Every finding on record at Avalon Healthcare - Tacoma

Based on interview and record review, the facility failed to notify the responsible party for 1 of 3 residents (Resident 1) reviewed for hospitalization. Failure to notify the resident representative of transfer to a hospital placed the resident at risk for not having their representative involved in their health care decision-making with timely care and services. Findings included .Resident 1 was admitted to the facility on [DATE]. Review of Resident's 1's admission record documented a brother as the resident's Power of Attorney for Health Care.During an interview on 08/06/2026 at 11:32 AM, Collateral Contact 1 (CC1), Resident 1's family member, stated that the resident had been sent to the hospital on [DATE] and nobody at the facility called to let the family know until the day after Resident 1 was sent out to the hospital.Review of a progress note, dated 07/28/2026 at 10:32 AM, documented that Resident 1 was transferred to the hospital Emergency Department for further evaluation and treatment due to an episode of confusion.A progress note, dated 07/28/2026 at 11:58 AM, documented Resident 1 had increased confusion, attempts to reorient the resident were unsuccessful, and the resident became agitated and more confused. The provider was notified and a new order was given to send the resident to the hospital for further evaluation of the resident's altered mental status.Review of Resident 1's electronic health record showed no documentation that any family or responsible party was notified.During an interview on 08/07/2026 at 2:34 PM, Staff C, a Registered Nurse and the Resident Care Manager (RCM), said family should be notified right away when residents are sent out to the hospital.On 08/07/2026, when asked where staff documented notification to Resident 1's family when the resident was sent to the hospital on [DATE], Staff C said, they were not able to find it, that it was not in Resident 1's record.During an interview on 08/07/2026 at 2:51 PM, Staff A, Administrator, said family members should be notified when residents are sent out to the hospital. Refer to WAC 388-97-0320 (1)(d) .

Based on interview and record review, the facility failed ensure that the infection prevention and control program (IPCP) was overseen by a qualified individual who had completed specialized training in infection prevention and control to properly assess, develop, implement, monitor, and manage the IPCP for the facility. This failure placed residents and staff at risk for communicable diseases and a decreased quality of life. Findings included.During an interview on 07/15/2026 at 9:30 AM, Staff N, Registered Nurse/Infection Preventionist (RN/IP), stated they had started the position as infection preventionist in October 2025 but had not completed any specialized training. Review of the provided training records for the infection preventionist showed only module 1 out of 23 of the CDC training modules as completed in 2022 with no name included on the page. During an interview on 07/15/2026 at 9:41 AM, Staff B, Director of Nursing Services, stated they were unaware that Staff N, RN/IP, had not completed the training but should have completed the training by now. During an interview on 07/15/2026 at 9:54 AM, Staff A, Administrator, stated it was their expectation that Staff N, RN/IP, complete specialized infection control training. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure food was safely stored/prepared when reviewed for kitchen sanitation. This failure placed residents at risk of foodborne illness, avoidable decline in condition, and a diminished quality of life. Findings included.Observation on 07/13/2026 at 9:25 AM showed a standing rack in the dry storage area which held a pan of raw bacon and a pan of breaded chicken pieces. Observation showed the rack was near dry food goods, clean cooking implements, and clean food serving items. Review of the lunch menu for 07/13/2026 showed the main course was sweet and sour chicken with an alternate of a BLT sandwich. Observation on 07/15/2026 at 11:42 AM showed a rack with clean silverware and other clean food serving items. Observation showed the rack also contained a personal cell phone, a coffee drink from an outside coffee shop, and a personal water bottle. During an interview on 07/15/2026 at 2:27 PM, Staff O, Dietary Manager, stated the facility would thaw food product in the refrigerator or submerged under running cold water. Staff O stated the bacon and chicken thawing in the dry storage did not meet expectations. Staff O stated that personal items, such as drinks and cell phones, should not be stored in the kitchen. Staff O stated the observation of a personal cell phone, a coffee drink from an outside coffee shop, and a personal water bottle stored in the kitchen area did not meet expectations. During an interview on 07/15/2026 at 2:33 PM, Staff A, Administrator, stated cold food should not be thawed in the dry storage area and the observation of bacon and chicken stored in dry storage did not meet expectations. Staff A stated personal items should not be stored in the kitchen and the observation of a personal cell phone, a coffee drink from an outside coffee shop, and a personal water bottle stored in the kitchen did not meet expectations. Reference WAC 388-97-1100(3), -2980

Based on interview and record review, the facility failed to maintain eight hours registered nurse (RN) coverage daily for 1 of 30 sampled days (07/04/2026) reviewed for eight-hour RN nurse staff coverage. This failure placed residents at risk of not having an RN available for resident assessment and treatment, a delay in emergency care, and a diminished quality of life. Findings included.Review of the 30-day staffing pattern, dated 06/13/2026 to 07/13/2026, showed there were no RN working on any shift on 07/04/2026. During an interview on 07/16/2026 at 12:25 PM, Staff A, Administrator, stated the facility ensured they had an RN available for at least eight hours a day by using agency RN staff when there was a call-off by regular staff. Staff A stated there was an RN call-out on 07/04/2026 and no RN was working in the 24-hour period on 07/04/2026. Staff A stated the lack of RN staff coverage on 07/04/2026 did not meet expectations. WAC Reference: None applicable

Based on interview and record review, the facility failed to develop a timely and/or comprehensive collaborative care plan involving Hospice care (end of life care and services) for 3 of 3 sampled residents (Residents 6, 21, and 41) reviewed for Hospice. This failure placed residents at potential risk for unmet needs and a diminished quality of life. Findings included .Review of the facility's policy titled, Administration Hospice, dated 07/2018, showed, The facility and the hospice will establish a coordinated plan of care which identifies the specific services/functions each provider is responsible for performing. Resident 6Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain malfunction), heart failure, and peripheral vascular disease (a condition when blood circulation outside of the brain and heart narrow, become blocked or spasm). Resident 6 was able to make needs known. Review of the provider order dated 06/09/2026 showed Resident 6 was admitted to Hospice Care on 06/09/2026. Review of Resident 6's EHR showed a Hospice plan of care/coordination of care was received by the facility with a start date of 06/09/2026. Review of Resident 6's focused care plan for Hospice care showed it was initiated on 06/16/2026 and did not specifically show or identify specific services/functions that would be provided by Hospice. Review showed Hospice services were not integrated into Resident 6's plan of care. During an interview on 07/16/2026 at 10:12 AM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated a resident with orders for Hospice services should be care planned as soon as possible and within 48 hours. Staff C stated Resident 6's Hospice care plan was not initiated until 06/16/2026 and did not include what type of Hospice staff would be providing care. Staff C stated Resident 6's care plan did not show what type of hospice services were being offered/provided and should have. During an interview on 07/16/2026 at 11:39 AM, after reviewing Resident 6's current care plan, Staff B, Director of Nursing Services (DNS), stated the Hospice care plan was not initiated timely. Staff B stated Resident 6's care plan did not meet expectations and needed to be revised to include Hospice care and services being provided integrated into the comprehensive care plan. Resident 21Review of the EHR showed Resident 21 readmitted to the facility on [DATE] with diagnoses to include cancer (abnormal body cell growth that crowded out healthy cells causing damage), dementia (decline in mental ability severe enough to interfere with daily life), and asthma (a disease of the airways that causes breathing difficulties). Resident 21 was sometimes able to make needs known. Review of the order dated 12/04/2025 showed Resident 21 was admitted and certified for Hospice care. Review of the EHR showed Resident 21's Hospice plan of care/coordination of care was received by the facility with a start of date of 12/04/2025. Review of Resident 21's focused care plan for Hospice care showed it was initiated on 12/30/2025 and did not specifically show or identify specific services/functions that would be provided by Hospice. Review showed Hospice services were not integrated into Resident 21's plan of care. During an interview on 07/16/2026 at 10:23 AM, Staff C, (RN/UM), stated Resident 21's Hospice care plan was initiated on 12/30/2026 and should have been initiated within 48 hours of the Hospice order being obtained. Staff C stated Resident 21's care plan did not show what hospice staff would be doing and/or who would be making visits. Staff C stated Resident 21's care plan did not meet expectations. During an interview on 07/16/2026 at 11:48 AM, Staff B, DNS, stated Resident 21's Hospice care plan should have been initiated once the Hospice order was obtained. Staff B stated Resident 21's comprehensive care plan did not meet their expectations for a collaborative/integrated care plan with Hospice care and services and needed to be revised. Resident 41Review of the EHR showed Resident 41 readmitted to the facility on [DATE] with diagnoses to include malignant neoplasm of brain (an aggressive, fast-growing tumor/mass that invades health tissue), metabolic encephalopathy (brain malfunction), and diabetes (too much sugar in the blood). Resident 41 was able to make needs known. Review of the provider order dated 05/21/2026 showed Resident 41 was admitted and certified for Hospice care. Review of the EHR showed Resident 41's Hospice plan of care/coordination of care was received by the facility with a start date of 05/21/2026. Review of Resident 41's focused care plan for Hospice care showed it was initiated on 05/22/2026; however, it did not specifically show or identify specific services/functions that would be provided by Hospice. Review showed Hospice services were not integrated into Resident 41's plan of care. During an interview on 07/16/2026 at 10:27 AM, Staff C, (RN/UM), stated Resident 41's care plan did not show what type of Hospice services or functions were being provided and did not meet expectations for a collaborative comprehensive care plan involving Hospice. During an interview on 07/16/2026 at 11:52 AM, Staff B, DNS, stated Resident 41's care plan did not meet expectations related to Hospice care and services and needed to be revised. Reference WAC 388-97-1620(1)(2)(b)(i)(ii), -0220

Based on interview and record review, the facility failed to log, initiate, investigate, and resolve concerns of the resident council related to resident care for 5 of 6 sampled resident council meetings minutes (January 2026, February 2026, March, May and June 2026) reviewed for grievances. This failure placed residents at risk for unmet care needs, dissatisfaction, and a diminished quality of life. Findings included .During an interview on 07/15/2026 at 11:37 AM, Resident 4 stated management did not follow up with concerns discussed during the resident council meetings. Review of the resident council meeting minutes for January 2026 showed residents expressed concerns related to staff shortage on the weekends, long call light response times during evenings and weekends. Review of the resident council meeting minutes for February 2026 showed residents expressed concerns related to Certified Nursing Assistants on their cell phones and not answering call lights timely. Residents stated staff disappeared on the night shift and care needs were not being met. Review of the resident council meeting minutes for March 2026 showed residents expressed, Still waiting longer times for staff to answer call lights during evening and night shift. Review of the resident council meeting minutes for May 2026 showed residents expressed, Call lights are not being answered and no assurance that someone will be there to help. Staff take minimum of 20 minutes to respond to call lights. Review of the resident council meeting minutes for June 2026 showed residents expressed, Not enough staff, call light wait times remain longer than they should, staff will come in turn off the light and not return to provide care requested. Review of the grievance log, dated January 2026 through June 2026, showed no grievances that corresponded with concerns verbalized at resident council meetings. During an interview on 07/14/2025 at 1:57 PM, Staff J, Recreation Director, stated they documented resident concerns during the resident council meetings and provided the information to the Administrator for follow-up. During an interview on 07/16/2026 at 12:48 PM, Staff A, Administrator, stated it did not meet their expectation that specific concerns brought up in resident council had not been addressed and followed up on. Reference WAC 388-97-0920

Based on observation and interview, the facility failed to have sufficient staff to ensure residents received timely call light responses. This failure placed residents at risk for accidents, injuries, and diminished quality of life. Findings included . Resident 23During an interview on 07/13/2026 at 10:37 AM, Resident 23 stated, My only concern is the staffing, they need more help, they try hard, but I've had to wait an hour once. Resident 34During an interview on 07/13/2026 at 9:47 AM, Resident 34 stated, I had to wait an hour, when I put my call light on, I looked at the clock and it stayed for an hour on the night shift, and I can hear them out there. Resident 44During an interview on 07/13/2026 at 11:48 AM, Resident 44 stated, Staff take a long time to respond to call lights on the weekends. Resident 46During an interview on 07/13/2026 at 11:50 AM, Resident 46 stated, It's mostly at nighttime, the call light wait is an hour or two. I am shy and have not told anyone. Resident 7During an interview on 07/13/2026 at 9:51 AM, Resident 7 stated, The usual call light wait time is half an hour. Observation on 07/13/2026 at 9:51 AM showed the automated call light system at the central nurse's station on 07/13/2026 at 9:51 AM showed room [ROOM NUMBER]'s call light went unanswered for 21 minutes. Observation on 07/15/2026 at 11:06 AM of the automated call light system showed room [ROOM NUMBER]'s call light went unanswered for 22 minutes. RESIDENT COUNCIL MINUTESReview of the resident council (a resident group who meets monthly to discuss facility concerns) meeting minutes for January 2026 showed residents expressed concerns related to staff shortage on the weekends, long call light response times during evenings and weekends. Review of the resident council meeting minutes for February 2026 showed residents expressed concerns related to Certified Nursing Assistants on their cell phones and not answering call lights timely. Residents stated staff disappear on the night shift and care needs were not being met. Review of the resident council meeting minutes for March 2026 showed residents expressed, Still waiting longer times for staff to answer call lights during evening and night shift. Review of the resident council meeting minutes for May 2026 showed residents expressed, Call lights are not being answered and no assurance that someone will be there to help. Staff take minimum of 20 minutes to respond to call lights. Review of the resident council meeting minutes for June 2026 showed residents expressed, Not enough staff, call light wait times remain longer than they should, staff will come in turn off the light and not return to provide care requested. During an interview on 07/15/2026 at 12:59 PM, Staff B, Director of Nursing, stated call light response time was an ongoing issue. Staff B stated the expectation was that response time should not be longer than 15 minutes. Reference WAC 388-97-1060(3)(d)

