Every finding on record at Avamere Olympic Rehabilitation of Sequim

Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to provide assistance in a timely manner without long wait times, as evidenced by facility grievance records, and staff and resident interviews for 2 of 3 units (Units 1 and 3) reviewed for care related concerns. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included.Review of the facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed 09/2025, showed the facility would provide sufficient staff to assure resident safety, maintain their highest practicable well-being, and meet resident needs. Minimum staffing requirements imposed by the state would be adhered to but were not necessarily determinant of sufficient staffing; other factors included resident physical and cognitive limitations and acuity of the population. On 05/18/2026 at 2:41 AM, The State Agency received information regarding concerns for inadequate staffing and conditions that reduced staff's ability to meet required care standards. The report indicated that management was aware of the concerns but failed to make any changes in staffing.Grievances Review of the facility grievance log for 05/16/2026 through 06/15/2026 showed four resident grievances related to call light response time and one grievance related to missed showers. Four of the five grievance were on Unit 1. The grievances were as follows:On 05/15/2026, Resident 1 reported call light times had been longer than usual. Review of the call light audit showed that Resident 1 had call light wait times up to 23 minutes. On 05/28/2026, Resident 2 reported he had long call light wait times. Review of the call light audit showed call light wait times up to 35 minutes. On 06/01/2026, Resident 3 reported they had been having an ongoing problem getting their Monday showers. Review of Resident 3's shower Task report for 05/15/2026 to 06/15/2026 showed they did not receive their shower on Monday 06/01/2026. On 06/10/2026, Resident 4 reported it took over an hour for someone to answer their call light the night before. Review of the call light audit showed that Resident 4 had wait times of up to 17 minutes. On 06/12/2026, Resident 5 (unit 3) reported floor staff told them they had 20 minutes to answer their call light, but resident had a medical condition that made it difficult to wait that long to be assisted to the bathroom and he was unable to get there by himself. Review of call light audit showed Resident 5 had call light wait times of up to 34 minutes, with an emergency call light response time of 13 minutes.Review of the Resident Census, dated 06/15/2026, showed there was a total facility census of 70, with 37 residents residing on Unit 1.Review of information provided by Staff B, showed Unit 1 had 19 residents that transferred by mechanical assistance and required two staff members. Review of the staffing schedule for Monday 06/15/2025 showed that there were three Nursing Assistants (NAs) assigned to Unit 1 for day shift. InterviewsOn 06/12/2026 at 5:39 PM, a reporter who wished to remain anonymous, said the staffing concerns were mostly on the long-term side of the building, Unit 1, where there were more heavy care residents requiring mechanical lifts and staff assistance for activities of daily living. Resident 4 was admitted to the facility on [DATE]. The admission minimum data set (MDS), an assessment tool, dated 06/12/2026, showed Resident 1 was cognitively intact.On 06/15/2026 at 2:47 PM, Resident 4 said call light times were anywhere from ten minutes to two hours and seemed to be worse at shift change. On 06/15/2026 at 2:54 PM, Staff E, NA, said they usually have 10-13 residents to provide care for on their shift and did not always have time to complete all of the tasks assigned, especially charting. Staff E felt there was not enough staff to provide timely care to the residents, especially Mondays when there were usually only three NAs scheduled on the unit. Staff E said they were not always able to take a lunch break in order to meet resident needs. Staff E said they had the opportunity to let management know there was not enough staff to meet resident needs, but there had not been a response.On 06/15/2026 at 2:59 PM, Staff D, Licensed Practical Nurse, said they were able to complete all tasks assigned to them but did not feel there was enough NAs assigned to the unit. She said, she did the best she could to help them. Staff D brought this to management's attention, and they were instructed to encourage, better time management.Resident 5 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 5 was cognitively intact. On 06/15/2026 at 3:10 PM, Resident 5 said, call lights were usually answered in about 20 minutes, sometimes longer. Resident 5 said he recalled waiting 30 minutes on some occasions. Resident 5 said once he had a call light on and requested to go to the bathroom and the nursing assistant asked if he could wait until they had finished passing meal trays . he could not. Resident 1 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 1 was cognitively intact. On 06/16/2026 at 1:55 PM, Resident 1 said they did not really use their call light much, but the response times depended on how many other residents needed help at the time. Resident 1 said they did not think there was enough staff to meet resident needs, they said there were two staff assigned to this hall and they really needed three. On 06/16/2026 at 2:50 PM, Staff C, Registered Nurse (RN), Resident Care Manager, said he believed that staffing was determined by the census and meeting state requirements. He did feel Unit 1 would benefit from more staff to better meet the acuity of the unit and meet resident needs timely. Staff C has heard from Unit 1 staff that they need more help, and he has reported it to Staff A and B. The response was that the unit was adequately staffed. Staff C said he would not expect residents to wait 20 minutes or longer for a call light to be answered. Staff C said the facility did not use agency staff.On 06/16/2026 at 3:34 PM, Staff B, RN, Director of Nursing Services, said they had a weekly meeting to discuss staffing, and Staff A, Administrator, lets them know how many staff they can have based on census, however the numbers can change based on needs and acuity. Staff B reported she had not heard directly from staff that Unit 1 may require more staff. Staff B said they generally felt the unit was adequately staffed but at times residents may be more needy and have frequent call lights and that gets stretched sometimes. Staff B said they would not expect residents to wait 20 minutes for call light response and would prefer to have more staff available to meet resident needs in a timely manner. Staff B said the facility did not use agency staff. On 06/16/0206 at 4:04 PM, Staff A, Administrator said staffing was a collaborative conversation between himself and Staff B. Staff A said staff had reported to him that they needed more help on the floor, stating, whether there is two or ten on the floor there is the impression there could be more. Staff A said they have tried to staff a fifth person on Unit 1 when they can. Staff A said they have tried to have supplies ready for staff and worked with staff regarding time management. Staff A said he did not expect residents to wait 20 minutes to receive assistance from staff but felt those were outliers, or events that pull staff away once in a while. Staff A said they were working on a contingency plan to manage staffing when there were call-ins, they do not use agency staff as they were not needed and felt there was enough staff to meet resident needs. Reference WAC 388-97-1080 (1) (9)

Based on interview and record review, the facility failed to provide bowel care in accordance with provider orders and the facility's bowel protocol for 2 of 4 residents (Resident 1 & 2) reviewed for bowel management. This failure placed residents at risk for abdominal pain/discomfort, decreased appetite and other potential health complicationsFindings included. Review of the undated facility policy titled, Bowel Protocol for Constipation, showed that additional interventions would be initiated on Day 3 for a resident not having a recorded bowel movement (BM). Interventions included use of a stool softener or stimulant laxative, if no results on day 4, MiraLAX or Milk of Magnesia would be initiated, day 5 use of a suppository and day 6 administration of an enema. Resident 1Resident 1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 01/24/2026, showed Resident 1 had severe cognitive impairment, required substantial to maximum assistance for transfers to the toilet, and was frequently bowel incontinent. Review of the bowel and bladder evaluation, dated 10/27/2025, showed Resident 1 was not aware of his toileting needs, incontinent of stool on a daily basis, and required the assistance of two staff for toileting. Review of Resident 1's Bowel record for January 2026 showed no recorded Bowel Movement on 01/25/2026, 01/26/2026, 01/27/2027 and 01/28/2028. Review of Resident 1's Medication Administration Record (MAR) for January 2026 showed no as needed bowel medications were administered on 01/27/2026 or 01/28/2026. Resident 1 discharged to home with spouse on 01/28/2026. Review of the discharge instructions showed no documentation of the need for, or education to the spouse regarding Resident 1's constipation.Review of the Hospital admission record for Resident 1, dated 01/29/2026 showed the resident was admitted to the hospital with admitting diagnosis including small bowel obstruction, constipation, and other impaction of the intestine. On 04/14/2026 Resident 1's spouse said the resident discharged home and about an hour later started puking, the next day he was admitted to the hospital and he was impacted. The facility never told me he was constipated and had not had a BM. Resident 2Resident 2 was admitted to the facility on [DATE]. The admission MDS showed the resident was cognitively intact, required partial to moderate assistance for toileting, was continent of bowel and constipation was present. Review of the bowel and bladder evaluation, dated 04/17/2026, showed Resident 2 was always continent of bowel and required two staff to assist with toilet transfers. Review of Resident Bowel record for 04/18/2026 through 05/16/2026 showed no documentation of a bowel movement for 05/07/2026 through 05/16/2026. Resident 2 discharged home on [DATE].Review of Resident 2's May 2026 MAR, showed no as needed bowel medications were documented as given during the last 10 days of their stay. On 05/19/2026 at 2:02 pm, Staff E, Nursing Assistant (NA), said residents were monitored for constipation by documenting BMs in the PCC (the electronic health record -EHR) task record. If a resident does not have a BM in 3 days, the nurse is alerted and they make a BM list for the nursing assistants. On 05/19/2026 at 3:00 pm, Staff D, Licensed Practical Nurse (LPN), said the NA's notify the nurse if a resident has not had a BM in 3 days as well as there is a dashboard alert if there has not been one documented, although that can sometimes be false if a resident is independent with toileting; staff would need to ask the resident so it can be logged. If a resident has not had a BM in 3 days they can give a variety of things such as prune juice, various bowel medications, a suppository or an enema. Staff D said if a resident has not had a BM in 3 days and was discharging home with spouse on day 4, they would expect they would have received some medication to assist with constipation or sent home with them and the spouse to be informed, stating, Yes, definitely, I don't think an impaction would be very comfortable.On 05/19/2026 at 3:12 pm, Staff C, Resident Care Manager, Registered Nurse (RN) said, Residents are monitored for constipation with the NA's documenting in PCC and the nurses will get an alert on their dashboard if they have not had a BM in 3 days, they would initial bowel protocol. Staff C said they would expect a resident discharging on day 4 of no BM to be given something prior to discharge, if they received meds prior to discharge, and the spouse to be educated regarding. On 05/19/2026 at 3:39 pm, Staff B, Director of Nursing, RN, said they monitor residents for constipation by NAC staff documenting bowel movements in the EHR. If there were no bowel movements documented, it alerts the nurse. Staff B said it was harder to keep track with residents who were self-directed and take themselves to the toilet. Staff B said the bowel protocol was different for each shift and included MiraLAX, colace and enemas and would be documented in the MAR if administered. Staff B said they would expect a resident who had not had a BM in over 3 days and discharging home on day 4, to receive medication for constipation and their spouse to be informed. Reference WAC 388-97-1060

