation. Reference: WAC 388-97-1060(1)This is a repeat deficiency from the Statement of Deficiencies dated 06/12/2026.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident 1) reviewed for continuity of care (the process by which a patient and their healthcare team work together to provide smooth, ongoing, and connected medical care over time). This failure placed the residents at risk for delays in care and treatment. Findings included. Review of a policy titled, Administration Resident Records - Identifiable Information, dated 07/2018, showed the facility would maintain a complete, accurate, readily accessible and systematically organized medical record in accordance with accepted professional standards and practices for each resident. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a urinary tract infection (an infection that happens when bacteria enter and grow anywhere in the urinary system), protein-calorie malnutrition (a condition that happens when your body does not get enough protein or total calories from food that causes extreme weight loss, severe muscle and fat wasting, fluid swelling and a weak immune system that leads to frequent infections), and anxiety (the body's response to stress or danger that causes feelings of tension, worried thoughts, and physical changes). The 06/25/2026 comprehensive assessment showed Resident 1 required substantial assistance of one staff member for activities of daily living (activities related to personal care). The assessment also showed Resident 1 had a severely impaired cognition. Record review of behavioral health office visit notes dated 04/21/2026, showed Resident 1 was seen for a follow-up of psychiatric management. The record showed the resident's physical condition had declined and were excessively sedated. The behavioral health provider recommended decreasing their olanzapine (a medication used to treat mental health conditions that can cause drowsiness) from 2.5 milligrams [(mg) a unit of weight measurement] twice daily to 1.25 mg twice daily to alleviate the excessive sedation. A second behavioral office visit note dated 06/02/2026, showed Resident 1 was seen for a follow-up appointment related to their medication management and reduction in olanzapine. The note showed the facility had not implemented the recommendation to reduce Resident 1's olanzapine on 04/21/2026 until 05/28/2026, five weeks after the recommendation. Record review of Resident 1's urology clinic office visit physician order dated 07/30/2026, showed the facility was to obtain a urine culture and fax the results to the urology clinic. Record review of nursing progress notes (PN) dated 07/31/2026, showed Resident 1 had returned from a urology appointment, despite the urology clinic's physician order dated 07/30/2026. Further review of the PNs showed the facility received the order for the urine culture on 08/03/2026. During an interview on 08/14/2026 at 12:53 PM, Resident 1's Representative (RR) stated on 04/21/2026, the facility had provided the behavioral health clinic with an envelope of documents at the time of the appointment. They stated the provider completed the forms, and the envelope was returned to the facility. The RR stated the facility had called them on 05/28/2026, stating they needed to do a gradual dose reduction (a planned tapering of a medication dose to see if a lower amount controls symptoms or if the drug can be safely stopped) on Resident 1's olanzapine. The RR stated the facility was not aware that the dose reduction should have been completed on 04/21/2026. During an interview on 08/25/2026 at 2:27 PM, Staff C, Resident Care Manager, stated the process for communication with outside provider was to complete a packet to send with the resident that included a demographic sheet, the medication administration record, and a blank physician progress note sheet. They stated the forms often get returned to the facility incomplete and the facility would follow up with the clinic. Staff C stated they were not aware of the behavioral health recommendation for the dose reduction as they did not get the paperwork returned from the office visit. They stated they should have called the clinic. Staff C stated the order for the urine culture was not entered timely, but they had called the clinic to obtain the visit recommendations. Staff C stated there was definitely a fall out with continuity of care. During an interview on 08/25/2026 at 4:10 PM with Staff D, Regional Nurse Consultant, stated the process to ensure continuity of care with outside clinic providers would be for the facility medical records personnel to call the clinic and obtain the visit records. Staff D agreed that the process was not followed. Reference: WAC 388-97-1620(1)(2)(b)(ii)

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) remained free from significant medication errors. The facility failed to accurately transcribe Resident 1's admission medication orders onto the Medication Administration Record (MAR), which resulted in the entry of an incorrect medication suboxone (a medication used to help people recover from addiction to pain medication) rather than the ordered pain medication buprenorphine (a medication used to treat chronic pain) transdermal patch (an adhesive patch designed to deliver a specific dose of medication through the skin and into the blood stream) , and failed to remove a previously applied transdermal patch prior to administering a new one, leaving the resident with two active medication patches simultaneously. These failures placed the resident at risk for adverse drug events, toxicity, and potential opioid overdose. Findings included.Review of the medical record showed the resident admitted on [DATE] with diagnoses including cerebral amyloid angiopathy (a serious medical condition where protein builds up in the brain, causing bleeding and tissue damage). The 07/21/2026 comprehensive assessment showed Resident 1's cognition was moderately impaired, and they required the assistance of one staff member with activities of daily living. Review of the hospital discharge orders dated 07/18/2026 showed an order for a buprenorphine transdermal patch to be applied weekly. Review of Resident 1's July 2026 MAR showed that the facility inaccurately transcribed the order as suboxone transdermal patch to be applied weekly. During an interview on 07/30/2026 at 3:25 PM, Staff E, Registered Nurse (RN), stated on 07/19/2026, they received a new order for the buprenorphine transdermal patch, and the transcribed Suboxone order was discontinued. During an interview on 07/30/2026 at 3:35 PM, Staff B, Licensed Practical Nurse, stated upon admission, they transcribed the resident's medication order as suboxone transdermal patch instead of the ordered buprenorphine transdermal patch because they believed suboxone was the same medication. Staff B stated they did not assess the resident's body at the time of admission to determine if the resident had an existing transdermal patch already present, which would have revealed the presence of the active patch and identified the type of medication it contained. Staff B further stated that entering the wrong medication was a significant error. During an interview on 07/30/2026 at 11:22 AM, the Resident Representative (RR) stated on 07/26/2026, facility staff applied a new pain patch to Resident 1 without removing the old patch. The RR stated Resident 1 had two active pain medication patches on simultaneously for three days. The RR stated they discovered both patches on 07/29/2026 and brought them to the attention of Staff C, RN, before removing them. During an interview on 07/30/2026 at 1:26 PM, Staff C, stated the RR notified them Resident 1 had two active pain medication patches applied simultaneously. Staff C stated they assessed the resident and discovered one patch on the right shoulder and a second patch on the left shoulder. Staff C further stated they immediately removed the older patch and reported the incident to Staff D, Resident Care Manager (RCM). During an interview on 07/30/2026 at 1:43 PM, Staff D, RCM, stated Staff C, RN, had reported the discovery of the two active patches to them. Staff D further stated they reported the incident to Staff A, Director of Nursing Services (DNS). During an interview on 07/30/2026 at 2:00 PM, Staff A, DNS, stated the facility's process for medication errors included interviewing the involved staff, notifying the physician, initiating alert charting, and implementing specific monitoring for high-alert medications like pain medications. Staff A stated when the two active patches were reported to them, they failed to investigate the incident. Staff A further stated they should have completed a medication error report for the incident. During a follow-up interview at 4:16 PM, Staff A stated there was no documentation from the reviewing nurses on the transfer orders for Resident 1. Staff A stated the facility's admission process required a three-step verification, where two nurses review orders upon admission, followed by a third review the next day or the following Monday. Staff A stated they would expect each nurse to review the transfer orders to ensure the accuracy of those orders, and that process was not followed for Resident 1. Staff A further stated the facility had processes that need fixed and worked out, and confirmed the inaccurate transcription of the medication was a medication error. Reference: WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to implement safety interventions to prevent an avoidable fall for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the residents at risk for additional falls and substantial injuries. Findings included . Review of a policy titled, Quality of Care Accident Hazards/Supervision/Devices, dated 07/2018, showed the facility would provide an environment that was free of accident hazards and provide supervision and assistance devices to residents to avoid preventable accidents. Efforts to minimize the risk to residents includes individualized, resident-centered interventions to reduce individual risks related to hazards in the environment. Individualized interventions would be developed to reduce the potential for accidents. Resident specific interventions would be reflected in the resident's person-centered, individualized care plan. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a broken bone in the neck, quadriplegia (paralysis that affects both arms and legs, and the torso), and major depressive disorder (persistent low mood and loss of interest in activities. The 06/12/2026 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living (activities related to personal care). The assessment also showed Resident 1 had an intact cognition. Record review of Resident 1's care plan dated 06/09/2026, showed Resident 1 was dependent on two staff members for repositioning and turning in bed. Record review of an investigation dated 07/12/2026 at 8:20 PM, showed a witness statement written by Staff B, Nursing Assistant. Staff B was instructing Resident 1, verbally, to turn on to their back from their left side, but they rolled completely on their left side and onto the floor. The witness statement showed Resident 1 stated they were trying to roll to their side but there wasn't any space on that side. The investigation showed the root cause (reason why) the fall occurred was staff was assisting the resident with incontinent care. The resident used their grab bars (metal rails attached to a bed to help residents move in bed) for mobility, pulling themselves toward the edge of the bed with their lower extremities coming off the bed. Staff were unable to reach other side of bed prior to the resident falling out of bed. During an interview on 07/20/2026 at 9:56 AM, Resident 1 stated they had a fall when Staff B was placing a mechanical lift sling under them to transfer them to a chair. Resident 1 stated Staff B had first pulled them to the right so they could roll them to the left and placed the sling under them. They stated Staff B then helped them roll to the right, but there was not enough room to roll and there was no one standing on the right side to catch them. Resident 1 stated their left leg came over top of the right leg and pulled their lower body off the bed, and their right arm was caught in the grab bar. They stated they were able to get to the floor, and Staff B went to get help. During an interview on 07/20/2026 at 2:30 PM, Staff B stated they were assisting Resident 1 with incontinent care from Resident 1's left side and had instructed them to roll on to their back. They stated Resident 1 rolled all the way to their right side before they could get to the other side of the bed. Staff B stated they were unsure if Resident 1 required assistance of one or two staff members for bed mobility. They stated that information would be found on the Kardex (a summary of a resident's care plan and key information that provides quick access for individualized resident care). Staff B stated they had not reviewed Resident 1's Kardex. During an interview on 07/20/2026 at 2:53 PM, Staff C, Resident Care Manager, stated the fall occurred when Staff B was in the resident room alone providing incontinent care to Resident 1. They stated the resident rolled to one side and was not far enough over on the bed. Their lower half fell off the bed, and the weight of their legs pulled them to the floor. They stated it was unacceptable that Staff B was in the room alone. Staff C stated the care plan showed Resident 1 required assistance of two people for bed mobility and the nursing assistants had access to that information. During an interview on 07/20/2026 at 3:41 PM, Staff A, Director of Nursing, stated the fall occurred because Staff B did not follow the Kardex or care plan for assistance with bed mobility. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) met the qualifications for experience, education, and training or certification for the role to assume responsibility for the facility's Infection Prevention Control Program (IPCP). This failure placed residents, family members, and staff at risk of contracting communicable diseases.Findings included .Record review of the facility's policy titled, Infection Prevention and Control Program, revised on 06/08/2022, showed the facility would identify a staff member to be responsible for the infection prevention and control program and trained as the IP to provide on-site management of the IPCP.In an interview on 06/08/2026 at 9:35 AM, Staff B, Director of Nursing (DON), stated they had been handling the infection control program. Staff B stated they had not completed the specialized training in infection prevention and control. Staff B stated they had their regional nurse currently acting as the facility's IP.In an interview on 06/08/2026 at 4:04 PM, Staff C, Regional Clinical Nurse, stated the facility did not currently have an acting IP as the last IP worked in the facility in May 2026 and a new IP was due to start within the next couple of weeks. Staff C stated they had not completed the specialized training in infection prevention and control.In an interview on 06/08/2026 at 4:12 PM Staff H, Regional Clinical Nurse, stated that Staff R, Regional Nurse Consultant (RNC), had been the acting IP until the second week of May 2026. Staff H stated they were not actually acting IP and thought Staff C was going to do the training and then did not. Staff H stated no one had the required Centers for Disease Control and Prevention (CDC) training or had been acting as the current IP for the last three weeks.Review of an email dated 06/09/2026 showed Staff R, RNC, had been the facility's IP and their last day in the facility was on 05/11/2026 (the facility had been without a certified IP for the last 28 days).In an interview on 06/09/2026 at 8:20 AM, Staff A, Administrator, acknowledged Staff B and Staff C did not have the required specialized training in infection prevention and control. Staff A stated the facility had some changes with the facility's IP.Reference: WAC 388-97-1320(1)(a)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Review ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were done prior to admission and were corrected on admission, had the required level two referral sent if residents had a positive level one PASARR, as needed for 2 of 5 residents (Resident 65, and 2) reviewed for unnecessary medications. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Findings included . Review of the facility policy titled, Resident Assessment Preadmission Screening and Resident Review (PASARR) revised 08/2018, showed a Preadmission Screening and Resident Review (PASARR) screening would be completed for each resident prior to admission. Resident 65Review of the medical record showed Resident 65 admitted to the facility on [DATE] with diagnoses to include anxiety disorder (a mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), depression (a serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in activities), and Post Traumatic Stress Disorder ([PTSD], a mental health condition triggered by experiencing or witnessing a terrifying or life threatening event). Resident 65's comprehensive assessment dated [DATE], showed the resident's cognition was intact and required moderate assistance of one person for dressing themselves and transfers. Further review of Resident 65's medical record showed there had not been a completed PASARR Level I screening document or evidence of an approved exemption in the resident medical record. Review of Resident 65's PASARR Level I completed by the facility on 06/10/2026, showed under section I, SMI/ID the resident had three mental health diagnoses marked yes to include the diagnoses of mood disorder, depression and a PTSD disorder. A referral for a Level II PASARR was required if any questions in Section 1A (1, 2, and/or 3) was marked yes. There was no evidence of a PASARR Level I or that a referral had been sent for review in the resident's medical record. Resident 2Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses that included anxiety/panic attacks (a sudden, intense surge of overwhelming fear of discomfort that triggers severe physical reactions) and hallucinations (seeing, hearing, feeling something that does not exist in reality). A PASARR Level I was completed on 03/13/2026 from their hospital stay before being admitted to the facility. During an interview on 06/10/2026 at 3:30 PM, Staff A, Administrator stated the hospital sent the PASSAR Level I with request for a Level II assessment but did not send the request to the evaluator. Staff A stated the facility failed to send the recommended Level II request. During a continued interview on 06/10/2026 at 3:30 PM, Staff A, confirmed that the facility had not received a PASARR screening for Resident 65 from the hospital. Staff A stated the PASARR evaluation required had not been completed for Resident 65 upon admission. Reference: WAC 388-97-1915(1)(2)(a)-(c)

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control [(CDC) a public agency that protects the public's health and well-being] guidance for temperature monitoring of vaccines and medications in 1 of 2 medication storage refrigerators (Refrigerator 1) reviewed for medication storage. This failure placed the residents at risk of receiving compromised or ineffective vaccines and/or medications.Findings included .Review of the CDC guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily.Review of a policy titled, Pharmacy Services, Labeling and Storage of Drugs and Biologicals, dated 11/2017, showed the facility stored drugs and biologicals in locked compartments under proper temperature controls.An observation and record review on 06/11/2026 at 1:58 PM, accompanied by Staff B, Director of Nursing, showed Refrigerator 1, located in the medication storage room, had a temperature log taped to the front of the refrigerator. The log was titled Food Refrigerator Temperature Log, and was dated 05/2026. The log showed temperatures were to be taken and recorded daily on the night shift. The temperature log had one column for daily temperature readings, despite the requirement for twice daily temperature readings. The log showed temperatures were not documented on 05/01/2026, 05/02/2026, 05/03/2026, 05/04/2026, and 05/05/2026. Additionally, there was no log for the month of 06/2026. The refrigerator contained 61 doses of influenza (a highly contagious viral infection that attacks the respiratory system) vaccines, four Respiratory Syncytial Virus (a highly contagious virus that infects the lungs and breathing passages) vaccines, eight shingles (a viral infection that causes a painful rash and nerve damage) vaccines, and 29 pneumococcal vaccines. Additionally, the refrigerator contained the following medications that required refrigeration: four insulin (a medication that turns food into energy and manages the blood sugar) pens, one vial of insulin, one calcitonin nasal spray (a medication used to treat bone loss), and two bottles of prescription eye drops. Staff B stated they had provided the 06/2026 temperature log to Staff I, Unit Manager Registered Nurse, to post on Refrigerator 1 for refrigerator temperature monitoring. Staff B stated they were unsure where the new log was and it was their responsibility to make sure the staff posted it.During an interview on 06/11/2026 at 2:45 PM, Staff I stated the refrigerator temperature log was posted for the night shift nurses to complete. They stated the Infection Preventionist was responsible for posting it but since there was no one in that position, Staff B was posting it.During a follow up interview on 06/11/2026 at 4:06 PM, Staff B stated the facility should have been checking Refrigerator 1 temperatures twice daily for vaccine storage; once daily for the medications. Staff B stated the process for medication storage was not followed.During an interview on 06/12/2026 at 9:14 AM, Staff A, Administrator, stated the Infection Preventionist was responsible for monitoring the medication refrigerator temperatures. Since the facility did not currently have anyone in that position, the monitoring didn't get followed through.Reference: WAC 388-97-1300(2)

Based on observation, interview, and record review, the facility failed to perform timely and thorough assessments and monitoring of 1 of 3 residents (Resident 56), reviewed for a change in condition. Additionally, the facility failed to identify and provide needed care and services for 1 of 3 residents (Resident 70) reviewed for wheelchair positioning. This failure placed the residents at risk for delayed care, health complications, skin breakdown, and poor clinical outcomes.Findings included. Review of a policy titled, Quality of Care, revised 08/2018, showed the facility would identify and provide resident centered care and services in accordance with the resident's preferences, goals for care, and professional standards of practice that meet the resident's physical, mental, and psychosocial needs. Resident 56 Review of the medical record showed Resident 56 was admitted to the facility on [DATE] with a full code directive (a medical order for healthcare providers to use every available medical intervention to attempt to save a life during a life-threatening crisis) with diagnoses including significant respiratory failure, heart failure with continuous oxygen use, and GI bleeding with blood loss. The 05/29/2026 comprehensive assessment showed Resident 56 was alert, oriented, and able to direct their care. Resident 56 required assistance of two staff members and a mechanical lift for transfers and assistance with toileting and dressing. During an observation and concurrent interview on 06/08/2026 at 10:50 AM, Resident 56 was lying on their bed with the head of the bed elevated to 75 degrees (an upright, seated position that uses gravity to relieve breathing difficulties). Resident 56 was wearing an oxygen nasal cannula (thin plastic tube with two prongs used to provide oxygen directly into the nose) that was attached to a supplemental oxygen device. The resident's face was pale with a yellowish/gray color and significant edema (swelling) to their left arm and fingers. The top of their left forearm showed large areas of dry, brown, flakey skin. During the same interview, Resident 56 stated they felt weak and were unable to stand and bear weight (supporting one's own body weight). The resident stated they could not successfully participate with physical therapy. Resident 56 stated they had informed the nursing staff on 06/04/2026 and 06/05/2026 that they needed to be seen by a doctor to run a blood test and a chest x-ray because they had similar symptoms in the past that led to hospitalization for pneumonia (a lung infection) and a GI bleed. During the 06/08/2026 conversation, the resident was short of breath and only able to speak in short sentences. Resident 56 stated that there was no communication from the staff as to when the physician would see them. Review of Resident 56's June 2026 Medication Administration Record (MAR), showed the Resident 56 was taking an anticoagulant (a medication that thins the blood). The MAR showed staff were to monitor adverse reactions to the anticoagulant medication that included no adverse reaction, occult stools (obtaining a stool sample and testing it for blood) and other monitoring examples. Nursing documentation on the MAR showed no adverse reactions to the anticoagulation medication. During an interview on 06/08/2026 at 11:00 AM, Staff L, Registered Nurse (RN), stated the resident's left arm had been swollen. Staff L stated the resident had low blood pressure and pulse measurements. Staff L stated they were not aware of Resident 56's shortness of breath and the physician had not ordered any recent laboratory work. During an interview on 06/08/2026 at 12:45 PM, Staff P, RN, stated Resident 56 had previously been hospitalized with pneumonia and a GI bleed. The surveyor asked Staff P if they could assess Resident 56 due to pallor (extreme paleness of the skin and mucous membranes) and shortness of breath. Staff P stated that Staff I, RN Unit Manager, was Resident 56's care manager. During an interview on 06/08/2026 at 1:30 PM, the surveyor informed Staff B, Director of Nursing, that they were concerned about Resident 56's condition and requested them to assess the resident. Staff B verified that Resident 56 was pale and edematous. Staff I was asked by Staff B to assess Resident 56's lung sounds and notify the physician of Resident 56's diminished lung sounds and increased edema, especially in the left arm. During an interview on 06/09/2026 at 9:30 AM, Staff B stated that Resident 56's physician would examine the resident in the facility that afternoon. Review of a nursing progress note (PN) dated 06/09/2026 at 6:38 PM, showed the physician decreased Resident 56's blood pressure medication due to their low blood pressure readings and increased their diuretic (a medication used to remove extra fluid from the body) medication due to the increased edema in the resident's body. Resident 56 was placed on alert monitoring (additional assessments and charting used when a resident experiences a change in condition) to be assessed by nursing staff. Review of a nursing PN dated 06/09/2026 at 8:59 PM, showed the physician assessed Resident 56 for pursed lip breathing (a technique used to help move oxygen into the lungs and carbon dioxide out of the lungs) and diminished lung sounds at all bases. Resident 56 was to be weighed three times weekly and weights were to be reported to the physician. During an observation on 06/10/2026 at 8:40 AM, Resident 56 showed difficulty speaking, was short of breath, confused, and shaking. During an interview on 06/10/2026 at 9:00 AM, Staff B stated Resident 56 appeared worse, referring to their level of consciousness, breathing, edema, and pale color. During an observation and concurrent interview on 06/10/2026 at 10:00 AM, Staff I spoke to the surveyor about sending Resident 56 to the hospital. Staff I called the physician and an ambulance for transfer to the hospital. Review of the 06/10/2026 History and Physical from the hospital showed that Resident 56 was short of breath, had an increased heat rate of 105 beats per minute (normal is 60-100 beats per minute), anemia [lack of healthy red blood cells with deficient (Hemoglobin (Hb) a protein in red blood cells that carry oxygen)], their blood level was critically low at 6.1 g/dl (unit of measure- normal is 13.4-15.2 g/dl). Resident 56 required a blood infusion (a medical procedure in which donated blood or blood components are delivered directly into the blood stream) to replace their blood loss. Additionally, Resident 56 had pulmonary edema (too much fluid in the lungs making it hard to breathe). Resident 70Review of the medical record showed Resident 70 was admitted to the facility with diagnoses including right sided hemiplegia and hemiparesis (weakness and/or paralysis on one the right side of the body), dementia (a progressive disease that destroys memory and other important mental functions), and polyneuropathy (damage to nerves that can cause problems with sensation, coordination, or other body functions). The 03/15/2026 comprehensive assessment showed Resident 70 was dependent on one to two staff members for activities of daily living. The assessment also showed Resident 70 had a severely impaired cognition. An observation on 06/08/2026 at 11:08 AM, showed Resident 70 in their tilt-in-space wheelchair (a specialized wheelchair designed to maintain proper positioning and redistribute pressure by maintaining a seated position while tilting the entire seating system backwards) outside of the activities room watching television. The supportive armrest tray (a flat board covered with foam/material that clamps to the wheelchair, that is used to position a weak/paralyzed arm) was attached to the right side of the wheelchair and tilted away from Resident 70's body, causing their arm to fall off the tray. Resident 70 was observed to pick up their right arm with their left hand and place it across their abdomen for support. Resident 70 had both feet on the right foot pedal of the wheelchair, and their hips were shifted to the left in their seat. Their head was resting on the far left of the head support (a curved shaped device that attaches to a wheelchair, used to support the head and neck). During a concurrent observation and interview on 06/10/2026 at 1:23 PM, Resident 70 was observed in their wheelchair, watching television outside of the activities room. Resident 70 was observed in the same position as the observation on 06/08/2026. They stated they were not comfortable and their legs were sore. During an interview on 06/11/2026 at 8:56 AM, Staff E, Registered Nurse, stated the nursing assistants would report concerns with a resident's wheelchair positioning to them, and they would inform the therapy department of the need for a wheelchair evaluation. Staff E stated they had not received any reports or concerns. During an interview on 06/11/2026 at 11:52 AM, Staff G, Director of Rehabilitation, stated they received notification of positioning concerns during their daily interdisciplinary team meeting. They stated there was no formal process to inform therapy of positioning concerns and they had not received any concerns regarding Resident 70 until that same day. During an interview on 06/11/2026 at 4:00 PM, Staff B, Director of Nursing, stated the nursing assistants should inform the licensed nurses if a resident complained of pain while in their wheelchair. They stated they would check the residents' seating, assess the resident, and refer them to therapy for an evaluation. During an interview on 06/12/2026 at 8:23 AM, Staff A, Administrator, stated the nursing assistants should report concerns to nursing staff so they could evaluate the resident. Staff A stated the process was not followed for Resident 70. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure care and services were provided for 2 of 4 residents (Resident 4 and 31) reviewed for restorative nursing for Range of Motion (ROM) services to prevent decrease in range of motion and mobility. This failure placed the residents at risk for a decrease in mobility, and inability to maintain their current level of functioning. Findings included .Review of the facility policy titled, Restorative Nursing Programs revised 06/2018, showed to assist residents in obtaining and maintaining their highest practicable functional levels, prevent unnecessary declines, and provide an active and healthy living environment.Resident 4Review of Resident 4's medical record showed the resident had been admitted to the facility on [DATE] with diagnoses including left hemiplegia (paralysis that affects one side of the body), muscle weakness, difficulty walking and reduced mobility. The comprehensive assessment dated [DATE] showed Resident 4's cognition was intact and was dependent on staff for care and mobility.In an interview on 06/09/2026 at 12:40 PM, Resident 4 stated they were told that their insurance stopped in March 2026 and had not received any type of therapy since then. During an observation and concurrent interview on 06/11/2026 at 2:44 PM, Resident 4 was lying in bed, stated they had a good morning. Resident 4 stated they had not received any therapy and it had been since March 2026 since they had walked with staff.Review of Resident 4's care plan dated 03/22/2026, showed the resident had limited physical mobility related to weakness and deconditioning. The care plan further showed the resident required supervision or touching assist by one staff member to walk.Resident 31Review of Resident 31's medical record showed the resident had been admitted to the facility on [DATE] with diagnoses including kidney failure, vision loss and a knee amputation on the left with a left leg prosthesis. The comprehensive assessment dated [DATE] showed Resident 31's cognition was moderately impaired and was dependent on staff for care and mobility.In an interview on 06/08/2026 at 3:02 PM, Resident 31 stated it had been six weeks since their last therapy session. Resident 31 stated they had lost strength in their legs and feeling like they did when they first arrived at the facility. During an observation and concurrent interview on 06/10/2026 at 9:17 AM, Resident 31 was sitting in their wheelchair in the hallway, stated they were doing upper body stretching and exercises. Resident 31 stated that since they had no therapy, they do the exercises to keep themselves going.In an interview on 06/11/2026 at 9:20 AM, Staff K, Nursing Assistant (NA), stated they were aware that some residents' care plans had a restorative program, and for those residents' they utilized dressing the residents for their ROM. Staff K stated nursing assistants did not have time to do a real restorative program with residents. Staff K stated they tried to do the best they could for their residents.In an interview on 06/11/2026 at 9:27 AM, Staff G, Director of Rehabilitation (DOR), stated they were aware that the restorative nursing program had not been consistently provided to residents. Staff G stated that the program had been inactive for approximately one month. Staff G indicated that the facility was in the process of restarting the restorative program, but that the process was moving slowly.In an interview on 6/12/26 at 9:22 AM, Staff A, Administrator, acknowledged that there had been inconsistency with the facility's restorative program. Staff A stated that Staff G was working on strengthening their program to ensure residents were offered and received the service.Reference: WAC 388-97-1060(3)(d)