Based on interview and record review, the facility failed to ensure residents were provided psychotropic (mind altering) medications in response to mood/behavior issues for 4 of 5 sampled residents (Residents 4, 8, 46, and 59) reviewed for unnecessary medications. This failure placed residents at risk of avoidable medication side effects, sedation, possible chemical restraint, and a diminished quality of life. Findings included. Resident 4 Review of the electronic health record (EHR) showed Resident 4 readmitted to the facility on [DATE] with diagnoses to include fracture of the left leg, anxiety disorder, and depressive disorder. Resident 4 was able to make needs known. Review of the provider's orders showed Resident 4 had the following orders: (1) clonazepam (psychotropic medication used to treat panic disorders and manage severe anxiety) as needed (PRN) for anxiety for 14 days dated 06/01/2026; (2) clonazepam PRN for anxiety for 14 days dated 06/16/2026; and (3) clonazepam PRN for anxiety for 14 days dated 07/02/2026. Review showed staff should monitor Resident 4's mood/behavior and provide non-pharmacological (non-medicated) interventions for mood/behavior. Review of the June and July 2026 MAR from 06/01/2026 through 07/13/2026 showed Resident 4 received clonazepam PRN on 21 of 43 days. Review showed Resident 4 had no mood/behavior issues documented and was not provided non-pharmacological interventions for mood/behavior during this period. During an interview on 07/14/2026 at 1:40 PM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated residents receiving psychotropic medication PRN should have documented mood/behavior issues before being provided the medication. Staff C stated Resident 4 received clonazepam PRN and had provider's order to monitor mood/behavior and provide non-pharmacological interventions. Staff C stated nursing staff should have documented the mood/behavior issue being addressed prior to providing clonazepam PRN. During an interview on 07/14/2026 at 2:46 PM, Staff B, Director of Nursing Services (DNS), stated residents mood/behaviors should be documented prior to being provided with PRN psychotropic medications. Staff B stated Resident 4's behavior/mood monitoring should match when they received their PRN clonazepam, and this did not meet expectations. Resident 8 Review of the EHR showed Resident 8 was readmitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), dysphagia (difficulty swallowing), depression, and end of life care. Resident 8 was not able to communicate needs. Review of the MAR for July 2026 showed Resident 8 was ordered lorazepam (antianxiety, mind altering) medication dated 07/12/2026 and was administered on the 07/12/2026 and the 07/15/2026 without behaviors documented. Review of the July 2026 MAR showed Resident 8 was administered mirtazapine (antidepressant mind altering medicine) for depression without behavior monitoring. During an interview on 07/15/2026 at 9:28 AM, Staff C, RN/UM, stated there should be behavior monitors for antianxiety and antidepressant medications. Resident 46 Review of the EHR showed Resident 46 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a chronic and severe mental disorder that affects a person's ability to think, feel, and perceive reality), anxiety, and depression. Resident 46 was able to communicate needs. Review of July 2026 MAR showed Resident 46 was administered aripiprazole (antipsychotic mind altering) for schizophrenia, citalopram (antidepressant, mind altering) for depression, lorazepam for anxiety, and buspirone (antianxiety, mind altering) for anxiety daily. Review of the EHR showed Resident 46 was not monitored for behaviors that showed if the medications were effective or not. During an interview on 07/16/2026 at 9:10 AM, Staff B, DNS, stated lack of behavior monitoring for Resident 8 and 46 did not meet expectations. Resident 59 Review of the EHR showed Resident 59 admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI), dementia without behavioral disturbance and visual hallucinations. The resident was able to make needs known. Review of the provider orders showed Resident 59 was prescribed an antipsychotic medication (risperidone) 2 milligrams (mg) daily for dementia, hallucinations with a start date of 07/08/2026. The order was changed on 07/10/2026 to 1 mg daily for dementia without behavioral disturbances. Review of the EHR on 07/14/2026 showed Resident 59 had no behavior monitor in place for the use of an antipsychotic medication. During an interview on 07/14/2026 at 10:23 AM, Staff M, Social Services Assistant (SSA), stated Resident 59 should have had a behavior monitor in place and the diagnosis should have been the visual hallucinations. During an interview on 07/14/2026 at 11:33 AM, Staff B, DNS, stated Resident 59 should have had a behavior monitor in place when they started antipsychotic therapy. Staff B stated Resident 59's order for antipsychotic medication should have had an appropriate diagnosis for its use. Reference WAC 388-97-1060(1)(3)(e), -1280(1)(a)(b)(3)(a)

Based on interview and record review, the facility failed to maintain an infection prevention and control program by completing and analyzing infection control data, identifying trends, and completing follow-up activities in response to those trends for 4 of 4 months (April, May, June and July 2026) reviewed for Infection Control. This failure placed the residents at risk for communicable diseases, poor clinical outcomes and a decreased quality of life. Findings included.Review of the facility policy titled Infection Preventions and Control Program dated 08/2022 showed the surveillance log will include the pathogen and the infection preventionist will use the information to identify trends; to minimize further spread and the information would be used to implement changes and/or education to address the trends. Review of the facility infection control line listing documentation for June 2026 showed an entry for Resident 30 for an in-house acquired urinary tract infection (UTI) with an onset date of 06/08/2026, the log did not include the identified organism. Also, an entry for Resident 49 for a present on admission UTI with an onset date of 06/29/2026. The log did not include the identified organism. Review of the facility infection control line listing documentation for July 2026 showed an entry for Resident 10 for an in-house acquired urinary tract infection with an onset date of 07/10/2026. The log did not include the identified organism. Review of the Monthly Infection Surveillance Report for April 2026, May 2026 and June 2026 showed no documentation that the data was analyzed to identify trends. During an interview on 07/15/2026 at 9:30 AM, Staff N, Registered Nurse/Infections Preventionist (RN/IP), stated they were not in the practice of following up on the labs to identify the organisms present if it was not included in the resident's medical record and no trends to identify because their census was so low. During an interview on 07/15/2026 at 9:41 AM, Staff B, Director of Nursing Services, stated Staff N, RN/IP, should have followed up on lab results when a resident was admitted on an antibiotic or had a new antibiotic order to be able to track which organisms were present in the facility to identify trends but was not and this did not meet expectations. Reference WAC 388-97-1320(2)(a)

Based on interview, and record review, the facility failed to ensure the resident or the resident's representative was informed of and participated in treatment decisions regarding the initiation/continuation of a prescribed antidepressant/antianxiety medication, including discussion of the risks, benefits, and alternatives, for 2 of 5 residents (Residents 8 and 3) reviewed for unnecessary medication. This failure had the potential to violate the residents' right to make informed treatment decisions and participate in their care planning. Findings included.Resident 8 Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses to include major depression, dementia (loss of memory, language and thinking abilities), and end of life care. Resident 8 was not able to communicate their needs. Review of the medication administration record (MAR) for July 2026 showed Resident 8 was ordered lorazepam (antianxiety, mind altering) medication dated 07/12/2026 and was administered on the 07/12/2026 and the 07/15/2026. Review of the EHR showed Resident 8 did not have written consent about lorazepam that explained risk and benefits of the medication. During an interview on 07/15/2026 at 9:23 AM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated antianxiety medications require consent, and there should have been one for Resident 8. During an interview on 07/16/2026 at 9:21 AM, Staff B, Director of Nursing Services (DNS), stated lack of consent for lorazepam for Resident 8 did not meet expectations. Resident 3 Review of the EHR showed Resident 3 admitted to the facility on [DATE] with diagnoses that included dementia, adjustment disorder with anxiety (excessive nervousness, worry, or feelings of being overwhelmed in response to a specific life change or stressful event), depression (mood disorder), and diabetes (excessive sugar in the blood). Resident 3 was able to make needs known. Review of the EHR showed Resident 3 was prescribed an anxiety medication on 03/03/2026. A consent in the EHR dated 03/05/2026 showed documentation Resident 3's representative was unable to be reached to consent for the medication. Further review showed the consent was signed by the provider and a member of nursing staff. During an interview on 07/16/2026 at 11:10 AM, Staff L, Advanced Registered Nurse Practitioner (ARNP), stated they were unable to obtain authorization from Resident 3's legal decision maker prior to administration of the medication. Staff L stated they consented on Resident 3's behalf as they believed Resident 3 was in crisis. During an additional interview on 07/16/2026 at 11:51 AM, Staff L stated they had obtained consent from Resident 3's legal decision maker on 03/04/2026; however, there was no documentation in the medical record of consent and discussion of risk and benefits. During an interview on 07/16/2026 at 9:53 AM, Staff B, DNS, stated the expectation was for staff to obtain consent for behavioral health medications prior to administration. Reference WAC 388-97 -0260 -0300(3)(a) -1020(4)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure residents with identified dental needs received dental services for 1 of 2 sampled residents (Resident 4) reviewed for dental services. This failure placed residents at risk of difficulty chewing, reduced nutritional intake, unplanned weight loss, and a diminished quality of life. Findings included.Review of the electronic health record showed Resident 4 readmitted to the facility on [DATE] with diagnoses to include fracture of the left leg, anxiety disorder, and depressive disorder. Resident 4 was able to make needs known. Observation and interview on 07/13/2026 at 9:59 AM showed Resident 4 had missing and damaged teeth. Resident 4 stated they needed two teeth extracted and a set of dentures made, and they had not seen a dental practitioner while at the facility. Review of the admission minimum data set assessment dated [DATE] showed Resident 4 had obvious or likely cavity or broken natural teeth. Review of the plan of care, initiated 04/15/2026, showed Resident 4 was at risk for oral/dental health problems and the facility would coordinate arrangements for dental care. Review of a dental report, dated 12/16/2024, showed Resident 4 had multiple missing/broken teeth and they would like extractions and dentures. Review of the census showed Resident 4's payer source was Medicaid. During an interview on 07/14/2026 at 1:33 PM, Staff C, Registered Nurse/Unit Manager, stated when a resident admitted to the facility, their dental needs would be assessed, and the social services department would schedule any needed dental care. Staff C stated Resident 4 had broken natural teeth and had not seen a dental practitioner since admitting. During an interview on 07/14/2026 at 2:38 PM, Staff B, Director of Nursing Services, stated when residents admitted to the facility, the admission nurse would assess residents for dental needs, their name would be placed in a consult book, and social services would follow-up with needed referrals. Staff B stated Resident 4 had obvious cavities or broken teeth. Staff B stated Resident 4's name was placed in the consult book, but they had not been seen when the facility's dentist was in the facility on 05/21/2026. Staff B stated Resident 4 should have been seen by the dentist and this did not meet expectations. Reference WAC 388-97-1060(3)(j)(vii)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of 5 errors were made in 27 opportunities during a medication administration for 1 of 5 sampled residents (Resident 24) reviewed for medication administration. This placed the residents at risk for receiving medications that were not effective or less effective and a diminished quality of life. Findings included .Observation of medication administration on 07/15/2026 at 11:16 AM showed Staff P, Registered Nurse (RN), prepared and administered the medications vitamin D, senokot (laxative), tamsulosin (for treatment of enlarged prostate) and at 11:40 AM administered vitamin B-12 and pantoprazole (antiacid) to Resident 24. Review of a provider's orders for Resident 24 showed orders for vitamin D, vitamin B-12, senokot, tamsulosin and pantoprazole with a specific time of administration to be administered between 7:00 and 10:00 AM. During an interview on 07/15/2026 at 1:06 PM, Staff P, RN, stated there were many distractions and the time was not black and white. During an interview on 07/15/2026 at 1:10 PM, Staff B, Director of Nursing Services, stated the expectation was for nurses to follow orders including the correct time of administration and this did not meet expectations. Reference WAC 388-97-1060(3)(k)(ii)