Based on interviews and observations the facility failed to provide a clean, homelike environment for 2 of 5 (East, West) shower rooms reviewed for clean and homelike environment, by not maintaining the condition and appearance of the room to meet expected standards. These failures place residents at risk for potential exposure to unidentified substances, diminished mood, and a diminished quality of life. Findings included.Review of the facility policy titled, Homelike Environment, revised February 2021, showed the facility would provide to its residents, a clean, sanitary, and orderly environment that reflected a homelike setting. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/21/2025 showed the resident was cognitively intact and medically complex. Resident 1 discharged to home on [DATE]. On 02/13/2026 at 12:15 PM, Resident 1 said during their stay at the facility they were concerned with the shower room. Resident 1 said it lacked cleanliness and had an odor and had dirty linen left over from previous use. This left him feeling he did not want to take another shower until he discharged home. On 02/18/2026 at 11:59 AM, observations of Shower Room West, located on Grey Wolf Hall, showed deep scratches on the toilet seat with brown and beige encrusted particles lodged in the crevices. Black matter in the tiles of the shower stall to the left wall, and black matter in the crevice between wall and tiles underneath the sink, nearest the corner.On 02/18/2026 at 12:07 PM, observations of Shower Room East, located on Dungeness Hall, showed a used, wet washcloth underneath the sink, the trash can was full of trash with the lid in an open position and black matter observed around the base of the toiletOn 03/18/2026 at 11:53 AM, observations of Shower Room West, located on Grey Wolf Hall, showed deep scratches in the toilet seat, black substances on the tiles' edges surrounding the bottom of the shower floor, and under the sink near the wall in the corner. During observation and interview on 03/18/2026 at 12:40 PM, Staff D, Housekeeping supervisor, said the shower rooms were mopped every day and deep cleaned once a week. Staff D said, they scrubbed the grout weekly, but it was hard to keep up with it due to the age and ill repair of the bathroom. Staff D said they reported their concerns to the previous administrator and Staff E, the maintenance director. Staff D said they believed the substance to be mildew. When asked why it keeps coming back, Staff D said they suspected there was mold behind the walls. Observation of the corner of the wall, near the heater, in Shower Room [NAME] on Dungeness Hall showed an area of wall near the floor to be soft and spongy when pressed on and there was a black substance along both edges with peeling and bubbling to the wall above it. Staff D believed the black substance to be mold saying, this is mold, and there is most likely colonization in the wood behind the wall.On 03/18/2026 at 12:47 PM, observations of the Shower Room East located on Dungeness Hall, showed a used wet washcloth in the corner of the shower stall, and the head of the shower touching the floor. The floor had black and pink matter visible. Black matter was observed going down the lines of the tiles behind a metal plate. The toilet seat was observed with visible scratches on the seat and black matter around the base of the toilet on the floor. Resident 2 was readmitted to the facility on [DATE]. The quarterly MDS, an assessment tool, dated 12/20/2025 showed the resident was cognitively intact. Resident 2 resides on Dungeness Hall. On 03/18/2026 at 1:14 PM, Resident 2 said they did not use the shower room on the Dungeness Hall because the last time she was in there, it was a mess, and the handle broke off, and the temperature doesn't stay steady it goes from hot to cold, they need to fix the showers. Resident 2 prefers to use the shower room located on Unit 2. On 03/18/2026 at 1:55 PM, Staff C, Infection Control Nurse, Registered Nurse (RN), said she had not been in the shower rooms on Grey and Dungeness Halls for quite some time, she was not aware of a black substance in there, but did recall that Staff E had done a full fungicidal spray and let it soak for a while. Staff C could not recall how long ago that was. On 03/18/2026 at 2:01 PM, Staff B, Director of Nursing, RN, said she had been able to inspect the shower rooms and that staff had reported a problem with mold in them, because there was no vent and they had to keep the door closed. Staff A was not aware if there had been any testing for the presence of mold. When asked if the shower rooms represent a clean, home like environment, Staff A said the rooms are old and look worse than they really are.On 03/18/2026 at 2:06 PM, Staff E, Maintenance Director, said housekeeping staff had told him they were having trouble keeping the tiles clean and handling the build up. Staff E said they were not sure what the black substance was, it could be some type of growth or staining. Staff E said they had not tested for mold. When asked if the shower rooms represent a clean, homelike environment for the residents, Staff E said, they could be better.On 03/18/2026 at 2:16 PM, Staff A, Administrator, said the shower rooms were clean, but they were old and could be improved. Reference WAC 388-97-0880

Based on observation, interview and record review, the facility failed to adequately and consistently assess developing/worsening skin conditions/breakdown, follow the care/treatment plan and interventions as ordered, and report changes to medical provider in a timely manner for 1 of 1 sampled resident (Resident 24) reviewed for pressure ulcers. Resident 24 experienced harm when their Moisture Associated Skin Damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to moisture) on their coccyx (tailbone) that was present on admission to the facility worsened and developed into two unstageable pressure ulcers (PU - a type of wound where the depth cannot be determined due to the presence of dying tissue or eschar, making it difficult to assess the extent of tissue damage) over the coccyx and left buttocks, which showed signs of infection and caused an increase in pain levels and a diminished quality of life. Findings included .The facility's policy titled Skin and Wound Management, dated November 2025, documented: .2) the Nurse Manager and/or designee will evaluate any new skin integrity and document findings in the clinical record. 6) skin checks are completed by the Licensed Nurse weekly. 7) if a Resident is identified to have a new skin alteration the Licensed Nurse will document in the resident record the evaluation of the wound, provider notification and obtain treatment orders. 8) Skin documentation of wounds or pressure injury identification is complete in the resident's record. An assessment will be complete for each area. Areas include, but not limited to pressure injuries.10) Actual pressure injuries. wounds will have weekly documentation that included measurements and how the wound is progressing (improvement, worse unchanged).On 12/01/2025 at 1:13 PM, Staff W, Receptionist, emailed to the department, the full resident Matrix (list of all residents and identified care concerns). The Matrix, dated 12/01/2025, documented that no one in the facility had any pressure ulcers, either admitted with or facility acquired. Resident 24 was admitted to the facility on [DATE]. The admission Minimum Dat Set, (MDS, an assessment tool) dated 11/19/2025, documented Resident 24 was cognitively impaired, was dependent on staff for all cares and admitted with an unstageable pressure ulcer on the right heel and MASD on their coccyx.Resident 24's skin integrity care plan, dated 11/13/2025, documented Resident 24 had an open area buttocks (sacrum) 1.5 cm [centimeters] x 0.5 cm and also made note of a right heel concern with measurements documented. Care plan interventions included: .-Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocol for treatment of injury. -LN [Licensed Nurse] to complete weekly skin assessment.-Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx [signs and symptoms] of infection, maceration [breakdown] etc. to MD [Medical Director].-Obtain blood work such as CBC with Diff [Complete Blood Count with Differential is a comprehensive blood test that provides valuable information about the different components of your blood], Blood Cultures and C&S [culture and sensitivity] test, a laboratory procedure used to identify specific microorganisms, such as bacteria or fungi, responsible for an infection and to determine their susceptibility to various treatments] of any open wounds as ordered by Physician.-Patient has a LAL [low air loss - used for reducing moisture and pressure] mattress to protect the skin while in bed. Check settings every shift. [no setting parameters were documented/ordered]-[Resident 24] has pressure relieving/reducing wheelchair cushion to protect the skin whileup in chair.A physician's order, dated 11/13/2025, documented to cleanse the buttocks with wound cleanser, pat dry, and apply foam dressing, to change daily for skin care and PRN [as needed] for soilage/loosening and to notify the provider of any changes. A physician's order, dated 11/15/2025, documented weekly skin assessment to be completed, with a 'N' for no new skin issues and 'Y' for new skin issues.A physician's order, dated 11/15/2025, documented weekly skin assessment to be completed, with staff to check a 'N' for no new skin issues and 'Y' for new skin issues on the form.A Weekly Skin audit, dated 11/15/2025, showed a right elbow skin tear marked as being noted with no other skin conditions documented.A physician's order, dated 11/17/2025, documented a LAL mattress for skin care and for staff to check pressure and settings every shift for safety was ordered. No LAL mattress settings were included in the order.A Daily Skilled progress note, dated 11/19/2025, documented Resident 24's skin was intact and had no wounds present.A Weekly Skin audit, dated 11/22/2025, had skin irregularities marked as being noted, but no new irregularities. Documentation included a skin tear to the right elbow, right hip incision and right heel blister. There was no documentation regarding condition of skin of the coccyx.A Weekly Skin audit, dated 11/29/2025, had skin irregularities marked as being noted, but no new irregularities. There was no additional documentation about Resident 24's skin conditions. A Daily Skilled progress note, dated 11/30/2025 at 7:41 PM, documented resident has a pressure injury, wound with no signs and symptoms of infection present with small amount of drainage, physician orders in place for daily dressing change. This was the first documentation that showed a change from MASD to pressure injury. The electronic health record (EHR) showed no documentation the MD had been notified of a change in Resident 24's skin condition.On 12/01/2025 at 2:52 PM, Resident 24 was observed seated in their wheelchair and said they had been waiting two hours for staff to come and get them back in bed. Resident 24 said they were in pain, from sitting in the wheelchair for so long, due to having a pressure ulcer on their buttock. At this point staff walked into the room and transferred Resident to the bed. An additional observation was made of a standard foam mattress on Resident 24's bed, no LAL mattress was in place.On 12/01/2025 at 3:33 PM, Resident 24 was observed lying in bed on their back.On 12/02/2025 at 8:22 AM, Resident 24 was sitting in bed at a 45-degree angle. Resident 24 said they had a pressure ulcer on their buttock, felt it was getting worse, and it had been causing more pain. Resident 24 said they had been waiting for the new air mattress to arrive to help relieve the pressure on their buttock. Resident 24 was observed on a standard foam mattress. No Low Air Loss (LAL) mattress was in place. Daily observations from 12/01/2025 through 12/04/2025 showed Resident 24 had a standard foam mattress pad on their bed. Review of two Wound Evaluations, completed by facility (in house) wound team staff, both dated 12/02/2025, documented Resident 24 had 1. MASD located in the middle of coccyx 3.5 cm x 0.7cm x 0.2cm (larger then when admitted ), 2. MASD located Right inner buttock 2.3cm x 0.8 cm x 0.2cm, serous (a type of fluid that comes out of a wound with tissue damage) and the area was now two distinct areas, documented as caused from MASD which would be followed weekly by [in facility] wound team until resolved. The EHR documented the areas were identified as pressure injuries three days prior, on 11/30/2025. The EHR showed no documentation the MD had been notified of these evaluations/change in skin condition. During observation of Resident 24's wound and wound care on 12/04/2025 at 10:53 AM by Staff T, Registered Nurse (RN) and Staff R, Infection Preventionist (IP), Staff T removed the old foam dressing and said the wound(s) smelled like fish. Staff T said there were now two distinct open areas on the coccyx/buttock.On 12/05/2025 at 8:50 AM, Resident 24 was sitting up in bed, at a 45-degree angle, with a bedside table across their lap. Resident 24 said they received the LAL mattress the day prior and they were not sure if it was relieving any pressure because their buttock was still painful. The LAL mattress was observed with a