Based on interview and record review, the facility failed to ensure residents who were trauma survivors received trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma), in accordance with professional standards of practice, for 2 of 3 residents (Resident 7 and 65), reviewed for trauma-informed care. This failure placed the residents at risk for unidentified triggers and re-traumatization. Findings included. Review of a policy titled, Trauma-Informed Care, dated 09/20/2022, showed the facility would provide residents who were trauma survivors with culturally competent care that accounts for the residents' experiences and preferences, to eliminate or mitigate triggers that may cause re-traumatization. Residents would be screened upon admission to assist in the identification of residents who may be trauma survivors. The facility would collaborate with the resident/resident representative and members of the interdisciplinary team (a group of healthcare professionals from different disciplines to help people receive the care they need) to identify potential re-traumatization triggers. Resident centered care plans would be developed to reflect resident needs and preferences related to trauma. Resident 7Review of the medical record showed Resident 7 was admitted to the facility with diagnoses including major depressive disorder (ongoing sadness, hopelessness, and loss of interest that lasts at least two weeks), post-traumatic stress disorder [(PTSD) a mental health condition that's caused by an extremely stressful or terrifying event], and psychophysiologic insomnia (the inability to sleep due to excessive worry and anxiety about sleep). The 03/18/2026 comprehensive assessment showed Resident 7 was dependent on one to two staff members for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 7 had a moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). Record review of a document titled, Post-Traumatic Checklist dated 03/21/2023, showed Resident 7 avoided activities or situations because they reminded them of a stressful experience from the past. The form showed watching specific shows on television were stressful and/or overwhelming that reminded them of negative experiences from their past. The form showed the resident had identified interventions that were helpful to them during stressful/whelming situations. Record review of the care plan dated 03/12/2026, showed the resident had a potential mood problem due to their diagnoses of major depressive disorder and PTSD. There were no triggers or interventions listed on the care plan related to PTSD, despite Resident 7 identifying them on the Post-Traumatic Checklist form. During an interview on 06/08/2026 at 10:03 AM, Resident 7 stated they were sexually assaulted in the past. They stated they had received counseling and therapy related to that event, but watching a movie or television show with scenes related to the event would trigger memories related to the traumatic event, causing them to be stressed and overwhelmed. Resident 7 stated they colored pictures to distract themselves from the triggering events. Resident 65 Review of the medical record showed Resident 65 was admitted to the facility on [DATE], with diagnoses that included mood disorder (a mental condition that primarily affects your emotional state), depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities once enjoyed), and PTSD. The comprehensive assessment dated [DATE] showed Resident 65's cognition was intact and required assistance with ADLs. During an interview on 06/09/2026 at 8:57 AM, Resident 65 stated they were a trauma survivor. The resident stated their trauma started at age two and continued until their adolescence. Resident 65 stated they had triggers (sensory experiences, emotions, or situations that activate the trauma response such as bring back intense memories, physical reactions that make it feel as if the trauma is happening again) were things like clowns, or women with lots of make-up on their face. Review of Resident 65's care plan dated 5/20/2026, showed the resident had signs, symptoms, and concerns with mood related to PTSD. Further review of the resident's care plan showed there were no triggers or person-centered interventions that could help guide caregivers on how to help Resident 65 when they experienced triggers. During an interview on 06/11/2026 at 9:20 AM, Staff K, Nursing Assistant, stated they were unaware of residents who were trauma survivors. Staff K stated information like that (resident triggers) would be helpful for the residents' care. During an interview on 06/11/2026 at 11:04 AM, Staff H, Regional Nurse Consultant, stated the process for trauma-informed care included completing an evaluation on admission, readmission, and quarterly to identify past trauma. Depending on the results of the evaluation, another assessment would be completed to assist with care planning. The care plan would show a brief synopsis of the trauma, triggers, and interventions. Staff H stated Resident 7's diagnosis of PTSD would have triggered the trauma-informed care evaluation. They stated the process was not followed. During an interview on 06/12/2026 at 8:23 AM, Staff A, Administrator, stated the process for trauma-informed care would be to follow the facility policy. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to maintain an accurate facility assessment [(FA) an evaluation that determines the resources required to meet each resident's care and services needs]. The assessment contained inaccuracies regarding resident demographics, the involvement of a qualified Infection Preventionist, and lacked active involvement of the Medical Director and Director of Nursing. This failure placed the residents at risk for inadequate care, potential infections, and poor health outcomes.Findings included.Review of a policy titled, Administration Facility Assessment, dated 11/2017, showed the FA was reviewed and updated at least annually or when the facility planned for any change that would require a substantial modification to the assessment. The FA may include the current number of residents and resident capacity, care required by the resident population, staff competencies for the resident population, and considerations for ethnic, cultural, or religious factors that may impact the care of the population.Record review of the FA, dated 06/01/2026, showed the demographics of the resident population within the facility included residents that had a socio-economic status of poor and sexual orientation of straight (attracted to the opposite sex/gender), despite the facility accepting residents of all socio-economic backgrounds and sexual orientation as evidenced by private pay residents and housing of a same sex couple. Additional review of the FA showed the facility would employ a Registered Nurse or Licensed Practical Nurse with certification in Infection Prevention and Control, at a minimum of part time basis. The assessment showed the facility did not employ Medication Aides (a nursing assistant that is authorized to administer medications in a long-term care facility under the supervision of a registered nurse. Further review of the FA showed the persons involved in completing/reviewing the FA included the Director of Nursing and the Medical Director.Record review of the facility staff list, provided to the surveyors on 06/08/2026, showed no staff identified as the Infection Preventionist. The staff list also showed the facility employed one medication aide.During an interview on 06/12/2026 at 9:14 AM, Staff B, Director of Nursing, stated they had not seen the FA and were not involved in reviewing it.During an interview on 06/12/2026 at 8:53 AM, Staff A, Administrator, stated the facility did not currently have an Infection Preventionist. They stated the facility did employ one Medication Assistant. They stated the Medical Director, Director of Nursing, and Administrator were involved in reviewing the 06/01/2026 FA. During a follow-up interview at 9:41 AM, Staff A stated with the inaccuracies in demographics and staffing, the FA was inaccurate and needed to be re-done from the start.During an interview on 06/12/2026 at 11:48 AM, Staff J, Medical Director, stated they did not know what a FA was and were not involved in reviewing the current FA completed on 06/01/2026.During an interview on 06/12/2026 at 11:53 AM, Staff H, Regional Nurse Consultant, stated the FA was inaccurate and both Staff B and Staff J should have been involved in reviewing the FA.Reference: WAC 388-97-1620(1)(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure a safe discharge that included necessary medications, durable medical equipment [(DME) reusable, medically necessary equipment prescribed by a doctor for use in the home to treat an illness or injury, such as a wheelchair, mechanical lift, or hospital bed], and home health services prior to discharge for 1 of 3 residents (Resident 1) reviewed for inappropriate discharges. This failure placed the resident at risk for medical complications and hospitalization.Findings included. Review of a policy titled, Post Discharge Plan, revised 03/2010, showed when a resident discharged the facility, a post-discharge plan would be provided to the resident and/or their representative. The post-discharge plan would identify specific resident needs after discharge such as personal care and self-administration of medications. Appropriate referrals would be made by social services and documented in the medical record. Social services would review the plan with the resident and family, and a copy of the post-discharge plan would be provided to the resident. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including hemiplegia (complete loss of voluntary movement in the muscles on one side of the body) and hemiparesis (mild to moderate muscle weakness) following a cerebral infarction (a blockage in blood vessels supplying the brain that result in tissue death), schizophrenia (a severe mental disorder that affects how people think, feel, and behave) and bipolar disorder (extreme mood swings). The 02/06/2026 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living (activities related to personal care) and set up/clean up assistance of one staff member for eating. The assessment also showed Resident 1 had an intact cognition (the mental action or process of acquiring knowledge and understanding through though, experience, and the senses). Record review of a document titled, Discharge Planning and Summary, dated 04/23/2026 at 12:17 PM, showed Resident 1 was discharged to home under the care of an organized home health service on 04/23/2026. DME was recommended by the Interdisciplinary team (a group of healthcare professionals from different disciplines to help people receive the care they need), however the recommended DME was not listed nor was there an order for the equipment or a delivery date listed. The form showed medications were faxed to the resident's pharmacy. There was no contact information listed for the identified home health agency. The form showed education was provided regarding medications. The remainder of the form was incomplete, including the post-discharge plan and facility contact information for assistance after discharge. During an interview on 04/27/2026 at 11:23 AM, Resident 1's Representative (RR) stated when Resident 1 discharged from the facility, there were supposed to be caregivers waiting for them at their home. They stated the Hoyer lift (a mechanical lift used to transfer a person from one surface to another) was not there and they had to call emergency medical services to help transfer the resident to their bed. The RR stated the facility sent Resident 1 home without medications. They stated the morning following their discharge, Resident 1 was transported to the local hospital because they needed 24-hour care and could not care for themselves at home. During an interview on 04/29/2026 at 1:24 PM, Resident 1 stated the facility did not give them any medications when they discharged and went three days without their medications. During a follow up interview on 04/30/2026 at 9:15 AM, Resident 1 stated they were currently in a different hospital because they were not doing well at home by myself and were unable to care for themselves. They stated the nurse discharged them from the facility and did not provide medications or tell them they could pick them up at a pharmacy. Resident 1 stated they did not receive any instructions for their discharge. During an interview on 04/29/2026 at 1:45 PM, Staff C, Resident Care Manager/Licensed Practical Nurse, stated they discharged Resident 1 to home. They stated the process for discharge included obtaining discharge orders and prescriptions from the provider, ensuring DME and referrals were completed prior to the resident leaving the facility. Staff C stated they were able to send medications home with the resident depending on their insurance and would provide written prescriptions for narcotic (strong pain medications) medications. For residents that did not have insurance that allowed them to take their medications with them, Staff C stated they faxed the prescriptions to the resident's pharmacy. The process also included social service completing the discharge packet and nursing would perform a final skin check. Staff C stated when Resident 1 discharged , social services was not available and nursing picked up the pieces. They stated as Resident 1 was loaded on the van to transport them home, they gave them a discharge packet. They had prescriptions written for a short time for pain medications. They stated they did not send Resident 1 home with their medications and was told by Resident 1 to send the prescriptions to the pharmacy. Staff C stated they faxed the prescriptions to the pharmacy twice; on the day of discharge and a second time on 04/25/2026 as a backup. During an interview on 04/29/2026 at 2:09 PM, Collateral Contact 1 (CC1), Pharmacist, stated the pharmacy received prescriptions for Resident 1 via fax on Saturday, 04/25/2026 at 12:44 PM. They stated there was nothing received by the pharmacy prior to that date and time, and the pharmacy was not open on weekends for customers to pick up medications. During an interview on 04/30/2026 at 8:53 AM, Collateral Contact 2 (CC2), Home Health Services 1, stated they had no referral for Resident 1 and had not provided any services for them, despite the discharge summary listing them as the agency providing home health services. During an interview on 04/30/2026 at 9:32 AM, Collateral Contact 3 (CC3), Home Health Services 2, stated they had received a referral for home health services for Resident 1. They stated they provided a caregiver who was at the resident's home at 3:15 PM on 04/23/2026 (day of discharge). They stated the Hoyer lift was not in the home and the resident's bed was not completely assembled. CC3 stated Resident 1 gave them a written prescription for a pain medication during their visit on 04/23/2026 that they dropped off at the pharmacy for the resident. They stated there were no other prescriptions or medications for the resident. CC3 stated Resident 1 required 24-hour care but did not have hours approved for that coverage. During an interview on 04/30/2026 at 12:09 PM, Staff B, Interim Director of Nursing, stated the facility received a phone call from Resident 1 on 04/24/2026 (the day after discharge) stating they were unable to fill their pain medication at the pharmacy but had not said anything about other medications. They stated the resident's caregiver called the facility on 04/25/2026 midday and asked for discharge paperwork to review how to care for the resident. They stated the nurse that answered the phone told the caregiver to call back Monday for that information. Staff B stated that response was unacceptable and they had personally returned the call to Resident 1 and their caregiver to discuss their concerns, however Resident 1 was being loaded into an ambulance due to their inability to care for themselves at home. Staff B stated no one mentioned the need for prescriptions or medications at that time. They stated they contacted Staff C and told them to call the caregiver and to fax the discharge paperwork to them. Staff B stated the process for safe discharge included obtaining discharge orders from the provider that included medications to continue upon discharge. The facility then contacted the pharmacy, home health services, ordered DME and ensured it was in the home prior to discharge. The facility set up transportation home, and before leaving, staff reviewed the discharge information with the resident/RR and had them sign the discharge paperwork. Medications or prescriptions would then be provided to the resident. Staff B stated the facility did not follow the process for a safe discharge for Resident 1. During an interview on 04/30/2026 at 1:24 PM, Staff A, Administrator, stated the process was not followed for ensuring Resident 1 had their medications available at home after discharge. They stated the normal process for DME included social services ensuring the DME was in place prior to the resident discharging. They stated the facility had used a new system for obtaining DME for discharging residents that included the provider of the DME only communicating with the resident regarding delivery of the DME once the order for the equipment was received by that provider. Reference: WAC 388-97-0120(3)(a)

Based on observation, interview and record review, the facility failed to ensure medication administration services provided met professional standards of practice for 3 of 5 nurses (Staff C, D, and E) reviewed for medication administration. This failure placed the residents at risk for medication errors, unmet medication needs and adverse health consequences.Findings included. Review of a facility titled, Pharmacy Services, Medication Administration, dated 08/2018, showed residents would be provided with safe and accurate medication administration. Medications would be administered following the six rights: the right order, resident, time, dose, route and practices (accepted standards of practice). Staff CReview of the facility investigation dated 04/02/2026, showed a medication error occurred on 03/20/2026 when a resident was provided with two Oxycodone (medication to relieve moderate/severe pain). The investigation showed Staff C assumed the resident could have two Oxycodone instead of one as their pain level was eight out of 10 on the pain scale. Additionally, the resident was not placed on alert charting (nursing documentation for any sudden changes in a resident's condition). Review of the resident's physician order dated 02/19/2026 showed the resident may have one Oxycodone every four hours for moderate pain. Review of a nursing progress note (PN), dated 03/20/2026, showed Staff C misread the physician's order to administer one oxycodone medication and administered two oxycodone medications to a resident in error. During an interview on 04/07/2026 at 11:10 AM, Staff C, Licensed Practical Nurse (LPN), stated they gave two Oxycodone medications based off the resident's pain level. Staff C stated the process to administer medication was to verify the order in the electronic medical record, and the medication prescription labels, document in the narcotic logbook and then administer the medication to the resident. Staff C stated they did not follow the process for accurate medication administration for this resident which resulted in the resident receiving twice the dosage of Oxycodone. Staff C stated they did not place the resident on alert charting. Staff DReview of Resident 1 medical record showed they had diagnoses including lupus [autoimmune disease-that causes the body to attack itself) affecting skin, joints and organs], diabetes (excess sugar in the blood) and respiratory failure. Review of the 02/23/2026 comprehensive assessment showed Resident 1 had an intact cognition. Review of the facility investigation dated 04/02/2026, showed Staff D administered Resident 1 medications that were not prescribed for them. Review of Staff D's PN dated 03/24/2026, showed they provided Resident 1 with another resident's medications. During an interview on 04/02/2026 at 9:57 AM, Resident 1 stated they were provided with the wrong medications as they were medications for another resident. Resident 1 stated they slept for over 12 hours and were very sleepy after they received the medication. Resident 1 stated they would double-check the medications before they take them now. During an interview on 04/09/2026 at 7:41 AM, Staff D, LPN, stated on 03/23/2026, they had prepared medications for a resident, and the resident had refused their medications. Staff D stated they returned to the medication cart and placed the medications into the medication cart. Staff D stated they proceeded to take these medications they placed into the medication cart and administered to Resident 1. Staff D returned to the medication cart and upon preparing Resident 1's medication, they realized they had administered the wrong medications to the wrong resident. Staff D stated the process for when a resident refused their medication was, they were to attempt a second time and when still refused, they were to dispose of their medications. Staff D stated they were overwhelmed (feeling of extreme stress), and they did not follow the correct process for medication administration or disposal. Staff EReview of the facility investigation dated 04/02/2026, showed Staff E failed to administer morning medications for 14 residents on 03/28/2026. The investigation showed that when Staff E began to feel ill, they were advised to call the on-call nurse and they did not. The investigation showed on 03/28/2026 at 10:30 AM, the Director of Nursing (DON), was called by a resident that they had not received their morning medications. The DON arrived at the facility and found Staff E on a medication cart and most of the residents in their assigned hall had not received their morning medications. Review of a nursing PN dated 03/28/2026, showed the Medical Director was contacted regarding missed medications for 14 facility identified residents. The PN showed the facility received orders to either hold or administer the medications. During an interview on 04/03/2026 at 12:32 PM, Staff E, Registered Nurse (RN), stated shortly after arriving for their shift on the morning of 03/28/2026, they began to feel ill. Staff E stated they informed another nurse they felt ill and were told they would call the supervisor. Staff E stated between 9:00 am and 10:00 am, they needed to leave the facility and change clothes. Staff E stated when they returned, they received a phone call at the nurse's station from a resident's family that the resident's medications had not been provided. Staff E stated they told the family they were aware the residents' medications were late as well as many other residents. Staff E stated they proceeded to prepare the resident's medication and were walking to the resident's room when they were approached by a nurse manager and told to waste the medications, provide the medication cart keys to them and leave the facility. Staff E stated they recognized their failure to administer the resident medications timely were medication errors. During an interview on 04/07/2026 at 10:12 AM, Staff F, RN, stated they were working on 03/28/2026 when Staff E told them they were not feeling well around 9:00 AM. Staff F stated they advised Staff E to notify the on-call nurse. Staff F stated at 10:00 AM Staff E told them they needed to leave the facility to change their clothes. Staff F stated Staff E was gone for approximately 45 minutes before they returned to the facility. Staff F stated they told Staff E again, if they were not feeling well, to notify the on-call nurse. Staff F stated they proceeded to notify the on-call nurse and informed them Staff F was ill. Staff F stated the on-call nurse told them they would come in and relieve Staff E. Staff F stated the process when a staff member, including themselves when they were ill, was to notify the facility and stay home or if they became ill at work was to notify the on-call nurse. During an interview on 04/07/2026 at 3:55 PM, Staff G, Staffing Coordinator, stated staff were instructed to not come to work when ill or when at work they became ill were to call/text the on-call nurse. Additionally, staff were also instructed to notify them by call/text to ensure staffing was covered for the shift. Staff G stated on 03/28/2026 they were notified by Staff F that Staff E was ill. Staff G stated they attempted to call/text Staff E and received no response. Staff G stated they called the DON and the on-call nurse manager to notify them they had not received a response. During an interview on 04/07/2026 at 4:18 PM, Staff H, RN, stated they were the on-call nurse manager on 03/28/2026. Staff H stated they were notified by Staff F at 11:45 AM, that Staff E had not administered the morning medications to their assigned residents as they were ill and left the facility. Staff H stated they notified the DON and they both proceeded to come to the facility. Staff H stated when they arrived at 12:00 PM, Staff E was on the medication cart and told them to dispose of any medications and they would be taking over for them. Staff H stated they proceeded to audit the residents' charts in the assigned area for medications, and many residents' charts had shown their medication pass was 'red', which meant they had not received their medications. During a concurrent interview on 04/07/2026 at 1:24 PM, Staff A, Administrator, stated they were unsure if the process for the medication errors were followed. Staff A stated they referred nursing concerns to the Director of Nursing. Staff B, Interim Director of Nursing, stated through the facility investigation, they identified medication errors when Staff C had prepared one resident's medication and when they went to administer the medications, the resident had refused to take them. Staff B stated Staff C did not discard the medications and believed they prepared other medications for a second resident; however, they administered these medications to a second resident. Staff B stated nurses were to follow the rights of medication administration to ensure residents received the correct medications. Staff B stated the process for when a nurse became ill was to contact them and the on-call nurse manager to ensure coverage was provided to administer medication timely. Staff B stated providing a resident another resident's medication, providing wrong dosages of medications and medication omissions were medication errors. Reference: WAC 388-97-1620(1)(2)(b)(ii)