Based on observation, interview, and record review, the facility failed to monitor a fluid restriction for 1 of 3 sampled residents (Resident 13) reviewed for nutrition. This failure placed the resident at risk for fluid imbalance and a decreased quality of life. Findings included.Resident 13Review of the electronic health record (EHR) showed Resident 13 admitted to the facility on [DATE] with a diagnosis of end stage renal disease (kidney failure) and required dialysis (a procedure to filter blood of toxins). The resident was able to make needs known. Review of EHR showed a provider order for a fluid restriction with a start date of 04/27/2026. Nursing was to provide 740 milliliters (ml) of fluids per day. Review of the July 2026 medication administration record (MAR) showed the following totals:07/02/2026 showed a total of 600 ml.07/03/2026 showed 400 ml on day shift and 400 ml on evening shift, the total for 24 hours was documented as 600 ml.07/04/2026 showed 500 ml on day shift and 500 ml on evening shift, the total for 24 hours was documented as 600 ml.07/05/2026 showed 600 ml on day shift and 600 ml on evening shift, the total for 24 hours was documented as 600 ml.07/10/2026 showed 300 ml on day shift and 300 ml on evening shift, the total for 24 hours was documented as 300 ml.07/12/2026 showed 500 ml on day shift and 500 ml on evening shift, the total for 24 hours was documented as 300 ml. Review of the EHR on 07/14/2026 showed no care plan or Kardex (directions for caregivers) for the fluid restriction. The Kardex showed Offer fluids at bedside and with meals to help maintain hydration. During an observation and interview on 07/14/2026 at 10:12 AM, Resident 13 laid in bed and there were three cups of various drinking fluids on the overbed table. When asked about the fluid restriction, Resident 13 stated That's not going to happen. I drink what I want. During an interview on 07/14/2026 at 10:38 AM, Staff H, Certified Nursing Assistant (CNA), stated they would look in the Kardex to tell who was on a fluid restriction. During an interview on 07/14/2026 at 10:52 AM, Staff F, CNA, who was assigned to Resident 13, stated they would know who was on a fluid restriction by looking at the Kardex. Staff F stated none of their assigned residents were currently on a fluid restriction. During an interview on 07/14/2026 at 11:37 AM, Staff B, Director of Nursing Services, stated it was their expectation that residents on a fluid restriction have it included in their care plan/Kardex and it should be monitored and documented accurately. Staff B stated the fluid restriction for Resident 13 did not meet their expectations. Reference WAC 388-97 -1060(3)(i)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accident risks related to the smoking program or fall prevention for 3 of 7 sampled residents (Residents 28, 23, and 8) reviewed for accidents. This failure placed residents at risk for smoking injury, fall injury, and a diminished quality of life. Findings included.<Smoking> Review of a facility policy titled PHYSICAL ENVIRONMENT: Smoking – Supervised Smokers, revised 03/2019, showed 5. Residents who smoke will be supervised by staff members while smoking. Smoking will occur at designated smoking times, 6. Smoking paraphernalia will be managed by nursing staff and will be made available at designated smoking times, and 7. [.] Oxygen tanks and concentrators will be placed outside of designated smoking areas. Review of a facility document titled Smoking Acknowledgement, undated, showed, All traditional combustible materials (including cigarettes, cigars, and lighters) must be secured and locked with the nurse and may only be used under the direct supervision of staff during the following designated times: 9:30 AM – 9:45 AM, 1:30 – 1:45 PM, 6:00 PM – 6:15 PM. Observation on 07/15/2026 at 1:57 PM showed Resident 28 sat in their wheelchair in the designated smoking area where other residents were actively smoking. Observation showed Resident 28's wheelchair had an oxygen tank in a large pocket on the back of their wheelchair. Observation showed Staff Q, Activity Assistant, was supervising the smoking time. During an interview on 07/15/2026 at 2:05 PM, Staff A, Administrator, stated oxygen should not be in the smoking area. Staff A, after they observed Resident 28 with an oxygen tank in the smoking area, stated the oxygen was not a concern because it was five feet away from residents who were actively smoking. Observation on 07/16/2026 at 9:49 AM showed Resident 23 sat in the designated smoking area smoking a cigarette. Observation showed no staff members were present in the designated smoking area. Observation on 07/16/2026 at 9:55 AM showed Resident 28 finished smoking their cigarette and re-entered the facility without staff member intervention. During an interview on 07/16/2026 at 9:35 AM, Staff Q, Activity Assistant, stated they supervised designated smoking times. Staff Q stated they did not receive any training specific to safe smoking practices but had been provided with a copy of the facility's policy. Staff Q stated unused oxygen tanks were allowed in the designated smoking area during smoking times if the oxygen tank was kept five feet away from residents who were smoking. During an interview on 07/16/2026 at 12:22 PM, Staff A, Administrator, stated residents with oxygen tanks were allowed in the designated smoking area when other residents were smoking if they kept five feet away. Staff A stated the smoking area should be monitored to ensure residents did not smoke between smoking times. Staff A stated Resident 28 smoking without supervision during a non-designated smoking time did not meet expectations. <Fall Prevention> Resident 8 Review of the electronic health record (EHR) showed Resident 8 was readmitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), dysphagia (difficulty swallowing) and NPO status (nothing by mouth) with artificial tube feeding. Resident 8 was not able to communicate needs. Observation on 07/13/2026 at 9:38 AM showed Resident 8 was in a low bed, the bed next to the wall, and a thin mattress was next to the bed. Review of incident log showed Resident 8 had a fall on 05/19/2026 at 7:00 AM and sustained lacerations to the left forehead, left shin and left elbow. A new intervention was to get the resident up before breakfast. Review of the care plan with fall focus showed Resident 8 had an intervention dated 01/16/2026 to be up for meals (includes breakfast). Review of the incident log showed Resident 8 had a repeat fall on 05/31/2026. During an interview on 07/16/2026 at 9:04 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was each fall to have a new intervention, and that did not happen for Resident 8. Reference WAC 388-97 -1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure residents were consistently offered/received services to maintain or prevent declines in mobility 2 of 3 sampled residents (Residents 3 and 46) reviewed for range of motion (ROM). This failure placed the residents at risk of decreased motion/mobility and a diminished quality of life. Findings included. Resident 3 Review of the electronic health record (EHR) showed Resident 3 admitted to the facility on [DATE] with diagnoses that included dementia (decline in mental abilities severe enough to interfere with daily life), adjustment disorder with anxiety (excessive nervousness, worry, or feelings of being overwhelmed in response to a specific life change or stressful event), depression (mood disorder), and diabetes (excessive sugar in the blood). Resident 3 was able to make needs known. During an interview on 07/13/2026 at 9:43 AM, Resident 3 stated they were not getting as much therapy as they would like. Review of Resident 3's EHR showed they had both impaired upper and lower extremities. Review of Resident 3's therapy care plan initiated 05/30/2026 showed staff were to Provide gentle range of motion as tolerated with daily care. Review of the daily task in the EHR showed no documentation Resident 3 was offered or provided gentle range of motion as tolerated. During an interview on 07/15/2026 at 1:19 PM, Staff R, Certified Nursing Assistant (CNA), stated Resident 3's Kardex (list of tasks to be completed by CNA) did not specify which body parts were supposed to be exercises. Staff R stated, I just try to encourage the resident to get up into their wheelchair. During an interview on 07/16/2026 at 10:08 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was when the range of motion care plan was entered there should have been a place for staff to document if passive range of motion was completed with Resident 3. Resident 46 Review of the EHR showed Resident 46 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (damage impacts the brain's right hemisphere), diabetes (high blood sugar) and heart failure. Resident 46 was able to communicate needs. Observation on 07/13/2026 at 11:56 AM showed Resident 46 with a contracture (permanent tightening or shortening of muscles, tendons, skin or other tissues that causes joints to become stiff and restrict normal movement) to the left arm and hand. Resident 48 stated they did their own exercises and were pulling on the left fingers with the right hand. Observation on 07/14/2026 at 11:11 AM showed Resident 46 sat in their wheelchair and leaned towards the right side. Resident 46 stated staff were not doing anything about the contractures to the left hand and arm. During an interview on 07/16/2026 at 9:13 AM, Staff B, DNS, stated the contractures were managed by therapy and they had spoken with therapy and there were no recommendations for Resident 46 to do any more exercise or range of motion. Staff B stated the expectation was for the facility to continue with range of motion exercises to make sure the contractures were not getting worse. Reference WAC 388-97 -1060(3)(d)(j)(ix)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 1 of 16 sampled residents (Resident 46) reviewed for comprehensive care plan. This failure placed the residents at risk for not receiving required services, worsening of contractures (permanent tightening or shortening of muscles, tendons, skin or other tissues that cause joints to become stiff and restrict normal movement) and diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 46 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (damage impacts the right brain hemisphere), diabetes (high blood sugar), and heart failure. Resident 46 was able to communicate needs. Observation and interview on 07/13/2026 at 11:56 AM showed Resident 46 with a contracture to left arm and hand. Resident 46 stated they did their own exercises and were pulling on the left fingers with the right hand. Review of the annual minimum data set (MDS, a required assessment tool) dated 12/23/2025 showed Resident 46's activities of daily living care area assessment showed At risk for not having needs met, increased contractures and would proceed with care planning. Review of the care plan dated 01/09/2023 and revised 06/16/2026 showed no contracture management focus area, goal, or intervention. During an interview on 07/15/2026 at 9:24 AM, Staff B, Director of Nursing Services, stated the expectations were for contractures to be in the care plan. Reference WAC 388-97 -1020(1)(2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment was accurate for 3 of 16 sampled residents (Residents 8, 33, and 41) reviewed for accuracy of the comprehensive assessment. Failure to accurately code Resident 8's ability to communicate, Resident 33's use of corrective lenses, and Resident 41's Hospice services placed residents at risk of inaccurate plan of care, unmet needs, and a diminished quality of life. Findings included.Resident 8 Review of the electronic health record (EHR) showed Resident 8 was readmitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), dysphagia (difficulty swallowing) and NPO status (nothing by mouth) with artificial tube feeding. Resident 8 was not able to communicate needs. Observation on 07/13/2026 at 9:38 AM showed Resident 8 was in a low bed and had been administered tube feeding with eyes closed. Review of the quarterly minimum data set (MDS, a required assessment tool) dated 06/30/2026 showed Resident 8 had clear speech, was able to be understood and was able to understand and was able to hear and see well. During an interview on 07/15/2026 at 9:28 AM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated Resident 8 was not able to communicate and did not speak. During an interview on 07/16/2026 at 9:21 AM, Staff B, Director of Nursing Services (DNS), stated the quarterly MDS dated [DATE] was not accurate. Resident 33 Review of the EHR showed Resident 33 admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain malfunction), diabetes (too much sugar in the blood), and dementia (decline in mental ability severe enough to interfere with daily life). Resident 33 was able to make needs known. During an interview on 07/13/2026 at 11:22 AM, Resident 33 stated they had glasses, but they went missing about a month ago and that staff were aware. Review of the admission MDS dated [DATE] showed Resident 33's vision was adequate with corrective lenses. Review of the current care plan on 07/14/2026 showed no documentation that Resident 33 had impaired vision or used corrective lenses. Review of Resident 33's inventory list dated 06/03/2026 showed the section for glasses on the form was left blank. Review of Resident 33's hospital transfer order form dated 06/03/2026 showed glasses was marked No on the form. Review of the facility's grievance logs for June 2026 through 07/10/2026 showed no grievance logged for missing glasses. During an interview on 07/14/2026 at 11:00 AM, Staff F, Certified Nursing Assistant (CNA), stated they had never seen Resident 33 wear glasses and the resident had never reported they had missing glasses. Staff F stated Resident 33 was confused at times. During an interview on 07/14/2026 at 1:12 PM, Staff G, RN, stated Resident 33 had never reported that they had missing glasses, they had not seen Resident 33 ever wear glasses, and their care plan did not show Resident 33 used glasses. During an interview on 07/14/2026 at 1:19 PM, Staff D, Registered Nurse/Minimum Data Set Clinical Reimbursement Specialist (RN/MDSCRS), stated to assess if a resident had adequate vision with corrective lenses would require asking the resident if they had corrective lenses and then having the resident put on glasses and document whether, they could read/see newspaper/newsprint with glasses on. Staff D stated they needed to look into Resident 33's EHR and follow up with Resident 33, family, and staff to see if the admission [DATE] MDS was coded accurately. During a follow up interview on 07/15/2026 at 9:21 AM, Staff D, RN/MDSCRS, stated that Resident 33 did not have glasses and the MDS was coded inaccurately and needed to be modified. During an interview on 07/15/2026 at 11:05 AM, Staff B, DNS, stated they were unaware Resident 33's admission MDS was coded inaccurately for vision and expected staff to follow the Resident Assessment Instrument (RAI) manual (guidelines to properly assess, code, and care-plan for residents) when completing MDS. Resident 41 Review of the EHR showed Resident 41 readmitted to the facility on [DATE] with diagnoses to include malignant neoplasm of brain (an aggressive, fast-growing tumor/mass that invades healthy tissue), metabolic encephalopathy, and diabetes. Resident 41 was able to make needs known. Review of the provider order dated 05/21/2026 showed Resident 41 was admitted and certified for Hospice care. Review of the EHR showed Resident 41's Hospice plan of care/coordination of care was received by the facility with a start date of 05/21/2026. Review of Resident 41's EHR showed documentation of Hospice staff visits were completed from 05/21/2026 through 07/14/2026. During an interview on 07/16/2026 at 10:42 AM, Staff D, RN/MDSCRS, stated Resident 41's admission MDS dated [DATE] was coded No for Hospice care and should have been coded Yes. During an interview on 07/16/2026 at 11:53 AM, Staff B, DNS, stated they were not aware that Resident 41's admission MDS dated [DATE] was coded No for Hospice care and this did not meet their expectations. Staff B stated Resident 41's MDS needed to be modified/corrected to reflect Hospice care. Reference WAC 388-97 -1000(1)(a)(b)(4)(a)

Based on observation, interview, and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed within 14 days after the facility determined, or should have determined, that there was a significant change in a resident's physical or mental condition for 1 of 5 sampled residents (Resident 8) reviewed for an unnecessary medications. Failure to identify Resident 8's decline in activities of daily living (ADL) function and to complete a SCSA, placed the resident at risk for unidentified and/or unmet care needs. Findings included .Review of the Resident Assessment Instrument Manual (RAI, a manual that directs staff on how to accurately assess the status of residents), showed a SCSA comprehensive assessment must be completed when the Interdisciplinary Team (IDT) has determined that a resident met the significant change guidelines for either major improvement or decline. According to the guidelines, a SCSA was appropriate if there was a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (brain dysfunction caused by chemical imbalances or systemic illnesses in the body), depression and compression fractures of T11-T12 (fracture in lower back). Resident 8 readmitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of ischemic stroke that occurs when a blocked blood vessel deprives brain tissue of oxygen and vital nutrients, causing cell death), dysphagia (difficulty swallowing) and NPO status (nothing by mouth) with artificial tube feeding. Resident 8 was not able to communicate needs. Observation on 07/13/2026 at 9:38 AM showed Resident 8 was in a low bed and had been administered tube feeding with eyes closed. Review of the admission minimum data set (MDS, a required assessment tool) dated 01/09/2026 showed Resident 8 had clear and adequate speech and was able to feed self with set up and was able to do oral hygiene with supervision. Review of the quarterly MDS dated [DATE] showed Resident 8 had clear speech and was able to communicate needs and was dependent on staff for hygiene, eating, dressing and moving. During an interview on 07/16/2026 at 9:21 AM, Staff B, Director of Nursing Services, stated Resident 8 was doing well initially and was working on going home, but they sustained a stroke recently, and had a significant change in condition. Resident 8 now depended on staff for eating, care, and they were not verbal. During an interview on 07/16/2026 at 10:44 AM, Staff D, Registered Nurse/Minimum Data Set Clinical Reimbursement Specialist (RN/MDSCRS) stated Resident 8 should have had a SCSA done when readmitted in May of 2026. Reference WAC 388-97-1000(3)(b) -1000(3)(b)

Based on interview and record review, the facility failed to ensure residents who discharged from the facility received written notification of discharge and/or bed hold notice and notify Ombudsman and/or Adult Protective Services for 3 of 4 sampled residents (Residents 9, 10, and 57) reviewed for discharge/hospitalization. This failure placed residents at risk of not knowing their rights during discharge and a diminished quality of life. Findings included.Resident 9 Review of the electronic health record (EHR) showed Resident 9 was admitted to the facility on [DATE] with diagnoses to include heart failure, dementia (loss of memory, language and thinking abilities), and depression with anxiety. Review of the EHR showed Resident 9 was sent to the hospital on [DATE]. Review of the EHR showed Resident 9 was not given a bed hold or transfer form prior to discharge or after. During an interview on 07/15/2026 at 9:20 AM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated the process was for the nurses to provide the bed hold, when possible, at the time of discharge. Resident 10 Review of the EHR showed Resident 10 was admitted to the facility on [DATE] with diagnoses to include head injury, status post pedestrian versus vehicle accident, and depression. Resident 10 was able to communicate needs. Review of the EHR showed Resident 10 was discharged to the hospital on [DATE], 04/14/2026 and 07/07/2026. Further review of the EHR showed Resident 10 had no bed hold provided with all discharges, and no transfer form given on 07/07/2026. During an interview on 07/16/2026 at 9:01 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was for bed hold and transfer form to be provided at the time of discharge and be scanned into medical records. Resident 57 Review of the EHR showed that Resident 57 was admitted to the facility on [DATE] with diagnoses to include traumatic subdural hemorrhage with loss of consciousness (pooled blood compressing the brain causing unresponsiveness), diabetes (too much sugar in the blood), and depression. Resident 57 was able to make needs known. Review of the discharge minimum data set assessment (MDS) dated [DATE] showed Resident 57 had an unplanned discharge to home/community on 05/07/2026 with return not anticipated. Review of Resident 57's focused discharge care plan, initiated on 03/17/2026, showed Resident 57 wished to be discharged home with their power of attorney (POA, a legal document that authorizes a trusted person to make decisions or act on behalf of someone else in legal, financial, or medical matters). Review of Resident 57's progress note dated 05/07/2026 showed Resident 57's POA was in the facility and stated they were there to take Resident 57 home. It showed the provider was in the facility and provided education to Resident 57 and the POA since there was not a safe discharge plan in place and would be a discharge against medical advice (AMA). It showed available medications were provided, the POA educated on the care needs and verbalized understanding and signed the paperwork. It showed, Resident discharged from the facility AMA. Review of the AMA Release Form, dated 05/07/2026 showed it was signed by the POA on 05/07/2026. Review of the EHR showed no documentation that the Ombudsman or Resident 57 and their POA had received in writing the notification of discharge from the facility or that adult protective services (APS, a statewide government agency dedicated to service vulnerable adults and offer protective services as needed) had been notified of Resident 57 leaving AMA. During an interview on 07/16/2026 at 9:33 AM, Staff E, Social Services Director (SSD), stated they were unable locate documentation that Resident 57 had a Nursing Home Transfer or Discharge Notice form completed and sent to the Ombudsman, or a copy provided to the resident or their POA and there should have been. Staff E stated they were unable find documentation that APS had been notified of Resident 57 leaving AMA on 05/07/2026 and they should have been notified. Staff E stated this did not meet their expectations. During an interview on 07/16/2026 at 11:58 AM, Staff A, Administrator, stated they were not aware that Resident 57 had left AMA on 05/07/2026, the Ombudsman nor Resident 57 or their POA had not received written notification of the discharge, or that APS had not been notified. Staff A stated this did not meet their expectations. Reference WAC 388-97-0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080, -0140(1)(a)-(c)(i)-(iii)

Based on observation and interview, the facility failed to ensure personal privacy was protected for 3 of 3 sampled residents (Residents 28, 29, and 33) reviewed for resident rights. This failure placed the residents at risk for embarrassment, a violation of their privacy, and a diminished quality of life. Findings included . The facility's 400 hall shower room exterior window faces the smoking area and portable offices in the middle courtyard. Observation on 07/15/2026 at 9:28 AM showed the shower room window open. Resident 28 was being assisted with showering. Observation on 07/15/2026 at 11:34 AM showed the shower room window open. Resident 29 was being assisted with showering. Observation on 07/15/2026 at 12:55 PM showed the shower room window open. Resident 33 was being assisted with showering. During an interview on 07/15/2026 at 1:24 PM, Staff K, Certified Nursing Assistant (CNA), who provided resident showers for the day, stated they were unaware residents were visible from the exterior window. During an interview on 07/16/2026 at 10:07 AM, Staff B, Director of Nursing Services, stated the expectation was to ensure resident privacy while bathing or showering. Staff B stated the window should not have been open. Reference WAC 388-97-0360, 0500(1)