control box attached to the end of the bed. The settings on control box were marked at 75 pounds. On 12/05/2025 at 9:45 AM, Staff T, RN, said when there was a change in a resident's skin condition(s) the facility would monitor for redness, if it was non-blanchable or there were open areas they would notify the physician, resident care manager (RCM), and wound team [an in-house team]. Staff T said if it was a new skin condition, staff would document it in a progress note, complete a skin incident worksheet, update the resident's record and notify the RCM, Assistant Director of Nursing Services (ADNS), and Director of Nurse Services (DNS). Staff T was asked about the wound(s) on Resident 24's buttock. Staff T said Resident 24 had two wounds on their buttock, that they would assess them to be Stage 2 pressure ulcers; one on the coccyx and another on the left buttock, both with a wound base of 90% slough (dead tissue that appears in wounds and can hinder healing). When asked about staging and 90% slough on the wound beds, Staff T said they did not stage/assess wounds, that was the responsibility of the wound care team. When asked if the wounds would be considered MASD, Staff T stated, no, they are pressure ulcers. Staff T was asked to review the 12/02/2025 Wound Evaluations. When asked if the evaluations were correct, Staff T said no, the wounds were not MASD, they were pressure ulcers, the wound evaluation was incorrect. Staff T said Resident 24 had one pressure ulcer upon admit (on the heel) and now had three (one on the heel, one on the coccyx and one on the left buttock). On 12/05/2025 at 11:15 AM, Staff K, Residential Care Manager (RCM), said when a staff member has identified a new or change in an old skin condition, they were to notify the RCM, ADNS and DNS, who would evaluate the wound and notify the MD. Staff K said themself and Staff C, Assistant Director of Nursing Services made up the wound care team. The resident would then have weekly skin assessments and would be followed by the wound care team. Staff K was asked about Resident 24's admitting skin conditions. Staff K said Resident 24 had red, flaky skin on his coccyx, it was assessed as MASD and a large blister on the heel assessed as an unstageable deep tissue injury, due to not being able to assess what was beneath the wound. When asked about Resident 24's current wound(s), Staff K said the coccyx wound now had two wounds, but they had not reviewed the wound care treatment report and did not have any further information. When asked about slough, Staff K said there was no slough in prior assessments and did not know if there was slough currently. Staff K was unable to provide update or documentation about the wound observation on 12/04/2025. On 12/05/2025 at 12:11 PM, when asked about Resident 24's change of mattress, Staff T, RN, said they were not aware Resident 24 had a mattress change. Staff U, Certified Nursing Assistant (CNA) sitting at the nursing station, said they had changed the mattress out the previous day (12/04/2025), due to the old mattress malfunctioning. When asked how long the bed had been malfunctioning, Staff U said less than 24 hours. Review of Resident 24's November and December 2025 Treatment Administration Record (TAR), showed staff documented three times a day from 11/17/2025 through 12/05/2025, that they had checked the pressure and inflation setting on Resident 24's LAL mattress. Resident 24 had a standard mattress until 12/04/2025 when the LAL mattress arrived. A Weekly Skin audit, dated 12/06/2025, documented skin irregularities noted, but no new irregularities. Notes documented No new skin issues noted or reported. R [right] elbow has dry scab where old skin tear was. R elbow scab left open to air. R heel blister w serosang dng [serosanguinous drainage - mixed blood and serum] to old dressing of sm-mod [small to moderate] amount. Dsg [dressing] to R heel changed per order. Coccyx open area-wnl [within normal limits], L buttock open area wnl. This was the first weekly skin audit to document all of Resident 24's current skin conditions. A Daily Skilled progress notes, dated 12/06/2025 at 7:52 AM, documented resident has a pressure injury, wound with no signs and symptoms of infection wound bed with slough. physician orders in place for daily dressing change. The EHR showed no documentation the MD had been notified of the change in Resident 24's skin condition.On 12/08/2025 at 10:42 AM, Staff V, Maintenance Director, said he was informed about a request for an order form for a new bed for Resident 24. Staff V said he reviewed all the TELs requests for room [ROOM NUMBER] and the only order request found was from 10/12/2025 (one month prior to Resident 24' admit), regarding concerns that a bed would not go up and down. Staff V said the Maintenance Assistant replaced the control handle and sprayed the bed down to help with the bed going up and down and there had been no other problems reported with that bed since. Staff V said they had no order for a new LAL mattress on/about 11/17/2025, there were no reports of a broken control box or broken LAL mattress for Resident 24, and they had never installed a new LAL mattress until 12/04/2025. On 12/08/2025 at 10:46 AM, Staff B, DNS, said when there was a change in a resident's skin condition, they expected staff (if CNA) to notify the nurse, who would notify the RCM, ADNS, DNS, who then would notify the provider. When asked about Resident 24' skin conditions, Staff B said Resident 24 admitted with a pressure ulcer on their heel and MASD on the coccyx. Staff B said they were made aware that a second wound had developed on the coccyx area. Staff B was asked to review the Wound Evaluations and daily skilled progress notes. When asked about what the wounds were currently identified as (per the documentation), Staff B said they did not know because each report called them something different and they would have to look into it further. When asked what interventions were in place to prevent worsening or development of new pressure ulcers, Staff B said good nutrition, pressure-relieving boots, weekly skin assessments, LAL mattress, report skin conditions, pressure reliving cushion for chair, treatments as ordered and use caution to prevent striking arms and legs. When Staff B was asked about Staff T, RN, and Staff R IP, who completed the wound treatment, assessment of both wounds to be Stage 2's with 90% slough. Staff B said with 90% slough, the wounds would not be stageable and should have been documented as unstageable. When asked if there were any reports of Resident 24 reporting an increase in pain, Staff B said they did not know if there was an increase in Resident 24's pain. Staff B was asked to review the LAL mattress order and confirmed Resident 24 had an order for a LAL mattress on 11/17/2025 and for staff to check the LAL every shift. Staff B reviewed the EHR and found no documentation a LAL had ever been installed on 11/17/2025 and said they would have to check with maintenance. When Staff B was asked about the interview with Staff V who stated they had no order for a new LAL mattress on/about 11/17/2025. there were no reports of a broken control box or broken LAL mattress for Resident 24 and they had never installed a new LAL mattress until 12/04/2025, Staff B said they did now know Resident 24 did not have a LAL mattress and staff should not have been signing for a task they could not complete and stated, that was not acceptable.On 12/08/2025 at 1:04 PM, Staff K, RCM, was asked about the smell of fish reported during the wound care treatment. Staff K said that kind of smell would have been an indication of an infection, like Pseudomonas (a common cause of wound infections, particularly in immunocompromised patients, and can lead to serious complications if not treated promptly). Staff K said the only way to determine if it was an infection was to complete a culture test. When asked about notification to the provider about the change in Resident 24's skin conditions, Staff K said they had informed the provider on 12/02/2025 (two days prior to wound care treatment observation), in stand up (a clinical meeting). When asked to show documentation that the provider was notified, Staff K said they had no record the provider was notified. The EHR showed no documentation the provider was notified about Resident 24's change of skin condition as of this date, 12/08/2025 (four days after the wound care treatment observation). On 12/08/2025 at 1:22 PM, Staff R, IP, was asked about the smell reported during the wound care treatment on 12/04/2025. Staff R said the only way to identify the infection was to complete a culture of the wound. When asked if a culture had been ordered or completed, Staff R reviewed the record and confirmed no culture had been ordered or completed. On 12/09/2025 at 12:02 PM, when asked if they had been made aware of the concerns related to Resident 24' pressure ulcer, Staff A, Administrator, said they were told about the concern with the LAL mattress. It was explained that Resident 24 was documented to have a LAL mattress since 11/17/2025, but did not receive the LAL mattress until 12/04/2025, but staff had been signing off they were checking the setting three times a day. Staff A said signing for things staff did not actually complete was not acceptable. When Staff A was asked about the inconsistency in documentation regarding the diagnoses/staging of the skin conditions and the matrix, some of the documentation noting there were no wounds at all, the overall development and worsening of the pressure ulcers and no documentation that the MD had been notified were reported, Staff A said they were not aware of the concerns and said, that was not acceptable.Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to ensure residents were sent to the hospital with the required and necessary information to assure the safe transition of care for 3 of 3 residents (Residents 52, 81, & 1) reviewed for hospitalization. This failure placed residents at risk of incomplete emergency care, lack of services, lack of advocacy, and a diminished quality of care.Findings included. Review of the policy titled Transfer or Discharge, Preparing a Resident for, revised 12/2016, showed the policy did not include what documents were required to ensure the facility communicated appropriate and necessary information to the hospital when a resident was transferred. The policy documented, 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Further review showed the policy's last point outlined nursing services was responsible for preparing the discharge summary and post-discharge plan, and for providing this to the resident or their representative. The policy did not mention any information on requirements for documentation to be provided to the hospital; it outlined steps related to scheduled transfers or discharges but did not outline the steps required for an emergent or emergency transfer. Resident 52 Resident 52 was admitted to the facility on [DATE] and had diagnoses of benign prostatic hyperplasia (prostate gland enlarges, which can cause difficulty urinating and a weak stream), retention (bladder holds on to) of urine, calculus of ureter (hard mineral deposits in the urinary tract, also known as kidney stones), obstructive and reflux uropathy (blockage in the urinary system that prevents normal urine flow), and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/02/2025, showed Resident 52 was severely cognitively impaired, impaired with decision making, and dependent on staff for cares. Review of the electronic health record (EHR) showed before 10/25/2025, Resident 52 had a suprapubic catheter (an incision that was medically made through the abdomen which allowed a thin tube to drain the bladder) that would become clogged and needed regular irrigation. Resident 52 would sometimes refuse irrigation or changing of the catheter. Review of Resident 52's Treatment Administration Record for 10/18/2025 to 10/24/2025, showed Resident 52 had their suprapubic catheter changed on 10/19/2025, and the resident allowed staff to irrigate, with sterile water, the suprapubic catheter 12 out of 14 times. Review of Resident 52's nursing progress notes, dated 10/25/2025, showed nursing staff documented Resident 52 was sent to the Emergency Department (ED) for catheter placement. Nursing staff documented when they started their shift, Resident 52 was in extreme discomfort, they were unable to flush the (suprapubic) catheter, they bladder scanned the resident who had 179 milliliters (mls) of urine in their bladder and they removed the (suprapubic) catheter. The nurse documented, Not attempting re-cathing due to history of failed attempts. Further review of the EHR, dated 10/25/2025, showed no documentation of a report or handoff being called to the Emergency Department (ED) by the facility Review of Resident 52's ED Encounter showed the ED provider documented, Per EMS [emergency medical services] report, the patient's Foley catheter [conflicting with facility documentation] was discontinued this morning after staff determined it was