Based on interview and record review, the facility failed to address and provide feedback related to identified concerns brought forth by the Resident Council [(RC) a group of residents that meet regularly to improve the quality of life and care in the nursing home] representatives for 4 of 4 residents (Resident 1, 2, 3, and 4) reviewed for grievances. This failure prevented the residents from reporting concerns that placed them at risk for abuse/neglect, frustration, and diminished self-worth. Findings included. Review of a policy titled, Resident Rights - Right to Organize and Participate in Resident Groups in the Facility, dated 07/2018, showed the facility would consider the views and act promptly upon the grievances and recommendations brought forth by the resident and/or family group concerning the issues of resident care and life in the facility. The facility would demonstrate a response and rationale for the response in relation to the expressed grievances and recommendations. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including respiratory failure, kidney failure, and anemia (a condition where there are not enough healthy red blood cells to carry oxygen to the body's tissues). The 02/23/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 1 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During an interview on 03/13/2026 at 1:13 PM, Resident 1 stated they were Resident Council president. They stated a few weeks ago the facility corporate staff were at the facility doing a mock survey (a simulated, proactive inspection of a healthcare facility to ensure compliance with regulations). Resident 1 stated they had a special Resident Council meeting with the corporate staff. They stated the residents presented the corporate staff with several grievances, including activities, dietary concerns, resident rights, staffing concerns, showers, and call light response times. Resident 1 stated the Resident Council had not received any response to their grievances from the facility or corporate staff. They stated they felt slapped in the face, betrayed, and genuinely hurt. During a follow-up interview on 03/19/2026 at 9:24 AM, Resident 1 stated they still had not received a response from the corporate staff regarding the grievances. The lack of response made them feel like the corporate staff didn't care and their concerns were unimportant. Resident 2Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), muscle weakness, and depression. The 12/12/2025 comprehensive assessment showed Resident 2 was independent with ADLs. The assessment also showed Resident 2 was cognitively intact. During an interview on 03/13/2026 at 11:03 AM, Resident 2 stated they had attended the Resident Council meeting with corporate staff. They stated there had been no improvement on the issues that were brought forward and no actions on their concerns. During a follow-up interview on 03/19/2026 at 9:58 AM, Resident 2 stated there was still no response to their concerns from corporate staff. They stated that made them feel ignored, insignificant, and a little bit hopeless. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including high blood pressure, heart failure, depression, and anxiety. The 09/29/2025 comprehensive assessment showed Resident 3 was dependent on one to two staff members for ADLs. The assessment also showed Resident 3 was cognitively intact. During an interview on 03/13/2026 at 10:54 AM, Resident 3 stated they were at the Resident Council meeting with other residents and corporate staff. They stated the facility administrator was not present at the meeting. Resident 3 stated they had concerns about their activities program and dietary issues. They stated they had not received any feedback on their concerns. During a follow-up interview on 03/19/2026 at 9:11 AM, Resident 3 stated they felt disappointed and had expected the corporate staff to at least consider what was presented to them. Resident 3 stated for nothing to change for the better is frustrating to say the least. Resident 4Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including Takotsubo Syndrome (a temporary, reversible heart condition triggered by intense emotional or physical stress), spina bifida (a condition that occurs when the spine and spinal cord don't form properly), and diabetes. The 01/12/2026 comprehensive assessment showed Resident 4 required moderate to dependent assistance of one to two staff members for ADLs. The assessment also showed Resident 4 was cognitively intact. During an interview on 03/19/2026 at 9:18 AM, Resident 4 stated they were at the corporate Resident Council meeting. They stated it felt odd that corporate staff said they would get back to us and we are still waiting; we have not heard a thing. During an interview on 03/17/2026 at 3:35 PM, Staff C, Social Services Director, stated the residents had invited them to attend the corporate Resident Council meeting. They stated they listened to the concerns brought forth by the residents and would have considered some of them grievances. They stated the process should have been to complete a grievance form and follow up with the residents. Staff C stated they did not complete the grievance forms because corporate staff were running the meeting and taking notes. During an interview on 03/17/2026 at 4:11 PM, Staff A, Administrator, stated the process for filing a grievance could be done verbally or in writing. Grievances were reviewed in the daily morning meeting. Grievances were logged in the grievance logbook and assigned to the appropriate manager to follow up with the resident. Staff A stated the expected follow-up time frame was three to five days. Staff A stated they were not sure if corporate staff would have given them a list of the grievances from the Resident Council meeting held on 02/19/2026. During an interview on 03/17/2026 at 4:44 PM, Staff D, Regional [NAME] President, stated they attended the Resident Council meeting on 02/19/2026. They stated some of the concerns presented were addressed immediately with the residents. They stated the process should have been to generate grievance forms for tracking and follow through with the residents. During an interview on 03/17/2026 at 5:20 PM, Staff E, Chief Nursing Officer, stated the concerns brought forth at the Resident Council meeting were grievances. They stated the facility had received a list of the grievances and should have followed up on them and provided feedback to the residents. Staff E stated the facility should have followed the grievance process. Reference: WAC 388-97-0460(2) This is a repeat deficiency from the Statement of Deficiencies dated 05/27/2025.

Based on interview and record review, the facility failed to ensure an allegation of verbal abuse was reported to the State Agency as required for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk for additional/continued abuse.Findings included. Review of the policy titled, Freedom From Abuse, Neglect, and Exploitation Abuse Reporting and Responsibilities of Covered Individuals, revised 09/13/2022, showed the facility will report to the State Agency any reasonable suspicion of a crime against any individual residing in or receiving care from the facility. The facility will report alleged violations involving abuse, neglect, exploitation, or mistreatment and submit investigation results within timeframes required by federal and state law. Resident 5Review of the medical record showed Resident 5 was admitted to the facility with diagnoses including kidney and urinary disorders, high blood pressure, and bipolar II disorder (a mental health condition with alternating episodes of major depression and elevated mood). Review of a nursing Function Data collection tool dated 03/07/2026, showed Resident 5 required set up/clean up assistance of one staff member for activities of daily living (activities related to personal care). The 03/10/2026 comprehensive assessment showed Resident 5 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During an interview on 03/17/2026 at 10:00 AM, Resident 5 stated they tried to advocate for themselves but there was resistance from one of the staff. Resident 5 stated there was one nurse that made inappropriate remarks and would not leave the room when they wanted to talk with a different nurse. During an interview on 03/17/2026 at 12:33 PM, Staff F, Registered Nurse (RN), stated they had written a witness statement regarding an allegation of verbal abuse regarding an incident between Resident 5 and Staff G, RN. Staff F stated they immediately informed Staff B, Director of Nursing Services, of the incident but had not reported the incident to the State Agency, despite being a mandated reporter (a person that is legally required to report suspected incidents of abuse, neglect, abandonment, or financial exploitation of an elderly person). During an interview on 03/19/2026 at 12:20 PM, Staff B stated they were notified of the incident on the day it happened (03/07/2026) and should have reported it within two hours of the incident. Staff B stated Staff F also should have reported the incident to the State Agency. During an interview on 03/19/2026 at 12:35 PM, Staff A, Administrator, stated the incident was verbal abuse and Staff F, Staff B, and Staff A should have reported the incident to the State Agency Hotline. Cross reference to F600 and F607 for further information.Reference: WAC 388-97-0640(1)(5)(a)

Based on interview and record review, the facility failed to identify an incident of verbal abuse in a timely manner, failed to protect the resident's right to be free from verbal abuse, and take timely action to prevent further abuse for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk of continued verbal abuse, mental anguish, and emotional distress.Findings included. Review of a policy titled, Freedom From Abuse, Neglect, and Exploitation, dated 09/13/2022, showed verbal abuse included conduct which causes or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered a type of mental abuse. Verbal abuse may be oral, written, or gestured communication or sound that residents may hear regardless of the resident's ability to comprehend. Staff were expected to be in control of their own behavior at all times, act professionally, and understand how to work with the facility population. Retaliation by staff is abuse, regardless of whether harm was intended. Resident 5Review of the medical record showed Resident 5 was admitted to the facility with diagnoses including kidney and urinary disorders, high blood pressure, and bipolar II disorder (a mental health condition with alternating episodes of major depression and elevated mood). Review of a nursing Function Data collection tool dated 03/07/2026, showed Resident 5 required set up/clean up assistance of one staff member for activities of daily living (activities related to personal care). The 03/10/2026 comprehensive assessment showed Resident 5 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. During an interview on 03/17/2026 at 10:00 AM, Resident 5 stated there were some things that should not have happened when I first got here. They stated they tried to advocate for themselves but there was resistance from one of the staff. Resident 5 stated there was one nurse that made inappropriate remarks and would not leave the room when they wanted to talk with a different nurse. Record review of Resident 5's incident statement dated 03/07/2026, showed they had approached Staff G, Registered Nurse (RN), regarding their catheter (a thin tube used to drain urine from the body) leaking. They stated Staff G was not listening to me and didn't feel comfortable with Staff G providing their care and had asked for a different nurse. Resident 5 reported they were in their room when Staff G entered and stated, I need to know what your problem is with me and continued to argue with the resident. Resident 5 told Staff G they had urinated on the dining room floor, was so embarrassed and needed Staff G to help them, however Staff G stated that was a nursing assistant thing. They stated Staff G continued to argue with them, so they asked them to please leave their room. Staff G told Resident 5 they were not going to leave the room until Resident 5 settled down. Resident 5 stated they told Staff G they would not settle down until they left the room. Staff G again stated they would not leave the room. Resident 5 told Staff G to get out now. Staff G told Resident 5 they weren't going anywhere, you need to settle down. Staff G left the room when Staff F, RN, entered the room and told them to leave. Resident 5 stated they had asked Staff G to leave more than four times and they wouldn't leave. Record review of a witness statement dated 03/07/2026 at 1:45 PM, showed Staff F, was notified that Resident 5 would like to speak to a different nurse than the one assigned to them (Staff G, RN). Resident 5 stated they were uncomfortable with Staff G and wanted a different nurse. Staff G approached Staff F and wanted to know why Resident 5 had requested a different nurse. Staff F informed Staff G that Resident 5 asked for a different nurse and if Resident 5 wanted to disclose the reason, that was their decision. Staff G told Staff F they needed to know what the problem was. Staff F then noticed Staff G enter Resident 5's room. Staff F overheard Resident 5 speaking to Staff G in a frantic tone regarding an incident with their catheter leaking in the dining room and stated to Staff G do you have any idea how embarrassing that was? Staff G replied to Resident 5 that the catheter problem was a nursing assistant problem, and they had not done anything wrong. Resident 5 told Staff G they were uncomfortable talking to them. Staff G told Resident 5 they needed to settle down. Resident 5 stated they were not going to settle down until Staff G left the room. Resident 5 again stated please leave my room. Now. Leave. Staff G stated, I'm not going to leave until you settle down. Resident 5 wheeled themselves with their walker towards Staff G and stated MOVE. GET OUT OF MY ROOM! Staff F intervened at that time and told Staff G you need to leave now. Staff G stated no, I am not leaving. Resident 5 stated GET [THEM] OUT OF MY ROOM NOW! MAKE [THEM] LEAVE! Staff F told Staff G again that they needed to leave the room. Resident 5 reported to Staff F after the incident that they had a headache and wanted to know when they had their last blood pressure medication. Staff F approached Staff G and asked when Resident 5 received their last dose of blood pressure medication; Staff G replied, you had no right to intervene and Resident 5 doesn't get to choose their nurse. During an interview on 03/17/2026 at 1:52 PM, Staff B, Director of Nursing Services, stated they became aware of the incident between Resident 5 and Staff G the same day the incident occurred (03/07/2026). They stated they had informed staff to obtain interviews. Staff B stated if abuse was alleged, Staff G would have been suspended. Staff B stated they had reported the incident to their regional staff and then was out sick. They stated Resident 5 did not want Staff G in their room to provide care. Staff G had gone back into Resident 5's room to have a conversation. Staff B stated they informed Staff G that another nurse would take over care for Resident 5, gather statements, and the resident was placed on alert charting. Staff B stated, at the time, I didn't hear abuse allegations. The process for allegations of abuse would have been to suspend Staff G pending investigation. Staff B stated they informed Staff G they needed to switch residents with Staff F to protect Resident 5, then stated I don't know why that didn't happen. During a concurrent interview on 03/17/2026 at 1:00 PM with Staff A, Administrator, and Staff D, Regional [NAME] President, Staff A stated they were not fully aware of the incident between Resident 5 and Staff G until 03/13/2026, six days after the incident. Staff A stated the process would have been to immediately initiate an investigation and suspend Staff G until the investigation was completed. Staff D stated the facility needed to do their due diligence for investigating at the time of the incident. During a follow-up interview on 03/19/2026 at 12:35 PM, Staff A stated Staff G should not have gone back into Resident 5's room after they asked Staff G not to. They stated Resident 5 was not protected from Staff G. Staff A stated the incident was verbal abuse due to the confrontation by Staff G. They stated Staff G should not have had continued contact with Resident 5 and Staff F, Staff B, and Staff A should have reported the incident to the State Agency hotline. Reference: WAC 388-97-0640(1)

Based on interview and record review, the facility failed to implement their abuse prevention policy in the areas of identification, investigation, protection, and reporting for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk for unidentified abuse and neglect.Findings included. Review of a policy titled, Freedom From Abuse, Neglect, and Exploitation Preventing and Prohibiting Abuse, revised 09/13/2022, showed the facility's policy is to prevent abuse and neglect of residents. Staff will receive training related to identifying, recognizing, and reporting abuse/neglect. Allegations of abuse/neglect will be investigated to determine whether the abuse/neglect occurred and to what extent. During an investigation of alleged abuse/neglect, to the extent possible, the facility will protect residents from harm during and after the investigation. Staff will immediately report alleged violations to the administrator, state agency, and other required agencies. Resident 5Review of the medical record showed Resident 5 was admitted to the facility with diagnoses including kidney and urinary disorders, high blood pressure, and bipolar II disorder (a mental health condition with alternating episodes of major depression and elevated mood). Review of a nursing Function Data collection tool dated 03/07/2026, showed Resident 5 required set up/clean up assistance of one staff member for activities of daily living (activities related to personal care). The 03/10/2026 comprehensive assessment showed Resident 5 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. Record review of a facility follow up investigation, undated, showed on 03/07/2026, Staff G, Registered Nurse (RN) was assigned to care for Resident 5. During their shift, Resident 5 informed Staff F, RN, that they no longer wanted Staff G to care for them. Staff F informed Resident 5 that they would assume their care for the rest of the shift. Staff G, aware of Resident 5's request, approached Resident 5 in their room and asked what happened to cause them to request another nurse. Resident 5 stated Staff G did not help them with their catheter (a thin tube used to drain urine from the body) when they requested assistance earlier, which caused Resident 5 to urinate on themselves. Staff G left the room when Staff F entered the room. Staff F immediately reported the incident to Staff B, Director of Nursing Services. Staff B educated Staff G that resident requests for a change in caregiver must be respected. The investigation summary showed the facility immediately initiated an investigation into the allegation that Staff G did not respect Resident 5's rights. Staff B removed care of Resident 5 from Staff G's responsibilities. The investigation confirmed that Staff G's failure to respect Resident 5's rights did not result in abuse or neglect. During an interview on 03/17/2026 at 12:33 PM, Staff F stated they had written a witness statement regarding an allegation of verbal abuse regarding an incident between Resident 5 and Staff G. They stated Staff G was arguing with Resident 5 and demanding the resident provide a reason for their request change nurses. Staff F stated Staff G would not leave Resident 5's room after multiple requests by the resident, despite the resident yelling at Staff G to get out. They stated they informed Staff B of the incident immediately but did not report the incident to the State Agency. Staff F stated the incident happened on 03/07/2026, and as of 03/17/2026, there had been no progression on the investigation and Staff G was currently providing care to Resident 5. Staff F stated they would have reported the incident to the State Agency on 03/17/2026, however a State Agency investigator was in the building. During an interview on 03/17/2026 at 12:52 PM, Staff B stated if there was alleged abuse, Staff G should have been suspended pending investigation to protect Resident 5. They stated Staff F had reported the allegation of abuse on 03/07/2026, and they had requested staff to gather witness statements. Staff B stated they reported the incident to the regional staff and then went out sick. Staff B stated they did not report the incident to the State Agency, but Staff A, Administrator, was aware of the incident. Staff B stated they told Staff G, after the incident, that another nurse would take over care of Resident 5, however Staff G continued to provide care to the resident. Staff B stated the process should have been to suspend Staff G pending investigation. They stated, I would have suspended them, I don't know why that didn't happen. During an interview on 03/17/2026 at 1:00 PM, Staff A, Administrator, stated they were not made aware of the staff to resident incident on 03/07/2026 until 03/13/2026 (six days after the incident). Staff A stated the process would have included suspending Staff G and completing an investigation. During a follow-up interview at 1:43 PM, Staff A stated Staff G had been suspended, an investigation had been started, and the facility would be reporting the incident to the State Agency (six days after the incident). Record review of the facility's incident reporting log, dated 03/02/2026 through 03/14/2026, showed no entries for an allegation of abuse that occurred on 03/07/2026. Refer to F600 for further information.Reference: WAC 388-97-0640(1)(2)(a)(b)(3)(a)(5)(6)(a)(b)(c)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 5 residents (Resident 5) reviewed for abuse. This failure placed the residents at risk for further unidentified and/or further abuse.Findings included . Review of a policy titled, Freedom From Abuse, Neglect, and Exploitation Preventing and Prohibiting Abuse, revised 09/13/2022, showed the facility will investigate allegations of abuse, neglect, exploitation, and misappropriation of residents property, including identifying staff responsible for the investigation, identifying and interviewing involved persons, witnesses, and others that may have knowledge of the incident, determining if abuse, neglect, exploitation and/or mistreatment occurred, and documenting the investigation. Resident 5Review of the medical record showed Resident 5 was admitted to the facility with diagnoses including kidney and urinary disorders, high blood pressure, and bipolar II disorder (a mental health condition with alternating episodes of major depression and elevated mood). Review of a nursing Function Data collection tool dated 03/07/2026, showed Resident 5 required set up/clean up assistance of one staff member for activities of daily living (activities related to personal care). The 03/10/2026 comprehensive assessment showed Resident 5 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During an interview on 03/19/2026 at 12:20 PM, Staff B, Director of Nursing Services, stated their process for addressing allegations of abuse included notifying the administrator of the allegation, launching an investigation that included collecting witness statements, and reporting the allegation to the required reporting agencies. They stated they had initiated an investigation into the allegation of verbal abuse from Staff G, Registered Nurse, towards Resident 5 the day the incident occurred (03/07/2026). They stated they gave the initiated investigation to Staff A, Administrator, to complete as they were out sick the week following the incident. They stated the investigation did not get finished. During an interview on 03/19/2026 at 12:35 PM, Staff A stated the incident of verbal abuse should have been investigated by Staff B or turned over to the Resident Care Manager to complete the investigation if Staff B was unable to. Cross reference F600 and F607 for further information. Reference: WAC 388-97-0640(6)(a)(c)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 residents (Resident 6) reviewed for accidents. This failure placed the residents at risk for serious injury and/or exposure to the elements.Findings included. Review of a policy titled, Quality of Care Accident Hazards/Supervision/Devices, dated 07/2018, showed the facility would provide an environment free of accident hazards and provide supervision and assistance devices to avoid preventable accidents. Review of a user and installation manual (provided by the facility) for the WanderGuard Departure Alert System (a wearable bracelet that triggers door locks to alert staff immediately upon a resident approaching an exit, used to prevent at-risk resident's from wandering), undated, showed if attempts to use a wrist placement for the wanderguard bracelet have failed, mount the bracelet away from the metal frame of a wheelchair. The metal in a wheelchair frame, or any other metal items, may interfere with the bracelet's signal to the door modules. Call technical service before putting the bracelet on a wheelchair. Resident 6Review of the medical record showed Resident 6 was admitted to the facility with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), disorientation (a state of mental confusion), and aphasia (impaired speaking caused by brain damage). Review of the 12/11/2025 comprehensive assessment showed Resident 6 was dependent on one to two staff for activities of daily living (activities related to personal care). The assessment also showed Resident 6 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and had no wandering behaviors. Record review of a facility investigation dated 03/08/2026 at 11:23 AM, showed Resident 6 was found outside the facility on the ground by good Samaritans, who assisted the resident off the ground and back into their wheelchair. They sustained a small cut noted on the right side of their head. A WanderGuard was on the resident's wheelchair and alarmed when they were assisted back into the building. The investigation showed Resident 6 had a recent reduction in their psychotropic medication (drugs that alter brain chemistry to treat mental health conditions by managing symptoms like depression, anxiety, and mood swings), which resulted in an increase in their exit seeking. After this was identified on 03/05/2026, the medication was returned to the previous dose and a WanderGuard alarm was placed on the resident's wheelchair. A root cause analysis (a process used to identify the underlying cause of a problem or incident) was completed and showed the WanderGuard placement on Resident 6's wheelchair resulted in the wheelchair blocking the system from reading the WanderGuard. During an interview on 03/13/2026 at 3:27 PM, Staff H, Maintenance Director, stated they were notified of an elopement on 03/08/2026 around 12:00 PM. They stated they tested all the doors, and all alarms were working. They checked the security footage that showed Resident 6 leaving the building through the service door. The alarm was not sounding. Staff H stated Resident 6 had the WanderGuard on their wheelchair. Staff H stated they removed the WanderGuard from the resident's wheelchair, passed it through the door, and the alarm worked. They placed the WanderGuard back on the resident wheelchair, in the same location, and the alarm didn't trigger. Staff H stated the entire back of Resident 6's wheelchair was metal. They stated the metal was blocking the signal to the door module. During an interview on 03/17/2026 at 2:39 PM, Staff I, Registered Nurse, stated they had placed the WanderGuard on Resident 6's wheelchair on 03/05/2026, on the back, bottom right side of the wheelchair. They stated they did not push the wheelchair through the door to ensure the alarm was working. Staff I stated they had not received training or instructions on how or where to place the WanderGuard. During an interview on 03/19/2026 at 12:20 PM, Staff B, Director of Nursing Services, stated the facility had no staff trained on the correct placement of a WanderGuard. Staff B stated the Maintenance Director verified the placement of Resident 6's WanderGuard was incorrect. During an interview on 03/19/2026 at 12:35 PM, Staff A, Administrator, stated staff needed to follow the manufacturer instructions for placement of the WanderGuard to ensure it was working properly. Reference: WAC 388-97-1060(3)(g)This is a repeat deficiency from the Statement of Deficiencies dated 05/27/2025.