Based on observation, interview, and record review, the facility failed to implement a hot food and beverage policy to protect 2 of 3 sample residents (Resident 1 & 2) reviewed for avoidable burns. Resident 1 experienced harm when they were served hot coffee without securing the lid/top of the coffee cup in a closed or locked position which spilled in their lap resulting in a second-degree burn (involves the first two layers of skin, may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin). Resident 2 experienced harm when they were served hot soup without being temperature checked which spilled in their lap resulting in second-degree burns to their thighs and groin. This failed practice placed residents at risk for accidents and injuries. Findings included . Review of the facility Hot Food and Beverages/Thermal Burns policy, dated 02/27/2001, showed the facility would provide hot food and beverages to residents at a temperature that was palatable but minimized the risk of thermal burns/scalds. Residents would be discouraged from carrying hot drinks in their laps in wheelchairs, hot beverages/liquids would be served at 150 degrees Fahrenheit (dF) or less, hot beverage dispensers from the kitchen would have temperatures obtained by kitchen staff, and if beverages/liquids were warmed in the microwave, facility staff will verify the temperature prior to giving the liquid to the resident and record the temperature on the Resident beverage log. <Resident 1> According to the 09/11/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 was assessed with moderate cognitive impairment, bilateral lower extremity limited range of motion, was independent in a motorized wheelchair, had a mechanically altered, and therapeutic diet. Review of the Hot Beverage Safety Evaluation, dated 09/11/2024, showed Resident 1 had a diagnosis of neuropathy or other neurological impairment, and may require set up assistance while consuming hot beverages. Review of the Self Care Performance Care Plan, revised 09/25/2024, showed the resident preferred to feed self independently after set up assist. Review of a 12/01/2024 Nursing Note showed Resident 1 was at the nurses' station after asking for coffee to be poured into their coffee cup. Resident 1 started traveling in the wheelchair and the coffee cup turned over onto their leg (right lower inner aspect) and the resident complained of a burning sensation (redness noted). The lid/top of the coffee cup was not closed or locked before the resident started to travel in their wheelchair. Record review showed on 12/02/2024, Resident 1 was assessed by the medical provider to have a second degree burn on their right lower medial leg, an intact fluid filled blister with surrounding redness and warmth. Review of a 12/02/2024 Nursing Note showed education was provided to the resident to hand the travel coffee mug to the staff and have them refill the coffee and put the lid back on to prevent the burns. Another Hot Beverage Safety Evaluation was dated as done on 12/02/2024 which showed Resident 1 no longer had neuropathy or other neurological impairment, but did demonstrate poor safety awareness, impaired short term memory, and/or impulsiveness. Resident 1 had a history of injury related to independent consumption of hot beverages and demonstrated non-compliance with awaiting needed assistance with consumption of hot beverages and/or attempts to independently obtain hot beverages. Review of Resident 1's care plan showed on 12/02/2024 it was revised to evaluate the need for adaptive equipment related to hot beverage consumption, Resident has a travel mug, and Resident uses lids for all hot beverages to decrease risk of spills. Review of the facility investigation showed on 12/06/2024 the facility identified the root cause for this event was that resident self directs his own care and insisted on using his personal coffee mug for his coffee, resident placed the cup improperly in his chair, at which point it fell over, and the cup did not close all the way. The facility identified a preventive measure was to educate the resident on the risks of continuing to use the coffee mug and to prevent further burns or another incident like this in the future, to replace his coffee mug with one that closed. During an interview on 12/30/2024 at 10:51 AM, Staff B, Director of Nursing, stated the kitchen staff said they were monitoring beverage temperatures before the beverages left the kitchen. Staff B was unable to state when, on 12/01/2024 the coffee was brought out from the kitchen, or what the temperature was prior to being sent out to the floor. Review of the Kitchen Weekly Hot Beverage Temp Log showed dietary staff were documenting the temperatures of coffee and hot water once for breakfast, once for lunch, and once for dinner. Review of the log dated 11/04/2024 through 12/01/2024 showed no temperatures were obtained for the dinner time hot beverages. On 12/01/2024 staff documented at breakfast the coffee was 157 dF and the hot water was 189 dF. After the incident on 12/02/2024 and 12/03/2024 it was 160 dF and 190 dF, and on 12/04/2024 169 dF and 193 dF. Review of education documents showed on 12/05/2024 staff were educated on proper drink temps for residents and the need to properly temp all hot beverages to 165 dF before leaving the kitchen. Temps were to be taken before each meal service and documented. Lids and stir straws should be readily available and utilized. During an interview on 12/30/2024 at 11:42 AM, Staff E, Dietary Aide, stated they checked the coffee and hot water temperatures first thing in the morning, around 6:00 A.M. Staff E stated the hot beverages cannot leave the kitchen if they were over 165 dF. <Resident 2> According to the 09/20/2024 Annual MDS, Resident 2 was assessed as alert and oriented, with bilateral lower extremity impaired range of motion, and required set up assistance to eat. Review of a 09/20/2024 Hot Beverage Safety Evaluation Resident 2 had a diagnosis of neuropathy or other neurological impairment so they may require set up assistance while consuming hot beverages. Review of Resident 2's Care Plan showed a 08/20/2024 revision that resident was able to hold cup, feed self, and eat finger foods independently. Review of 12/08/2024 Nurses Note showed the resident spilled hot soup on their groin area while in bed. Resident 2 was assessed with burns to upper inner left and right thighs and groin where blisters had started to form. During an interview on 12/30/2024 at 12:00 PM, Resident 2 stated they had a cup of noodle soup and spilled it in their lap, the soup was hot and burnt their leg. Resident 2 stated at the time the burn hurt at a level 10 (on a scale of 1-10). Resident 2 stated the burn still hurt, at a 7, not all the time, but when the dressing was changed or when the area was bumped into. Review of the facility 12/12/2024 incident investigation showed a Certified Nursing Assistant (CNA) heated up a cup of soup, for 2 minutes in the microwave. CNA brought it to resident and told her, Be careful (Resident 2), it's hot! And set it on their table. Resident picked up the cup and realized the cup was warm and went to set it back down. When this occurred, Resident 2 splashed a little soup from the cup on themselves, which they reacted to and due to neuropathy, ended up spilling the whole cup in their lap. Resident was dependent on staff for care, meals, and mobility. Resident 2 was assessed with two blisters in their groin\thigh area measuring 3'' x 3 and the blister on their right thigh had some fluid build up in it along the edge. The facility identified the root cause for this event as related to resident's neuropathy and impaired mobility. During an interview on 12/30/2024 at 11:09 AM, Staff B stated the CNA was from a staffing agency and did not temp the soup before giving it to the resident because they were unaware they needed to. Education to prevent burn incidents was dated 12/09/2024 and included review of the Hot Food and Beverages Policy. Observation on 12/30/2024 at 11:15 AM of the area where the microwave was located showed a thermometer and a binder with instructions to complete prior to giving resident's heated food/beverage items. Inside the binder was a Food Temperature Log with instructions, Food and beverages must NOT be served over 150 dF! If measured above it must be cooled PRIOR giving it to the resident. During an interview at 12/30/2024 at 11:18 AM Staff D, Staff Development, stated staff were instructed if an item was over 150 dF, they were to cool and recheck. Review of the food temperature log showed the first entry was dated 12/09/2024. During an interview on 12/30/2024 at 11:18 AM. Staff B stated the food temperature log was not implemented prior to Resident 2's incident. Further review of the log showed on 12/12/2024 staff documented mashed potatoes were 160.5 dF, on 12/19/2024 a cup of noodles was 175 dF. Neither entry had a recheck temperature logged. During an interview at 12/30/2024 at 11:18 AM, Staff B stated, They're not following policy. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to provide the necessary care and services for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents at risk for lack of or delay in initiating provider ordered treatments and/or recommendations related to wound management, unidentified worsening of wounds, wounds not identified or timely addressed in the residents' plan of care, and failure to consistently obtain measurements to accurately evaluate/assess wound healing progress. This resulted in harm to Resident 1 who developed eschar (dead tissue that is usually black in color) to the left great toe and pain, swelling, redness to the second and third toes, medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included . Review of the facility's policy and procedure titled, Wound Management Guidelines, dated 08/25/2020, showed, Upon Admission the admitting nurse and/ or designee will complete a skin evaluation and document the patients skin condition in the residents' clinical record utilizing the Nurse admit user defined assessment or Re-entry user defined assessment. It further showed, If a Resident is identified to have a new skin alteration the Licensed Nurse will: . Documentation of the new skin alteration will be completed in the resident's clinical records. Documentation will include: 1) Location 2) Size 3) Wound description 4) Drainage type 5) Surrounding tissue. Additionally, the document showed that the physician should be notified and orders obtained as indicated. Orders will include: 1) Area to be treated. Actual pressure injuries, venous stasis ulcers, arterial ulcers, diabetic/neuropathic ulcers and open surgical wounds will have weekly documentation that includes measurements and how the wound is progressing (improvement, worse, unchanged). RESIDENT 1 Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 01/30/2021, showed that Resident 1 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further showed Resident 1 had a surgical wound and was able to make needs known. Review of Resident 1's Admission Nursing Database dated 01/23/2021 showed, Skin intact with no open wounds noted / observed. Dry, scaly heel feet and intact. Review of the progress note dated 02/09/2021 at 12:41 PM showed that Resident 1 came back from an appointment and per staff and resident report, a deep tissue injury was noted on the tip of the left big toe. An additional progress note dated 02/09/2021 at 1:13 PM showed Resident 1 had, Dark Purple non-blanching area [darkened area does not fade when pressed on] noted on the tip of the Left big toe. It further showed that Resident 1 was not aware how it occurred and that the Advanced Registered Nurse Practitioner (ARNP), was notified and had advised to continue monitoring. Review of the care plan dated 02/12/2021 (three days after the wound had been identified) showed that Resident 1 had a diabetic foot ulcer; however, this care plan did not identify the location of the wound. In addition, the interventions listed were not created until 03/03/2021 (22 days after the diabetic foot ulcer to the left great toe was initially identified on 02/09/2021). On 04/07/2021 at 12:20 PM when asked why Resident 1's wound location identified on 02/09/2021, to the left great toe was not care planned, Staff B, Director of Nursing Services (DNS), was unable to provide an explanation; however, stated that it should have been. When asked if Resident 1s interventions related to the diabetic foot ulcer, which were created on 03/03/2021, met expectations for being done timely, Staff B, DNS, stated, No. Review of Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 had another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's electronic health record (EHR) on 04/07/2021 at 11:00 AM, showed no documentation that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's medical imaging fax sheet that showed, DATE TO BE DONE 02/12/21, had the Venous Doppler code circled on the form to request the exam be conducted to Bilat Lower. This sheet further showed to fax all orders to a fax number and that STAT orders were to be circled on the form and to Call if Exam is STAT! However, the order for the Venous Doppler was prescribed by Staff C, NP, on 02/11/2021 (one day earlier). The facility was unable to provide the medical imaging fax sheet for the ABI Doppler prescribed for Resident 1 on 02/12/2021. On 02/16/2021, Collateral Contact D (CCD), Contracted Wound Specialist (CWS), evaluated Resident 1's left great toe and determined it was a diabetic foot wound. The evaluation showed that Resident 1's lower leg and/or foot had reduced sensation (decreased sense of touch which could decrease the feeling of pain). On 04/15/2021 at 6:19 PM, when asked about the orders she had prescribed for Resident 1's Venous and ABI Doppler exams, Staff C, Nurse Practitioner (NP), stated that as soon as she saw a dark area on Resident 1's left great toe she was trying to evaluate if it was a circulation issue or a diabetic issue and placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Staff C, NP, stated that she had prescribed for Resident 1 to be seen by the contracted wound specialist. Staff C, NP, stated that when she checked back with the facility, Resident 1's Doppler had not been done so she ordered the ABI Doppler exam, STAT, the next day (02/12/2021). During further interview, Staff C, NP, stated that she went to the facility on [DATE] and realized that neither one of the Doppler orders had been done and asked why not, what was going on? Staff C, NP, stated that the Director of Nursing (DNS) at that time informed her that the Venous Doppler had not been conducted; however, the contracted wound specialist had assessed Resident 1 and determined it was a diabetic foot ulcer. When asked about orders for the Venous and the STAT ABI Doppler exams that were not done, and that CCD/CWS, did not assess Resident 1's wound until 02/16/2021 (five days after the initial order) met her expectations, Staff C, NP, stated, No, there was no justification for that because a STAT order should be carried out STAT. On 04/20/2021 at 8:44 AM, when asked about Resident 1's Venous and ABI Doppler exam orders, Staff L, Registered Nurse/Resident Care Manager (RN/RCM), stated that she had placed both orders and she could not speak for what happened after that. When asked why the STAT ABI Doppler exam was not identified as not being obtained on the day it was ordered, Staff L, RN/RCM, stated that she did not know; however, she had placed both orders in Resident 1's February 2021 Treatment Administration Record (TAR). Review of Resident 1's TAR dated February 2021 showed that both Venous and STAT ABI Doppler exam orders were noted in the TAR; however, there was no documentation to show the exams had been done. This TAR was left blank/empty with no initials on the dates of 02/11/2021 and 02/12/2021. On 03/02/2021, CCD/CWS, evaluated Resident 1's diabetic foot wound on the left great toe and documented that the resident continues to have a scab and needed to be placed on the podiatry list for nail care. On 03/09/2021, CCD/CWS, evaluated Resident 1's diabetic foot wound on the left great toe and documented that the resident needed to be placed on the podiatry list for nail care. On 03/18/2021, CCD/CWS, evaluated Resident 1's wound and documented that the left great toe was an Eschar covered diabetic foot wound. This documentation further showed that Resident 1 complained of pain to the second and third toes with some swelling and redness observed. In addition, documentation showed, Resident 1 was going to be discharged next week and recommendations were to refer to podiatry, and to obtain an X-ray of the left foot/toes. On 04/15/2021 at 6:19 PM, after being informed that the contracted wound specialist had recommended on 03/02/2021, 03/09/2021 and again on 03/18/2021 for Resident 1 to be put on the Podiatry list to be seen by a podiatrist; however, that had not occurred prior to discharge on 03/25/2021, Staff C, NP, stated, So they had time there, that is concerning. when asked if the facility had informed her of Resident 1's CCD/CWS, progress note dated 03/18/2021, recommendations for a referral to podiatry and an X-ray to the left foot/toes, Staff C, NP, stated that she and Resident 1's physician had not been notified of those recommendations. When asked if she would have agreed to those recommendations if she had been notified, Staff C, NP, stated, Yes, I would have gotten the X-ray before he was discharged and made sure that Resident 1 had an appointment scheduled before he left the facility with somebody either in vascular or podiatry. On 04/16/2021 at 4:52 PM, when asked why on 03/02/2021 she recommended that Resident 1 be put on the podiatry list for nail care, CCD/CWS, stated, Because he is diabetic and his nails were pretty long and thick and I was concerned that they were going to roll underneath and cut his other toes when asked if she wanted Resident 1's recommendations on 03/18/2021 for a referral to podiatry and an x-ray to left foot/toes to be obtained prior to discharge, CCD/CWS, stated that she hoped that they would get done before Resident 1 went home because the wound had changed. It now wasn't a scab it was eschar which indicated that there may be something else going on. In addition, CCD/CWS, stated that Resident 1 was complaining of second and third toe pain and when she looked at them, she was concerned that he may have had a fracture. That was the reason for the x-ray and a referral to podiatry and if podiatry felt that Resident 1 needed a vascular follow up then they could refer him to vascular after he was evaluated by them. When asked if she had ever told the facility that the x-ray to Resident 1's foot/toes were not necessary, CCD/CWS, stated, I did not. On 04/19/2021 at 10:41 AM, when asked if Resident 1 could have been seen by podiatry prior to discharge on 03/25/2021, if the facility had started the process with the veterans administration (VA) on 03/02/2021, Collateral Contact K (CCK), stated, I do not see why not, that is a long time to wait for somebody to be seen. On 04/19/2021 at 11:55 AM, when asked if preauthorization needed to be obtained for a veteran with a VA contract in order to be seen by the in house podiatrist, Staff G, Social Service Director (SSD), stated No, not in any of my years in social services have I had to do that. When asked why Resident 1 had not been seen by the podiatrist when he was placed on the referral list on 03/02/2021, Staff G, SSD, stated that podiatry will not come into the facility to see just one person. She further stated that the Resident Care Manager (RCM) could have put Resident 1 in for an outpatient referral at that time; however, she only dealt with in house referrals. When asked if an outpatient referral needed to be scheduled who would do that, Staff G, SSD, stated that the RCM deals with outpatient referrals and would have needed to schedule that. On 04/19/2021 at 12:55 AM, when asked if he had ever reported to the primary provider the multiple recommendations made by CCD/CWS for Resident 1 to be seen by podiatry, Staff E, Licensed Practical Nurse/ Resident Care Manager (LPN/RCM), stated, No. When asked if Resident 1's podiatry needs were handled timely, Staff E, LPN/RCM, stated, No, it wasn't followed through well, because it didn't happen. Review of the Discharge Summary Plan dated 03/22/2021 showed that Resident 1 needed to follow up with podiatry and vascular regarding a diabetic ulcer to the left great toe. It further showed that Resident 1 needed an x-ray of the left femur (long bone of the upper leg) a couple of days before seeing an orthopedic surgeon. (There was no documentation that showed an x-ray was needed for the toes of the left foot as recommended by CCD/CWS on 03/18/2021). On 03/31/2021 at 3:59 PM, Collateral Contact N (CCN), stated that Resident 1 was discharged from the facility on 03/25/2021 in the late afternoon. CCN, further stated that Resident 1 was home less than 20 hours when he was seen by home health agency that assessed him on the 26th because he could not walk at all and needed to go to the emergency room right away because of his wound on his toe. In addition, CCN, stated that he was admitted to the hospital with [CONDITION(S)] [a life-threatening complication of an infection], had [CONDITION(S)] [bone infection] in that one foot, and the toe had to be amputated [surgically cut off], had [CONDITION(S)]-resistant staphylococcus aureus (MRSA, an infection that is difficult to treat because of resistance to some antibiotics) in his blood throughout his body, had to be put on a ventilator [a machine that provides breathable air into and out of the lungs to a person who is physically unable to breathe sufficiently], and was very sick. RESIDENT 2 Review of Resident 2's EHR on 04/21/2021, the MDS tracker showed, that the resident entered the facility on 03/22/2021. In addition, the census section of the EHR showed that the resident was a readmission to the facility. Review of Resident 2's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's current care plan on 04/09/2021 showed that there was no care plan developed for skin or wound management. On 04/19/2021 at 3:37 PM, when asked to provide wound measurement for Resident 2's wounds for the lower legs and feet and wounds to the left and right toes since admit, Staff B, DNS, stated that she would provide that information. However, Resident 2's wound measurements from the day of admit (03/22/2021) and for the week of April 4th, 2021 through April 10th, 2021, were not provided. The following wounds that were identified in physicians orders and/or the facility's wound evaluation conducted on 03/25/2021 showed the following: -Right great (big) toe wound documented as an abrasion and was present on admission. -Second toe to the left foot documented as a diabetic wound and was present on admission. -Left ankle unstageable ulcer/wound was not evaluated. -Four abrasions to the left foot showed that they were present on admission. This evaluation showed that the ARNP, described the wounds as COVID foot (however, usually termed COVID toes: red-purple, tender or itchy bumps that develop mostly on the toes, but also on the heels and fingers). This evaluation showed that these wounds had measurements documented except for there were none documented for the four new abrasions to the left foot and no assessment or wound measurements for the left ankle unstageable ulcer. In addition, there were no wound measurements provided for these wounds to show they were assessed by the contracted wound specialist on 03/25/2021. Review of Resident 2's wound evaluations dated 04/01/2021, showed evaluations and measurements for the following wounds: -Right great toe wound now showed it was documented as a diabetic wound. -Left foot toes showed that it was documented as diabetic wound. This evaluation did not show an assessment or measurements completed for the left ankle unstageable ulcer and only showed measurements for the right great toe. Review of Resident 2's assessment dated [DATE] by the contracted wound specialist showed measurements and an assessment for the right great toe as a diabetic wound; however, there were no wound measurements for the left toes diabetic wounds; but, showed, scattered scabbing. This evaluation did not show an assessment or measurements completed for the left ankle unstageable ulcer. In addition, there was no documentation showing that wounds were identified as COVID foot. Review of Resident 2's EHR on 04/21/2021, showed no wound assessment or measurements documented for Resident 2 for the week of April 4th, 2021 through April 10th, 2021. Also, no assessments were provided by Staff B, DNS, for that time frame; however, Resident 2 was present in the facility during that time. Review of Resident 2's wound evaluations dated 04/15/2021 showed evaluations and measurements for the right great toe and the left foot second toe; however, there were no measurements for the four abrasion/scabbed areas over the left foot. This evaluation did not show an assessment or measurements completed for the left ankle unstageable ulcer. Review of Resident 2's assessment dated [DATE] by the contracted wound specialist showed measurements and an assessment completed as with the previous weekly assessment; however, the assessment included a new diabetic foot wound that showed, no measurable depth - Scattered scabs over foot. There were no documented measurements for these added wounds and there was no documentation showing that wounds were identified as COVID foot. Review of Resident 2's treatment administration record (TAR) dated March 2021 showed there was a treatment order dated 03/22/2021 for the Left foot open wound, to be completed every three days; however, did not indicate the location of the wound. This TAR did not show any treatment order or show to monitor the four abrasions/scabbed areas to the left foot or to monitor and treat any wound to the left foot toes; however, did show a treatment order dated 03/22/2021 to monitor for changes to the left ankle unstageable ulcer every day. Review of Resident 2's TAR dated April 2021 showed that the treatment order to the left foot open wound to be completed every three days dated 03/22/2021 was discontinued on 04/16/2021. Then the order for the left foot open wound treatment was changed to be completed every night shift and then this treatment was discontinued on 04/19/2021 and showed no further orders or monitoring for the left foot open wound after this date. This TAR also showed a treatment order for four left foot scabbed wounds dated 04/19/2021; however, this order did not show the locations of the wounds. This TAR further showed that there was a treatment dated 04/13/2021 for the left toes classified as a diabetic wound; however, Resident 2's wound assessment documented on 03/25/2021 showed that the wound to the left second toe was present on admission 03/22/2021 (this showed that monitoring and/or treatment was not initiated until 22 days later). This TAR continued to show to monitor the left ankle unstageable ulcer for changes (however, this wound had not been measured since admit). On 04/15/2021 at 2:31 PM when asked how soon a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, when asked how often a diabetic wound or other types of wounds should be measured and assessed, Staff B, DNS, stated, Weekly. On 04/16/2021 at 11:17 AM, Staff B, DNS, provided Resident 2's wound measurement documentation via email. Staff B, DNS, had written in the email that Resident 2 had been in and out of the hospital many times. If a weekly measurement was not completed then that was a time the resident was most likely not in the facility. On 04/22/2021 at 12:30 PM, when asked if a resident was admitted with four abrasions/scabbed areas on a foot, what was the expectation for how it should be documented when assessed, Staff B, DNS, stated that each wound would be measured separately and the location identified. When asked if an evaluation skin assessment showed that there was a treatment or monitoring for a wound, what was the expectation for documentation and physician orders, Staff B, DNS, stated that there should be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked how soon a care plan should be developed if a resident admits with wounds, Staff B, DNS, stated within 48 hours. When asked if Resident 2's wound measurements that were missing even though she was in the facility met her expectations, Staff B, DNS, stated No. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure residents had enough supervision and assistive devices to prevent accidents for two of three Sampled Residents (#s 1 & 2) reviewed for falls. This failure placed residents at risk for further falls and caused actual harm to Resident #1 when he fell and sustained a suspected fractures. Findings included . RESIDENT #1 Review of Resident #1's care plan dated 08/24/17, identified Resident #1 had a history of [REDACTED]. Further review of the care plan showed the Activities of Daily Living section, which showed Resident #1 required assistance of two staff members for transferring. Review of the facility's incident investigations showed Resident #1 had fallen while being assisted by staff three times; 08/31/17, 09/15/17 and 09/19/17. Additionally, Resident #1 had two other falls (08/25/17 & 08/27/17) in which the facility failed to assess for fall risk after the fall occurred in order to identify and implement interventions to prevent future falls. FALL 08/31/17 - SUPERVISION Review of the facility's fall investigation dated 08/31/17 showed Staff E, Nursing Assistant - Certified, NAC, was assisting Resident #1 to transfer to his wheelchair when he fell . The investigation indicated there were no other staff present at the time of the fall. During an interview on 10/05/17 at 2:46 PM, Staff C, Licensed Practicle Nurse/Resident Care Manager, LPN/RCM, stated there was not any other staff present at the time Staff E, NAC, assisted Resident #1 to transfer to his wheelchair and he fell . FALL 09/15/17 - SUPERVISION Review of the facility investigation dated 09/15/17 showed Staff F, NAC, was assisting Resident #1 to a standing position in order to change his clothes, when he fell . During an interview on 10/05/17 at 2:46 PM, Staff C, LPN/RCM, stated Resident #1's care plan directed nursing staff two staff members were necessary to transfer Resident #1. Staff C, LPN/RCM, stated Staff F, NAC, did not have assistance from a second staff member when she assisted Resident #1 in transferring on 09/15/17. FALL 09/19/17 - SUPERVISION Review of the facility investigation dated 09/19/17 showed Staff D, NAC, was assisting Resident #1 in the shower room when he fell . The investigation included an x-ray report dated 09/20/17, which indicated Resident #1 had two areas on his clavicle (collar bone) with suspected fractures. During an interview on 10/03/17 at 2:14 PM, Staff D, NAC, stated she was assisting Resident #1 to transfer from his wheelchair to the shower chair at the time of the fall. Staff D, NAC, stated there was not any other staff members present during the transfer. During an interview on 10/05/17 at 2:46 PM, Staff C, LPN/RCM, stated Resident #1's care plan directed nursing staff to use two people when transferring Resident #1. Staff C, LPN/RCM, stated when Resident #1 fell in the shower room, Staff D, NAC, did not have assistance from a second staff member. Failure to have two people staff present to assist Resident #1 during transfers, resulted in him falling three times, one resulting in two suspected fractures. FALL 08/25/17 - ASSESSMENT During an interview on 10/05/17 at 2:20 PM, Staff C, LPN/RCM, stated the facility expectation is, if a resident falls the nurse on duty will start an incident investigation to determine the cause of the fall. In addition, Staff C, LPN/RCM, stated the computer program used for incident investigations will automatically prompt the nurse to complete a fall assessment for each fall to determine the resident's fall risk. Review of the facility policy titled Falls - Clinical Protocol dated April 2013, showed For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. Review of the facility investigation dated 08/25/17 showed Resident #1 fell at 3:25 PM in the hallway while leaning forward in his chair. The investigation included a fall risk assessment which was dated 08/27/17, two days after the fall. Additionally, the investigation summary showed the facility would supply Resident #1 with a tilt wheelchair (wheelchair that reclines back) as a means of fall prevention. Review of Resident #1's medical record shows the tilt wheelchair was not implemented until 08/28/17. During an interview on 10/05/17 at 2:20 PM, Staff C, LPN/RCM, stated the facility expectation is if a resident falls, the nurse on duty should start an incident investigation to determine the cause of the fall. Staff C, LPN/RCM, stated the computer program that is used to complete the investigation will automatically prompt the nurse to complete a fall assessment for each fall to determine the each resident's fall risk. FALL 08/27/17 - ASSESSMENT Review of Resident #1's record showed he fell while leaning forward from his chair on 08/27/17 9:45 PM. During an interview on 10/05/17 at 2:20 PM, Staff C, LPN/RCM, stated for any resident who has had a fall, staff should complete a fall risk assessment after the fall. Review of the investigation related to Resident #1's 08/27/17 fall included a fall assessment dated [DATE] at 9:15 AM, twelve hours before the fall actually occurred. There was no documentation to show Resident #1 had been assessed for risk after he fell on [DATE]. Upon further review it was noted the fall assessment dated [DATE] at 9:15 AM was used for both the 08/25/17 fall investigation and the 08/27/17 fall investigation. During an interview on 10/05/17 at 2:20 PM, Staff C, LPN/RCM, reviewed the investigation files and confirmed both falls had the same assessment. Staff C, LPN/RCM stated the assessment was not completed timely after the first fall, and should have been used for the second fall on 08/27/17. RESIDENT #2 SECOND FALL Record review of Minimum Date Set (MDS-a required assessment) dated 10/02/17, showed that this Resident # 2 admitted from an acute hospital with the [DIAGNOSES REDACTED]. Resident #2 had moderately impaired cognition with poor decisions making skills. During an observation on 10/05/17 at 11:45 AM, showed that Resident #2 was laying on a regular mattress with bed in low position(height of bed closest to floor), with a full thickness mattress on the floor next to the bed on right side of bed (between bed A & bed B). Record review of facility investigation for a fall on 08/31/17 showed that Resident #2 had an unwitnessed fall with skin tears and a lump to the back of his head. On 09/01/17, the facility identified that Resident #2's middle (3rd) finger on his right hand, was swollen. The doctor was notified and ordered an x-ray which, identified a presumed fracture (broken bone) in his finger. Record review of the facility investigation for the fall on 08/31/17, showed that the new intervention that had been put in place was a concave mattress (a mattress that have elevated outer edges that assist with defining parameters of the bed). Record review of Resident #2's care plan dated 08/31/17, showed that the facility did not initiate a concave mattress to define the mattress edges as stated in the facility's investigation. Review of Resident #2's record showed a fall assessment was not completed after the fall on 08/31/17. During an interview on 10/05/17 at 2:10 PM, Staff C, LPN/RCM, when ask to clarify whether Resident #2 had been provided the concave mattress as stated in facility's investigation. Staff C, LPN/RCM confirmed that the concave mattress had not been placed on the bed or on the care plan, as it should have been. In addition, Staff C, LPN/RCM stated that her expectation was that when a resident falls that a fall assessment needs to be completed to assist in preventing further falls. RESIDENT # 2 THIRD FALL During an observation on 10/05/17 at 11:45 AM, showed that Resident #2 was laying on a regular mattress (not concave) with bed in low position(height of bed), with a full thickness mattress on the floor next to bed on right side of bed-between bed A & bed B. Record review of facility's investigation for a fall on 09/12/17 showed that Resident # 2 was to have fall mats to both sides of the bed. Record review of facility's care plan dated 9/17/17, showed that mats were to be on floor to prevent injury related to falls. During an interview on 10/05/17 at 2:10 PM, Staff C, LPN/RCM, was ask to clarify why, Resident #2 had a mattress on the floor next to his bed on the right side instead of mats on both sides of the bed as stated on the care plan. Staff C, LPN/RCM stated that the facility did not have any more fall mats at that time. Failure to have mats on both sides of the bed, as outlined in the plan of care, placed Resident #2 at potential risk of injury related to falls. Refer to F224. WAC 388-79-1060 (3)(g)