not functioning properly. Since removal, no urinary output has been noted. Facility staff sent the patient to the ED for evaluation and possible placement of a suprapubic catheter. Patient is alert and oriented x4, GCS 15 [Glasco coma score, a tool used to determine level of consciousness, a score of 15 is the highest it goes indicating the resident had eye, verbal, and motor responses], and denies abdominal or flank pain, fever, chills, nausea, or vomiting. No history of trauma. Reports similar issues with catheter function in the past. Further review showed the provider documented, Discussed with patient that placement of a suprapubic catheter is not feasible in the emergency department on a Saturday night, as it is a planned procedure typically requiring sterile technique and urology involvement as it has been greater than a month since the last suprapubic has been in. Patient was initially hesitant to have a Foley catheter [also called indwelling urinary catheter - a thin tube that goes through the penis tip and into the bladder] replaced, expressing anxiety about the procedure. After discussion, 1 mg [milligram] IV [intravenous] Versed [a calming/ antianxiety medication] was administered for anxiolysis [anxiety relief]. Foley catheter was then placed with immediate return of clear yellow urine, confirming retention. Additionally, the provider documented the historians used were the patient and the chart. The provider documented Resident 52 would need a follow up appointment with urology for consideration of long-term suprapubic catheter. Review of Resident 52's After Visit Summary (AVS), dated 10/25/2025, showed the ED had scheduled a urology appointment for 07/10/2026 (9 months out) Review of Resident 52's nursing progress notes, dated 10/26/2025, showed nursing staff documented the ED called to give them report prior to transfer of Resident 52 back to the facility. The nurse was told that the suprapubic catheter could not be replaced due to the prolonged amount of time it was removed for, reported by EMS of over a month, and urology would need to see the patient. The nurse was informed that Resident 52 had a penile Foley catheter placed in the ED, and there was slight bleeding noted to the penis. The facility filled out a SNF/NF [Skilled nursing facility/nursing facility] to Hospital Transfer form (a document used by nursing homes to provide receiving facilities with the required information for transition of care) for 10/25/2025, which showed a creation date of 10/28/2025 (three days after initial hospitalization, after the resident was already back at the facility). This form had included information the facility was to provide the hospital at the time of transfer. Under the information for transfer section, staff documented, Other: catheter placement. Respiratory rate (taken 10/24/2025), temperature (taken 10/18/2025), and oxygen saturation (taken 10/24/2025) were documented from vitals taken on days prior to the day of transport on 10/25/2025, showing a complete set of vitals was not obtained before transfer. Under the resident/patient decision making capacity section, staff documented, Requires proxy and under mental status, documented, alert, disoriented, but can follow simple instructions. The form had information with contact information for Resident's 52's representative, contact information for who to call at the facility to get questions answered, and facility provider contact information. Under the report called in by (facility staff) and report called in to (ED staff) section, the fields were blank (no names were filled in). The form did not show any information on the size or type of catheter (suprapubic catheter) the resident had. There was a box on the form that was checked that selected urinary catheter. Further review of the EHR showed Resident 52's prior two hospitalizations, dated 04/25/2025 and 06/14/2025, showed the SNF/NF to Hospital Transfer forms were completed late, on 04/29/2025 and 06/16/2025 respectively. Review of nursing progress notes after the hospitalization, from 10/26/2025 to 12/04/2025, showed Resident 52 had complications with the penile Foley catheter, such as refusals for staff to change the penile Foley catheter, blood in the urine, and penile erosion (breakdown and loss of tissue on the penis, can cause sensitivity). The penile Foley catheter was also noted to have gone through the suprapubic site. A nursing progress note, dated 11/03/2025, documented moderate leaking and bleeding was observed under the monitor for signs of penial erosion. Another note on 11/03/2025, documented nursing found the tip of the penile Foley catheter was slightly protruding through the opening of the suprapubic catheter site (the Foley catheter went through the opening in the penis, up into the bladder, and out the hole in the abdomen), the penile Foley catheter was retracted (pulled back from the suprapubic hole and into the bladder), and urine began flowing again. On 11/06/2025, nursing documented there was signs of stress showing at the meatus (tip) of the penis, and wrote, would do better with SP [suprapubic] replaced. On 11/10/2025, blood was noted to be coming from the meatus. At this time, Resident 52's penile Foley catheter was removed and Resident 52 would not allow a new penile Foley catheter to be placed and held firmly onto his penis. Documentation showed Resident 52 had 7/10 (typically on a scale of 0-10, with zero being no pain and ten being the worse pain) suprapubic pain from urinary retention, which the provider explained would not go away until they replaced the penile Foley catheter, then Resident 52 agreed. On 12/04/2025, nursing documented there were signs of erosion to the underside of penis, with yellow/green discharge from the penis and continued bloody urine that appeared to be increasing. During an observation on 12/01/2025 at 11:17 AM, Resident 52's penile Foley catheter tubing was noted to have blood-tinged sediment in the tubing. During an observation and interview on 12/03/2025 at 11:59 AM, Resident 52's penile Foley catheter tubing was noted to have dark red drainage in 75% of tubing that was visualized. At 12:02 AM, Staff F, Registered Nurse (RN), said since Resident 52 had switched to the penile Foley catheter (no longer had the suprapubic), the output had been mucous like and bloody since. Staff F lifted the tubing in attempt to drain it and it was slow moving from the tubing into the drainage bag. The drainage bag was visualized with similar thick dark blood drainage. During an interview on 12/03/2025 at 1:51 PM, Staff E, Resident Care Manager/RN, said Resident 52 had dementia and did not have great cognition, he was able to know who he was and where he was but was not fully aware of the situation. Staff E said Resident 52 was not a candidate for a transurethral resection of the prostate (TURP, a procedure that trims away extra prostate tissue blocking urine flow) due to cardiac issues. During a follow up interview at 3:42 PM, Staff E said the facility did not have a way to accurately monitor and record hematuria (blood in the urine), and Resident 52 would need a urology appointment (scheduled for 07/10/2026) for a suprapubic catheter replacement. During an interview on 12/05/2025 at 12:41 PM, Staff D, Medical Doctor when asked next steps for Resident 52's catheter needs, said they expected urology to put the suprapubic catheter back, and it would be up to the urologist if they fixed or put in a new suprapubic ostomy (new opening), but most likely it would be a new suprapubic ostomy. During an interview on 12/08/2025 at 12:08 PM, Staff C, Assistant Director of Nursing (ADON)/RN, said they normally send residents to the hospital with a face sheet, the medication administration record, order to evaluate and treat, and usually that was all that was sent. Staff C said they sometimes included the treatment administration record but did not say this was provided for every resident. When asked for documentation of what was sent to the hospital about Resident 52's suprapubic catheter, Staff C, said there was no record of what was sent. When asked about the process for providing information, if it was only reported to EMS, Staff C said it was dependent on how busy staff were, and their expectation was for staff to call and give the ED a heads up. When asked about the SNF/NF to Hospital Transfer form, Staff C said nurses did not fill those out but that they personally filled out the form after residents went to the ED. Staff C said they had recently sent a few residents out to the ED, and they were not caught up with this form. When asked if they knew of anything being communicated to the ED about Resident 52's anxiety, refusals with catheter changes, or mental status, Staff C said no. During an interview on 12/08/2025 at 1:53 PM, Staff B, Director of Nursing Services (DNS), said their expectation regarding information from this facility to the hospital during hospitalization, was for residents to be sent with information of why they are being sent, their symptoms, and the transfer sheet. Staff B was told of Resident 52's hospitalization on 10/25/2025, that no documentation was found by staff that the facility provided the ED with pertinent information of the situation. Staff B said their expectation was that documentation should have been sent with the resident to the hospital. Resident 1 Resident 1 was admitted to the facility on [DATE]. Review of the Discharge MDS, dated [DATE], showed Resident 1 was transferred to the hospital, return anticipated. A 12/04/2025 7:47 AM nurse's note documented Resident 1 had increased confusion, a weight gain of 10 pounds in two days, adventitious (abnormal) lung sounds and was sent to the hospital for further evaluation. There was no documentation present to show facility staff provided required information to the receiving health care institution. Review of the EHR showed a SNF/NF to Hospital Transfer Form, dated 05/06/2025, two days after Resident 1 discharged . Resident 81 Resident 81 was admitted to the facility on [DATE]. The 5 Day MDS, dated [DATE], indicated Resident 81 had some difficulty making decisions regarding tasks of daily life in new situations only. Record review showed Resident 81 was transferred to the hospital on [DATE]. Review of the form titled, A Skilled Nursing Facility/Nursing Facility to Hospital Transfer, showed it was created on 09/08/2025, two days after resident 81 transferred to the hospital. On 12/09/2025 at 1:06 PM, Staff C, Assistant Director of Nursing/RN, when asked what documentation was sent with a resident when they were transferred to the hospital, Staff C said normally a Medication Administration Record, the Treatment Administration Record if pertinent, a face sheet, an order, and copy of the Physician Orders for Life Sustaining Treatment. Staff C said she had never sent a transfer form. When asked what is done with the Skilled Nursing Facility/Nursing Facility to Hospital Transfer form, Staff C said, the form was filled out after a resident left for the hospital, and the facility was not sending it with residents. 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 provide appetizing and palatable food for 7 of 24 sampled residents (5, 17, 24, 11, 84, 10, and 28) and 1 of 1 test tray sampled for food quality. The facility also failed to prepare pureed foods for residents following the written recipe to ensure the nutritional value was maintained. These failures placed residents at risk for a decline in nutrition and a diminished quality of life. Findings included .Resident Food1) On 12/01/2025 at 1:15 PM, Resident 5 said the food was cold.2) On 12/01/2025 at 12:38 PM, Resident 17 said they were the last to get their food on this hallway and sometimes it was cold. Resident 17 stated, I had a cold burger, and I sent it back.3) On 12/02/2025 at 8:37 AM, Resident 24 said the pasta was not thoroughly cooked and it did not taste good. 4) On 12/01/2025 at 1:06 PM, Resident 11 said they do not like fish but still gets it on their tray.5) On 12/02/2025 at 8:19 AM, Resident 84 said they have had burnt cake for dinner and sometimes the breakfast was cold.6) On 12/01/2025 at 2:57 PM, Resident 10 said the food was overcooked and they once got a grill cheese that was burnt.7) On 12/04/2025 at 9:47 AM, Resident 28 was observed with three burnt chicken tenders that were blackened on the outside. Resident 28 stated, I ate what I could around the burnt part.Test TrayOn 12/03/2025 at 1:50 PM, the shrimp on the test tray tasted dry and had a rubbery texture. On 12/03/2025 at 2:23 PM, Staff CC, Dietary Services Manager, stated we encourage visitors and families to try the food and let us know.On 12/08/2025 at 10:29 AM, Staff BB, Registered Dietician, said they heard about the burnt chicken tenders and the staff were educated on what was appropriate to serve the residents. Staff BB said her expectation was that the staff were managing temperatures on the tray line and making sure the food was palatable throughout the tray line. Staff BB said they have also educated the staff to pass the meals to the residents timely once the trays were out on the hallways.Pureed Food PreparationOn 12/03/2025 at 11:00 AM, Staff DD, Cook, was observed making pureed green beans in the blender. Staff DD added vegetable base and water to the green beans before starting the blender. When asked if the water and vegetable base were on the recipe, Staff DD said no. Staff CC, Dietary Services Manager, said to Staff DD, do what it tells you, it is supposed to be god's words.On 12/03/2025 at 11:13 AM, Staff DD said they had found faults in the recipes and measurements. Staff DD stated, I don't always measure everything.On 12/03/2025 at 12:44 PM, Staff DD was observed adding pump liquid thickener to the gravy while on the serving line. Staff DD pumped twice and mixed the gravy, then pumped twice and mixed it again. Staff DD pumped another two times and mixed the gravy again. On 12/03/2025 at 2:23 PM, Staff CC, Dietary Services Manager, when asked if the recipes were followed stated, I know what you are getting at. Staff CC said the vegetable base and water were not in the recipe for pureed green beans. Staff CC was asked if there was a recipe for the gravy and she said they do not usually use the liquid pump on the serving line. Staff CC said they did not know the measurements on the liquid pump, Staff CC stated, It could be a long pump or a short pump. I can't say. Staff CC said they would prefer the staff to use the powder thickener and mix it while on the counter. Reference WAC 388-97-1100 (1), (2)