Based on observation, interview, and record review, the facility failed to ensure infection control interventions were implemented during a medication pass for 1 of 3 staff (Staff G) reviewed for infection control. This failure placed the residents at risk for infection, illness, and cross contamination.Findings included. Review of a policy titled, Infection Prevention and Control Program, revised 06/08/2022, showed the facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program provides guidance related to standard precautions (minimum infection prevention practices apply to all resident care that includes hand hygiene) to be followed, hand hygiene practices, and staff education and competency regarding infection prevention and control practices. Staff will perform hand hygiene before and after contact with a resident, before performing an unsterile task, after contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in resident room. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including respiratory failure, kidney failure, and anemia (a condition where there are not enough healthy red blood cells to carry oxygen to the body's tissues). The 02/23/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 1 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During an observation on 03/13/2026 at 10:15 AM, Staff G, Registered Nurse, at a medication cart. Staff G's fingernails extended beyond the end of their fingers and there was dark brown matter under their nails. Staff G obtained a card of narcotic medication, popped the pill out of the back of the medication card into their hand and placed the pill into a medication cup. During an interview on 03/13/2026 at 1:13 PM, Resident 1 stated Staff G did not handle medications properly. They stated Staff G did not wear gloves, did not wash their hands before or after passing medications, popped medications into their bare hand and then put them into a medication cup. Resident 1 stated they had observed Staff G with poor infection control practices on more than one occasion, then touch the medications. During a concurrent observation and interview on 03/17/2026 at 10:52 AM, Staff G entered a resident room with a medicine cup containing medications. They handed the medication cup and a plastic cup of water to the resident. The resident took their medications and water and handed both the medication cup and empty plastic water cup back to Staff G. Staff G exited the resident room, returned to their medication cart and obtained a medication card for a different resident. They popped the medication into a medication cup. Staff G did not perform hand hygiene after exiting the resident room or before preparing the next resident's medication. Staff G stated it was not their normal practice to pop medications into their bare hand, except maybe narcotics sometimes if they are little. Staff G stated their normal practice was to perform hand hygiene before entering a resident room and when exiting the room. They stated they did not recall missing hand hygiene. During an interview on 03/17/2026 at 11:49 AM, Staff B, Director of Nursing Services, stated the process for passing medications included ensuring the right medication was administered to the right resident, with the right dose. They stated staff should not touch medications with their bare hands; the medication should be popped from the card into a medication cup. Staff B stated staff were expected to perform hand hygiene before entering each resident room and upon exiting the room. They stated the process was not followed for infection control with medication pass. During an interview on 03/19/2026 at 12:35 PM, Staff A, Administrator, stated staff should never touch medications/pills with their bare hands. They stated staff were expected to have clean hands and were to perform hand hygiene between residents. Reference: WAC 388-97-1320(c)(2)(a)(b)

46722 Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1) received treatment and care in accordance with professional standards of practice after the resident was found with medications in their bed and when a change of condition was not identified timely. Resident 1 experienced harm when their change of condition was not promptly identified, monitored by staff, and not reported timely to the medical provider for evaluation which delayed interventions and the resident being emergently transferred to the hospital. This failure placed Resident 1 and other residents at risk for unidentified care needs and poor clinical outcomes. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses including osteomyelitis (an infection in a bone), sepsis (a life-threatening condition that arises when the body's response to infection caused injury to its own tissues and organs), respiratory failure (a condition where there was not enough oxygen in the blood that caused difficulty in breathing) and weakness. A 02/27/2024 admission assessment showed Resident 1 was alert and oriented and required the assistance of one to two staff for activities of daily living. Review of Resident 1's vital sign records showed on 03/03/2024 at 7:16 AM, there were one set of vital signs recorded as followed; blood pressure 121/78 (normal range 120/80), oxygen saturation 96% (normal range 95-100%), and respirations 18 breaths per minute (bpm) (normal range 12-16 bpm). There were no other recorded vital signs for the day. Review of the 03/04/2024 ambulance report showed emergency medical services (EMS) was notified on 03/03/2024 at 10:12 PM to respond for Resident 1 with altered mental status where staff had reported the resident had been asleep all day and snoring. The report also showed Resident 1 was found in their bed with multiple tablets scattered in the bed of gabapentin (medication used for seizures and nerve pain) and baclofen (a muscle relaxant). When EMS arrived Resident 1 was found not alert with a Glasgow coma scale (GCS - used to measure a person's level of consciousness), of three which showed Resident 1 in a deep coma (a deep state of prolonged unconsciousness, unable to be aroused, respiratory problems and the body's inability to maintain normal bodily function). The report showed the following vital signs were obtained by EMS: 10:26 PM, blood pressure 75/50, oxygen saturation 74%, respirations 8; 10:37 PM, blood pressure 55/30, oxygen saturation 80%, respirations 8; 10:40 PM, blood pressure 53/26, oxygen saturation 95% with supplemental oxygen delivery, respirations 0; 10:43 PM, Resident 1 was intubated (a tube placed into airway, (windpipe) for ventilation (breathing), blood pressure 92/42, oxygen saturation 95%, respirations 13. During an interview on 03/14/2024 at 11:30 AM, Staff C, Nursing Assistant (NA), stated they worked the night shift on 03/03/2024 and at 9:30 PM was asked by Staff D, NA, to assist them with Resident 1 as the resident had been in a deep sleep during their shift. Staff C stated that was uncommon for Resident 1 to sleep all day. Staff C stated upon entering Resident 1's room the resident was asleep in their bed. Staff C stated they attempted to arouse Resident 1 by a sternal rub (to rub the sternum of the chest vigorously to assess a level of consciousness). Staff C stated this was unsuccessful as the resident would not wake up. Staff C stated they exited Resident 1's room to report their findings to Staff G, Registered Nurse (RN). During an interview on 03/14/2024 at 12:03 PM, Staff D, NA, stated Resident 1 was out of it and did not awake during their shift from 2:00 PM to 10:00 PM. Staff D stated they were informed from the day shift NA that Resident 1 was found with a bunch of pills and unsure how many they had taken, and the resident would be out of it most of the day. Staff D stated they observed the resident every few hours during their shift because they were concerned. Staff D stated they asked the nurse on duty, Staff H, RN, about Resident 1's condition and being incoherent. Staff H advised that would be normal for Resident 1 because of the pills they ingested. Staff D stated they did attempt to arouse the resident for dinner without success. Staff D told Staff H the resident did not look right and was limp. Staff H said to Staff D that would be common, and was told to watch and observe Resident 1 and was not told to obtain any vital signs during their shift. Staff D did raise the head of the bed for Resident 1 as they were concerned with their breathing and snoring. Staff D stated they did inform the night shift nurse, Staff G, RN, of their concerns, Staff D stated that Staff G stayed working on the medication cart and did not assess the resident. During an interview on 03/14/2024 at 12:44 PM, Resident 1's Representative (RR), stated they had not had any communication with the facility on 03/03/2024 about Resident 1 having been found with prescription bottles and loose medication in their bed and on the floor and their declining condition throughout the day. The RR further stated Resident 1 was cognitive and was able to make their needs known. The RR stated the only communication they received was after Resident 1 had left the facility in an ambulance. During an interview on 03/14/2024 at 1:33 PM, Staff E, Medical Director, stated they were not informed that Resident 1 was found with loose prescription medication in their bed and on their floor, with the concern they may have ingested them at the time of the incident. Staff E further stated they would have expected the nurse to immediately inform them of the incident that occurred right when it happened. Staff E stated they would have immediately sent Resident 1 to the hospital for evaluation and possible treatment. During an interview on 03/15/2024 at 9:36 AM, Staff F, NA, stated they worked the dayshift with Resident 1. Staff F stated during the breakfast tray delivery, the medications were found in Resident 1's bed. Staff F stated they told Staff H, who asked Staff F to obtain vital signs. Staff F stated they were unable to obtain a blood pressure because the resident was shaking and unable to remain steady. Staff F stated they told this to Staff H, who informed them to observe Resident 1 throughout the day. Staff F stated they would check on Resident 1 and the resident would be quietly moaning. Staff F further stated they reported the resident's condition to the oncoming shift NA. During an interview on 03/15/2024 at 9:55 AM, Staff G, RN, stated they received report from Staff H when they arrived on shift on 03/03/2024 at 6:00 PM, who informed them Resident 1 was found with loose medication in their bed and on their floor earlier in the day. Staff H further stated Resident 1 was not arousable, and they called the on-call provider who advised the resident did not need to go to the hospital because they were snoring. Staff G stated they did not assess Resident 1 until almost four hours later when Staff C came to them and stated Resident 1 was not arousable and was very concerned. Staff G stated the resident was not arousable and snoring. Staff G stated they obtained an oxygen level of 75 percent. Staff G stated they then called the on-call provider and left a message that stated they were sending Resident 1 to the hospital. Staff G then called for an ambulance. Staff G further stated they should have immediately assessed Resident 1 at the beginning of their shift but had become busy with other tasks. During an interview on 03/15/2024 at 10:46 AM, Staff H, stated Resident 1 was alert and oriented on 03/03/204 at 6:00 AM. Staff H stated they were informed about the loose medications in the resident's bed by Staff F maybe sometime between 10:00 AM and 12:00 PM. Staff H stated they searched Resident 1's room and found additional loose medications and partially filled prescription bottles. Staff H stated they disposed of the loose medications and placed the prescription bottles into the medication cart. Staff H stated at 5:00 PM, Resident 1 was unarousable. Staff H attempted to arouse the resident by tapping their shoulder, light shaking, yelling in their ear and a sternal rub, without success. Staff H stated they obtained vital signs which were normal and called the on-call provider, Staff E. Staff H stated they did not record the vital signs and were informed by Staff E to monitor Resident 1 and send them to the hospital if Resident 1's vital signs became abnormal. During a follow-up interview and record review on 03/19/2024 at 10:11 AM, Staff H, provided documentation for their phone call to Staff E on 03/03/2024 at 5:53 PM. Staff H stated this was the only call they made to Staff E. During an interview on 03/15/2024 at 11:26 AM, Staff B, Director of Nursing Services, stated they would have expected Staff H to notify the provider of the found medications at the time of the incident and obtain orders on how to proceed with Resident 1. Staff B also stated they should have called poison control and placed Resident 1 on alert charting. Reference WAC: 388-97-1060(1) This is a repeat deficiency from Statement of Deficiencies dated 05/17/2023.

Based on interviews and record review, the facility failed to provide timely pain management to 1 of 3 residents (Resident 1) on comfort measures. This failed practice resulted in harm to Resident 1 when they experienced unrelieved pain when waiting a prolonged period of time for pain medication while on comfort measures during their active dying process. This failure placed other residents at risk for unrelieved pain and diminished quality of life. Findings included . <Resident 1> Review of the electronic medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included malnutrition, adult failure to thrive (condition with the associated symptoms of weight loss, decreased appetite, poor nutrition and inactivity) and anorexia (lack or loss of appetite). Review of a Progress Note, dated [DATE] at 11:30 AM, showed Resident 1 had increased lethargy (sluggishness, slowness, lack of energy) and audible wheezing with a non-productive cough. The resident would open their eyes to verbal stimuli and close them immediately. The physician was to assess and call Resident 1's representative to discuss comfort care options (included physical, emotional, social and spiritual support for residents and their families, the goal for comfort care was to control pain and other symptoms so the resident could be as comfortable as possible). Review of a physician assessment, dated [DATE], showed the resident was on comfort measures and continued to deteriorate. Review of a nursing assessment, dated [DATE] at 2:41 AM, showed per the physician the resident had declined and was actively dying. All medications were discontinued by the physician. Review of a physician assessment, dated [DATE], showed the Resident's Representative (RR) changed Resident 1's code status in [DATE] to comfort measures only. By [DATE], it became evident [Resident 1's] impending death was days away. They stopped eating and only took minimal amounts of fluid. Resident 1 expired on [DATE]. Review of Resident 1's Medication Administration Record for [DATE] showed Morphine (narcotic medication - used to treat moderate to severe pain) was ordered on [DATE] to be administered every three hours as needed for palliative care pain (used to manage a medical condition that was serious or life threatening by easing pain). Morphine was administered on [DATE] at 7:34 PM by Staff L, Licensed Practical Nurse (LPN), for a pain level of seven (showing strong pain on a scale of zero-10 with zero being no pain and 10 being worst pain possible), and was not administered again. There were no other narcotic pain medications ordered for Resident 1. The RR stated, during a telephone interview on [DATE] at 3:50 PM, they received notification from the facility on [DATE] informing them Resident 1 was dying. The RR arrived at the facility at 9:00 PM on [DATE]. On [DATE] RR stated they asked Staff K, LPN/Resident Care Manager (RCM), regarding Hospice services (a program that gave special care to residents who were near end of life) as they felt that would ensure Resident 1 would not suffer from pain. Staff K informed RR there could be possible associated fees depending on Resident 1's payment source. The RR said that Staff K stated the facility could provide what Hospice provided as Resident 1's physician could order pain medications. The only difference between Hospice and the facility was that Hospice provided their own pain medications. The RR stated on [DATE] they requested pain medication for Resident 1 at approximately 2:30 PM as the resident nodded their head yes when asked if they were in pain (the resident was nonverbal at that time). As there was no narcotic pain medication ordered for Resident 1 (despite the resident being on comfort care) RR stated they were told the resident's physician would be in the facility between 3:00 to 4:00 PM that day to order the narcotic medication. The RR stated Resident 1 appeared to be in much distress as they began twitching their arms and made paddling motions with their feet. The RR stated it made them feel helpless as they continued to observe Resident 1 in pain. The RR stated that pain medication was not given to Resident 1 until approximately 7:30 PM on [DATE] (five hours later). The RR stated that Resident 1 suffered unrelieved pain for several hours before medication was given. The RR stated 1.5 hours following the administration of pain medication they had asked the Licensed Nurse on duty (Staff L) for additional pain medication and was told Resident 1 would have to wait an additional 1.5 hours as it was too early to give an additional dose. Resident 1 expired at the facility at 11:07 PM on [DATE]. In an interview on [DATE] at 9:05 AM, Staff K, LPN/RCM, stated when RR was requesting Hospice services, they informed RR it was dependent on the resident's payment source and there might be associated fees. Staff K stated they informed RR the facility was able to provide the same services as Hospice did. The physician could order pain medication and the only difference was Hospice supplied their own pain medication. Staff K stated Resident 1's physician handwrote the prescription for Morphine on [DATE] and it was given to the pharmacy at 4:48 PM on [DATE]. The Morphine order was not generated by the pharmacy until 7:00 PM on [DATE] (two hours and 12 minutes later). At that time, the facility received an authorization code which allowed staff to access the emergency supply for narcotics. In a telephone interview on [DATE] at 7:11 PM, Staff L, LPN, (cared for Resident 1 between 2:00 PM to 11:00 PM on [DATE]), stated when they arrived to work on [DATE] they did not know Resident 1 was so bad knew [Resident 1] was close [to dying], couldn't believe they did not have the Morphine already. Staff L stated staff were saying Resident 1 was dying for over a week due to their weight loss. The resident's eyes were open, but they were nonverbal. Staff L stated RR requested something for pain for Resident 1. When Staff L was asked how they determined Resident 1's pain level was a seven (out of 10) at 7:34 PM on [DATE], they stated Resident 1 was not able to tell them the level. Staff L was not sure if RR told them the resident was in extreme pain so Staff L stated they decided it was a seven on the pain scale. Staff L said that Staff K told them they were waiting for the pharmacy authorization code so Staff L could obtain the Morphine from the emergency supply in the facility. Staff L stated they were unable to recall RR requesting additional pain medication 1.5 hours after the initial dose of Morphine. In a telephone interview on [DATE] at 7:33 PM, Staff I, Nursing Assistant, stated that when they arrived to work at 2:00 PM on [DATE] Resident 1 had difficulty swallowing and could not take their medications. The resident was nonverbal the entire evening until they expired. Staff I stated when Resident 1 was questioned regarding pain their eyes would get really big. When the resident was repositioned between 4:30 to 5:00 PM on [DATE] it caused pain and discomfort as they made a grunting type sound. Resident 1 had a scared look on their face throughout the shift. Staff was waiting for an authorization code from the pharmacy so they could administer the liquid Morphine to the resident. Reference (WAC) [DATE] (1) 45117

Based on interview and record review the facility failed to ensure that 1 of 2 residents (Resident 8) reviewed for constipation were assessed daily for frequency of bowel movements, and signs and symptoms of impaction or obstruction in accordance with professional standards of practice. Resident 8 experienced actual harm and was hospitalized for fecal impaction (severe constipation resulting in hardened stool getting backed up into the colon (a tube like organ connected to the intestine in the stomach). Findings included . Record review of the facility's undated policy titled Bowel Protocol and Bowel Tracking showed If constipation was suspected, bowel movements would be assessed daily by the nurses for signs and symptoms of fecal impaction or obstruction. If there was no bowel movement for three days, the resident's bowel protocol would be initiated. If there was still no bowel movement the physician would be notified for further instructions. Resident 8. Review of the resident's electronic health record (EHR) showed the resident admitted to the facility on [DATE] with diagnoses including failure to thrive, muscle weakness, and dysphasia (difficulty in swallowing). The resident used a gastrostomy tube (a tube surgically placed in the resident's stomach to receive nutrition). Review of Resident 8's bowel record from 04/16/2023 to 04/29/2023 showed no documented bowel movement for 13 days. Review of Resident 8's progress notes from 04/13/2023 to 04/27/2023 showed only two assessments of the resident's bowel status to include signs and symptoms of constipation or fecal impaction. Review of the Resident 8's hospital record, dated 05/01/2023, showed on 04/30/2023 the resident was admitted to the hospital and discharged on [DATE]. Review of a hospital note, dated 05/01/2023, showed Resident 8 had an abdominal scan and the results showed, .A large amount of fecal matter in the colon with significant distention of large fecalithe (a hard mass of stool) consistent with constipation and rectal impaction . During an interview on 05/11/2023 at 11:25 AM, Staff E, Licensed Practical Nurse (LPN), stated that if a resident did not have a bowel movement for three or more days the dashboard (a type of computer graphic that shows information for the resident) in the EHR alerted them in red that the resident had gone three days without a bowel movement. Staff E stated they were aware the resident had gone numerous days without a bowel movement and stated they had not documented an assessment of the resident's abdominal status. Staff E stated the Resident Care Manager had previously printed out a list of residents who needed bowel care however they were no longer doing it because they were busy. Staff E stated I try to print one out when I can. During an interview on 05/16/2023 at 9:03 AM, Staff B, Director of Nursing Services, stated that the nurses were expected to perform abdominal assessments if a resident did not have a bowel movement and contact the physician. Staff B acknowledged that the resident's EHR showed a lack of daily documentation of bowel assessments or physician notification. Staff B stated We don't have a good system in place. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to implement [MEDICATION(S)] and/or reduction interventions when one of three residents (30) experienced pain at a 10 out of 10 (on a scale of zero to 10, with zero being no pain and 10 being worst pain), when being weighed by the facility's mechanical lift. Failure to assess the pain resulted in actual harm to the resident when the same process to weigh the resident continued (seven weights obtained since admission) without pain control interventions. Findings included . Review of the facility's policy, Safe Lifting and Movement of Residents, dated 08/31/2018, showed that resident safety, dignity, comfort and medical condition would be incorporated into decisions regarding transfers. Nursing and Therapy staff would assess individual resident's transfer needs and staff responsible for direct care would be trained in the proper usage of the mechanical lifting. Resident 30. Review of the medical record showed the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 09/23/2021 comprehensive assessment showed the resident required extensive assistance of two-persons or more for assistance with transfers and repositioning in bed. The assessment showed the resident was cognitively intact. Review of the resident's weight history in the medical record showed the resident was weighed on 09/16/2021, 09/17/2021, 09/18/2021, 09/23/2021, 09/30/2021, 10/07/2021 and 10/14/2021. All documented weights were obtained via mechanical lift. During an observation and interview on 10/19/2021 at 9:36 AM, the resident was observed in bed. A purple sling (a fabric device which attached to the mechanical lift and cradled under the resident to support the body) was observed draped over a chair in the corner of the room. The resident stated that staff used the sling to weigh me. The resident stated that they had been weighed numerous times since admission to the facility and that it hurts so bad I just scream in pain . and that they just try to do it quickly and it hurts my legs .it's so painful. On a scale of 0-10 the resident rated her pain at 10 out of 10. During a concurrent observation and interview on 10/21/2021 at 9:59 AM, three staff were observed in the resident's room preparing the resident to obtain weight via the facility's mechanical lift. Staff H, Registered Nurse (RN) explained to the resident that the staff had just told them that the lift caused pain to the resident's legs and knees, and that it hurts you a lot. Staff H then stated to this surveyor, (Resident 30) is very nervous because it's painful. The resident stated they've known and I scream . and I feel horrible and embarrassed. Two Nursing Assistants (NAs), Staff I and J (who regularly cared for the resident), stated that they were aware of the pain it caused, every time they weighed Resident 30. During the continued observation, the resident was prepared for the mechanical lift, Staff I and J placed a larger sling (not the sling that was observed on the chair) beneath the resident and positioned the lift over the bed. The resident began to grimace, squeeze their eyes shut and began shaking at the arms and hands. The resident was then offered not to obtain a weight, but the resident stated, I want to get it, I know it's best for me. At 10:07 AM, the resident was lifted off the bed, and they began crying out and held their hands to their mouth, the hands were shaking. Staff H, RN, was positioned near the resident's legs and was holding them up, to relieve the pressure that the back of the sling was causing. The sling edge was approximately 6 inches down from the resident's buttock and approximately 2/3 up from where the back of the knee bent. The resident stated hold them (legs) up, hold them up . it hurts. The resident was tearful. The lift was at the highest mechanical point, however the resident's bottom was still partially on the bed. A weight was not obtained and the resident was then placed back on the bed and the sling was removed. During an interview on 10/21/2021 at 10:22 AM, Staff J stated that the NAs previously did not get guidance of which sling to use and that we go by weights, this is the best one we have but it does not go down far enough on her legs. Staff J stated that the resident had yelled out during previous lifts, we always tell the nurse. Further, Staff J stated that this time it was better than previously because nursing staff had directed the NAs to use a different, larger sling, during the observation with this surveyor. Staff J stated that neither therapy nor nursing staff had been involved in the selection of the sling, nor had nusing staff assessed the resident's pain during other mechanical lifts/weights obtained, that they were aware of. During an interview on 10/22/2021 at 10:40 AM, Staff H, RN, stated that the facility needed to determine what was best as this method did not work .[Resident 30] was clearly in pain. During an interview on 10/22/2021 at 12:03 PM Staff I, NA, stated that she had not received lift/transfer training at the facility. When asked how the sling sizes were selected for the residents, Staff I stated that for Resident 30 we just look for the biggest one - because of (Resident 30's) weight, they can rip. Staff I further stated that the resident did scream out in pain during the previous lift/weight procedures but that this time it did not hurt the resident as much as it previously did because they were using the larger sling .before, we used the smaller slings .no one really tells us, we go by weights. Further, Staff I stated that this was the first time a nurse was in the room to assist in obtaining the weight. During an interview with Staff B, Director of Nursing (DON) and Staff I on 10/25/2021 at 10:51 AM, Staff I stated we told the nurses (Resident 30) had pain, they knew she had pain, but we had to get the weights. Staff B, DON, stated she was not aware of any pain assessment or interventions that were implemented to address the pain the resident experienced during weights. Review of the resident's medical record from 09/16/2021 (admitted ) through 10/21/2021 showed there were no interventions to assess and reduce/remove the pain the resident experienced during seven documented weights obtained via mechanical lift. During an interview on 10/26/2021 at 11:08 AM, Staff C, Licensed Practical Nurse/ Resident Care Manger, stated that the facility was currently trying to determine other options and had ordered other slings. On 10/26/2021 copies of pain assessments during lift transfers and copies of in-service training related to mechanical lift transfers was requested. As of 11/02/2021 the facility did not provide the requested documentation. The facility repeatedly applied a mechanical lift procedure inducing severe pain, and did not comprehensively assess, evaluate or address the resident's pain, to determine interventions and strategies for preventing or minimizing pain with transfers and obtaining weights. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure adequate monitoring of an anti-coagulant ([MEDICATION(S)]) for one of one resident (2) for unnecessary medications; to clarify whether the anticoagulant medication had to be held for a period of time before and after significant dental surgery (extraction of five teeth). This failure resulted in harm to Resident 2 who experienced signs and symptoms of excessive bleeding from dental surgery. The resident was taken to the emergency room in less than 24 hours after the surgery and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Resident 2. Review of the medical record showed the resident initially admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 10/16/2021 comprehensive assessment showed the resident had some cognitive impairment but was alert and made needs known. The resident received an anticoagulant daily for an abnormal heart rhythm. Review of a progress notes on 10/01/2021 at 11:24 AM showed that the resident returned from dental surgery (five teeth extracted) and after care directions for a soft diet for 48 hours and over the counter medications for pain for 72 hours. The resident also received their anti-coagulant medication. The resident had dental surgery on 10/01/2021 where five teeth were extracted. A 10/02/2021- 8:17 AM progress note showed the resident's mouth was bleeding and a gauze was placed in their mouth to bite down on. The family representative was notified of the resident's bleeding gums. A 10/02/2021- 12:44 PM progress note showed the resident continued to have excessive bleeding and the physician was called and gave orders to hold the anti-coagulant medication for three days, apply gauze, obtain vital signs (blood pressure, pulse, and respirations) for three days and obtain blood work in the morning. A 10/02/2021- 10:32 PM progress note showed the Nurse Practioner gave an order to send the resident to the emergency room for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2 returned to the facility at 9:20 PM. Review of the emergency room (ER) physician's note on 10/02/2021 at 8:45 PM showed Resident 2 had excessive bleeding gums with suturing of the extraction site. Orders were given to place the resident on a liquid diet for 24 hours, then a soft diet for 24 hours to prevent disruption of the clot formation to the suture line .hold the anti-coagulant for the next two to three days. Review of the Nurse Practioner's 10/04/2021 post hospital/emergency room visit note that was a face to face visit, showed the resident had an episode of excessive bleeding after extraction of five teeth on 10/02/2021. The area was sutured, and the resident was returned to the facility. They are now on a soft diet and the anti-coagulant was still on hold. During a concurrent observation and interview on 10/20/2021 at 10:00 AM, the resident was seated in their wheelchair in their room and showed their teeth to the surveyor. The resident stated that they went to the hospital after their teeth were removed and had been bleeding. Resident 2 stated they had to get stitches in their mouth and really did not have an appetite after that. During an interview on 10/29/2021 at 9:12 AM, Staff C, Licensed Practical Nurse/ Residential Care Manager (LPN/RCM) stated they were aware the representative took the resident to a dental appointment on 10/01/2021 and the dentist extracted five teeth (but was unaware of the dental appointment until Resident 2 had returned from the 10/01/2021 appointment). Staff C stated that the resident was on a blood thinner (on 10/01/2021 and 10/02/2021 with no order to hold the medication) and experienced excessive bleeding and was sent to theER on [DATE]. The facility did not know about the extractions. During an interview on 10/29/2021 at 10:00 AM, Staff K, LPN stated that if a resident was to have dental extractions and was on an anti-coagulant, they would notify the physician about the appointment. Staff K also stated that if a resident had extractions and was still taking their anti-coagulant, they would hold the medication and call the physician due to risk of bleeding which could lead to other complications. During an interview on 10/29/2021 at 10:56 AM, Staff B, Director of Nursing (DON), stated that they were unaware whether the agency nurse that worked on 10/02/2021 witnessed the increased bleeding of the resident's gums. They stated they did not know about the resident's dental appointment on 10/01/2021 until the resident's representative picked the resident up the morning for the appointment. During an interview on 10/29/2021 at 11:11 AM, the resident's representative stated the resident's dentist made the appointment a few months ago concerning the extraction of the resident's five teeth. The representative stated they notified the facility and asked to provide a list (of the resident's medications) from the facility to provide to the dentist and made sure the list was given to the dentist. Also, the representative took the medication list to the dentist on the day of surgery (10/01/2021). The representative stated the dental provider gave the representative a handout with post extraction instructions for Resident 2 (which they had given to the facility on [DATE]). The representative was not clear on what the instructions were but stated the staff were to observe the resident for excessive bleeding of the extraction site. A November 6, 2020 informational guide from [MEDICATION(S)]/[MEDICATION(S)] stated the anti-coagulant may need to be stopped prior to surgery or a medical, or dental procedure. Your doctor will tell you when you should stop taking [MEDICATION(S)]/[MEDICATION(S)] and when you may start taking it again. When should I start [MEDICATION(S)] after tooth extraction? According to the insert of the anti-coagulant medication and questions/answers to people who were on the medication who were to have dental surgery/extractions stated to resume [MEDICATION(S)] the day after the procedure, after at least 24 hours have elapsed and when hemostasis (bleeding stops) is secured. Reference: WAC 388-97-1060(3)(k)(i)