Based on observation, interview and record review the facility failed to provide care as outlined in the care plan for five of six Sampled Residents (#s 1, 2, 5, 6 & 7) reviewed for falls. This failure placed residents at potential risk for further falls and/or accidents and resulted in harm for Resident #1 who fell and sustained a suspected fracture. Findings included . Review of the facility policy titled Abuse Prevention Policy and Procedure, dated 08/11/17, showed that Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. RESIDENT #1 Observations on 10/03/17 at 10:45 AM, showed Resident #1 in his wheelchair with his left arm in a sling. During an interview on 10/03/17 at 10:50 AM, Resident #1 stated he fell in the shower room while being assisted by staff and broke his shoulder. Review of Resident #1's Minimum Data Set (MDS - an assessment tool) dated 08/30/17 showed Resident #1 required extensive assistance from two staff member in order to transfer from one surface to another. Review of Resident #1's care plan dated 08/24/17, identified Resident #1 had a history of [REDACTED]. Further review of the care plan showed the Activities of Daily Living section showed Resident #1 required assistance of two staff members for transferring. Review of the facility's incident investigations showed Resident #1 had fallen while being assisted by staff three times on 08/31/17, 09/15/17 and 09/19/17. FALL 08/31/17 Review of the facility's fall investigation dated 08/31/17 showed Staff E, Nursing Assistant - Certified, NAC, was assisting Resident #1 to transfer to his wheelchair when he fell . The investigation indicated there were no other staff present at the time of the fall. During an interview on 10/05/17 at 2:46 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, LPN/RCM, stated Resident #1's care plan directs that his condition requires assistance from two staff members to transfer as an intervention. Staff C, LPN/RCM, confirmed there was not any other staff present at the time Staff E, NAC, assisted Resident #1 to transfer to his wheelchair and he fell . FALL 09/15/17 Review of the facility investigation dated 09/15/17 showed Staff F, NAC, was assisting Resident #1 to a standing position in order to change his clothes, when he fell . The investigation indicated there were no other staff present at the time of the fall. During an interview on 10/05/17 at 2:46 PM, Staff C, LPN/RCM, stated again, Resident #1's care plan directed assistance from two staff members to transfer at the time of the fall. Staff C, LPN/RCM, confirmed Staff F, NAC, did not have assistance from a second staff member when she assisted Resident #1 to a standing positon. FALL 09/19/17 Review of the facility investigation dated 09/19/17 showed Staff D, NAC, was assisting Resident #1 to transfer from his wheelchair to the shower chair when he fell . The investigation showed Staff D, NAC, was the only staff member present at the time of the fall. The investigation included an x-ray report dated 09/20/17, due to a suspected fracture. During an interview on 10/03/17 at 2:14 PM, Staff D, NAC, stated she was assisting Resident #1 to transfer from his wheelchair to the shower chair at the time he fell . Staff D, NAC, confirmed there was not any other staff members present at the time of the transfer and fall. During an interview on 10/05/17 at 2:46 PM, Staff C, LPN/RCM, stated Resident #1's care plan directed assistance from two staff members to transfer at the time Resident #1 fell in the shower room, and that Staff D, NAC, did not get assistance from a second staff member. Staff C, LPN/RCM, stated failure to provide assistance by two staff as directed in the care plan did meet the definition of neglect. RESIDENT #2 Resident #2 admitted to the facility on [DATE]. Review of Resident #2's care plan dated 08/25/17 showed he required two staff to provide assistance with transfers. Review of NAC documentation between 9/22/17 and 10/05/17 showed that staff documented Resident #2 transferred with one person assistance on two different occasions during the 2 week period, and twice and on one occasion, staff provided set up assistance only. RESIDENT #5 Review of Resident #5's care plan dated 09/09/16 showed he requires the use of a mechanical lift (a machine used to lift a resident who is sitting in a sling that is hooked to the machine) to transfer from one surface to another. Review of the facility policy dated October 2010, titled, Lifting Machine, Using a Portable, showed the use of a mechanical lift requires two staff to perform the transfer unless the resident has been assessed to have the ability to participate. Record review showed there was no documented evidence Resident #5 had been assessed to participate in a mechanical transfer. Review of the NAC documentation over the last thirty days 09/05/17 through 10/05/17 showed staff documented eleven times that they had transferred Resident #5 with one staff member physically assisting the resident (instead of using two people and the mechanical lift). RESIDENT #6 Resident #6 admitted to the facility on [DATE]. Review of Resident #6's care plan dated 09/30/17 showed he required two staff to provide assistance with transfers. Review of NAC documentation between 09/30/17 and 10/04/17 showed staff documented Resident #6 transferred with no assistance from staff, but with set up help only, on two of the five days, and that Resident #6 transferred with no assistance and no set up help from staff on two of the five days. RESIDENT #7 Review of Resident #7's care plan dated 08/08/16 showed she required the use of a sit and stand mechancal lift with transfers. Record review showed there was no documented evidence Resident #7 had been assessed to participate in a mechanical transfer. Review of NAC documentation between 09/06/17 and 10/05/17 showed staff transferred Resident #7 with one staff member physically assisting on 16 of the 30 days reviewed. Refer to F323. WAC: 388-97-0640 (3)(a-d)