.Based on interview and record review, the facility failed to ensure Minimum Data Sets (MDS, an assessment tool) accurately reflected residents' health status and care needs for 5 of 22 sample residents (Residents 7, 26, 2, 8 & 12) whose assessments were reviewed. These failures placed residents at risk for unidentified and/or unmet care needs and decreased quality of life.Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, version1.20.1, m October 2025, showed Respiratory therapy services included coughing, deep breathing, treatments, assessing breath sounds and mechanical ventilation, which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training. Providers should record services for Respiratory Therapy when the following criteria are met: The therapy was ordered by the physician. The physician's order included a statement of frequency, duration, and scope of treatment. The services must be directly and specifically related to an active written treatment plan that was based on an initial evaluation performed by qualified personnel. The services were required and provided by qualified personnel. The services must reasonable and necessary for treatment of the resident's condition. When developing the plan of care, the therapist or qualified personnel must determine the mode(s) of therapy and the amount of time the resident will receive. The therapist or qualified personnel should document the reason a specific mode of therapy was chosen as well as anticipated goals for that mode of therapy. Only medically necessary therapies, ordered by a physician, based on a qualified therapists assessment and treatment plan, that were documented in the resident's record, care planned, and periodically evaluated to ensure the provision and effectiveness of the treatment plan, should be coded. MDS personnel should review the resident's therapy evaluation and treatment records and consult with each qualified care provider to collect the information required for this item. Resident 7 Resident 7 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set, (MDS, an assessment tool), dated 10/21/2025, showed Resident 7 required the use of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder for continuous urine drainage), and did not have a diagnosis of neurogenic bladder (a condition where nerve damage to the brain, spinal cord, or peripheral nerves disrupts the signals controlling bladder function, leading to loss of control, incontinence, urinary retention, or incomplete emptying). The hospital Discharge summary, dated [DATE], documented Resident 7 had a diagnosis of neurogenic bladder with chronic suprapubic catheterization (catheter inserted through abdominal wall into bladder). On 12/09/2025 at 11:29 AM, Staff H, MDS Coordinator, said Resident 7's MDS was inaccurate and neurogenic bladder should have been coded as an active diagnosis. Resident 26 Resident 26 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the resident had diagnoses of stroke, heart dysrhythmias (an abnormal or irregular heartbeat) and asthma, and received anticoagulant medication and Respiratory Therapy services during the assessment. The assessment showed Resident 26 did not receive antiplatelet medication. Review of the November 2025 Medication Administration Record (MAR) showed Resident 26 received aspirin (an antiplatelet medication) on six of seven days during the assessment period. During an interview on 12/09/2025 at 11:29 AM, Staff H said Resident 26's MDS was inaccurate and needed to be modified to include antiplatelet medication. Record review showed Resident 26 had a physician order, dated 11/14/2025, that directed staff to provide incentive spirometry (IS, a handheld device to help you take slow, deep breaths, improving lung function, clearing mucus, and preventing complications like pneumonia, especially after surgery or with lung conditions) four times a day for asthma. The nurse was to document the total minutes it took to set up the incentive spirometer, perform patient education, and to complete pre and post respiratory evaluations. The order did not include the duration the therapy was to be provided for. Review of the comprehensive care plan, initiated 11/14/2025, showed no care plan that addressed Resident 2's respiratory therapy, the goals of treatment, the frequency, duration, or scope of treatment had been developed or implementedReview of the electronic health record (EHR) showed no documentation that Resident 26's had an initial evaluation performed by a respiratory therapist or trained respiratory nurse or that a written treatment plan was developed. Review of the IS treatment on the December 2025 MAR, showed for the pre- and post-respiratory evaluations staff were provided a space to document the following six assessments:a) Under IS staff documented the volume of air the resident was able to inhale into their lungs during a deep breath. b) Under Lung [sounds] staff documented either a Y [yes] or N [No]. The documentation on the TAR did not identify what the lung sounds were, if they were adventitious (abnormal lung sounds that are heard over a patient's lungs and airways utilizing a stethoscope. These sounds include fine and coarse crackles, wheezes, pleural rubs and stridor, which provide important clues used for diagnosing numerous cardiac and pulmonary conditions) or if the post treatment lung sounds had improved, worsened or were unchanged after the treatment. c ) Under Min staff documented the minutes it took to set up the IS, perform patient education, and perform the pre and post lung evaluations, which was documented as 5 minutes for every treatment provided.d) The last three assessed items that were documented were the resident pulse, respiratory rate and oxygen saturation (SpO2). Review of the EHR showed Resident 26's pre and post IS treatment lung sounds were not documented.Review of the pre and post treatment respiratory evaluation documentation for the 9:00 AM and 1:00 PM treatments from 11/15/2025 - 11/30/2025, showed the pre and post pulse, respiratory rate and minutes to provide the treatment were the same for 32 of 32 reviewed. The residents pre and post treatment SpO2 was the same for 31 of 32 reviewed. On 12/09/2025 at 9:13 AM, when asked if the nurses came daily to instruct them on how to use the IS (one was located on Resident 26's overbed table) Resident 26 stated, No, why would they tell me how to use it or watch. I know how to use it. I know how. I use it when I need to. I have to use it every time I go to the Hospital. Resident 2 Resident 2 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident had a diagnosis of chronic congestive heart failure (CHF, a chronic condition where the heart muscle weakens and can't pump enough oxygen-rich blood to meet the body's needs, leading to fluid buildup (congestion) in the lungs, legs, and other organs, causing symptoms like shortness of breath, fatigue, and swelling) and received RT services during the assessment period. A physician order, dated 11/21/2025, directed staff to provide incentive spirometry four times a day for CHF. The nurse was to document the total minutes it took to set up the incentive spirometer, perform patient education, and to complete pre and post respiratory evaluations. The order did not include the duration the therapy was to be provided for. Review of the comprehensive care plan, initiated 07/1/2025, showed no care plan that addressed Resident 2's respiratory therapy, the goals of treatment, the frequency, duration, or scope of treatment had been developed or implemented. Review of the electronic health record (EHR) showed no documentation that Resident 2's had an initial evaluation performed by a respiratory therapist or trained respiratory nurse or that a written treatment plan was developed. Review of the IS treatment on the December 2025 MAR, showed for the pre- and post-respiratory evaluations staff were provided a space to document the following six assessments:a) Under IS staff were to document the volume of air the resident was able to inhale into their lungs during a deep breath. b) Under Lung the trained respiratory nurses documented a Y or N. The documentation identify what the residents lung sound were, if they were adventitious, or if the post treatment lung sounds had improved, worsened or were unchanged, to indicate if the IS treatment was effective.c) Under Min staff documented the minutes it took to set up the IS, perform patient education, and perform the pre and post lung evaluations, which was documented as 5 minutes for every treatment provided.d) The last three assessments were the resident's pulse, respiratory rate and SpO2. Review of the EHR showed Resident 2's pre and post IS treatment lung sounds were not documented in the record. During an interview on 12/09/2025 at 12:00 PM, Staff MM, MDS Coordinator, explained if a resident had an IS respiratory therapy program, each day during the assessment period where 15 minutes or more was documented would be coded as Respiratory therapy on the MDS When asked if they spoke with the qualified staff who provided the IS treatments, or ensured the services were directly and specifically related to an active written treatment plan that was based on an initial evaluation performed by qualified personnel. Staff MM, MDS Coordinator, said no, and indicated the respiratory therapy collected on the above reference MDSs, met the RAI criteria for respiratory therapy and were accurately coded. Resident 8 Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE] showed Resident 8 was cognitively intact. Review of Resident 8's electronic health record (EHR), showed they had a fall on 6/23/2025 that resulted in bruising. Review of Resident 8's Quarterly MDS, dated [DATE], showed no fall had been recorded. During an interview on 12/5/2025 at 8:44 AM, Staff H, MDS Coordinator/ Registered Nurse (RN), said both minor and major injuries were recorded on the MDS. Staff H reviewed minor injury criteria and said they recorded how many falls since admission or prior assessment. Staff H said a bruise from a fall would be considered a minor injury. When asked about Resident 8's fall on 6/23/2025 that resulted in bruises, which MDS this should have shown up on, Staff H said the Quarterly MDS done on 8/28/2025 and confirmed this was not coded as a fall. Resident 12 Resident 12 was admitted to the facility on [DATE] and had a diagnosis of dementia. The Quarterly MDS, dated [DATE], showed they had severe cognitive impairment, had two or more falls with no injury, had one fall with minor injury, and did not use a wander/elopement alarm. Review of Resident 12's orders showed they had a wander guard (wander/elopement alarm) ordered since 5/22/2025. During an observation on 12/3/2025 at 11:15 AM, a wander guard was seen on Resident 12's wheelchair. Review of Resident 12's EHR and fall investigations, showed they had two recent falls with injury, on 11/4/2025 that resulted in bruising, and 11/14/2025 that resulted in a laceration. During an interview on 12/5/2025 at 8:49 AM, Staff H, MDS Coordinator/ RN, said for elopement alarms, section p of the MDS assessment specifically asks whether the residents have an alarm. Staff H reviewed the 11/19/2025 MDS, confirmed the wander guard was not coded and said it should have been. Staff H also confirmed the two falls with injury should both have been recorded on the 11/19/2025 MDS and acknowledged it was not accurately recorded. During an interview on 12/8/2025 at 1:53 PM, Staff B, Director of Nursing Services, said their expectation for MDS assessments was for them to be accurate. Reference WAC 388-97-1000(4)(b)(5)(a)(e)(i)-(iii) .