Based on interviews and record review the facility failed to ensure appropriate treatment and services were provided to one of five residents (#1) reviewed for behaviors and emotional well-being. Resident #1, who had a history of [REDACTED]. This resulted in actual harm to Resident #1 as he was found five days later in bed with a bed control cord wrapped twice around his neck. Findings included: Record review of the facility's policy titled, Suicidal Precautions Checklist, dated May, 2020, showed the checklist was to guide the facility with steps to be initiated when a resident makes suicidal statements. The checklist included: - safety check of the resident's room - one to one supervision initiated and to continue until otherwise indicated - notify clinical team - physician notified and orders for suicide precautions and mental health consultation received - responsible party notified - social services contacted - mental health professional contacted, and referral made - care plan initiated and individualized - alert charting initiated for each shift and to continue until otherwise indicated - dietary referral made for plastic utensils - suicidal risk assessment completed - interdisciplinary team to meet with resident/representative - interdisciplinary team to review [MEDICAL CONDITION] medications - physician/pharmacist to review medication regimen for possible changes Resident #1. Review of the resident's medical record showed he was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the comprehensive nursing assessment, dated 06/15/2020, showed the resident had moderate cognitive loss; no behavioral issues; felt tired or had little energy; required two staff to assist with turning in bed and transfers; two staff to assist with dressing, personal hygiene, and toileting; continent of bowel; and occasionally incontinent of bladder. Review of Progress Notes (PNs), dated 07/09/2020, showed the resident had improved with activities of daily living (ADLs) as he only required stand by assistance with transfers, used a hemiwalker (provides support for residents with limited or no use of one hand) for ambulation walking 135 feet, and minimal assistance with ADLs. Review of a facility investigation report, showed the resident was found on the floor of his bathroom on 08/28/2020 at 4:35 PM complaining of pain to his right hip and leg. He was transported to the hospital where x-rays showed a fractured right hip. Review of the hospital History and Physical, dated 08/28/2020, showed the resident had a history of [REDACTED]. On admission to the hospital he was scored as moderate risk and placed on one to one protocol. Documentation showed he had a [MEDICAL CONDITION] disorder and was taking an antidepressant at home. On 08/31/2020 hospital records showed the resident agreed with the surgeon regarding a nonsurgical approach to treat the right [MEDICAL CONDITION]. The resident was not suicidal currently. Review of PNs, dated 09/01/2020, showed the resident was readmitted to the facility from the hospital with an antidepressant ordered to be administered daily. Progress Notes regarding discharge planning, dated 09/02/2020, documented by Staff A, Social Services, showed it was unclear if the resident would be returning home. That was the resident's initial plan, however he might not be able to return home. Progress Notes, dated 09/03/2020, showed the resident was alert and oriented to person, place, and situation. He expressed sadness regarding his [MEDICAL CONDITION] stating, I probably won't go home. A mechanical lift was utilized for all transfers, required extensive assistance with turning in bed and toileting, and was unable to walk. Progress Notes, dated 09/04/2020 and 09/05/2020 by Staff B, Licensed Practical Nurse (LPN), showed the resident expressed dissatisfaction with the [MEDICAL CONDITION] . continues to refuse treatment for [REDACTED]. Review of the resident's plan of care showed no problem addressing the resident's depression, mood changes with suicidal thoughts. Staff B stated during a telephone interview on 09/16/2020 at 1:50 PM, that on 09/04, 05/2020 between approximately 6:00 to 6:30 AM he entered the resident's room to perform blood sugars. The resident was watching television and began crying stating he had a past experience of imagining himself jumping from a boat or ferry but he did not do it because of the boat propeller. The resident expressed he needed help with his feelings. Staff B stated the resident was crying which made it difficult to understand him. Staff B stated he informed Staff C, LPN/Resident Care Manager when she arrived to work at approximately 8:00 AM on 09/04/2020 and she instructed Staff B to write a PN regarding the incident and to ask the resident if he had a suicide plan. Staff B was told by the resident he did not have a plan. When Staff B documented his discussion with the resident on 09/04,05/2020 he thought the physician was reading those PNs as he had marked the PN to be forwarded to the 24 hour report, which would ensure the resident would get help. However, Staff B later learned he had to put information to share with the physician in a blue book located at the nursing station, which he had not done, nor had he notified the physician by phone. An interview with Staff C on 09/16/2020 at 2:30 PM, showed Staff B reported to Staff C that the resident had been tearful, but denied any information given by Staff B regarding the resident needing help with his mood and suicidal thoughts. Staff C stated upon checking on the resident that day he was not crying and he talked about being in the lake and having bad dreams, which was unusual for him. Staff C stated any information the physician needed to be alerted to had to be placed in the blue book at the nursing station. Twenty-four hour reports were discussed amongst the management staff during morning meetings Monday through Friday, but not on weekends. Progress Notes, dated 09/08/2020 at 1:24 AM, showed the resident had been crying out loud stating he could not move and help himself without being a burden to anybody. On 09/08/2020 at 3:35 PM documentation showed the resident expressed dissatisfaction and sadness related to the [MEDICAL CONDITION] and the impact it has made on his daily life. Review of a facility investigation report, dated 09/10/2020 at 6:00 AM, showed Staff D, Nursing Assistant, heard the resident making groaning noises from his room. Upon entering the resident's room his face was blue/purple and he had wrapped the bed control cord around his neck multiple times and positioned the head of the bed straight up. Staff D tried to pry the bed control out of the resident's hand telling him to let go, which he responded by stating, I can't. After releasing the cord from the resident's neck he repeatedly stated, I tried so hard, I tried so hard to kill myself. The resident did not want to be a bother to his spouse and it would be easier for her if I go. When the resident was asked if he would accept help he stated yes. The resident was transported to the hospital with mental health and emergency personnel. Staff D stated during a telephone interview on 09/17/2020 at 1:35 PM, that after the resident's fall with fracture he needed to be changed for incontinency episodes. On the morning of the suicide attempt the resident put the head of the bed all the way up which was strangulating him. She stated it took approximately 20 seconds to get the bed control out of his hand. Staff E, Registered Nurse, stated during a telephone interview on 09/17/2020 at 1:10 PM, that three days prior to the suicide attempt she was taking the resident's blood sugar and he was crying stating he could not move. Staff E stated usually the resident was happy, but he seemed depressed as he was incontinent of stool and needed staff assistance to help him. She denied any awareness of the resident having suicidal thoughts and requesting help. An interview on 09/16/2020 at 11:30 AM with Staff A, showed prior to the resident's fall causing the [MEDICAL CONDITION] he was scheduled to go home on 09/07/2020 and was excited about that. Staff A stated that prior to the resident's fall he was walking. She stated she was unaware of the resident making any suicidal statements. A telephone interview on 09/16/2020 at 1:29 PM with the resident's spouse, showed the resident was going to be discharged to home on 09/07/2020 and he was so happy about that. Following his fracture the resident expressed to her how challenging it would be to come home after the [MEDICAL CONDITION]. Reference WAC 388-97-1060(1)(3)(e)

Based on interviews and record review the facility failed to provide adequate supervision and develop interventions to ensure resident safety following an elopement incident involving one of three residents (#1) reviewed for elopement. This resulted in actual harm to Resident #1, who eloped twice from the facility approximately 42 hours apart, and due to changes in his condition following the second elopement was taken by ambulance to the hospital due to respiratory and heart distress. Findings included: Resident #1. Review of the resident's medical record showed he was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated 08/10/20, showed he was at risk for falls due to weakness, received insulin injections for diabetes, fluid restriction of 1800 milliliters per day, prescribed treatments for pressure ulcers to both feet, and required monitoring of respiratory and heart status due to problems with shortness of breath, low blood pressure, and pacermaker in place. Review of the Nursing Admission Evaluation form, dated 08/06/2020, showed the resident had no cognitive impairments, received prescribed treatments to wounds on both feet, on a fluid restriction, utilized a walker for mobility, displayed shortness of breath or difficulty breathing with exertion, had [MEDICAL CONDITION] issues to both legs, and was at risk for falls and pressure ulcers. Review of the hospital History and Physical, dated 08/04/2020, showed the resident had been previously hosptalized on [DATE] for [MEDICAL CONDITION] due to his diabetes and was intubated (a tube was placed down the resident's mouth into the airway to help with breathing). Following the resident's discharge from the hospital on [DATE] he became increasingly weaker as noted by his statements of not being able to walk or perform daily activities. In addition, he did not fill the diabetic medication prescriptions, thus had not been managing his diabetes. The resident had heart problems which included the placement of a pacemaker, and chronic low blood pressure readings for which medication was being administered. The resident was readmitted to the hospital on [DATE] for generalized weakness, blood sugar level over 600 (normal is 80-100), and a chest x-ray showing [MEDICAL CONDITIONS] (condition in which there is excess of fluids in the lungs causing breathing problems), and diminished heart function. Review of Progress Notes (PNs), documented by Staff A, Registered Nurse on 08/25/2020 at 8:55 AM, showed Staff A was alerted by another staff member arriving to work that she observed the resident walking down the street towards a high traffic intersection. Staff A yelled at the resident but he ignored her, thus she got into her car to look for him. He was located two streets away waiting for the bus. He stated they would not let him on the bus as he did not have shoes on. He stated he left the facility to go to a store to purchase items. The resident was observed to have difficulty breathing. He was then taken back to the facility. Staff A stated during a telephone interview on 08/31/2020 at 3:20 PM, that the resident had left the faciity on [DATE] between approximately 6:45 to 7:15 AM and was found at the bus stop. She stated she was unaware the resident had left the facility until informed by a staff member coming to work. The resident did not have his walker, was having difficulty breathing, was wearing only socks, and had an open wound to his right foot with a recent open wound to the left foot. Staff A stated she informed all the staff of the incident, however she did not make any revisions to the resident's plan of care. Review of the resident's plan of care showed there was no problem addressing the resident's elopement from the facility on 08/25/2020, and no plan was put in place to monitor the resident's whereabouts to ensure his safety. Review of PNs documented by Staff B, Social Services on 08/27/2020 at 3:39 PM, showed the resident left the facility early that morning without staff knowledge (second elopement). The neighborhood was searched, but was unsuccessful in locating the resident. The mission, local hospital, and state agencies were notified. The resident left without any of his medications. Review of PNs, documented by Staff C, Registered Nurse/Charge Nurse on 08/27/2020 at 4:28 PM, showed the resident received his medications at approximately 9:00 PM on 08/26/2020. At 5:30 AM a therapist started to enter the resident's room however the resident was coughing, thus she decided to work with another resident. When the therapist returned the resident was not in his bed and staff had not observed him leaving his room. Staff attempted to locate the resident, however were unsuccessful. The physician was notified and orders were received that if the resident was located staff could provide medications for a safe discharge. Staff C stated during a telephone interview on 09/01/2020 at 5:00 AM, that she was unaware the resident had eloped from the facility the first time on the morning of 08/25/2020 (despite her being the charge nurse the following evening/night shift). She stated the last time she had seen the resident prior to him being reported missing the morning of 08/27/2020 was at approximately 9:00 PM on 08/26/2020 when she administered medications to the resident. She stated, I don't think anyone checks on him. Every night the resident doesn't want anyone checking on him. The resident wanted his door closed. Staff C stated staff was unaware the resident had left the facility until the therapist went to his room after 5:00 AM on 08/27/2020 and he was not there. Staff C stated residents were to be checked every two hours and the resident was not due to his behaviors, doesn't want to be checked. An interview on 08/3`/2020 at 6:08 PM with Staff E, Nursing Assistant (primary caregiver for the resident on the night shift of 08/26-27/2020), showed she had not seen the resident during her shift. She stated one of the therapists would come in early and she would check on him. Staff E stated residents were to be checked every two hours. Staff D, Occupational Therapist, stated during an interview on 08/29/2020 at 11:50 AM, that she frequently worked with the resident at approximately 5:00 AM. On the morning of 08/27/2020 she was walking toward the resident's room when she heard coughing at approximately 4:50 AM, but was not totally sure it was the resident she heard coughing. Staff D decided to work with another resident. Upon returning to Resident #1's room at 5:30 AM she discovered he was not there, thus she alerted Staff C. Staff D had recommended to staff and the resident he needed to utilize a walker for longer distances, however he was noncompliant with recommendations. She stated the resident had no shoes, only gripper socks, and his legs were swollen. The resident had reached his maximum potential with therapy services. Staff G, Administrator, stated on 08/29/2020 at 1:00 PM, that the facility policy, which was not in written form, was for staff to check on residents every two hours throughout their shift. On 08/31/2020 at 10:40 AM Staff F, Director of Nursing, stated the resident was observed, via a facility camera, leaving the facility out the front door at 11:00 PM on 08/26/2020, and continued to be missing. Staff B stated per telephone interview on 08/31/2020 at 3:50 PM, that the resident had been located and was currently at the hospital. He had checked into a local hotel and was taken by ambulance on 08/30/2020 at 2:00 PM from the hotel to the hospital. The resident (who was in the hospital) stated during a telephone interview on 09/01/2020 at 3:55 PM, that the desk clerk at the hotel had called for an ambulance as she thought I was pretty sick. The resident stated his condition was worsening as he could no longer lay down due to his breathing, was panting a lot and heart was jumping, and he needed his [MEDICATION NAME] (water pill) as he was swelling up. He stated he just left the facility after doing 21 days of rehab. He stated, I'm making bad decisions, but I'm really sick. Review of hospital records, dated 08/30/2020, showed the resident was admitted to the hospital with [REDACTED]. Reference (WAC) 388-97-1060(3)(g) This is a repeat citation from the survey dated 08/07/2019 and 07/10/2019.

Based on interview and record review the facility failed to ensure staff provided adequate pain management in a timely manner for two of four residents (#'s 7, 8) receiving narcotic medication for pain. This failed practice resulted in actual harm to Resident #'s 7 and 8 who were admitted to the facility following surgery, and despite their requests for pain medication they waited for a prolonged period of time to receive medication. Findings included . Resident #7. Review of the resident's medical record showed she was admitted to the facility from the hospital on [DATE] following surgery for [REDACTED]. Review of hospital records showed on 07/22/19 the resident received four doses of [MEDICATION NAME] (narcotic medication) one tablet. Her pain level that day ranged between a seven to eight on a scale of zero to ten, with zero being no pain and ten being severe pain. On 07/23/19 the resident received four doses of [MEDICATION NAME] one tablet and one dose of two tablets for a pain level ranging between seven to eight. The last dose of [MEDICATION NAME] administered in the hospital was at 5:22 AM on 07/24/19 for a pain level of six. Review of a pain assessment, dated 07/24/19, showed the resident had intermittent sharp pain to the front of her right shoulder. The pain level at that time was four out of ten. Review of a comprehensive nursing assessment, dated 07/25/19, showed the resident had no cognitive impairments. Review of physician's orders [REDACTED]. The resident stated on 08/04/19 at 7:20 PM that she had problems receiving pain medication when she first was admitted to the facility. She stated she arrived at the facility on 07/24/19 at approximately 11:00 to 11:30 AM. She stated she did not receive any pain medication until approximately 8:00 to 9:00 PM as the facility did not have her pain medication. The resident stated she was in alot of pain in her right shoulder due to recent surgery and infection. In addition, four days later on 07/28/19 the facility ran out of her narcotic medication and she did not receive any until two days later (07/30/19). Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated on 08/06/19 at 4:00 PM that the resident was admitted to the facility on [DATE] at 11:44 AM, and she performed the above pain assessment right after the resident's admission. She had difficulty obtaining the resident's narcotic pain medication when she admitted to the facility due to issues with their consulting pharmacy and the ordering process. Review of the facility Narcotic Log showed [MEDICATION NAME] was not administered until 6:55 PM on 07/24/19 (approximately seven hours following the resident's admission to the facility, and 13.5 hours following the last dose of [MEDICATION NAME] given at the hospital), however the administration of the [MEDICATION NAME] was not documented on the resident's Medication Administration Record [REDACTED]. Review of a facility Grievance Form, dated 07/28/19, showed the resident had asked Staff J, LPN, for pain medication ([MEDICATION NAME]) several times on 07/28/19 and was denied each time. Staff J had told the resident the facility did not have any more of her narcotic pain medication. The resident stated she was offered Tylenol but that medication barely does anyting for the pain. She did not understand how a nursing facility could run out of pain medication. Review of a facility investigation report showed the facility did not administer [MEDICATION NAME] to the resident on 07/28/19 as they did not have the medication available for the resident due to problems with the ordering process and the consulting pharmacy. It was not administered to the resident until 07/29/19 at 2:50 PM, as shown by review of the facility Narcotic Log. Again, the [MEDICATION NAME] was not documented on the resident's MAR. There was no documentation a pain assessment was performed at that time. Prior to 07/28/19 the resident had received four doses of [MEDICATION NAME] on 07/27/19 for pain levels of seven with the last dose being given at 8:09 PM. Staff J verified during a telephone interview on 08/07/19 at 9:41 AM that the resident's [MEDICATION NAME] was not available in the facility to administer to the resident on 07/28/19. She stated she offered Tylenol to the resident however the resident declined to take it as it did not work for her pain. A telephone interview on 08/07/19 at 11:28 AM with the resident's collateral contact (CC) showed she had spoken with the resident on the telephone on 07/24/19 (day of admission) and the resident was in alot of pain due to her recent shoulder surgery. She stated the resident had been asking licensed nursing staff for pain medication and there was a delay in getting her the medication. The CC stated the second incident occurred on 07/28/19 when the facility ran out of the resident's pain medication. She stated she was with the resident that day (07/28/19) and the resident was having much pain. Resident #8. Review of the resident's medical record showed she was admitted to the facility from the hospital on [DATE] following back surgery. Review of a comprehensive nursing assessment, dated 07/30/19, showed the resident had no cognitive impairments. Review of a pain assessment, dated 07/29/19 at 8:15 PM, performed by Staff E, LPN/RCM, showed the resident's pain level was a nine out of ten at that time. The resident's CC stated during a telephone interview on 08/06/19 at 5:10 PM, the resident had two surgeries at the hospital, the first one was performed on 07/22/19 and the second one on 07/26/19. Despite staff knowing the resident was to be admitted to the facility on [DATE] when she arrived at 2:00 PM she did not have any pain medication available with the exception of [MEDICATION NAME] extended relief (ER) 18 milligrams (mgs), a narcotic medication, which she had brought to the facility for the resident. She stated it had been some time since she had received pain medication at the hospital prior to coming to the facility. Review of hospital records showed the [MEDICATION NAME] ER was last administered at the hospital at 9:51 AM on 07/29/19 (ordered to be routinely administered twice daily). The resident also had physician's orders [REDACTED]. Review of the resident's MAR indicated [REDACTED]. The [MEDICATION NAME] IR 15 mgs, ordered to be administered every six hours for pain, was not given until the following day on 07/30/19 at 10:27 AM for a pain level of ten out of ten. The resident's physician stated during an interview on 08/07/19 at 3:30 PM that staff should have had the [MEDICATION NAME] IR available to give to the resident when she was admitted as it was faster acting and the resident continued to have significant pain despite being given the [MEDICATION NAME] ER. Reference (WAC) 388-97-1060(1)