Based on observations, record review, and interview, the facility failed to ensure adequate supervision to prevent accidents for 2 of 2 Residents (#'s 1 & 2) reviewed for falls with injuries. The facility failed to provide adequate supervision to ensure Resident #2 was safely transferred with a Hoyer lift. During transfer, Resident #2 sustained harm (blunt head injury) when the lift tipped and the resident fell , hitting his head on the footboard. The resident additionally sustained a cut on his chin. Resident #2 subsequently transferred to the emergency room for evaluation. The facility failed to provide adequate supervision to ensure a care plan that required attendance of 2 staff in the room during care was followed for Resident #2. The resident rolled from bed during care provided with 1 staff in the room. The resident sustained [REDACTED]. The resident suffered harm from the pain and limited movement experienced after the fall which required pain medication. Findings include: Observations and interviews were conducted on 7/15/14. 1. On 6/25/14 Resident #2 was observed sitting in his room in the wheel chair, having just transferred from bed with the Hoyer lift. The sling was under the resident and was centered; staff repositioned the resident for comfort. The resident was not able to provide information specific to the fall incident. Record review revealed Resident #2 admitted to the facility during 6/2013 with medical [DIAGNOSES REDACTED]. The resident was at risk for bleeding related to use of blood thinning medication. Review of a facility investigation dated 6/25/14 revealed during Hoyer lift transfer from bed to wheel chair at approximately 3:30 p.m., while the lift was being moved over the wheel chair, it tipped and the resident fell approximately 3 feet to the floor, hitting his jaw on the footboard of the other bed in the room. The investigation indicated one staff member was able to intervene and cushion the resident's head; however, slight impact was still made. Review of nursing progress notes dated 6/25/14 revealed at approximately 5:00 p.m., Resident #2 was diaphoretic and complaining of a headache. Following assessment and physician notification, the resident was transferred to the emergency room for evaluation. Review of the emergency room report dated 6/25/14 revealed a CT scan of the head was negative for internal bleeding and no fractures were noted on a CT scan of the cervical spine. The physician's clinical impression was documented as blunt head injury. The physician noted the need in the facility for strict head injury precautions due to the blunt head injury and anti- coagulation (on blood thinning medications). Review of a witness statement by Staff E dated 6/25/14 revealed she went into Resident #2's room to ask for help with another resident. Staffs C and D (certified nursing assistants) were transferring Resident #2 with the Hoyer lift. Her statement indicated the transfer could have been more organized; the sling was not attached in sync with the other side and the Hoyer was too high. Staff C operated the lift and approached the resident's wheel chair from the side and the lift hit the wheel chair. The resident started rocking side to side and then the lift tipped over. Staff E stated she observed the resident hit the right side of his head and face on the footboard and the lift landed on the resident. During survey, interview with Staff E at 2:35 p.m. verified her statements as above. Staff E reiterated the sling was not attached equally on both sides and the Hoyer was up too high. She stated Staff C went in sideways with the lift next to the wheel chair instead of straight on; the lift bumped the wheel chair and tilted the Hoyer over. Review of witness statement dated 6/25/14 by Staff D revealed she was behind the resident's wheel chair to guide him in the sling to the proper position. She indicated she was taken by surprise when she suddenly saw the back of Resident #2 coming at her very fast. She grabbed the sling handles and held the resident as steady as she could; the lift was on its side. Staff D guided the resident to the floor, noting he was at a slant and clipped his jawline on the footboard. Review of witness statement written by Staff C (certified nursing assistant) revealed she was operating the lift and was opening the legs of the lift as she was pulling it out from underneath the bed; as she approached the wheel chair, the legs closed, the lift tilted and the resident fell . During interview on survey at 11:10 a.m., Staff C stated as far as she recalled, the lift was in good working order, the sling was attached correctly and the transfer was done properly. Staff C did not know why it would have tipped. The investigator reviewed the incident investigation with Staff B (director of nursing) at 10:55 a.m. She stated two of three staff in the room involved in the transfer (Staffs C & D) stated they felt the transfer was done properly. Maintenance staff checked the machine and did not find mechanical problems. Staff B stated immediate in-service education was started during the shift following the incident and continued until all staff were educated and able to demonstrate the proper technique. Staff B stated she knew something went wrong during the transfer in order for the lift to tilt and fall over. 2. Record review revealed Resident #1 admitted to the facility during 4/2013 with medical [DIAGNOSES REDACTED]. Review of the resident's care plan dated 4/15/2013 revealed a problem identified related to verbal and physical aggression and accusatory behaviors. One of the interventions care planned was to have two staff in the room with the resident for all care. On 7/15/14 at 7:55 a.m., Resident #1 was observed in her room walking from the bathroom using a seated walker. Staffs G & H (certified nursing assistants) were in the room walking with the resident. Staff assisted the resident to a chair using a gait belt. Interview with Staffs G & H revealed they had both cared for the resident previously and both stated she was care planned for two person care for as long as they could recall. During interview at approximately 8:05 a.m., Resident #1 stated she recalled falling out of bed and stated she hurt her shoulder, pointing to her right arm. The resident said her arm was not broken "but it might as well have been, they had to do 7 x-rays. The resident grimaced and held her shoulder as she talked about the x-rays done in her room. The resident stated she was not able to lift her arm up very far, demonstrating by lifting it approximately 3 inches from the chair arm. She stated "I use this arm to lift it" as she demonstrated lifting her right arm up with her left hand. Review of a facility investigation dated 6/24/14 revealed the resident fell from bed during care at approximately 5:30 p.m. The investigation revealed Staff I was assisting the resident in the room by herself; and, the resident was care planned for 2 staff related to behaviors and allegations against staff. The second staff, according to the investigation report, was to serve as a witness. Staff I admitted to not following the care plan by providing care without a second staff in the room. Review of a witness statement by Staff I dated 6/24/14 revealed she asked Resident #1 to roll onto her left side and proceeded to wash her. Staff I told the resident not to move. As Staff I reached for a clean wash cloth, the resident moved her right leg over her left leg and rolled off the bed onto the floor. Review of a nursing progress note dated 6/24/14 revealed the resident complained of 9/10 pain in her right shoulder and right upper arm following the fall and also sustained a small cut on her right forehead. Review of x-ray results dated 6/24/14 revealed no evidence of fractures. Review of Resident #1's medication administration record (MAR) dated 6/2014 revealed prior to the fall on 6/24/14, the resident had not requested "as needed" pain medication (Tylenol 500 milligrams (mg) every 6 hours as needed for breakthrough pain) from 6/1 through 6/23/14. The resident received Tylenol 500 mg following the fall on 6/24, twice on 6/25 and on 6/26/14 for arm and shoulder pain. Review of nursing progress notes dated 6/25/14 revealed the resident was on alert for a new order for Vicodin 1 tablet for pain on a scale of 1 -5. The resident's right shoulder was noted with swelling and redness. Review of the MAR dated 6/2014 and 7/2014 revealed the resident received Vicodin 1 tablet for arm and/or shoulder pain on 6/26, 6/27, twice on 6/28, twice on 6/29, on 7/1, twice on 7/2, and on 7/3 , 7/4 , 7/7, 7/8 & 7/9. Review of physician orders [REDACTED]. The resident received two tablets on 7/13/14 for right shoulder pain. During exit interview at 2:15 p.m., Staff B (director of nursing) concluded Resident #1's fall may or may not have occurred if a second staff was in the room as per the care plan.