Based on observation, interview and record review, the facility failed to ensure residents' care plans were comprehensive and person centered for 7 of 22 sampled residents (Residents 52, 54, 12, 1, 7, 73 & 9) reviewed for care plans. This failure placed residents at risk of lack of services or cares, and a diminished quality of life.Findings included.Resident 52 Resident 52 was admitted to the facility on [DATE], with diagnoses of depression and urinary retention (bladder holds on to urine). Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/02/2025, showed Resident 52 was severely cognitively impaired. The most recent Comprehensive MDS, dated [DATE], showed Resident 52 was considered to have serious mental illness, requiring a level II Preadmission Screening and Resident Review (PASRR). Review of Resident 52's level II PASRR, dated 02/26/2020, documented recommendations for plan of care. Under mental health services, it recommended the facility provide mental health counseling and psychiatric assessment and medication evaluation for depressive disorder. Under recommendation for nursing facility, recommendations were given for the environment, staff approaches/training, activities, and other. For environment, there was an intervention of monitoring the relationship between them and their roommate to make sure it would be amicable with volume of the television and verbal sounds. For staff approaches/training, there were interventions such as supporting Resident 52's self-esteem by focusing on their strengths and unique qualities, identifying with the resident coping skills, and providing them with Crisis Telephone numbers so they had someone to converse with when needed. For activities, they recommended assisting Resident 52 with televised snow skiing events. For other, they recommended that if Resident 52 was resistant to mental health services, that they should remind them that being seen once does not mean they have to continue with ongoing services or follow recommendations made, and to explain that this was an opportunity to process anything distressing with the hope of some resolve. Review of Resident 52's care plans on 12/03/2025, showed they did not have a level II PASRR care plan and the other care plans did not include a comprehensive list of interventions from the level II PASRR evaluation, nor did they document the effectiveness of the recommendations. Resident 52 had a potential for psychological well-being problem care plan, revised on 06/16/2025, with a goal to utilize effective coping mechanism without listing what they were, and had generic interventions such as Initiate referrals as needed or increase social relationships: (e.g. [example] Pastoral Care, Social Services, Psych Services) without listing if any had been used, attempted, or helpful in the past. This specific intervention also did not specify the recommendations for what to do when Resident 52 was resistant to being seen by a mental health provider. During an interview on 12/05/2025 at 8:08 AM, Staff X, Social Services Director, said for level II PASRR recommendations, they and the resident care managers review them, and update the care plans as needed. When asked if they put recommendations on the care plan, Staff X said yes, if it pertains to the care plan. Staff X said Resident 52 had no current credible suspicion for needing mental health counseling at the time and Resident 52 was not currently seeing a mental health counselor. When asked about Resident 52's care plans, Staff X said they did not make a section for level II PASRRs, but Resident 52 did have a depression and psychosocial well-being care plan. When asked about recommendations from the level II PASRR and if they were on the care plan, Staff X was unable to find the Crisis Telephone numbers or the mental health counseling recommendations but said the recommendation for mental health counseling would likely fall under referrals as needed. Review of Resident 52's electronic heath record showed they were hospitalized on [DATE], and they returned on 10/26/2025 without their suprapubic catheter (an incision that was medically made through the abdomen which allowed a thin tube to drain the bladder) replaced, and now had a penile indwelling urinary catheter (also called a Foley, a thin tube that goes through the penis tip and into the bladder). Review of Resident 52's Foley catheter care plan, revised on 10/30/2025, showed they had prior interventions that had not been removed, Please change suprapubic catheter every 3 weeks (21 Days) and Resident has occasional urinary incontinence, even with suprapubic [ .]. The care plan did not have information specific to the suprapubic catheter site, such as the date it was last accessed and the interventions being done post removal or of any monitoring. The care plan also did not mention Resident 52 was being monitored for penile erosion, related to the penile Foley catheter. Review of Resident 52's enhanced barrier precautions [special precautions taken when a resident has a MDRO -multidrug resistant organisms] care plan, dated 04/03/2025, showed they had a history MDROs of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacterales (CRE). The goal was listed as the risk of spreading MDRO infection or potential infection will be minimized. This care plan did not list where the MDROs had been detected on Resident 52 (possible examples: urine, skin, wound infection). Review of Resident 52's orders, showed Resident 52 had an order that was initiated 10/27/2025 for cleaning the old suprapubic site with wound wash, to pat dry, and cover with boarder dressing every dayshift. The most recent version of this order, ordered on 11/20/2025, showed staff were also applying Hydrocortisone 1% cream to the site. During an interview on 12/08/2025 at 12:08 PM, Staff C, Assistant Director of Nursing (ADON)/Registered Nurse (RN), regarding their expectation for updating care plans after hospitalization, said for new orders, they expected them to be put on the care plan. Staff C confirmed Resident 52's care plan did not have any mention of penile erosion being monitored and said there should be. Staff C confirmed there was no information on Resident 52's prior suprapubic catheter site, and said there should have been documentation of monitoring it, what they were doing about it, and how they were addressing it. When asked about Resident 52's care plans, if they had any mention of their blood or mucous in their urine, or how long they had had these symptoms, Staff C said there was a history of chronic urinary tract infection, a monitor for checking for blood in the urine, and for a urology consult as needed. Staff C confirmed Resident 52's care plan on enhanced barrier precautions did not have the location of where the MDROs were found on Resident 52. Resident 54 Resident 54 was admitted to the facility on [DATE], and had diagnoses including muscle weakness, difficulty walking, limitations of activities due to disability, and need for assistance with personal care. The Annual MDS assessment, dated 10/7/2025, showed Resident 54 was cognitively intact, and received a range of motion and a dressing/grooming restorative program for six days of the week. During an interview and observation on 12/01/2025 at 11:51 AM, Resident 54 showed they put their feet on a step stool and placed a weight on their leg, to work on straightening their legs. They reported they did this two to three times a day by themself. Review of Resident 54's care plans on 12/04/2025, showed there was not a care plan with their self-directed leg strengthening details. During a joint interview on 12/05/2025 at 9:16 AM, Staff G, Director of Rehabilitation, and Staff H, MDS Coordinator/Registered Nurse, were interviewed. Staff G said Resident 54 was working on hamstring stretching, Resident 54 had requested it, and the daughter was okay with the program, which encouraged Resident 54 to stretch their legs. Staff G said they do not normally tell nursing about this kind of program. When asked if there was anything specific about Resident 54 doing these hamstring exercises in the care plan, Staff H said no. Resident 12 Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired. Review of Resident 12's fall care plan, revised 11/20/2025, showed 14 falls were listed. One of the interventions listed was added on 10/18/2025, for 30-minute checks. This intervention did not have any other details, such as how long this intervention was being implemented for. During a joint interview on 12/08/2025 at 9:47 AM, Staff C, ADON/RN, and Staff J, Resident Care Manager/Licensed Practical Nurse, were asked about Resident 12. Staff C said the order for 30 minute checks was no longer in effect, and said this intervention should not be on the care plan. During an interview on 12/08/2025 at 1:53 PM, Staff B, Director of Nursing Services (DNS), when asked their general expectation for care plans, said everything should be care planned. Staff B provided examples, such as activities of daily living, skin, falls, wounds, blood thinners, fluid restrictions, and psychotropic medications. Staff B said any kind of cares should be included, it should be individualized per resident. Resident 1 Resident 1 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure (CHF, a condition where the heart muscle doesn't pump blood as well as it should and blood and fluid often backs up and fluid can build up in the lungs and lower extremities). Review of Situation Background Assessment and Recommendation forms (SBAR, a form used to communicate changes in residents conditions to the provider), dated 11/01/2025 and 12/01/2025, documented Resident 1 had weeping edema (swelling caused by too much fluid trapped in the body's tissues that leaks or weeps out through the skin) to both lower extremities. Record review showed Resident 1 had the following orders, dated 10/25/2025, for Lasix (a diuretic) twice daily for CHF and daily weights. Review of Resident 1's comprehensive care plan, initiated 10/25/2025, showed a care plan to address the resident's CHF, diuretic use, need for daily weights and weeping edema to bilateral (both) lower extremities had not been developed or implemented. During an interview on 12/05/2025 at 12:01 PM, when asked if Resident 1's CHF, diuretic use, daily weights, and weeping lower extremity edema should have been care Staff B stated Yes. Resident 7 Resident 7 was admitted to the facility on [DATE]. Record review showed 10/23/2025 orders to apply TED hose (compression stocking) daily for edema management and to start Lasix (a diuretic) 20 milligrams daily. Review of Resident 7's comprehensive care plan, initiated 10/17/2025, showed no plan was developed or implemented that addressed the resident's edema, use of diuretics and need for TED hose to be applied daily. On 12/05/2025 at 12:01 PM, when asked if a care plan addressing Resident 7's edema, diuretic use and need for TED hose daily should have been developed/ implemented, Staff B, said yes, but she did not see one. Resident 73 Resident 73 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had a diagnosis of sepsis (a serious condition in which the body responds improperly to an infection, and the infection-fighting processes turns on the body, causing the organs to work poorly), and received intravenous (IV) antibiotics via a central catheter during the assessment period. The Avaadmission Nursing Database, dated 11/04/2025, showed Resident 73 had a Peripherally Inserted Central Catheter (PICC, a long, thin, flexible tube inserted into a small arm vein and threaded to a large central vein near the heart) to the right upper arm. The November 2025 Medication and Treatment Administration Records (MAR/TAR) showed Resident 73 received Cefepime IV infusions every 12 hours for right lower extremity cellulitis (skin infection). Review of Resident 73's comprehensive care plan, initiated 11/04/2025, showed staff failed to develop and implement a care plan that addressed the resident's PICC line and treatment with IV antibiotics with identified goal and interventions. During an interview on 12/05/2025 at 11:45 AM, when asked if a care plan should have been developed and implemented for the resident's PICC line and IV antibiotics that identified goals and interventions for the care and maintenance of the PICC, Staff B stated, Yep, and I don't see any. Resident 9 Resident 9 was admitted to the facility on [DATE]. Review of the Modification of Quarterly MDS, dated [DATE], documented Resident 9 was severely cognitively impaired. Resident 9 had a diagnosis of dementia with psychotic disturbance (involves symptoms of hallucinations [seeing things not there] and delusions [fixed false beliefs].) Review of Resident 9's comprehensive care plan on 12/02/2025, showed no care plan was present for dementia. On 12/08/2025 at 10:57 AM, Staff K, Resident Care Manager/RN, when asked if a resident had dementia should they have a care plan for dementia, Staff K said yes. On 12/08/2025 at 12:59 PM, Staff B, DNS, when asked if a resident had a dementia diagnosis should they have a care plan for dementia, Staff B said yes. Regarding Resident 9, staff B confirmed they had a dementia diagnosis and did not have a dementia care plan and said one should be there. Reference WAC 388-97-1020(1), (2)(a)(b) Reference F690