Based on observation, interviews, and record review, the facility failed to ensure one of three residents (#1) reviewed for pressure ulcers, received timely assessments and interventions to promote healing and prevent infection. This failed practice resulted in actual harm to Resident #1 who had a pressure ulcer that worsened. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated 06/27/19, showed she required limited assistance by two staff to turn and reposition in bed, extensive two person assistance with toileting and transfers, extensive assistance by one staff for eating, and totally dependent on staff for personal hygiene and oral care. Review of a cognitive assessment, dated 07/01/19, showed the resident had severe impairment. Review of the admission assessment documented by Staff A, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), dated 06/27/19, showed the resident had an unstable pressure ulcer to her coccyx (tailbone). Despite staff identification of a pressure ulcer on 06/27/19, a review of skin assessments showed a thorough assessment of the pressure ulcer was not performed until 07/02/19 (five days later). The wound at that time was identified as an unstageable pressure ulcer (full thickness skin and tissue loss) in which the extent of tissue damage within the ulcer could not be confirmed as the wound bed was covered by slough (a non-viable, usually moist, dead tissue). The pressure ulcer on 07/02/19 measured 3.56 by 4.17 centimeters (cms) with no redness or swelling to the area surrounding the wound. Review of the resident's Treatment Administration Record showed a treatment for [REDACTED]. Review of Progress Notes (PNs), dated 07/03/19, showed the resident was sent to the emergency room (ER) at 1:45 PM following a fall to the floor. Review of the ER Report, dated 07/03/19, showed the resident had a pressure ulcer to her bottom with redness that extended out from the ulcer consistent with [MEDICAL CONDITION] (skin infection), thus antibiotic therapy was ordered for ten days. On 07/04/19 (seven days following the initial observation of the resident's pressure ulcer) PNs showed a protective cushion was placed in the resident's wheelchair and an air mattress was applied to her bed. There was no documentation of a plan of care regarding the pressure ulcer with interventions which included a turning program for the resident or use of positioning devices. Observation with Staff B, LPN/RCM, of the resident's pressure ulcer on 07/09/19 at 11:50 AM showed an odorous, open wound to the coccyx, covered with slough, with a large area of bright red skin surrounding the wound. The resident was observed on 07/09/19 at 1:30 PM in bed lying on her back. There were no pillows (with the exception of the one under her head) or positioning devices in the resident's bed. Review of a skin assessment, dated 07/09/19, showed the above wound measured 4.69 by 3.8 cms (increase in wound size since 07/02/19). No other assessment of the wound was documented. Review of an assessment by the Nurse Practitioner (NP), dated 07/09/19, showed the coccyx pressure ulcer measured approximately four to five cms, was five to eight millimeters in depth, had dark slough with odor, and redness surrounding the open wound. The NP ordered an urgent referral to the wound clinic and to continue on the antibiotics. Staff A stated on 07/09/19 at 11:55 AM and 07/10/19 at 11:45 AM that she could not complete a thorough assessment of the resident's pressure ulcer on admission as the resident was combative and would not allow the assessment. During the days following admission until 07/02/19, Staff A stated the resident would not get out of her wheelchair on her shift and then she had two days when she was not scheduled to work. Reference (WAC) 388-97-1060(3)(b) This is a repeat deficiency from the Statement of Deficiencies dated 05/13/19, 10/31/18, 08/06/18

Based on observation, interviews, and record review, the facility failed to ensure care and services were provided for the following areas: A) Non-pressure related skin issues Staff failed to perform thorough skin assessments, ensure monitoring of the observed skin problem, and/or to timely initiate treatment to promote healing and prevent infections for 3 of 4 residents (#'s 1, 2, 12) reviewed for skin problems. This resulted in actual harm to Resident #1 due to worsening of the burn area. B) Changes in Condition Staff failed to perform timely, thorough assessments, and evaluate for changes in condition for 2 of 6 residents (#'s 1, 14) reviewed for changes in condition. This failure placed residents at risk for a delay in treatment and/or serious medical complications. C) Implementation of physician's orders [REDACTED].>Nursing services were not provided in accordance with physician's orders [REDACTED].#'s 10, 13) reviewed for lab testing. Failure to implement physician's orders [REDACTED]. Findings included: A. Non-pressure related skin issues Resident #1. Record review of a Situation - Background - Assessment - Recommendation (SBAR) form showed the resident was observed on 09/30/18 with a red mark on her stomach measuring 11 by 7 centimeters (cms), painful, and warm to the touch. Per Nurse Practitioner (NP) assessment, dated 10/01/18, the above area was due to the resident spilling hot chocolate, thus burning her skin. The area was a superficial burn with blister (second degree burn) to the abdomen above the umbilicus (belly button). Staff was to monitor the area for signs/symptoms of infection or inflammation. The NP prescribed [MEDICATION NAME] 1% cream (topical anti-microbial medication used in the treatment of [REDACTED]. Review of Progress Notes (PNs) and weekly skin assessments showed no assessment of the above burn area until 10/11/18 (11 days later), at which time PNs showed Staff C, Licensed Practical Nurse, was attempting to remove the dressing to the resident's abdomen and the resident was pushing her hands away and crying. The dressing had adhered to the wound. Following removal of the dressing two additional Licensed Nurses (LNs) observed the wound. It was then determined the NP needed to assess the wound. Despite the above observation by three LNs the record did not show any nursing assessment of the burn area at that time. Per review of PNs by the NP, dated 10/11/18, showed a 3 by 3 cm deep thermal wound (burn) covered with slough (dead tissue) with no signs of inflammation. A new treatment was ordered utilizing Santyl to debride the slough tissue and was to be performed by staff at least three times per week or as needed. Despite the above treatment with Santyl ordered on [DATE], review of the Treatment Administration Record (TAR) showed the treatment was not initiated by staff until 10/15/18 (four days later). In addition, the previously ordered [MEDICATION NAME] treatment was not performed by staff on 10/12/18 and 10/14/18. Review of the Weekly Skin Observation forms, dated 10/5/18, 10/12/18, 10/26/18, did not show evidence of an assessment of the burn area to the abdomen per Staff R, Licensed Practical Nurse. In addition, Staff S, Licensed Practical Nurse, did not show evidence of an assessment of the burn area on the above form dated 10/19/18. Review of PNs between 10/11/18 to 10/23/18 showed no documentation assessments were performed by LNs. The assessment on 10/23/18 showed the burn area was reddened with slough to the wound bed, and was extremely painful to the resident. Additionally, between 10/23 to 10/31/18 the record did not show any further skin assessments of the burn area. Review of an assessment by the NP, dated 10/29/18, showed the deep thermal wound to the abdomen was not healing adequately, thus it was recommended the resident be seen in the hospital wound care clinic. Per interview on 10/24/18 at 8:30 AM with Staff C, Licensed Practical Nurse, she stated when she attempted to remove the dressing from the resident's burn area on 10/11/18 it appeared the [MEDICATION NAME] treatment was not being performed by staff twice daily as ordered due to the difficulty in removal of the dressing. On 10/24/18 at 1:15 PM the burn area to the resident's abdomen was observed to be red with some slough still present. The resident yelled out in pain during the application of the prescribed treatment. Staff C stated the resident had been premedicated prior to the dressing change. Resident #2. Review of the resident's medical record showed he was admitted to the facilty on 10/08/18 following back surgery. Review of hospital discharge orders, dated 10/08/18, showed the back surgical wound was to be kept clean and dry, and covered with a dry gauze dressing. Progress Notes, dated 10/08/18, showed the above surgical incision was scabbed with a small amount of drainage. The area was cleansed and a clean, dry dressing was applied. Review of the Weekly Skin Observation form, dated 10/17/18 at 4:35 AM, documented by Staff R, showed no evidence of the resident's surgical wound to his back. An assessment by the NP, dated 10/19/18, showed the above surgical wound had dehisced (wound separation) on 10/18/18. The area of separation measured 12 by 0.5 cms with 1.5 cms of depth and light pink, red drainage. A new treatment was prescribed by the NP to clean the wound with Normal Saline, debride foreign material as much as possible, and reinforce with [MEDICATION NAME] (dressing used to cover wounds with drainage) every three days. Review of the resident's TAR showed the above treatment, ordered to be done every three days, was not performed by staff on 10/1918 and 10/22/18. The treatment order was then changed on 10/24/18. Despite the recent wound dehiscence, and newly prescribed treatment, review of the Weekly Skin Observation form, dated 10/25/18 by Staff S, showed no evidence of an assessment of the surgical wound. Resident #12. Review of the resident's medical record showed he was admitted to the facility on [DATE] with a bone infection to his left foot/ankle. Review of the hospital discharge summary, dated 10/02/18, showed the bone infection to the resident's left ankle/foot was still present. Following wound debridement to the left foot a wound vac was placed. An assessment by the physician on 10/03/18 showed pink, reddish drainage with maceration (excessive amount of moisture) around the fourth and fifth toes of the left foot. physician's orders [REDACTED]. Per PNs, dated 10/12/18, the resident was cognitively intact, independent with all cares, and continued on intravenous (IV) antibiotics (administered via a catheter into a vein). Review of the resident's TAR showed treatments were not performed as ordered on [DATE] and 10/19/18. Staff C stated on 10/24/18 at 8:30 AM, she was informed by the resident LN staff had not performed dressing changes to his left foot on 10/15/18, 10/17/18, but was done on 10/19/18. Treatments don't get done. Per interview with the resident on 10/24/18 at 11:00 AM, he stated LN staff did not perform the treatment to his left foot on 10/15/18, 10/17/18, and 10/22/18. He stated it was done on 10/19/18. On 10/26/18 at 3:45 PM Staff F, Registered Nurse, was observed to perform the prescribed treatment to the resident's left foot. Per interview with the resident at 12:20 PM on 10/31/18, he did not have a dressing change done to his left foot on 10/29/18. Ten minutes later at 12:30 PM Staff F, accompanied the surveyor into the resident's room and verified the dressing to his foot was the one she applied on 10/26/18. The resident again replied it was not done on 10/29/18, and Staff F was the last one to do the dressing change on 10/26/18. Review of the resident's TAR showed Staff T, Licensed Practical Nurse, had initialed he had performed the treatment on 10/29/18. B. Changes in Condition Resident #1. Review of PNs, dated 10/16/18, showed the resident was given [MEDICATION NAME] (narcotic medication) and [MEDICATION NAME] (used to lower blood pressure) that morning. The resident left the facililty for an appointment and returned prior to lunch. The Nursing Assistant (NA) took her to the dining room where she became unresponsive during the meal. The NA and LN were unable to arouse her. The NA was instructed to place the resident in bed, while the LN determined the resident's code status. Upon the LN performing a sternal rub, the resident attempted to remove the LN's hand and grimmaced. The resident's blood pressure (BP) was 78/40 and her pulse was 52. The NP arrived and the resident slowly began to arouse. Her eyes were open, still very lethargic and unable to respond. New orders were received to discontinue the [MEDICATION NAME] and to use Tylenol instead, hold [MEDICATION NAME] if the BP was less than 90, start IV fluids for 24 hours, raise the head of the bed by 10 degrees to 20 degrees, arise slowly from supine to sitting to standing, use compression socks during the day, and obtain lab work. The resident remained in bed for the evening meal and was fed by staff eating 100% of the meal. Her BP increased to 116/72. The resident's color was much improved and staff was to place her on alert charting status to monitor and assess. The next documented assessment was on 10/17/18 at 5:05 AM (over 16 hours later), which showed the resident was crying loudly at 4:45 AM. Upon staff observation the catheter delivering IV fluids had infiltrated (came out of the vein), thus the resident's right arm was swollen and slightly red. The IV was then discontinued. The resident's BP at that time was 130/72. Despite a plan to monitor and assess the resident, further review of the resident's medical record showed no further assessment of the resident's condition relative to BP monitoring, and level of consciousness until 10/21/18 (three days later). Resident #14. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per PNs, dated 10/23/18 at 2:01 PM, the resident passed out while working on the standing table during restorative therapy. physician's orders [REDACTED]. Review of the resident's BPs taken on 10/23/18, 10/24/18, 10/25/18, and 10/26/18 showed orthostatic blood pressures were not taken by staff as ordered. Despite the resident having a change in condition on 10/23/18, review of documentation on 10/26/18 (three days later) showed no further nursing assessment of the resident's condition. The resident was observed on 10/31/18 at 12:40 PM seated in a wheelchair in her room. She stated she had a shower that morning and then took a nap, and felt she was getting better. C. Implementation of physician's orders [REDACTED].>Resident #13. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. [REDACTED].>The resident's physician stated on 10/31/18 at 10:30 AM, the stool specimen was ordered by the NP to rule out any active bleeding due to the resident's history and [MEDICAL CONDITION] problems. Resident #10. Review of the resident's medical record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An assessment by the NP, dated 10/22/18, showed on 09/20/18 he had ordered an A1C level (blood test that shows the average blood sugar levels over the past two to three months) to determine if the resident's insulin could be discontinued. However, there were no results on file. The resident's blood sugars were still running low, thus the A1C test was again ordered on [DATE]. Per interview with Staff E,Registered Nurse/Resident Care Manager the A1C level was never obtained prior to the resident's discharge on 10/25/18. Staff U, Medical Records, stated on 10/25/18 at 12:25 PM physician's orders [REDACTED]. She stated the week before she got a stack of physician's orders [REDACTED]. Staff U stated she had to ensure LNs signed off on the physician's orders [REDACTED]. Licensed Nurses spend so much time with medication problems they don't have time for physician's orders [REDACTED]. The Medical Assistant (worked directly with physician and NPs) stated on 10/25/18 at 1:00 PM, when she placed new physician's orders [REDACTED]. A couple of times she had to follow up with notes to staff regarding if the order had been processed. Reference (WAC) 388-97-1060(1) This is a repeat citation from the survey dated 08/06/18

Based on observation, interviews, and record review, the facility failed to provide adequate supervision as reflected on the plan of care for 1 of 4 residents (#1) reviewed for injuries and accident hazards. This failed practice resulted in harm to Resident #1 who [MEDICAL CONDITION] the abdomen from hot chocolate. Findings included: Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's plan of care, dated 08/28/18, showed the resident had difficulty with self feeding and history of impaired swallowing. The resident required extensive assistance by one staff with meals, and had moderate impaired cognition. The resident ate in the assisted dining room. Review of a Situation - Background - Assessment - Recommendation (SBAR) form written by Staff B, Registered Nurse, on 09/30/18, showed the resident had a red mark on her stomach measuring 11 by 7 centimeters (cms), painful and warm to the touch. Staff B documented, possible skin rash. Progress Notes (PNs), dated 10/01/18 at 10:36 AM, by Staff C, Licensed Practical Nurse, showed the resident had a reddened area to the abdomen. An assessment performed at that time showed the area was blistered with redness to the surrounding tissue. The physician was notified and prescribed [MEDICATION NAME] 1% cream (topical anti-microbial medication used in the treatment of [REDACTED]. The resident was placed on alert charting status to monitor and assess for signs and symptoms of infection. The facility investigation report, dated 10/1/18 at 8:14 AM, showed a blister was evident along with a large reddened area to the resident's abdoment which measured 10 by 6 cms. The resident stated she spilled hot cocoa on herself over the weekend in the dining room. The incident was then reviewed by the interdisciplinary team on 10/02/18 with correction action being to place lids on the resident's hot liquid cups. An assessment by the Nurse Practitioner, dated 10/01/18, stated the resident spilled hot chocolate and burned her skin above the umbilicus (belly button) which measured 11 by 7 cms. The resident reported the area was very painful upon removal of the dressing. There were no signs or symptoms of inflammation. Staff was to monitor for signs/symptoms of infection and inflammation. The resident was observed on 10/23/18 at 5:30 PM seated in a reclining type wheelchair with a tray table positioned across the wheelchair. She was postioned to the immediate left of the dining room entrance with no other residents seated next to her. Across the room to the right was a large table with seven residents and one staff member. Within approximately one minute two additional staff members entered the dining room to assist residents. A plate of pureed food items and two beverages with lids (one being tomato juice) were on the resident's tray table. The resident made no attempt to feed herself. Upon the surveyor asking a Nursing Assistant (NA) as to the resident's ability to feed herself the resident immediately opened one eye. The NA proceeded to feed the resident the entire dinner meal, and identified the other beverage as hot chocolate. There was no Licensed Nurse (LN) present in the dining room during the above observation. On 10/24/18 at 1:10 PM the resident was observed being transferred from the wheelchair to her bed via a mechanical lift device by Staff K and L, NAs. Both NAs stated the resident used her right hand to reach for items. The resident noted to have tremors to both hands and arms, with the right side being more tremorous. Upon asking the resident to reach for her plastic water container, her tremors increased as she began reaching for the container. The resident was observed on 10/25/18 at 7:50 AM seated in a reclining wheelchair in the dining room with a tray table positioned across her wheelchair. She was to the immediate left of the dining room entrance facing the window. She had pureed food items on her place with a cup of hot chocolate with a lid and straw on it. She made no attempt to feed herself. Staff N, NA came over to the resident and assisted in giving the resident the hot chocolate. Staff N stated in the past the resident had picked up the hot chocolate cup by herself. She would spill it at times, thus a lid was used. Staff N then demonstrated by tipping the cup to the side the hot chocolate was still able to be spilled. Staff N stated at times the resident would be positioned towards the television set. During those times the resident would have her back to the staff assisting in the dining room. There was no LN present in the dining room during the above observation. An interview on 10/24/18 at 12:25 PM and 10/29/18 at 1:48 PM with Staff B, showed the resident had been transferred to bed by NA staff following the noon meal on 09/30/18. Upon staff changing her they observed a red area to her abdomen. Staff M, NA, came to get Staff B to observe the area. The area was a big, red patch, bright red. She stated she observed the area at approximately 2:00 PM. Staff B stated she wrote a report on it. She was not sure what the red area was. When Staff B questioned the resident she stated the resident was hard to understand. Staff B was unaware if the resident was to have lids on her hot beverage cups. Staff C stated on 10/24/18 at 8:30 AM when she got to work on 10/01/18 the resident had a red mark to her abdomen with the center of the area being blistered, raised, and fluid filled. The resident had told her at that time she had spilled hot chocolate on the weekend, and staff was present in the dining room. The resident informed Staff C there was no lid on her cup, and she yelled out when she spilled it. The resident also stated staff cleaned it up, dried her off, and got her more clothes. Staff C stated the resident sits off to the side in the dining room with a tray table over her wheelchair, has shaking with both hands, and struggles with feeding herself. On 10/25/18 at 9:05 AM Staff E, Registered Nurse/Resident Care Manager, stated the resident should not be picking up cups without staff present to assist her as needed. Staff M stated on 10/29/18 at 2:15 PM she observed the red area on the resident's abdomen on 09/30/18 when she was changing the resident's disposable brief. She could see the red area without lifting the resident's shirt as the shirt was ill-fitting. The resident had stated to her she did not know how the red area developed. There was no hot chocolate stains or wetness on the resident's clothing upon changing the resident. Per interview with Staff G, NA, on 10/25/18 at 9:36 AM, she stated the resident spilled all the time, can't keep her arms steady; that's why we have lids on her cups. She usually spilled on her clothes, thus a clothing protector was utilized or a towel. The hot water pot coming from the kitchen to make the hot chocolate drinks was pretty hot, thus ice was placed in the cups to cool the drinks. Staff G stated the resident frequently tried to drink from a cup by herself, and could have dropped the cup as her arms got shaky, and she was unable to use her left arm. Everyone knows to put a lid on her cup .has a little opening in lid for her mouth. On 10/25/18 at 9:56 AM Staff H, NA, stated the resident would hold a cup (had lid and straw) and drink out of it. She stated she would spill out of it .maybe lid not on tight. We now assist her with drinking. The resident would shake with her right hand, it was hard for her to take fluids by herself. The water to make hot chocolate was pretty hot. Staff I, NA, stated on 10/25/18 at 10:02 AM, the resident would need assistance with meals at times as she could not use all of her fingers, due to contractures. She could hold beverages and would have some shaking. At times she would spill hot chocolate. She wore a bib, and would spill on that. There was never a time she did not have a lid on her cup. There were always two NAs assigned to her dining room with 10 to 12 residents. On 10/25/18 at 11:25 AM Staff J, NA, stated the resident sometimes ate independently and sometimes would need assistance. Staff would have to assist her when she would start shaking her right hand. The hot water brought to the dining room by the kitchen staff was sometimes too hot, let it sit or add an ice cube. Staff P, NA, stated on 10/29/18, the resident would keep her head down during meals making it difficult to feed her. She stated the resident definitely needed assistance. Staff P stated because there was no supervisor in the dining room during meals NA staff often were visiting with each other, on cell phones, and not paying attention to the resident. They can do what they want .no one to supervise them. Review of the kitchen Service Line Checklist forms revealed the following temperatures of hot beverages: 09/29/18 - breakfast - 140 degrees lunch - no temperature taken dinner - no temperature taken 09/30/18 - breakfast - 140 degrees lunch - no temperature taken dinner - no temperature taken 10/01/18 - breakfast - 195 degrees lunch - 145 degrees dinner - no temperature taken 10/02/18 - breakfast - 195 degrees lunch - no temperature taken dinner - unable to read 10/23/18 - breakfast - 175 degrees lunch - 175 degrees dinner - 175 degrees On 10/25/18 at 8:05 AM Staff O, Food Service Manager, stated the normal hot beverage temperature should be between 140 to 155 degrees. She stated she became aware of the hot chocolate incident involving Resident #1 during the morning meeting on 10/01/18 with administration. Staff O stated it took three minutes to obtain the hot water. Staff then perform the temperatures and let the hot water sit for approximately 30 minutes, prior to taking the hot water pots to the individual dining rooms for NAs to make the hot chocolate drinks and put the lids on the cups. She stated every resident should have a lid on their hot beverage cup. Staff O stated kitchen staff was not taking a second temperature on the hot water when it exceeded the normal limit prior to taking it out to the dining rooms. The Nursing Hot Beverage Safety Evaluation, dated 06/22/18 (day of admission), showed the resident might require set up assistance while consuming hot beverages. The resident's cognitive assessment performed at that time showed her cognition was better than the assessment performed in September, however her consumption of hot beverages was never reassessed despite the recent burn on 09/30/18 due to spilling hot chocolate. In addition, review of the resident's plan of care did not address the resident's tremors and the need to place lids on her cups with straws. Reference (WAC) 388-97-1060(3)(g) This is a repeat citation from the survey dated 06/14/18.