Based on observations, interview and record review, it was determined the facility failed to identify and ensure the resident call light system remained functional to assure residents, staff and visitors could alert facility staff and receive timely assistance when emergent situations arose on 3 of 4 unit wings (100, 200 & 400 halls) reviewed for a communication system. This deficiency resulted in potential harm for 6 of 6 current sampled residents (#s 84, 73, 44, 83, 92 & 54) and 64 additional residents receiving care at the facility if call lights did not function and staff did not timely identify resident needs. This deficiency constituted an Immediate Jeopardy on 11/15/12. Findings include: On 11/14/12 at 4:57 a.m. the Maintenance Supervisor (MS) reported the facility installed a wireless call light system approximately three years ago and stated every morning he looked at the computer system to determine if a call light had a low battery. Maintenance logs reviewed identified individual batteries were replaced only when needed and not on a scheduled basis. No other records were provided to indicate the facility had a system in place to routinely ensure call lights were consistently functional in resident rooms and in bathrooms that identified other potential call light malfunctioning issues. The MS showed surveyors a maintenance log (Communication Form) dated 9/26/12 through 11/12/12 which included responding to call light problems. The reported problems involved rooms and/or bathrooms on all wings of the facility (Room 107, 307, 306, 209, 108, 206, 403, 308, 304, & 208/Bathrooms between 207/208 & 205/206) including multiple reports of problems for some rooms and/or bathrooms. These were the concerns he responded to when reported to Maintenance. The MS did not verbally identify any specific system used to proactively and routinely determine if call lights were functional. The computer call panel at the nurse station would flag a low battery or call light malfunction. The MS reported daily checks and relied on the computer call panel at the nurse station to identify if batteries were low or if call lights malfunction. <Call Light System Concerns on 11/13/12> 1. Resident #84 was admitted to the facility on [DATE] and resided on the 200 hall. The resident's Minimum Data Set (MDS), an assessment tool, dated 09/14/12, indicated the resident was able to make needs known. On 11/13/12 at approximately 3:40 p.m., the call light in Resident #84's room, did not function. Nursing Assistant (NA) C, present in room with surveyor, confirmed the call light in the bathroom did not work. Resident # 84 reported at this time he did use the toilet in the bathroom without staff supervision at times. On 11/13/12 at 5:11 p.m., the MS reported staff had not reported the call light in the bathroom, between rooms 209 and 210, did not work. 2. Resident #73 was admitted to the facility on [DATE] and resided on the 200 hall. The resident's MDS, dated [DATE], indicated the resident had a history of [REDACTED]. The assessment did not identify the resident had cognitive deficits. On 11/13/12 at 3:45 p.m., the bathroom call light in Resident #73's room did not activate when pulled. At 3:48 p.m., Resident #122 reported Resident #73 banged on the bathroom wall approximately a week ago because she tried to get the attention of staff after being left on the toilet. At 4:30 p.m. Resident #73 reported about one week ago she put the call light on in the bathroom and no one came. Resident #73 reported she waited for a half an hour and then started banging on the wall. The resident reported the back of both thighs got sore from sitting. The resident reported it was easier for her to bang on wall than yell. The resident did not know why staff did not come after she put the call light on. Resident #73 spoke is a very soft voice during the conversation and had unclear speech and was difficult to understand. The resident did not succeed writing on a communication board when attempted and had difficulty coordinating use of both arms. At 4:35 p.m., Licensed Nurse (LN) C reported Resident #73 needed assistance from staff to transfer from the toilet to a wheelchair. 3. Resident #44 was admitted to the facility on [DATE] and resided on the 100 hall. The resident's MDS, dated [DATE], indicated the resident was able to make his needs known and did not identify the resident had cognitive deficits. On 11/13/12 at 3:57 p.m., Resident #44 reported call lights were problematic. The resident stated sometimes they worked and sometimes they did not. <Inconsistent Functioning Call Lights on 11/14/12 and 11/15/12> 1. Resident #83 was admitted to the facility on [DATE], and resided on the 400 hall. The resident's MDS, dated [DATE], indicated the resident was able to make her needs known and did not indicate the resident had cognitive deficits. The MDS assessments showed the resident had multiple hospitalization s, needed extensive assistance from staff in activities of daily living, and required use of a wheelchair for mobility. On 11/14/12 at 3:08 p.m., Resident #83 reported she pushed the call button at least ten minutes ago and no one came. The light outside the room door was not on at the time. The resident pushed the call light again and it still did not activate. Resident #83 stated in the past, staff did not always come when she put her call light on. The resident stated she did not know the call light did not come on, and felt frustrated to wait that long. At 5:18 p.m., the MS checked Resident #83's call light and confirmed it did not work. MS stated the computer system did not identify the call light was not working. At 5:39 p.m. the MS reported the resident's call cord was defective and it was replaced. 2. Resident #73 was admitted to the facility on [DATE] and resided on the 200 hall. The resident's MDS, dated [DATE], indicated the resident had a history of [REDACTED]. The assessment did not identify the resident had cognitive deficits. On 11/15/12 at 9:15 a.m., Resident #73 sat in her wheelchair. The resident reported she got up at 8:00 a.m. today but had put her call light on earlier, at 7:00 a.m., to get up and no one came. NA A reported her shift began at 06:30 a.m. and the resident's call light did not come on until 8:00 a.m. and had not signaled earlier. The surveyor looked at the resident's call light at this time. The cord that connected to the call button was frayed, had exposed wires and dangled from the cord. When pushed, the call light did not function and did not activate the signal at the room door or register an audible tone. On 11/16/12 at approximately 10:15 a.m., the call button in Resident #73's bathroom, next to the toilet, did not like outside the room door. The surveyor could not tell the call light did not activate while inside the bathroom. On a second attempt, the call button worked. 3. On 11/15/12 beginning at 10:04 a.m., surveyors checked all the call lights in the facility. The bathroom call light in room 206 did not consistently activate when pulled. The first time the surveyor pulled the bathroom call light, it did not shut off after it was activated. NA A confirmed it did not turn off and LN A also confirmed the light still showed on outside the room door. LN A reported she had to repeatedly move the red call light switch up and down to get the light outside the door to turn off. After the light turned off, the surveyor turned its back on again, and the light did not turn on or activate outside the room door. LN A confirmed the light did not come on at this time. 4. Resident #92 was admitted to the facility on [DATE] and resided in Room 208. The resident's MDS, dated [DATE], indicated the resident had short and long term memory impairment and severe impairment with daily decision making. The assessment identified the resident had a previous stroke with paralysis on one side and difficulty making himself understood. On 11/15/12 at 10:17 a.m., the call light in Resident #92's room did not work. The first time the surveyor pulled the call light LN B confirmed the malfunction. LN B reported if call lights were unplugged from the wall a white light came on outside the room door. At this time the lights outside the room door did not signal a white light to indicate an unplugged cord. LN B then unplugged the call light from the wall and reinserted it. The call light activated the light outside the room door only after it was unplugged and reinserted. LN B pulled the bed's call light switch for the third time, and again, it did not work. On 11/15/12 at 12:05 p.m., LN B reported she never heard Resident #92 speak and never heard the resident yell out. Although the resident could not use a call light, staff and visitors would not be able to immediately alert staff, when in the room, in the event Resident #92 required immediate assistance. 4.On 11/15/12 at approximately 10:10 a.m., when LN B pulled the call light switch for the call light in room 204, Bed A, it did not activate a signal. LN B reported the call light had a low battery. 5. Resident #54 was admitted to the facility on [DATE] and resided on the 400 hall. The resident's MDS, dated [DATE], indicated the resident was able to make his needs known, and did not identify the resident having cognitive deficits. On 11/15/12 at approximately 11:00 a.m., the surveyor asked Therapy Staff (TS) A to push the call button at Resident #54's bedside. The call light did not activate. The call light did not activate until the second attempt and after the surveyor informed TS A the call light did not work. On 11/15/12 at 11:30 a.m., the Director of Nursing Services (DNS) stated aides reported call lights did not always work. The DNS stated there was a 30 second delay before bathroom call lights inactivated after being turned off, and the bathroom call lights are a wireless system. The DNS said the resident bed call light system was not on a wireless system, but the bathrooms were. On 11/15/12 at 2:00 p.m., the facility Administrator and corporate Administrators were informed the resident call lights did not consistently function. The facility administration reported the facility was not aware of the inconsistent functioning of the call light system. The facility and corporate Administrators both reported the facility did not have a written policy or procedure that identified a maintenance plan to ensure the call light system consistently functioned. <Lack of Evidence of Staff Training Regarding the Call System> On 11/13/12 at approximately 3:45 p.m., NA C confirmed the call light in Resident #84's bathroom (between Rooms 209 & 210) did not work. At 5:11 p.m., the MS stated staff had not informed him the call light did not function in the resident's bathroom. On 11/15/12 at 8:50 a.m., when asked what to do if the computer indicated a low battery on the call system, LN D reported no one showed her what to do with a low battery. LN D reported she would have the aides check on the residents hourly if their battery signaled it was low. On 11/15/12 at 8:55 a.m., LN E was asked the same question and reported call lights did not have batteries and did not know what it meant when the computer indicated a low call light battery. LN E thought when the nursing station computer display indicated a call light had a low battery it could mean the call light was "unplugged." LN E reported no one informed her of what to do when the display indicated a low battery. LN E did not recall receiving any training about the call light system. On 11/16/12 at 10:52 a.m., LN B reported staff received training about the call light system from other staff during orientation on the floor. The surveyor requested evidence all staff received training at this time. On 11/16/12 at 11:19 a.m., LN B provided a copy of orientation training checklists for licensed and non-licensed nursing staff. Neither of the orientation packets contained information regarding how the call light system worked, how to identify call system malfunction, or what to do when it did malfunction. The facility failed to develop a policy and procedure that identified who, when, how and how often call lights were to be tested ensure call light failures and call cord damage were timely identified. A Care Management and System Support and Maintenance Instruction manual regarding the call light system identified, "it is recommended that you test the system on a regular basis. Please refer to your facility's policies regarding nurse call and emergency call systems for testing procedures." The facility did not implement a comprehensive maintenance program to ensure the facility call system remained consistently operational that included proper maintenance checks of actual call cords and routine and periodic testing of the call system at each resident's bedside and in their bathrooms. The facility did not provide evidence all staff received training on how the call light system worked, how to identify system malfunctions, or what procedures to follow when malfunction occurred. Without a system in place for the facility to identify call system failures in a timely manner, this placed all residents, staff and visitors at risk to not being able to request help and obtain timely assistance when needed or in the event of an emergency. This failure also placed residents at risk for psychological harm due to feeling insecure, not knowing if their call lights would work and if staff could immediately be contacted, and also to experience frustration while waiting for assistance after they assumed call lights were activated when actually they did not signal staff for assistance. .

Based on observation, interview and record review, it was determined the facility failed to maintain dignity during provision of assistance with toileting activities for 1 of 39 current sampled residents (#73) included in the stage 2 review. Failure to return timely and provide follow up assistant after a transfer to the toilet, resulted in psychological harm and loss of dignity. The facility also failed to ensure staff kept a urinary drainage bag covered for 1 of 2 current sampled residents (#15) reviewed for catheters. Failure to cover a urinary drainage bag placed the resident at risk to experience embarrassment and loss of privacy. Findings include: 1. Resident #73 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A behavior care plan, dated 05/2012, identified Resident #73 exhibited crying and tearfulness related to anxiety and pain and required one to one intervention and support from staff. A communication care plan identified the resident had difficulty with communication and [MEDICAL CONDITION]. Physician orders, identified on 05/09/12, directed staff to administer medication as needed to treat anxiety and medication to treat depression daily. Medication records for November 2012 identified staff administered medication to the resident nine times between 11/2/12 and 11/19/12 to treat anxiety. October 2012's medication records identified staff administered anti-anxiety medication to Resident #73 for 12 separate times. The resident's quarterly Minimum Data Set, an assessment tool, dated 01/14/12, identified the resident had unclear speech, had functional limitation of use of both upper extremities, used a wheelchair and required extensive assistance from staff to transfer and to toilet. The assessment did not identify any significant concerns with the resident's cognitive abilities. On 11/13/12 at 3:45 p.m., the bathroom call light in Resident #73's room was checked to see if it functioned and it did not activate when pulled by the surveyor. At 3:48 p.m., Resident #73's roommate reported, approximately one week ago, Resident #73 banged on the bathroom wall to try and get attention from staff after being left on the toilet too long. The resident did not know why staff did not return and check on her. At 4:30 p.m., Resident #73 reported about one week ago she put the call light on in the bathroom and waited for half an hour. When no one came, the resident reported the back of both thighs got sore from sitting and banged on the wall to get staff attention because it was easier than yelling. During the conversation Resident #73 spoke in a very soft voice and had unclear speech which was difficult at times to understand. At 4:35 p.m., when asked if Resident #73 needed help with toileting, Licensed Nurse (LN) C reported the resident needed assistance from staff to transfer from the toilet to a wheelchair. On 11/14/12 at 11:40 a.m., when asked if staff treated her with respect, Resident #73 replied, "no" and "sometimes." On 11/20/12 at 12:10 p.m., Resident #73 reported when left on the toilet and staff did not come, she felt "scared" and "frustrated." She reported feeling scared because she was afraid no one would come and that is why she started banging on the wall. The resident also reported she felt so scared she cried. Resident #73 also reported the same thing happened twice before this incident. When asked how she knew how long it took for staff to come, the resident reported she looked at the time on the clock in her room before going into the bathroom and again when she got out. At 12:24 p.m., observation in Resident #73's room revealed a green framed clock on the wall next to the window. At 12:25 p.m., Resident #73's roommate reported the day Resident #73 was in the bathroom and banged on the wall she was brought in by an aide and then the aide left. After a while, the banging got louder and more frequent, "like she was getting frustrated." Resident #73's roommate also reported when she got up to check on Resident #73. Resident #73 wanted to "get out so much. I put both of our call lights on." A different aide came, helped her back into her bed, and noticed the resident cried immediately following the incident. The surveyor informed the facility during survey Resident #73 reported being left on the toilet for 30 minutes. A facility investigation report, dated 11/15/12, documented when the resident pulled the call light in the bathroom and the string fell out, the resident then pulled the call light switch to activate it. The investigation also documented the resident reported the call light did not work, reported to staff the string fell out but did not report the call light did not work. On 11/21/12 at 9:15 a.m., when asked if the facility checked call light computer records during the time frame Resident #73 reported being left on the toilet to determine if the bathroom call light activated when pulled, the Director of Nursing Services (DNS) reported looking at computer records and did not remember what they indicated. The surveyor requested call light function records for this time frame and none were provided. At 11:45 a.m., the Social Services Director (SSD) reported when she asked Resident #73 for clarification on how she felt regarding the incident, the resident stated she felt "sad" and "left." When asked what the resident meant by being "left," the SSD reported the resident felt a lack of control of the situation. Resident #73 did not have the physical ability to get off the toilet without staff assistance, had a pre-existing anxiety disorder and did not receive timely follow up assistance from staff after being left in the bathroom. As a result, Resident #73 cried after feeling afraid, sad and frustrated when staff did not return after pulling the call light and banging on the wall. Staff failure to timely return after assisting Resident #73 onto the toilet resulted in psychological harm for this resident. 2. Resident #15 had multiple admissions and discharges to the facility and most recently readmitted on [DATE]. A quarterly assessment, dated 8/23/12, identified the resident had [DIAGNOSES REDACTED]. The resident was dependent on staff for activities of daily living including providing care to ensure dignity. On 11/13/12 at 3:23 p.m., Resident #15 was observed in bed with a urinary drainage bag haning on the lower right side of the bed frame that faced the door to the hallway. The urinary bag did not have a cover and urine in the bag was visible from the hallway. On 11/14/12 at 8:21 a.m., LN G reported the resident required a catheter and tubes to drain urine from the body. On 11/19/12 at 7:45 a.m. and 8:00 a.m., the resident was observed in bed with a urinary drainage bag hanging from the lower right side of the bed frame that faced the door to the hallway. The urinary bag was not covered and was visible from the hallway. On 11/20/12 at 1:50 p.m., Nursing Assistant (NA) C reported residents should have catheter bags covered at all times. On 11/20/12 at 2:40 p.m., Resident #15 lay in bed with an uncovered urinary drainage bag placed on the lower right side of the bed. The resident's wheelchair in the room had a urinary bag cover secured to it. NA C reported at this time the urinary drainage bag on the bed should be covered and did not know why it wasn't. On 11/20/12 at 3:37 a.m., NA D and NA E reported they were not informed to cover resident urinary bags placed at the bedside. On 11/20/12 at approximately 4:05 p.m., the DNS reported the facility did not have a specific policy that directed staff to keep urinary catheter bags covered at the bedside. Failure to cover urinary catheter bags had the potential to compromise dignity and privacy for Resident #15 and/or create discomfort for others who viewed them from the hallway. .