Based on observation, interview and record review, the facility failed to ensure professional standards were met related to following provider orders, medication administration practices, provider notification of weight variances, and/or accurate documentation practices, for 7 of 22 sampled residents (Resident 73, 1, 31, 12, 74, 9 & 24). This failure placed residents at risk of not receiving services being signed off on, lack of monitoring, medication complications, and a diminished quality of life. Findings included .Resident 73 Resident 73 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/10/2025, showed the resident had a diagnosis of heart failure, and received supplemental oxygen during the assessment period. Record review showed an order, dated 11/04/2025, for oxygen 1-2 liters via nasal canula as needed for shortness of breath, with direction to notify the physician when resident was placed on oxygen. On 12/02/2025 at 11:57 AM and 12/04/2025 at 5:57 AM, 8:34 AM and 9:37 AM, Resident 73 was observed receiving oxygen at 2 liters per minute via nasal canula. Review of the December 2025 Medication and Treatment Administration Records (MAR/TAR) showed that no nurses had signed the administered oxygen to Resident 37 during the month. On 12/04/2025 at 9:37 AM, Staff KK, Registered Nurse (RN), confirmed Resident 37 was receiving oxygen at two liters per minute via nasal canula and said the resident required oxygen use daily. When asked if there was documentation on the December 2025 TAR that showed Resident 37 was administered oxygen, Staff KK stated, No. On 12/04/2025 at 9:45 AM, Staff B, Director of Nursing Services (DNS), said they were familiar with Resident 37 and acknowledged the resident received oxygen therapy. When asked if there was any documentation on the TAR that Resident 37 had been administered oxygen in December 2025, Staff B said no, it was the expectation that nurses sign for all medications administered. Resident 1 Resident 1 was admitted to the facility on [DATE]. Record review showed an order, dated 11/05/2025, for hydralazine (blood pressure medication) three times daily, with direction to hold the medication for a systolic blood pressure (SBP) less than 120. The November 2025 MAR showed, on 11/27/2025 at 3:00 PM, Resident 1 had a SBP of 116, and hydralazine was administered instead of being held for a SBP less than 120 as ordered. On 12/04/2025 at 9:28 AM, Staff B, DNS, said Resident 1's hydralazine was administered outside of the physician ordered parameters and should have been held. Resident 31 Resident 31 was admitted to the facility on [DATE]. Record review showed the resident had the following pain management orders, dated 09/24/2025:-acetaminophen 650 milligrams (mg) every four hours as needed, for a pain level of 1-3 on a scale to 10.-oxycodone 2.5 mg every six hours as needed, for a pain level of 4-6 on a scale to 10.-oxycodone 5 mg every six hours as needed, for a pain level of 7-10 on a scale to 10. Review of the October 2025 MAR, showed the following:- On 10/20/2025 at 5:12 PM, Resident 31 had a pain level of 5 and was medicated with acetaminophen 650 mg, rather than oxycodone 2.5 mg as ordered.- On 10/27/2025 at 6:28 PM, Resident 31 had a pain level of 5 and was medicated with acetaminophen 650 mg, rather than oxycodone 2.5 mg as ordered. Review of the electronic health record (EHR), showed no documentation that Resident 31 requested acetaminophen be administered instead of the ordered oxycodone 2.5 mg for a pain level of 5. On 12/05/2025 at 11:33 AM, when asked if Resident 37's pain medication was administered in accordance with the physician ordered parameters, Staff B, DNS, stated, No. Resident 12 Resident 12 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 12 was severely cognitively impaired. Review of Resident 12's orders, showed they had an order for orthostatic blood pressures (when blood pressure readings were taken laying, sitting, and then standing, to assess if there was positional low blood pressure) to be taken every 28 days, because they were taking an antipsychotic medication. Review of Resident 12's September 2025 TAR, showed orthostatic blood pressures was not completed on 09/10/2025 for sitting, standing, or laying. Review of Resident 12's November 2025 TAR, showed only the sitting position had a blood pressure reading, and there was not a blood pressure reading for standing or laying. Review of Resident 12's MAR from 11/01/2025 to 12/07/2025, showed nurses had been administering Resident 12's lidocaine patch for 24 hours (unless refused/hospitalized ). For November, Resident 12 had 23/30 days, that they wore a lidocaine patch for twenty-four hours. For December, Resident 12 had 5/7 days, that they wore a lidocaine patch for twenty-four hours. The order had a start date of 07/25/2025, and nursing had not questioned the order since then (for about four months). During an interview on 12/03/2025 at 8:44 AM, Staff Q, Licensed Practical Nurse (LPN), confirmed Resident 12 was wearing their lidocaine patch for twenty-four hours a day. During a joint interview on 12/08/2025 at 9:47 AM, Staff C, Assistant Director of Nursing/RN, and Staff J, Resident Care Manager (RCM)/LPN, were asked about Resident 12. Staff C said Resident 12 required orthostatic blood pressures to be taken once a month, to monitor for side effects of their antipsychotic medication. When asked their expectation for when a nurse was unable to get orthostatic blood pressures on Resident 12, Staff C said they could not understand why the nurse would not be able to, as Resident 12 was able to stand, sit, and lie. Staff C reviewed the September 2025 for orthostatic blood pressure documentation and said they could not find a note on why it was not completed. Staff J reviewed November 2025 for orthostatic blood pressure documentation and said they found documentation the nurse was unable to perform safely. Staff J said they could understand that sometimes standing could be unsafe but could not say the same for lying down. Staff J said if the nurse truly thought it was unsafe, then there should have been a note put in that they talked to the doctor. Staff C said their expectation was that nursing would have reapproached on another day and tried again. When asked how long a lidocaine patch can be on a resident, both Staff C and Staff J said twelve on and twelve off. Resident 74 During a medication administration observation on 12/02/2025 at 11:38 AM, Staff J, RCM/LPN, gave Resident 74 their long-acting insulin (a type of insulin that provides a steady release of insulin over an extended period of time, to help manage blood sugar levels) that was due at 8:00 AM. Staff J had said Resident 74 did not eat breakfast and their earlier blood sugar reading was 73, but now it was 223. Staff J said their nursing judgment told them when to hold the medication, if under 100 they would wait until above. Staff J said they had given Resident 74 orange juice that morning, but they had not rechecked Resident 74's blood sugar level after the orange juice was consumed. Review of a medication progress note on 12/02/2025 at 9:08 AM, showed staff were to notify the provider if blood sugars were below 60 or above 400. The nurse had documented OJ provided and consumed. During an interview on 12/08/2025 at 1:53 PM, Staff B, DNS, said short acting insulin was immediate and long-acting insulin was for the life of the specific insulin, which would maintain glucose levels throughout the day. When asked if Resident 74's insulin order had parameters for holding, Staff B said yes and no, that on the order itself it did not, but there was an order to hold for below 60 and to notify the provider. When told of Resident 74's blood sugar reported to be 73, Staff B said the order did not say to hold it so it should not have been held. When asked if Resident 74 should have been reassessed after they were documented at 9:08 AM to have consumed their orange juice, Staff B said yes. Staff B said it did not meet expectations, that the recheck blood sugar level, provider notification, and administration did not occur until about 11:38 AM. Resident 9 Resident 9 was admitted to the facility on [DATE]. Review of the Modification of Quarterly MDS, dated [DATE], documented Resident 9 was severely cognitively impaired. Resident 9's EHR showed they had a Power of Attorney (POA, a person assigned authority to make decisions on behalf of another person) for healthcare. On 12/01/2025 at 1:52 PM, Resident 9's POA said she had wanted to talk with the doctor regarding Resident 9's medications and she had talked to Staff E, RCM/RN, and Staff E had said he would get back to them. On 12/08/2025 at 9:03 AM, Staff E, when asked their expectation of staff when a POA requested to talk with a doctor about a resident's medications, Staff E said they would get communication to the doctor. Staff E said if they could not directly find the doctor, they would do an SBAR (SBAR, a form to communicate to providers that outlines situation, background, assessment, and request) to request the doctor speak with the family. Staff E said they would try and follow up to make sure the doctor was going to get back to the family. When Staff E was asked if Resident 9's POA had requested to talk with the doctor about Resident 9's medications, Staff E said there were a few times the POA had requested this. Staff E said to their knowledge the doctor had seen them. Staff E said they themselves were able to answer some of the POA's questions about medications, but there was a period of transition from one provider to another and the initial request fell through the cracks. Staff E said they had requested the doctor to speak with the POA about medications, but he was not sure if the doctor had met with the POA or not. Record review of Resident 9's SBAR communications, from 06/11/2025 through 12/08/2025, showed no SBAR communications regarding Resident 9's POA request to talk with the doctor. On 12/08/2025 at 2:53 PM, Staff E said the request by Resident 9's POA to speak with the doctor was not that long ago, the last request had been maybe a month prior. When told review of SBAR communications did not show any communication regarding POA's request, Staff E said he knew it had been mentioned to the doctor a few times, but moving forward an SBAR would be good so it would be clear that the doctor had been communicated with. Resident 24 Resident 24 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 24 was cognitively impaired, was dependent on staff for all cares and admitted with an unstageable pressure ulcer on the right heel and moisture associated skin damage (MASD) on their coccyx (tailbone). On 12/01/2025 at 2:52 PM, a standard foam mattress was observed on Resident 24's bed, without a low air loss (LAL) mattress in place. Daily observations, from 12/01/2025 through 12/04/2025, showed Resident 24 had a standard foam mattress pad on their bed. Resident 24's skin integrity care plan, dated 11/13/2025, documented Resident 24 had a LAL mattress to protect the skin while in bed. Resident 24's order, dated 11/17/2025, documented to check settings every shift. Review of Resident 24's November and December 2025 TAR, showed staff documented three times a day from 11/17/2025 through 12/05/2025, that they had checked the pressure and inflation setting on Resident 24's LAL mattress (Resident 24 had a standard mattress until 12/04/2025 when the LAL mattress arrived). On 12/05/2025 at 8:50 AM, Resident 24 said they received the new LAL mattress the day before. A new LAL mattress was observed, with a control box attached to the end of the bed. On 12/08/2025 at 10:42 AM, Staff V, Maintenance Director, said he reviewed all the TELs requests for the room in which Resident 24 resided and the only order request found was from 10/12/2025 (one month prior to Resident 24' admit), and there had been no other problems reported with that bed since. Staff V confirmed they had no maintenance order for a new LAL mattress on or around 11/17/2025 (Resident 24's order for nursing to perform LAL checks), there were no reports of a broken control box or broken LAL mattress for Resident 24, and they had not installed a new LAL mattress until 12/04/2025. On 12/08/2025 at 10:46 AM, Staff B confirmed Resident 24 had an order for a LAL mattress on 11/17/2025 and for staff to check the LAL mattress ever shift. Staff B reviewed the EHR and found no documentation a LAL mattress had ever been installed on 11/17/2025 and said they would have to check with maintenance. When the interview with Staff V was explained, Staff B said they did not know Resident 24 did not have a LAL mattress and staff should not have been signing for a task they could not complete, that was not acceptable. On 12/09/2025 at 12:02 PM, when asked if they had been made aware of the concerns related to Resident 24' pressure ulcer, Staff A, Administrator, said they were only told about the concern with the LAL mattress. It was explained that Resident 24 was documented to have a LAL mattress since 11/17/2025, but did not receive the LAL mattress until 12/04/2025, but staff had been signing off they were checking the setting three times a day. Staff A said signing for things staff did not actually complete was not acceptable. Reference F686, F756 Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