Based on observation, interviews, and record review, the facility failed to ensure residents received the necessary care and services to promote healing, prevent infection, provide timely assessments and interventions, and/or prevent new pressure sores from developing for 4 of 4 residents (#'s 1, 2, 3, and 4) reviewed for pressure ulcers. This failure resulted in actual harm to Resident #'s 1,2,3 and 4, all of whom either developed and/or had pressure sores that worsened. Findings included: The National Pressure Ulcer Advisory Panel Pressure Ulcer Stages: A) Stage I - Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED] (redness). B) Stage II - Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. C) Stage III - Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation (pink-red moist tissue that fills an open wound when it starts to heal) tissue and rolled wound edges are often present. D) Stage IV - Full-thickness and tissue loss with exposed or directly palpable fascia (band or sheet of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. E) Unstageable Pressure Ulcer - Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (non-viable yellow, tan, grey, green, or brown tissue - usually moist) or eschar (dead tissue). F) Deep Tissue Pressure Injury (DTPI) - Intact skin with with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. Resident #1. review of the resident's medical record revealed [REDACTED]. The resident's plan of care, dated 07/06/18, noted he had potential for impairment to skin integrity related to the DTPI to the buttocks and excoratiaon of the groin area. The initial nursing assessment, dated 07/06/18, revealed the resident had a DTPI to the right buttocks with excoriated peri-wound (tissue surrounding the wound), black area measured 6.5 by 5.3 centimeters (cms), outer redness measured 5.8 by 9.0 cms. In addition, the assessment stated the resident's feet were grossly swollen starting at the ankles down. The resident required extensive assistance with turning and repositioning in bed, bathing, dressing, toileting, and transfers. The resident was alert with no cognitive impairments, and was incontinent of urine. Review of the Treatment Administration Record (TAR) revealed a treatment order for the DTPI right buttocks, dated 07/06/18, to apply [MEDICATION NAME] foam (dressing that allows for the formation and maintenance of a moist wound healing environment) - change every time it became soiled. Review of documentation revealed the dressing was not changed until 07/12/18 (five days later). On 07/12/18 an evaluation of the resident's above DTPI by the Nurse Practitioner (NP) revealed thin layer of skin over a black, blue injury that looks like if it peels off it would explode. In addition, a Stage II wound was found on the resident's left buttocks with drainage and inflammed margins (outer edges of the wound). The NP ordered a new treatment for [REDACTED]. Despite the resident's significant pressure ulcers, review of the Minimum Data Set (MDS) - (comprehensive nursing assessment), dated 07/13/18, revealed no turning/repositioning program, and no pressure relieving mattress for the bed. Review of hospital records noted the resident was transferred to the hospital on [DATE] for complaints of chest pain. The hospital physician (also the resident's physician in the nursing facility) assessment revealed in addition to the pressure ulcers to the right and left buttocks, the resident also had an unstageable pressure ulcer to the right heel. Review of an assessment by the hospital wound care consultant, dated 07/16/18, noted the following: Pressure ulcer to the right buttocks measured 8 by 6.4 cms with yellow drainage. The peri-wound was red, swollen, painful, with 50% moist, brown eschar, and 50% moist yellow slough. The pressure ulcer to the left buttocks was a Stage II and measured 2 by 2 cms with a depth of 0.1 cms. In addition, the resident had a pressure ulcer to the right heel which measured 8.0 by 4.4 cms, black and dusky. The right buttocks and right heel were noted to be unstageable. Imaging was ordered due to the induration (hardness) around the right buttock ulcer. There possibly would be a referral to the plastic surgeon pending the results of the imaging. In addition, the resident was having diarrhea, thus a rectal tube was placed. Review of the resident's bowel record revealed he had two episodes of diarrhea stools on 07/12, one episode on 07/14, and one episode on 07/15/18. Review of of the resident's medical record revealed despite the resident's above pressure ulcers to the right and left buttocks there was no further nursing assessment of those wounds since his admission to the facility on [DATE]. In addition, there was no nursing assessment of the pressure ulcer to the resident's right heel and no ordered treatment. Interviews conducted with the resident's physician on 07/26/18 at 10:30 AM and 07/31/18 at 12:45 PM revealed it was not acceptable for staff not to perform treatments to the resident's pressure ulcers between 07/07-12/18. The physician did not become aware of the resident's pressure ulcers to the buttocks area until 07/12/18, and no awareness of the right heel pressure ulcer until she evaluated the resident in the hospital on [DATE]. A interview on 08/02/18 at 10:50 AM with the above NP noted antibiotic therapy was ordered for the resident on 07/12/18 as the wound appeared infected due to the noted inflammation. The NP stated he did not become aware of the resident's pressure ulcer to the buttocks area until 07/12/18. An interview on 07/26/18 at 3:50 PM with Staff C, Licensed Practical Nurse, revealed the resident developed a pressure ulcer to his right heel possibly on 07/13 or 07/14/18 that several staff members were aware of. Staff C stated the resident's heels were not floated on a consistent basis, and an air mattress was not obtained for the resident until 07/13/18 (seven days following admission). She stated the resident's family member voiced concerns relative to the pressure ulcer worsening. Staff C stated wound rounds were not conducted on residents and the facility was utilizing many agency Licensed Nurses (LNs). She was the resident's medication/treatment LN for several shifts and only performed the treatment to his pressure ulcer on the buttocks once due to the dressing falling off, its embarrassing. Staff K, Registered Nurse/Resident Care Manager (RCM), stated on 07/26/18 at 3:40 PM, stated the RCM was to measure wounds on a weekly basis, however didn't get done. The resident's family member was interviewed by phone on 07/30/18 at 10:05 AM, and stated the resident continued to be hospitalized . He stated staff did not change the resident's dressings for days. Staff left the resident on his back for hours, and his right foot was against the footboard of his bed. He stated he never saw the resident's heels being floated. The resident had constant diarrhea, and was left for several hours before being changed. Per telephone interview on 07/30/18 at 12:15 PM, the resident revealed he sat in a wheelchair for approximately two hours at a time. I told them I wasn't supposed to sit on my buttocks very long. He stated his pressure ulcer worsened and became infected while in the facility. The resident stated his feet were never floated. He would gradually slide down in bed and then his feet were up against the footboard of the bed. The resident stated he was having episodes of diarrhea and would be left in messy diapers three to four hours at a time. Resident #2. review of the resident's medical record revealed [REDACTED]. The resident's plan of care, dated 07/11/18, noted the resident was totally dependent on staff for repositioning/turning in bed, and transfers; cognitive impairment, at risk for skin problems; incontinent of urine; and limited physical mobility. Despite the resident being at risk for skin problems there was no identified interventions to turn/reposition, no preventative mattress or wheelchair cushion, and no plan to float the resident's heels. The admission nursing assessment, dated 07/11/18, revealed the resident had no pressure ulcers. Review of the Weekly Skin Observation form noted on 07/20/18 (nine days following the resident's admission) the resident had a blister to the right inner heel. There was no further assessment of the area such as description, measurements, and color. Review of the resident's TAR noted a treatment to the right heel was not initiated until 07/24/18 (four days later). In addition, heel protectors to be worn when the resident was in bed was not initiated until 07/24/18. Despite a Stage II pressure ulcer to the resident's right heel, review of the MDS, dated [DATE], revealed no turning/repositioning program, and no pressure relieving mattress to the bed. Per PNs, dated 07/26/18, the blister to the right heel had opened and measured 3 by 2 cms. The right heel Stage II pressure ulcer worsened as evident by review of an untitled form, dated 07/27/18, with noted measurements of 2.5 by 4.0 cms with a depth of 0.1 cms. Observation of the resident on 07/30/18 at 1:13 PM revealed her to be lying supine in bed with her feet/heels positioned on the mattress. The heel protector boots (ordered by the physician on 07/23/18 to be worn when the resident was in bed) were noted to be in a chair in the room. When Staff I, Nursing Assistant, was questioned why the resident was not wearing the heel protector boots, she replied they only had to be on at night. The resident was again observed on 07/31/18 at 1:25 PM lying supine in bed with her feet/heels positioned on the mattress. The heel protector boots were in a chair in the resident's room. Per telephone interview on 07/31/18 at 8:09 PM with the resident's family member s/he had seen the heel protector boots in the resident's room, but not on the resident's feet. The resident was frequently in bed at the time the family member visited. Resident #3. review of the resident's medical record revealed [REDACTED]. Review of the nursing admission assessment, dated 06/07/18, noted an unstageable open pressure ulcer measuring 0.5 by 0.5 cms white core to the coccyx. Review of the resident's plan of care, dated 06/07/18, noted he required extensive staff assistance with turning/repositioning, toileting, bathing, and dressing. He required contact guard/stand by assistance with transfers and ambulation utilizing a wheeled walker. Despite the known pressure ulcer on admission to the facility there was no identified skin problem on the plan of care until 06/18/18 (11 days following his admission). In addition, a turning/repositioning program and pressure reduction mattress were not identified as interventions on the plan of care. Despite the above identified open pressure ulcer to the coccyx on admission (06/07/18), review of the TAR and physician's orders [REDACTED]. Per PNs the resident was transferred to the hospital on [DATE] for concerns related to constipation. No further skin assessments were documented by staff since the resident's admission to the facility on [DATE] (eight days prior). Review of hospital records noted an assessment of the above pressure ulcer on 06/15/18 by hospital staff revealed the wound had worsened. The wound was a Stage III measuring approximately 4 cms across, and white in the center. Upon the resident's return to the facility on [DATE], review of the assessment that day noted an unstageable open pressure ulcer measuring 2.5 by 1.5 cms with white/yellowish slough, and a Stage II red, open area measuring 0.1 by 0.3 cms with no identified location. A weekly skin observation performed on 07/02/18 did not identify the pressure ulcer. There were no further nursing assessments of the pressure ulcer to the coccyx until 07/12/18 (24 days later). Review of PNs, dated 07/12/18, noted the coccyx unstageable pressure ulcer measured 2.0 by 1.0 with a depth of 1.4 cms. The above Stage II (identified on 06/18/18) to the outer coccyx had healed The physician was notified due to the depth of the pressure ulcers, and changes to the treatment was prescribed. Per PNs an assessment by Staff J, Licensed Practical Nurse, on 07/27/18, noted the resident's pressure ulcer to the coccyx measured 4.0 by 2.0 with an increased depth of 1.5 cms. Due to the significant change in size, the surveyor requested a new measurement of the wound on 07/31/18, which was obtained at 3:08 PM, and was noted as 1.5 by 0.5 with a depth of 1.5 cms. There was 60% white fibrous slough inside the wound. Despite the resident's pressure ulcer to the coccyx, observation of the resident on 07/30/18 at 1:40 PM revealed he was not on a pressure reduction mattress. This was verified at that time by Staff B, Licensed Practical Nurse, who stated the resident was on a regular mattress. On 7/31/18 at 1:30 PM the resident was observed lying on an air mattress. He stated the mattress had been applied to his bed the day before and it was lumpy. Staff H, Director of Nursing, noted the air mattress was inflated to the maximum level designated for residents who weighed 450 pounds. Review of the resident's last recorded weight, as noted per review of the resident's record, was 132 pounds on 07/23/18, thus the air mattress was creating increased pressure to the resident's coccyx area due to the inaccurate setting. Resident #4. review of the resident's medical record revealed [REDACTED]. Review of the admission assessment, dated 07/24/18 by Staff G, Licensed Practical Nurse, noted the resident had a Stage II pressure ulcer to the coccyx with no further assessment to include measurements, color, drainage, and odor. The resident was totally dependent on staff for all his activities of daily living, and had cognitive impairments. Review of physician's orders [REDACTED]. Review of the Wound Assessment Details Report noted the pressure ulcer had worsened to a Stage III and measured 3.5 by 0.6 cms with a depth of 0.3 cms. There was redness around the wound and had 100% loose slough. Per PNs, dated 07/27/18, by Staff B, the resident was admitted with a Stage III to the coccyx. However, review of the above initial admission assessment and interview with Staff G on 07/30/18 at 3:30 PM confirmed the resident had a Stage II pressure ulcer on admission. Reference (WAC) 388-97-1060(3)(b)

Based on interviews and record review the facilty failed to ensure Licensed Nursing (LN) staff had specific competencies and skills to care for residents with pressure ulcers. Investigation of facility practice identified staff were not obtaining physician's orders [REDACTED]. Failure by staff to care for residents in a competent manner resulted in actual harm to 4 of 4 residents (#'s 1,2,3,4) with pressure ulcers. Failure by staff to ensure care was provided in accordance with current facility policies and procedures was inconsistent with competent nursing practice. Review of 3 of 3 licensed staff personnel files (#'s J,C,B) revealed performance/competency evaluations were not being conducted in a timely manner to determine appropriate training needs. In addition, the facility failed to ensure agency contracted LNs competencies were assessed and completed for 8 of 8 agency contracted LNs (#'s AA, BB, CC, DD, EE, FF, GG, HH) personnel files reviewed. Findings included: Review of the facility policies titled Pressure Ulcers/Injuries Overview and Pressure Ulcer/Injury Risk Assessment, revised (MONTH) (YEAR), and Pressure Sore Monitoring (Assessment and Documentation, revised in (MONTH) 2010 revealed the following: Conduct a comprehensive skin assessment with every risk assessment. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, condition of the skin, resident's clinical condition and stated wishes and goals. The interventions must be based on current, recognized standards of care, and the effects must be evaluated. On identifying a pressure ulcer a baseline nursing assessment of the ulcer as well as causative factors is completed. physician's orders [REDACTED]. Outcome of wound care interventions are assessed weekly by an interdisciplinary team. Staff education and recommendations are made by the wound team during wound rounds. A) Wound Assessment Stage the wound using the Presure Ulcer Staging Protocol. Describe the exudate using codes provided. Assess wound for odor after thoroughly cleansing it with normal saline. Estimate the percentage of granulated tisue versus necrotic tissue. Assess the surrounding skin for [DIAGNOSES REDACTED], maceration, orintactness. B) Weekly Wound Round Record Document what interventitons are in palce to manage pressure. Is pressure reduction achieved when the resident is in bed and chair? Check for pressure relief between all bones and under heels. Review of medical records revealed four residents suffered actual harm due to the incompetency of LNs as evidenced by the following: Resident #1 - A recent admission to the facility with a Deep Tissue Pressure Injury that worsened and became infected, and he developed a new pressure ulcler to the right heel. Resident #2 - She developed a pressue ulcer to the right heel, shortly after admission to the facility, which worsened Resident #3 - A recent admission to the facility with an open pressure ulcer to the coccyx that worsened. Resident #4 - A recent admission to the facility with an open pressure ulcer to the coccyx that worsened. Per interview on 08/06/18 at 10:30 AM with Staff A, Administrator, noted the only inservice recently conducted regarding pressure ulcers was a one hour computer course taken between (MONTH) and (MONTH) (YEAR). Review of inservice records revealed four of 17 LNs and six of eight Nurse Technicians employed by the facility had taken the course. Review of the personnel file for Staff J, Licensed Practical Nurse, revealed a performance/competency evaluation had not been completed since 03/31/17 until concerns were raised by the surveyor on 07/26 and 07/30/18 regarding inaccurate assessments of Resident #1 on 07/07/18, and Resident #3 on 07/27/18. A competency evaluation completed by administrative staff on 07/27/18 noted an unacceptable outcome. Review of the personnel file for Staff C, Licensed Practical Nurse, revealed a performance/competency evaluation had not been done since 04/25/17. Review of the personnel file for Staff B, Licensed Practical Nurse, revealed she was hired on 05/10/16. There were no performance/competency evaluations performed. Review of the personnel files for eight agency LNs (#'s AA,BB,CC,DD,EE,FF,GG,HH) revealed there was no skills assessment/competency evaluations completed by administrative staff to ensure the care provided to residents with pressure ulcers was performed in a competent manner. An interview with Staff A on 08/06/18 at 1:00 PM, revealed administrative staff had not performed any competency evaluations on agency staff. In addition, Staff A stated wound rounds had not been conducted by staff on residents until following the initiation of the state investigation. Refer to F686 for further information. Reference (WAC) 388-97-1090(1) Review of facility staffing records for (MONTH) (YEAR) revealed agency LNs worked a total of 40 shifts (12 hours each) in the facility.

Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to 1 of 3 residents (#5) reviewed with non-pressure related skin issues. Staff failed to perform thorough skin assessments, ensure monitoring of the observed skin problem, and to initiate treatment to promote healing and prevent infection to areas between the resident's toes in which maggots (originate from the eggs of flies) were found. This failed practice resulted in actual harm to Resident #5, who had a reoccurrence of maggots. The resident was transferred to the emergency room (ER) for complaints of left foot pain and was found to have a worsening skin problem. Findings included: Resident #5. Review of the resident's medical record noted she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, revised on 08/01/18, noted she required staff assistance with activities of daily living due to muscle weakness and chronic pain issues. The plan stated staff was to ensure the resident's shoes were removed daily and allowed to air dry, and to inspect them. If the shoes were wet from leg drainage they were to be sent to the laundry. Staff was to report alterations in the resident's skin integrity to the Licensed Nurse (LN). In addition, the resident was identified as being at risk for skin breakdown, per plan of care revised on 04/13/18, with interventions to follow facility policies/procedures for the prevention/treatment of [REDACTED]. Per Progress Notes (PNs), dated 07/03/18, noted the resident had swelling to both legs up to the knees with noted weeping of drainage, which soaked her pant legs and shoes. The resident refused to have her pants changed or legs cleaned. She would sit outdoors in her wheelchair most of the day. The resident was educated on elevating her legs and wrapping them with compression stockings , however she refused. Review of bathing records for (MONTH) (YEAR) showed the resident was scheduled for two showers per week. Staff was to report skin concerns to the LN. The resident received only four showers for the month due to her refusals. Review of the Weekly Skin Observation form, dated 07/22/18, noted the resident only allowed for a limited skin observation. There was noted [MEDICAL CONDITION] to the legs, however less than the previous week,, with mild crusting and no weeping of drainage. There was no documentation of the resident's feet/toes. Documentation per PNs revealed on 07/28/18 the resident's friend observed the resident had dried blood around her left small toes. Per LN assessment dried blood was found on the tops of the resident's three left outer toes. The area surrounding the toes was dark pink, swollen, and slightly warm. Upon irrigating between the toes with a saline solution, small maggots were noted to be infesting the wound between the toes. The resident complained of significant pain when attempting to clean the toes and evaluate the wounds between the toes. The physician was notified and orders received to transfer the resident to the ER. Review of ER records, dated 07/28/18, noted the assessment by the physician stated there was maceration (occurs when the area of skin surrounding a wound has an excessive amount of moisture in it, which can increase the potential for infection) and superficial ulceration (opening of skin tissue) between the third and fourth toes, and fourth and fifth toes. Redness, warmth, and swelling was present on the top of the left foot. Per PNs, dated 07/30/18, the resident returned to the facility following a two day stay in the hospital. The resident was diagnosed with [REDACTED]. An interview conducted on 07/31/18 at 4:00 PM with Staff F, Nursing Assistant, revealed she assisted the resident the evening of 07/17/18 with the removal of her tennis shoes. The shoes were noted to be wet, and she had worn them all day. Upon removal of the shoes maggots were observed dropping from the shoes onto the floor. In addition, maggots were present between each toe of the left foot. There was dried blood on top and between the toes. Staff F then proceeded to cleanse the resident's toes with water and a wash cloth. She alerted Staff D, Registered Nurse, of her observations. Per telephone interview on 07/30/18 at 2:30 PM with Staff D, she was alerted by Staff F of the resident's skin condition. She observed two little bugs between the third and fourth toes of the left foot .white, wormy. She requested Staff C, Licensed Practical Nurse, to assist with the skin evaluation. Staff C, stated on 07/31/18 at 12:05 PM, Staff D had asked her to assess the resident the evening of 07/17/18. Staff D stated, I think she has bugs. I think they could be maggots. Upon assessment of the resident's feet they were noted to be filthy dirty, .on the floor were two little bugs, could have been maggots. Open wounds were noted to both lower legs; and white, macerated areas between the toes, but no open wounds. Staff C stated the resident often sat outdoors with bare feet. Despite the above observations of the toes of the resident's left foot, review of the resident's medical record revealed [REDACTED]. The physician was not contacted for a prescribed treatment. There was no further assessment of the area until 07/28/18 (11 days later), at which time the resident was again observed with maggots between the toes of the left foot and dried blood. The area between the toes had worsened as evident by the above ER report. On 07/31/18 at 2:30 PM Staff G, Licensed Practical Nurse, was observed performing a treatment between the fourth and fifth toes of the resident's left foot. The resident expressed significant pain upon Staff G applying the medicated ointment. The resident was seated in a wheelchair with her feet on the floor. Her left leg was more swollen than the right. Multiple scabbed areas were present over the left lower leg. Refer to F726 for information on facility policies on pressure ulcers Reference (WAC) 388-97-1060(1)