Based on record review and interviews, the facility failed to ensure professional standards of practice were followed in regards to completing a thorough assessment and initiating CPR according to standards of practice for of 1 of 4 residents reviewed for change of condition (former Resident #10). There was no evidence two licensed staff (Staffs H & I) conducted a thorough assessment of the resident's respiratory and heart condition after having knowledge that the resident had possibly choked. Staff I initiated CPR with the resident in a sitting position. These failures resulted in harm to Resident #10 due to delay in management of a possible obstructed airway. Findings include: Review of Resident #10's hospital record summary dated [DATE] revealed the resident arrived at the hospital with CPR in progress after a possible choking episode. Further record review revealed food was removed from his right lung after emergency [MEDICATION NAME] (test used to view the airways) was done. He was placed on mechanical breathing support and subsequently expired after midnight on [DATE] following additional cardiac and respiratory arrests. Documented [DIAGNOSES REDACTED]. Review of Resident #10 ' s records at the facility on [DATE] revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the records, he was alert, oriented to person, place and time and was able to verbally make his needs known. He was on mechanical soft diet with thin liquid consistency. Resident #10 was also independent with meals. According to a licensed nurse ' s progress notes dated [DATE], Resident #10 ' s vital signs were stable. The [DATE] progress notes ' also revealed while Resident #10 was eating, he stated he was choking and was given water and was talking. Five minutes later, the resident started looking gray and was not talking. Review of facility investigation summary dated [DATE] revealed an allegation of delayed response by the nurses when Resident #10 ' s condition declined requiring resuscitation. The incident occurred in the resident ' s room at 5 p.m. on [DATE]. The facility reported the incident on [DATE] and conducted their investigation to include staff interviews on [DATE]. The facility documented the licensed nurse was suspended and was later terminated. Interview with Staff E (nursing assistant) on [DATE] at 2:35 p.m. revealed he notified Staff I (licensed nurse) on [DATE] (evening shift) that Resident #10 did not look right; according to Staff E, the resident was pale, sweating and not responding like he usually did. He stated Staff I did not come "right away" and after checking the resident, she told him "he is alright". Staff E asked another licensed nurse (Staff H) to check the resident and she also stated the resident was "ok". Interview with Staff F (nursing assistant) on [DATE] at 9:10 a.m. revealed in response to Staff E's request to check the resident, she witnessed Staff I touching Resident #10 on the cheek and stated "he should be ok, I just gave him some medication". Staff F stated the nurse did not check the resident's vital signs or listen to the resident's lungs. Licensed nurse (Staff H) checked the resident after Staff I and got a verbal response from the resident. During interview on [DATE] at 11:45 a.m., Staff H (licensed nurse) stated she checked Resident #9 after nursing assistants E & F told her they thought he might be choking. She stated the resident was pale and initially did not respond, however, did respond verbally "yes", he was ok. Staff H stated she asked the resident if he could cough because he sounded gurgly and he stated "no". Staff H stated she did not listen to the resident's lungs; she was going to get a stethoscope when Staff I entered the room. Staff H stated she left the room at that time. Approximately 10 minutes later, Staff H stated she responded to a request to check Resident #10 because his condition was worse. Staff H entered the room and saw Staff I administering CPR to the resident who was sitting upright in bed. Staff H stated she intervened and continued CPR with the help of another licensed nurse, Staff G, after lowering the bed and placing a back board under the resident. Interview with Staff G on [DATE] at 2:00 p.m. revealed she responded and assisted with CPR until 911 staff responded. She stated the resident vomited during CPR just as 911 staff arrived and continued CPR with breathing support. The resident was transported to the hospital where the resident subsequently expired. Expanded interviews with 5 nursing assistants and 5 licensed nurses on [DATE] (day/evening shifts) and [DATE] (night shift) revealed they were knowledgeable about response to a resident with potential choking, not breathing and/or without a pulse. Each staff interviewed knew the location of the crash cart and suction machines and the correct procedure for CPR.

Based on record review and interview, the facility failed to ensure professional standards were followed to ensure 1 of 8 residents (former Resident #1) taking a blood thinning medication ([MEDICATION NAME]) had ongoing blood tests (PT/INR) done to determine the appropriate dose of [MEDICATION NAME] to prevent blood clots and/or bleeding. The facility failed to obtain and monitor PT/INR tests for Resident #1 for approximately two and a half weeks while the resident received a daily dose of [MEDICATION NAME]. Multiple opportunities existed for nursing and/or physician staff to recognize Resident #1 was taking [MEDICATION NAME] without monitoring PT/INR levels. This failure resulted in actual harm to Resident #1 who was subsequently hospitalized with complications of a nose bleed, bleeding gums, and bleeding in the urine as a result of a critically high PT/INR associated with continued use of [MEDICATION NAME] and lack of PT/INR monitoring. The facility also failed to ensure professional standards of practice were followed related to staff not following up with the physician for 1 of 8 residents (Resident #2) regarding a low PT/INR which placed Resident #2 at risk for potential blood clotting. Findings include: Review of internet website uptodate.com article "Patient Information: [MEDICATION NAME] ([MEDICATION NAME]) (Beyond the Basics)" revealed in the paragraph entitled [MEDICATION NAME] Monitoring the goal of [MEDICATION NAME] was to decrease clotting tendency of the blood, but not to prevent clotting completely. Therefore the blood's ability to clot must be carefully monitored while a person was taking [MEDICATION NAME]. The article detailed the most commonly used test to measure the effect of [MEDICATION NAME] was the PT/INR. The PT was described as a test that measured how long it took for the clotting mechanism to progress. The INR was explained as a way of expressing the PT in a standardized way. The longer it took blood to clot, the higher the PT and INR. In most cases the target INR was between 2 and 3. If the INR was below the target range, there was a risk of clotting. If it was above the target range, there was a risk of bleeding.The dose may be adjusted periodically in response to changes in the INR or other conditions. Within the paragraph entitled [MEDICATION NAME] Side Effects it was noted that the major complication associated with [MEDICATION NAME] was bleeding due to excessive anticoagulation. Because the risk of bleeding increased as the INR increased, the INR is closely monitored and adjustments made to maintain the INR within the target range. 1. Review of a facility investigation dated 4/26/12 revealed former Resident #1 developed a nose bleed and bleeding in his urine on 4/26/12 at which time it was discovered the resident did not have evidence of a PT/INR done while in the facility. Results of a PT/INR drawn on 4/26/12 revealed it was critically high, greater than 10 (target range for Resident #1 was 2-3). The resident received an injection of Vitamin K to help the blood to clot. Record review revealed on 4/27/12, a follow-up PT/INR was done and showed results of PT 150 and INR "unable to calculate" (critically high). The resident received another dose of Vitamin K and transferred to the hospital for evaluation approximately 20 minutes later related to complaints of a headache and bleeding from the gums. Record review revealed the resident admitted to the facility from the hospital on [DATE] with multiple medical [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Interview with Staff A (admitting nurse) on 4/30/12 at 3:10 p.m. revealed she verbally verified the hospital discharge orders by telephone with the physician on 4/8/12. When she entered the orders into the computer, she then noticed the resident was on [MEDICATION NAME] and did not have an order for [REDACTED]. Review of physician progress notes [REDACTED]. Documentation under assessment revealed, in part, "[MEDICAL CONDITION] in good control but needing to continue oral anticoagulation. Will monitor and adjust accordingly to maintain INR between 2-3". There was no evidence of an order for [REDACTED]. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 4/26/12 [MEDICATION NAME] was placed on hold related to bleeding described above. There was no evidence licensed staff giving the [MEDICATION NAME] each day noticed there was no order for PT/INR and no PT/INR tracking flow sheet (per facility policy dated 11/2010). Review of the facility's "[MEDICATION NAME] Therapy Guideline"dated 11/2010 with Staff B (care manager) revealed paragraph #11 indicated all residents on [MEDICATION NAME] therapy would be evaluated by the care manager for appropriate routine lab draws and would request them from the attending physician. Staff B stated the evaluation would be done in the form of an audit of each resident that was taking [MEDICATION NAME]; however, frequency of audits was not directed by policy. Staff B confirmed there were no audits completed during the time period 4/8 - 4/25/2012. Staff B confirmed that each resident on [MEDICATION NAME], as per the above policy, paragraph #5, would also have a flow sheet for [MEDICATION NAME] therapy initiated. There was no evidence a monitoring flow sheet was initiated for Resident #1. Interviews with 4 licensed nurses on 4/30/12 between 1:15 and 4:15 p.m. revealed each staff stated if a resident was taking [MEDICATION NAME] and did not have an order for [REDACTED]. 2. Review of Resident #2's PT/INR flow sheet dated 3/30 - 4/30/12 revealed the resident admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. On 5/1/12, review of the PT/INR flow sheet revealed there was no documentation of the result from 4/30/12. Staff C (care manager) reviewed the lab book and saw that it was drawn as scheduled on 4/30/12. Staff C found the lab slip on the counter in the nursing station which indicated it had been received by fax during the afternoon of 4/30/12. The PT/INR result was 1.37. There was no evidence the physician had been notified as per facility protocol. Staff C contacted the physician on 5/1/12 and received an order to increase Resident #2's [MEDICATION NAME] dose to 11mg each day. On 5/2/12 at 9:00 a.m. during telephone interview, Staff B (care manager) informed the investigator she interviewed Staff D (licensed nurse). Staff D stated she received the results via fax and left a telephone message for the physician during the evening of 4/30/12. Staff D did not hear back and did not follow up with the physician or alert the following shift nurse to follow up. There was no documentation of the PT/INR results or that the physician was notified. Staff D gave Resident #2 the 10 mg of [MEDICATION NAME] on 4/30/12 that was already ordered based on the previous PT/INR result. The facility did not ensure professional standards of practice were followed related to Resident #1 receiving daily [MEDICATION NAME] without PT/INR monitoring which resulted in complications of bleeding and did not ensure staff followed up with a physician per facility protocol for Resident #2 related to a low PT/INR which resulted in a change to the [MEDICATION NAME] dose.

Based on observation, interview and record review the facility failed to permit 1 of 7 Sampled Residents (#1) to exercise her rights as a resident of the facility to review her prescribed medication. This failure resulted in actual harm of emotional distress and frustration for Resident #1. Findings include: Observation on 02/15/12 at 9:30 a.m. revealed Resident #1followed Staff C in the hallway; Resident #1 was tearful and repeatedly stated Staff C threw out the wrong medication. Staff C insisted she did not throw the wrong pill away. She eventually yelled at the resident and refused to show her the medication cards. Interview with Resident #1 on 02/29/12 at 3:45 p.m. revealed during medication administration on 02/15/12 all of the resident ' s medication were presented in a medication cup. Resident #1 requested the nurse hold the anti-nausea medication, Staff C removed a pill from the cup. Upon further inspection of the cup Resident #1 believed Staff C removed the wrong medication; a medication she needed instead of the anti-nausea pill. The resident asked the nurse to pull the medication cards so she can verify what pills were in the cup. Resident #1 said the nurse adamantly refused to accommodate her request. Interview with Staff C on 02/15/12 at 7:30 a.m. revealed she was new to the facility. It was her third day working and she just worked the previous night. Statement written by Staff C dated 02/15/12 indicated Resident #1 requested an anti-anxiety medication. Upon administering the medication, the resident indicated she did not want the anti-nausea medication. Staff C indicated the resident "exhibited manipulative, drug-seeking behavior". Staff C also indicated Resident #1 was " anxious and insisting she knew what the medication looked like " and Staff C threw away the wrong medication. Staff D asked Staff C to verify the medication and again Staff C declined. Resident #1 ' s medications were in blister pack cards (each pill individually sealed in a transparent cover permitting observation of the medication). The resident requested to look at the medication cards to verify the medications given to her were indeed the correct medications. Staff C refused to show Resident #1 the medication cards dismissing her requests and concerns. See F225 for evidence of Resident #1 not being treated with respect and being yelled at resulting to mental anguish. .

Based on observation, interview and record review the facility failed to implement measures to prevent development of a pressure ulcer for 1 of 3 Sampled Residents (#1) reviewed who had pressure ulcers. The facility failed to obtain physician orders, initially assess and care plan use of leg splints which resulted in development of a pressure ulcer and constituted harm for this resident. Findings include: An admission Minimum Data Set Assessment (MDS, an assessment tool) dated 5/6/11 identified Resident #1 initially admitted to the facility on [DATE] following an injury requiring surgery and hospitalization . The assessment indicated the resident did not have any pressure ulcers at the time of admission to the facility. [DIAGNOSES REDACTED]. A physical therapy evaluation dated 4/29/11 documented Resident #1 had partial use of some upper extremity muscles and flaccid extremities in both lower extremities and used a wheelchair. On 4/29/11 staff used a pressure ulcer assessment tool that identified the resident at high risk to develop pressure ulcers. The facility care plan dated 4/29/11 identified the resident required total assistance from staff for bed mobility, transfers, personal care. The care plan included interventions for ulcer prevention that included frequent turning while in bed, floating and protecting heels, daily skin checks during care and weekly skin evaluations. During observations on 8/23/11 at 2:50 p.m., Resident #1 lay in bed on a specialty air mattress with the head of bed elevated approximately 45 degrees. Both of the resident's lower legs were elevated at the end of the bed on top of a foam wedge. Both feet and ankles were individually wrapped in a heavily padded, soft, blue covering. A pillow placed beneath the lower part of the legs elevated both feet off the mattress. On 8/24/11 at 8:15 a.m. Staff D who reported providing care for Resident #1 since the time of admission. Staff D reported, upon admission, staff placed Podus boots (a specialty foot splint that elevates the heel to prevent formation of heel ulcers) on both of the resident's feet every evening when the resident went to bed and removed them in the morning when the resident got up. During this interview Staff D showed the surveyor the pair of Podus boots worn by the resident. The boot had a hard band that looped around the heel section of the foot to prevent pressure by floating the heel. Staff D pointed to the hard spot and reported the back of Resident #1's heel rested on that spot and the resident developed a blister at that location. On 8/24/11 at 10:10 a.m., Staff B changed a dressing on Resident #1's left foot that exposed a wound located behind and above the resident's left heel (Achilles heel). Staff B removed tissue covering the wound and exposed a red wound bed and reported it would "heal better if I can get the dead stuff off." Staff B reported the wound measured 1.0 cm by .6 cm (cm, 2.54 cm = 1 inch). A facility investigation conducted to determine the cause of Resident #1's blister documented on 5/13/11, Staff D informed licensed staff of a concern found following removal of the resident's Podus boots. The investigation documented staff noted a new, in house acquired, intact blister on the left Achilles heel that measured 5 cm by 2 cm. Staff then checked the resident's right leg and noted a 1 cm by 0.3 cm red area on the left Achilles heel. The investigation documented the resident reported "I don't feel anything." The investigation concluded the resident wore Podus boots in bed for heel pressure relief and they caused pressure to the Achilles areas. The investigation noted the resident had a specialty mattress in place since admission as a prevention measure. During an interview on 8/23/11 at 2:50 p.m., Licensed Staff C reported when Resident #1 wore the boots, both heels were floated but the inside of the splint placed pressure on the Achilles heel. Staff C reported nursing staff discontinued their use when they discovered the blister on the resident's Achilles heel. On 8/24/11 at 9:50 a.m., Staff C reported when "I looked at the boot I determined it was not padded enough." Facility pressure sore progress records identified the left Achilles blister resulted from pressure and documented monitoring of a pressure ulcer that developed. On 5/17/11, five days after discovery of the left Achilles blister, the blister opened and developed into a Stage 2 pressure ulcer (partial thickness skin loss involving upper layers of the skin that presents as a shallow crater) that measured 3.5 cm by 3.0 cm. On 5/26/11, the facility identified the wound progressed to a Stage 3 pressure ulcer (full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia). The wound, covered with slough, measured 3 cm by 2 cm by 0.1 cm. Following daily wound treatments, the pressure ulcer remained coded at Stage 3 through 8/17/11. By 8/23/11 skin notes documented the area coated with a "light brown colored scab." Resident #1's medical record contained no evidence the physician ordered use of Podus boots or staff initially assessed the resident for their use prior to implementation to ensure they did not contain any pressure points that could lead to development of a pressure ulcer. No plan of care was found that identified how staff were to position the resident's legs in bed with boots on to prevent pressure on the lower back of the leg or if they were recommended with use of the specialty mattress the resident lay on. On 8/24/11 at 11:35 a.m., Staff C reported and confirmed Resident #1's medical record did not contain a physician order [REDACTED].#1's Achilles blister was avoidable. The facility applied Podus boots to Resident #1 prior to obtaining a physician order [REDACTED]. As a result, on 5/13/11, after wearing Podus boots for two weeks, Resident #1 developed a blister that later developed into a Stage 3 pressure ulcer. Although considerably improved, the ulcer remains unhealed more than three months later and requires daily wound treatment.