Based on observation, record review, and interviews, the facility failed to follow correct procedures to ensure the safety for 1 of 3 residents (#1) related to transfers that involved the use of a mechanical lift. This failed practice resulted in actual harm to Resident #1 as she fell and sustained a head laceration that required seven staples. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of Progress Notes (PNs), dated 06/03/17, revealed the resident had mild confusion with left sided weakness. Due to difficulty with transfers with two assists, standing, and pivoting her plan of care was changed to transfers utilzing a mechanical lift. The following day (06/04/17) at 11:20 a.m. PNs stated the resident fell during a mechanical lift transfer. The resident was lying on her left side with the left side of her head bleeding profusely, and complaining of severe left hip pain. The mechanical lift and her wheelchair (w/c) were noted to be tipped over. The Nursing Assistant (NA) stated that when she was attempting to get the resident in a good position in her w/c using the handles on the mechanical lift, and tilting the w/c, bracing it against her legs, the mechanical lift and wheelchair tipped over, causing the resident to fall. Immediately following the incident the resident was transferred to the emergency room , where she received seven staples to the laceration on her head. Review of a facility investigation report, dated 06/05/17, relative to the above incident, revealed two NAs assisted with the mechanical lift transfer of the resident from her bed to the w/c. There was one leg of the mechanical lift that was centered in the middle of the chair between the wheels. The w/c brakes were locked. As staff was pulling the resident into the correct position over the w/c, the left wheel of the w/c pushed against the leg of the mechanical lift causing the base of the lift to narrow. The weight of the resident pulled the w/c and mechanical lift over onto their sides. The resident hit her head on the w/c and landed on her left side on the floor. An interview on 06/09/17 at 12:05 p.m. with Staff A, Maintenance Supervisor, revealed he examined the above mechanical lift immediately and nothing was wrong with it. He stated he felt the incident occurred due to staff not placing the w/c in the center of the legs of the mechanical lift, thus the center of gravity shifted which caused the fall to happen. Review of the facility training video, utilized to train NAs on mechanical lifts, revealed the w/c and the resident's weight were to be centered between the legs of the mechanical lift at all times. Staff B, Staff Development Nurse, stated on 06/09/17 at 3:06 p.m., that every NA hired was trained on mechanical lifts within the first four days of employment. Review of In-Service records revealed that in addition to the above training during orientation, the two NAs involved in the above transfer had also received recent training on 04/07/17. Observation of the resident on 6/7/17 at 11:30 a.m. revealed she was alert and talkative, and was able to recall her fall from the mechanical lift. The resident had a bandage to her left forehead covering the staples. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to ensure 2 of 3 residents (#1,#2) in the sample at risk for developing pressure ulcers received timely treatment to promote wound healing and prevent infection. The facility failed to ensure Resident #1 & #2's pressure ulcers did not progress and/or that Resident #1 received emergent care and services as necessary. That failure resulted in harm to Resident #1 when she developed a pressure ulcer and the facility failed to recognize the pressure ulcer had become gangrenous (dead black tissue) resulting in the resident needing immediate medical attention. Additionally, after Resident #1 had received emergency medical attention from an outside clinic and had readmitted to the facility, the facility staff failed to prevent potential further development of pressure ulcers. Findings included: Resident #1. The resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 07/23/12, the resident was referred to Occupational Therapy (OT) and Physical Therapy (PT) due to generalized weakness and her need for maximum assistance with transfers and most cares. The Braden Scale pressure ulcer risk assessments, dated 07/20/2012, documented the resident's risk as an "18." On 09/25/12 the facility referred the resident to OT. The OT notes, dated 09/25/12 documented , "She now requires skilled OT services again secondary to decline in functions with limited out of w/c (wheelchair) activity, decreased ambulation and transfers." The impression of OT after the first therapy session was the resident was confused frequently, she had declined since her admit on 07/20/12, and required total assist to toilet and to complete functional transfers. Additionally, she was rigid and had difficulty moving. The PT notes, dated 11/20/12 through 12/24/12, documented on 11/20/12, "appropriately sized wheel chair; however, in need of modifications for more appropriate fitting and long term use" and recommended a new seat back, seat pan, cushion and leg rests. On 12/24/12, the notes again documented, "pending arrival of chair." The assessment summary noted, "Precautions: ...skin breakdown due to high number of hours spent in the w/c." The Director of Nursing stated the resident had fallen on 01/21/13. Two days later a deep purple bruise was visualized over the sacrum (mid bottom area). The facility related the discolored skin to the fall and monitored the area. According to the treatment record an order to, "Change the [MEDICATION NAME] (an adhesive dressing) at the coccyx area every day" began on 01/23/13. On 01/30/13 the nurse, Staff Member M, documented, "remains having the pressure ulcer on the tailbone area" without further assessment or description. The first documented assessment of the pressure ulcer record was on 02/05/13. The resident had a wound of undetermined depth on her bottom area measuring approximately 2 inches length by 2 inches width. The ulcer was described as having an "odor" with necrotic tissue: "100 % light brown slough" and the surrounding edges were described as having a "purplish hue." Additionally, the record documented the ulcer was new as of 02/05/13, although Staff Member M had noted it as a pressure ulcer on 01/30/13. There were no other recorded nursing staff descriptions of the pressure ulcer by the nursing staff. On 02/20/13 at approximately 10:50 a.m. the Collateral Contact (CC) #4 at a community wound care clinic stated she was called to schedule an appointment for an evaluation and treatment on Resident #1 on 02/04/13. "I triaged the call and they said she had a wound related to a fall", it didn't sound bad so she was scheduled for 02/11/13." "But, when she came here we immediately noticed a smell." "I called staff to assist her thinking it was feces, but it wasn't." "We took off the dressings on the bottom and it was absolutely horrible." "The wound was black, with purulent drainage and smelled so badly our entire clinic was filled with the stench of it." The doctor looked at it and immediately ordered an ambulance be called for transfer to the emergency room . Later that day Resident #1 underwent the surgical removal of all of the dead flesh. The surgical removal went to the thin layer of fascia (clear skin like coating around muscle and bone) directly over the sacral bone (bottom area). On 02/20/13 at approximately 12:00 p.m. a shower aide, Staff Member L, stated she had bathed Resident #1 and had noticed a, "very strong, very strong smell" while bathing her. She stated the smell was noted in the week previous to her hospital admission and she had reported the smell to a Licensed Nurse. On 02/21/13 at approximately 12:00 a.m. a nursing aide, Staff Member N stated Resident #1 had smelled, "like rotten meat, like dying flesh" approximately a week previous to her hospital admission. The resident had smelled especially strong during personal cares and she had reported the smell to the night nurse, Staff Member K. Additionally, she reported that before the development of the pressure ulcer the resident had typically been up in her wheel chair a lot at night due to restlessness. Staff Member K stated on 2/25/13 she had looked at the wound and noted an odor; however, there was no documentation of her assessment or observations. On 02/21/13, Collateral Contact #5, a Nurse Practitioner, stated she had not been informed of any changes in the pressure ulcer wound after last seeing it on 02/06/13. Facility staff had not informed her of a foul, strong smell. The resident re-admitted to the facility on [DATE]. She had a large dressing with a vacuum suction attached to the pressure ulcer wound/surgical wound on her sacrum area. The schedule to change the dressing was ordered as Monday, Wednesday and Friday. The skilled nursing notes, dated Monday 02/18/13, did not document a dressing change had occurred and did not include a description of the wound at the scheduled dressing change. The Treatment Administration Record (TAR) noted the nurse, Staff Member O, had documented the dressing change had been done. The resident's most recent care plan, dated 02/18/13, noted the resident had a pressure ulcer and directed staff to encourage and assist the resident to change positions every one to two hours. Resident #1 was observed during both the days of the investigation laying on an air mattress and in the following positions; On 02/20/13; At 2:00 p.m. Resident #1 was lying in bed on her left side with her eyes closed. At 5:00 p.m., three hours later, the resident was again observed to be in the same position on her left side. At 7:00 p.m. the resident was placed on her back with the head of her bed elevated after a dressing change. At 11:00 p.m., four hours later, the resident was observed laying in the same position as she had been at 7:00 p.m. on her back with the head of her bed elevated and leaning slightly to the left. At 12:10 a.m. (On 02/21/13) the resident was observed laying on her back with the head of her bed up, again in the same position as the previous observation. On 02/21/13 at approximately 9:30 a.m. the resident was laying on her back in bed with the head of the bed up leaning to the left side. The positioning was the same as in the last observation made in the early morning that same day except the resident was leaning more to the left. Resident #2. admitted [DATE] with care needs related to difficulty walking and muscle weakness, poor circulation with lower extremity bilateral knee and leg contractures and a pressure ulcer (left hip). In August 2012 the resident developed wounds to his right heel and toes and left toes related to insufficient circulation. In December 2012, the resident developed pressure ulcers/wounds on his buttocks. Per review of the care plan, dated December 2012, the resident was identified to have actual skin breakdown and impaired skin integrity. The care plan directed the staff to float heels and use heel protectors when in bed, and to assist the resident to turn and reposition every 1-2 hours. Wound care included painting the affected toes with [MEDICATION NAME] and covering the right and left buttocks wounds with a [MEDICATION NAME] (a foam dressing) that was checked for placement every shift and changed every 3 days. On 02/01/13 the resident's third toe on the left foot was described as a "blue toe" after a fall. A fracture was ruled out and a wound clinic evaluation followed. On 02/14/13 Resident #2 was seen at the wound clinic and all of the residents wounds were evaluated with new treatment orders and interventions ordered, including the resident to have position changes to off load the pressure to his buttocks (bottom) every 15 minutes. The open wounds to the resident's buttocks and coccyx were described as due to pressure. On 02/20/13 at approximately 2:30 p.m., Resident #2 was tilted back in his wheel chair in his room. The resident was fidgeting and moaning. His lower legs at the ankles were crossed with his right heel resting on the left upper foot with his knees touching together. On 02/21/13 at approximately 9:45 a.m. the resident was in his room sitting in his tilted wheel chair; his knees were contracted in a bent position and he was not able to change position. While he was in his wheel chair, his left buttocks and coccyx pressed against the chair. He could be heard yelling loudly down the hall. The resident was asked if he was in pain and he shouted, "Yeah!" His legs were crossed at his ankles right foot over the top of his left foot and his inner knees were touching as he was leaning in a left sided position. His feet were not consistently touching the vinyl foot rest. Resident #2 was sitting on a mechanical lift sling and a wheelchair cushion (increasing pressure by decreasing effectiveness of the cushion). At approximately 10:00 a.m. Staff Member G and H, both Nursing Assistants, used a mechanical lift to transfer the resident to bed. According to Staff Member H the resident had been up in the wheel chair since approximately 7:00 a.m. for breakfast. (The resident was in the same position in his wheel chair for approximately 3 hours.) On 02/21/13 at approximately 10:30 a.m. the resident was positioned on an air mattress. The resident was laying on his right side with his knees contracted and legs crossed at the ankles with the right heel over the top of the left foot. A dressing change was done on the resident's bottom. There were smaller open wounds to the buttocks measured 0.3 centimeters (cm) to 0.5 centimeters surrounded by a deeper central wound measuring approximately 2 cm in diameter. The central wound had yellow and dark eschar (thick crusty tissue). Gangrene (dead black tissue) was observed on the left foot toes. Resident #2 was identified as being at risk for pressure ulcers and skin impairment. However, while in the facility he developed avoidable pressure ulcers of his buttocks and coccyx and was at risk for development of additional skin impairment due to the lack of protection of boney prominences. The care plan did not include individualized interventions focusing on pressure relief for his buttocks and observations revealed the facility continued to fail to provide position changing per physician directive to promote healing.

Based on observation, interview and record review the facility failed for 1 of 1 resident (Resident #2) who experienced pain to assess, evaluate and implement measures to manage the residents pain. As a result the resident experienced unnecessary pain as evidenced by yelling and calling out. Findings include: Resident #2. admitted [DATE] with care needs related to difficulty walking and muscle weakness, poor circulation with lower extremity bilateral knee and leg contractures, pressure ulcer and dementia. In August 2012 the resident developed wounds to his right heel and toes and left toes. In December 2012 the resident developed pressure ulcers/wounds on his right and left buttocks. On 02/01/13 the resident's third toe on the left foot was described as a "blue toe" after a fall. On 02/14/13 Resident #2 was seen at the wound clinic and all of the resident's wounds were evaluated with new treatment orders and interventions ordered, including the resident to have position changes to off load the pressure to his buttocks (bottom) every 15 minutes. The open wounds to the resident's buttocks and coccyx were described as due to pressure. The care plan dated December 2012 identified approaches to pain as, "medicate and treat as ordered for pain and to notify M.D. of pain not controlled by current pain regimen."There were no listed non-pharmacological methods that the staff identified as alternatives to alleviate the resident's pain. On 02/20/13 at approximately 2:30 p.m. the resident was tilted back in his wheel chair in his room. The resident was fidgeting and moaning. His lower legs at the ankles were crossed with the right heel resting on the left upper foot with his bare knees touching together. On 02/21/13 at approximately 9:45 a.m. the resident was in his room sitting in his tilted wheel chair his knees were bent and did not touch the wheel chair and he was tilted backwards in his wheel chair with his coccyx and buttocks pressing against the chair. He could be heard yelling loudly down the hall. The resident was asked if he was in pain and he shouted, "Yeah!" Additionally, his legs were crossed at his ankles right foot over the top of his left foot and his knees were touching as he was leaning in a left sided position. His feet were not consistently touching the vinyl foot rest. Resident #2 was sitting on a mechanical lift sling and a wheelchair cushion. At approximately 10:00 a.m. Staff Member G and H, Nursing Assistants, used a mechanical lift to transfer the resident to bed. The resident began to yell loudly and Staff Member G stated, "He usually yells when he is moved." Staff Member H asked the resident if he was in pain and the resident yelled, "Yes!" Staff Member G and H continued to transfer the resident into bed. According to Staff Member H the resident had been up in the wheel chair since approximately 7:00 a.m. for breakfast (3 hours prior). She then went to notify Staff Member D, Licensed Nurse, that the resident was in pain. While Staff Member D Licensed Nurse was obtaining the resident's pain medication, the resident could be heard yelling down the hallway. At 10:10 a.m. Resident #2's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." Staff Member D stated, "the Tylenol 500 mg PRN was what the resident got for pain and there was no other order." On 02/21/2013 the February 2013 MAR indicated [REDACTED]. The level or degree of pain the resident expressed through his yelling was not consistently assessed or treated according to the Pain Management Assessment Tool used by facility staff. On 2/20 and 2/21/13 a pain rating of "7" was recorded that indicated the resident was in severe or excruciating pain and recommended an opioid (narcotic medication); however, only Tylenol was given. On 02/21/13 at approximately 10:30 a.m. the resident was positioned on an air mattress. When Staff Member G removed the sock that covered the resident's left foot for an additional dressing change that day, Resident #2 was yelling for them to, "please stop" moving his foot. In reviewing the MEDICATION ORDERS FOR [MEDICATION NAME] (narcotic pain medication) 5/500 mg 1 tab every 6 hours PRN and may change to [MEDICATION NAME] (narcotic pain medication) 5/325 mg." On 02/21/13 the [MEDICATION NAME]/[MEDICATION NAME] medication order was not transcribed onto the MAR. The Director of Nursing reported on 02/25/13 that CC #5's written order did not initiate a new order; that it was a refill authorization for the same medication that was discontinued on 7/31/12. The facility staff did not seek clarification and they did not act on the order. Resident #2 was in pain when observed on 02/20/13 and 02/21/13 as described above. The resident would close his eyes but still moaned while up in his wheel chair that was tilted backward which increased the pressure to his coccyx and buttocks. Considering the extent and number of the resident's wounds, pain was an issue and not assessed thoroughly related to the resident's condition. Additionally, new orders for potential improved management of pain were not implemented.

Based on record review and interviews the facility failed to implement planned interventions for safe transfer techniques for 1 of 3 sampled residents (#2) reviewed for incidents. This failed practice resulted in harm to the resident as she sustained a fractured right leg during a transfer. Findings include: Resident #2: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had been hospitalized in November and December 2012 for changes in her condition. Review of the resident's plan of care revealed she was at risk for falls due to impaired cognition, visual impairment, incontinent of bowel and bladder. Nursing orders were to transfer the resident with two staff members utilizing a mechanical lift device. The resident's weight on 1/6/13 was 209 pounds. Review of a facility investigation report revealed on 1/7/13 two Nursing Assistants (NAs) were attempting to transfer the resident from her bed to the shower chair without the use of a mechanical lift. Upon standing the resident up the NAs noted she was soiled and attempted to provide perineal care before transferring her onto the shower chair. During the process the resident was not able to stand and staff was unable to transfer her to the shower chair. As they lowered the resident to the floor they heard a "pop." Once she was on the floor they observed her right leg was bent back under her. A nursing assessment at that time revealed deformity of the right lower leg. The physician was notified and orders received to transfer the resident to the emergency room . X-rays revealed she had a fractured right leg for which surgery was performed. Review of physical therapy (PT) notes between 12/10/12 - 1/3/12 revealed the resident was not able to stand during therapy and required total assistance with transfers utilzing a mechanical lift device. An interview on 1/17/13 at 3:40 p.m. with the PT revealed in late November or early December the resident declined in function due to a stroke with left sided weakness. Since that time the therapist stated she was no longer able to stand due to "extreme weakness" on both sides. Therapy staff always used a mechanical lift with any transfer as she was no longer able to bear weight. On 1/17/13 at 1:23 p.m. Staff NA B stated that on 1/7/13 she and another NA had attempted to transfer the resident from her bed to the shower chair without using a mechanical lift device. She stated that as the resident was standing they pulled down her pants and noted she was soiled with feces. They then attempted to clean her; however, "little by little I felt her giving out on us." Due to the resident's obesity the NA stated they were unable to transfer her onto the shower chair. She stated they heard a "pop" when the resident started sliding down to which the resident responded, "you broke my foot." The NA stated she knew the resident was a mechanical lift transfer with two staff however , "I figure I could do it" without the lift.

Based on observation, record review and interview, the facility failed to perform ongoing assessments and monitoring of skin for breakdown and/or to ensure appropriate interventions were in place for 2 of 3 residents (#1,3) in the sample who developed pressure sores. Findings include: Resident #1. admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The admitting progress note identified both heels were "pink and spongy", indicating damage from pressure. On 06/30/12 the Pressure Sore Risk Assessment noted a score of 15, which did not place the resident at high risk of developing a pressure sore. (A score of 12 or less would indicate high risk.) There was no further assessment of the heels in the medical record. On 07/02/12 at 3:25 a.m. progress notes documented the resident complained of pain on the coccyx. She was turned to her side to sleep and a "small area on coccyx observed." A topical treatment was started at that time. On 07/05/12 the Wound Summary noted "late note from Monday 07/02/12" and documented the resident had an open sore (Stage II) to her coccyx when admitted . However, there was no documentation of the coccyx area upon admission, thus it was unknown whether the resident admitted with the pressure sore or developed it while in the facility. The Nutritional Risk Assessment, not dated, did not identify any skin issues for the resident. Facility staff was to perform a weekly head to toe skin check; however, review of the treatment record for July 2012 revealed no assessments were done. The resident was no longer in the facility, thus no observation was made of the current condition of the resident's heels or coccyx. Resident #3. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing Assessment, dated 01/26/12, noted the resident had "some redness to R(ight) lateral heel." The pressure sore risk assessment on that date did not identify the resident as a high risk for the development of pressure sores. Neither was there documentation in the medical record related to the right heel until 03/13/12, which noted a new pressure sore was found on 03/01/12 on the side of the right foot, measuring 1.1 x 1.3 x 1.0 centimeters (approximately 1 inch in diameter). It was noted to be a Stage II ulcer (partial thickness loss of skin). The plan of care, dated 01/26/12, noted a problem for potential impaired skin integrity and staff was to encourage the resident to float his heels when in bed and use heel protectors when in bed. Staff was also to do a weekly head to toe skin check. Review of the Weekly Skin Integrity Action Tool for April 2012 noted the only head to toe check was on 04/21/12 with "no new skin issues." In May the weekly skin check was done twice, on 05/22,29/12, and noted "no new skin issues." In June the skin check was done on 06/05,13,20/12. Although there was a weekly skin integrity action plan, the documentation was incomplete and did not reflect an accurate assessment of the condition of the skin. On 04/09/12 the pressure area on the right foot was noted to have progressively worsened to a Stage IV, a full thickness tissue loss with exposed bone, tendon or muscle. A progress note, dated 04/12/12 noted the resident was admitted (01/26/12) for treatment of [REDACTED]. On 03/14/12 a culture of the wound was taken and the resident was started on antibiotic therapy for infection. Progress notes, dated 06/26/12, noted an aide reported an open wound on the left buttock below the coccyx, "appears to be pressure ulcer." The next documentation related to the pressure ulcer on the buttocks was dated 07/12/12 (16 days later) and noted it was 2.3 x 2.8 centimeters, less than one inch in diameter. There was no odor, tunneling or undermining noted. There was no further description or documentation of the buttock wound until 07/30/12 when progress notes documented "almost totally resolved." On 08/03/12 at approximately 10:50 a.m. the resident was observed in bed with a heel protector on his right foot. His heels were not floated off the mattress. Interview with the Nursing Assistant providing care (Staff A) stated a pillow was used between his legs, but his heels had never been floated off the bed to his knowledge.

Based on record review and interview, the facility failed to provide appropriate care and services to assist 1 of 6 residents (#5) in the sample to reach his highest physical potential following surgical intervention for a [MEDICAL CONDITION]. Due to the facility's failure to recognize and appropriately evaluate swelling in the left leg, a [MEDICAL CONDITION] (clot) developed and emergency treatment was delayed for Resident #5. Findings include: Resident #5. admitted [DATE] for care following repair of a [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. Review of the hospital documentation noted the resident had received [MEDICATION NAME] (an anticoagulant medication used to prevent [MEDICAL CONDITION], or clots) daily while in the hospital. The transfer orders from the hospital had no order for that medication or any other anticoagulation medication. The Admission Nursing Assessment, dated 06/01/12, noted the resident had pain with movement and had a lengthy incision to the left hip which had no redness or drainage at the time. There was no documentation related to the appearance of the lower leg. Review of the interdisciplinary assessment tool, dated 06/15/12, noted the resident required extensive assistance for bed mobility and transfers and was totallly dependent for toileting. Physical Therapy (PT) was started by 06/04/12; however, documentation by PT, dated 06/11/12 noted "making minimal progress secondary to consistent refusals of PT and inability to comply." Progress notes, dated 06/08/12 at 1:44 p.m., noted the resident "regularly has been refusing his therapies...". On 06/09/12 at 1:03 p.m. progress notes documented "mild [MEDICAL CONDITION] noted in left leg as compared to the right leg with 0. Good nerve and circulation check." On 06/14/12 there was no redness or drainage present. On 06/15/12 at 10:50 p.m. "Swelling continues to be noted at left lower extremity. Will keep monitoring before notifying MD." On 06/16/12 at 6:16 p.m. "Swelling continues to be noted at left lower extremity. Resident encouraged to have both legs elevated at bed time to manage [MEDICAL CONDITION]." Although staff recognized the left leg was swelling, they failed to assess for tenderness, pain, warmth and discoloration of the leg (all symptoms of a blood clot). On 06/17/12 at 6:47 p.m. "Left lower extremity swelling noted." On 06/18/12 at 9:06 p.m. "Swelling continues to be noted at left foot. Left foot elevated on the pillow at all times to manage [MEDICAL CONDITION]." On 06/19/12 at 8:51 p.m. "Left foot encouraged to elevate on pillow at bed time to manage [MEDICAL CONDITION]." On 06/20/12 at 9:24 p.m. "Left leg elevated at bed time to manage [MEDICAL CONDITION]." On 06/21/12 at 5:57 p.m. "Left lower leg elevated at bed time to manage [MEDICAL CONDITION]." The resident's temperature at that time was 99 degrees Fahrenheit. At 11:35 p.m. an "addendum" was noted which documented "skin to left leg warmer than right one. Swelling continues to be noted at left lower extremity. Tylenol given for high temperature with good result. Temperature rechecked 98.0. Will give report to wound care nurse for further evaluation." In spite of the resident experiencing [MEDICAL CONDITION] to the left lower extremity and frequent documentation of [MEDICAL CONDITION], or swelling, since 06/09/12 (12 days), there was no assessment of the left leg for tenderness, pain, warmth or discoloration. The physician saw the resident on 06/08 and 20/12; however, there was no documentation related to the resident's leg. There was no documented evidence that staff informed the primary physician or the surgeon of the increased inflammation in the leg. On 06/21/12 the resident was taken to the hospital by the family. Interview with a family member on 08/02/12 at approximately 8:30 a.m. revealed that the resident had begun complaining about the left leg around his 10th day (06/10/12) in the facility. Family requested the physician see the resident; however, the physician was "more concerned with pain management" than the appearance of the leg. The family member stated the leg was so swollen the resident could not bend it and the leg was red and hot. In addition, the family member stated the therapist suggested that the family member massage the leg. (If a blood clot was present, massaging the extremity could dislodge the clot and it could damage the heart or lungs.) Review of the ultrasound study of the left leg at the hospital on [DATE] noted "[MEDICAL CONDITION] from the posterior tibial vein up through the external iliac vein" (extensive leg involvement). A deep vein blood clot is potentially life threatening. The facility failed to recognize the resident's increased risk of developing a blood clot which included his history of vascular disease, the lack of anticoagulation medication, and decreased activity due to his refusals for walk. And, once the swelling in the leg developed (a sign of potential blood clot) the facility failed to recognize that a blood clot may be present for 12 days, thus emergency treatment was delayed.