Based on interview and record review, the facility failed to provide restorative services at the assessed frequency, for 2 of 2 residents (Residents 52 & 54) reviewed for restorative services. This failure placed residents at risk of decreased range of motion, loss of abilities to complete daily activities, and a diminished quality of life.Findings included.Review of the facility policy titled Restorative Nursing Services, with an approval date of 10/2025, documented the facility would provide restorative nursing care as needed to help promote optimal safety and independence for the residents. Resident 52Resident 52 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/02/2025, showed Resident 52 was dependent on staff for cares, and received a passive and an active range of motion restorative program for six days of the week. Review of Resident 52's 2025 September, October, November, and December (up to 12/03/2025) restorative charting, in the electronic health record (EHR), showed Resident 52 was not receiving restorative programs consistently at six days a week. For September, six days of restorative were recorded for the month. For October, eight days were recorded. For November, five days were recorded. For December, no documentation was found of restorative between 12/01/2025 to 12/03/2025. Review of the Restorative Quarterly Review, dated 10/30/2025, documented Resident 52 was participating in the programs and pain was not an issue. Recommendations were made to continue current programs, and to continue monitoring participation and progress.Resident 54Resident 54 was admitted to the facility on [DATE], and had diagnoses including muscle weakness, difficulty walking, limitations of activities due to disability, and need for assistance with personal care. The Annual MDS assessment, dated 10/07/2025, showed Resident 54 was cognitively intact, and received a range of motion and a dressing/grooming restorative program for six days of the week. Review of Resident 54's 2025 October, November, and December (up to 12/04/2025) restorative charting, showed Resident 54 was not receiving restorative programs consistently at six days a week. After the first week in October, Resident 54 had their programs about five days a week. In November, they received their programs Sunday through Thursday, which came out to five days a week. For December, no restorative program had been completed from 12/01/2025 to 12/04/2025 (all 4 days).During a joint interview on 12/05/2025 at 9:34 AM, Staff I, Restorative Aide, was interviewed with Staff G, Director of Rehabilitation, and Staff H, MDS Coordinator/Registered Nurse, present. Staff I confirmed Resident 52 was assessed to need restorative services six times a week. Staff I provided additional paper records, for Resident 52, to be reviewed during the interview. Staff G assisted with the review and confirmed that for the previous 30 days (11/06/2025 to 12/05/2025), only five refusals had been documented (either in the EHR or on the papers reviewed) and Resident 52 only received restorative services four times. Staff G said their expectation was that in the restorative meeting, if there was a pattern of missed opportunities or refusals, then there would be a discussion to discontinue or reevaluate on if a new program should be developed. During this interview, Staff I confirmed Resident 54's program was written for six days a week for range of motion and activities of daily living. Staff I said Resident 54 was on their partner's schedule, whose work schedule was only Sunday through Thursday, so Resident 54 was only getting five days of their program. During an interview on 12/08/2025 at 1:53 PM, Staff B, Director of Nursing Services, when asked their expectation for restorative programs being done at the frequency they were assessed to be done, said they should be done. Reference WAC 388-97-1060 (3)(d)(j)(ix)

Based on interview and record review, the facility failed to ensure staff monitored and accurately recorded fluid intake for 1 of 1 resident (Resident 3) reviewed for hydration. These failures placed residents at potential risk for medical complications, fluid overload, and a diminished quality of life.Findings included . The facility's policy titled, Encouraging and Restricting Fluids, dated 10/2010, said The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids.General Guidelines 1. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake.Resident 3 was admitted was admitted to the facility on [DATE] with a diagnosis of edema (swelling caused by excess fluid trapped in your body's tissues). The admission Minimum Data Set (an assessment tool), dated 11/01/2024, documented the resident was cognitively intact.Resident 3's diet restrictions care plan, dated 10/27/2025, documented, Fluid Restriction 1800ml [milliliters]/24 hours, Kitchen 240ml per meal tray, Nursing 360ml per shift.Resident 3's orders, ordered on 10/27/2025, showed:-Fluid restriction 1800ml/24 hours - record total fluid intake every shift. Include intake with meals.-Fluid Restriction: Total 24-hour intake every night shiftResident 3's Point of Care (POC) response history for task: amount eaten for Fluid intake in mls, dated 11/03/2025 - 12/01/2025 had entries documented one to three times a day.Resident 3's November and December 2025 Treatment Administration Record (TAR) showed documentation of the fluid intake for every shift: day evening and night in mls and documentation of the total 24-hour intake in mls.On 12/04/2025 at 10:48 AM, Staff C, Assistant Director of Nursing/ Registered Nurse, said the nurses were supposed to be calculating the day, evening and night shift totals for 24 hours in the TAR. Staff C stated while looking at the POC, I don't know what the aides were charting. Staff C said they were supposed to have sheets at the nurse stations to document on, and she would look for those sheets.On 12/04/2025 at 11:38 AM, Staff C provided fluid restrictions sheets for 10/30/2025, 11/01/2025, 11/02/2025, 11/03/2025, 11/04/2025, 11/10/2025, and 11/11/2025. When asked if she had fluid restriction sheets for the most recent 30 days, Staff C said she would have to look.On 12/04/2025 at 11:51 AM, Staff C, provided additional fluid restrictions sheets for 10/30/2025, 10/31/2025, 11/01/2025, 11/02/2025, and 11/12/2025 and stated, this is all I've got.On 12/08/2025 at 12:33 PM, Staff B, Director of Nursing Services, said regarding the POC, TAR and fluid restrictions sheets, the numbers did not add up correctly and stated, I don't know where they are getting those totals.Reference WAC 388-97- 1060 (3)(i)

Based on interview and record review, the facility failed to ensure peripherally inserted central catheters (PICC, a long, flexible tube inserted into a vein in the arm, used for prolonged intravenous access to deliver medications, fluids, and nutrition) were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 73 & 84) reviewed for IV therapy. This failure placed residents at risk for unidentified complications, loss of vascular access, infection, and other potential negative health outcomes.Findings included . Review of the facility's Vascular Access Devices and Infusion Therapy Procedures policy, dated August 2021, showed upon admission or insertion staff would measure the PICC external length and the residents arm circumference 10 centimeter (cm) above the insertion site, to establish a baseline. The PICC external length would then be measured weekly with PICC dressing changes and compared with the baseline measurement to rule out line migration or dislodgement. A resident's arm circumference would be measured as indicated to rule out phlebitis (inflammation of a vein) or deep vein thrombosis (blood clot). Needleless injection caps would be changed at least every seven days and as needed. All valved vascular access devices would be flushed with 10 cubic centimeters (cc) of Normal Saline (NS) before and after infusion. After drawing blood from a PICC, staff would flush the line with 20 cc of NS to maintain patency. Resident 73 Resident 73 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/10/2025, showed the resident had moderate cognitive impairment, a diagnosis of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), and received intravenous (IV) antibiotics via central catheter during the assessment period. The Avaadmission Nursing Database, dated 11/04/2025, showed Resident 73 had a PICC in their right upper arm. The assessment did not identify how many lumens (individual tubes or channels within a single PICC), the PICC had, what the external catheter length or resident's arm circumference was. Record review showed Resident 73's had the following IV medication, and PICC maintenance and monitoring orders, dated 11/04/2025.a) Cefepime IV infusion every 12 hours right lower extremity cellulitis (skin infection)b) Vancomycin IV infusion once a day for right lower extremity cellulitisc) Change IV administration set/ IV tubing every 72 hoursd) Change needleless injection caps with each dressing change and after blood draws and as needede) Change PICC dressing every seven days. Use a sterile dressing kit. Change injection caps and measure external catheter lengthf) Flush PICC with 10cc of NS before and after medication administrationg) Monitor PICC site every shift. Notify physician of any changesh) Flush PICC with 5cc NS. Draw 5 cc blood and discard, draw blood for labs, Flush with 10 cc NS as needed for blood draw The orders did not identify the location of Resident 73's PICC or the number of lumens that were present. Additionally, the facility's policy directed staff to flush with 20cc of NS after blood draws, not 10cc NS as ordered. The November 2025 Medication and Treatment Administration Records (MAR/TAR) showed Resident 73's weekly PICC dressing changes and external length measurements were scheduled to be done on 11/05/2025 and 11/12/2025. On 11/05/2025 staff documented 3 [resident out of facility]. The dressing change and external length measurement scheduled for 11/12/2025 was blank. Review of Resident 73's electronic health record showed there was no documentation facility staff measured the resident's PICC external length and arm circumference upon admission or any time thereafter. On 12/05/2025 at 11:16 AM, when asked if there was any documentation to show staff measured Resident 73's PICC external length or arm circumference upon admission or any time thereafter Staff B, Director of Nursing Services, stated, No. Staff B then confirmed that central lines should be flushed with 20 cc of NS after blood draws, not 10 cc NS as ordered, to ensure patency is maintained. Resident 84 Resident 84 was admitted to the facility on [DATE] with a diagnosis of sepsis. The admission MDS, dated [DATE], documented the resident was cognitively intact and had a special treatment of central IV (intravenous-referring to something given directly into a vein like fluids or medicine) access. Resident 84's orders, dated 11/25/2025, showed:- PICC dressing change with sterile dressing kit every evening shift on Wednesday and Measure external length of catheter with each dressing change. Resident 84's care plan IV Therapy provided through PICC Line dated 11/25/2025 said Document IV Line Measurements. Resident 84's TAR, where staff document dressing change and line measurement, showed on 11/26/2025 staff documented a 9 = other/see nurse notes. A review of Resident 84's nursing progress notes, dated 11/26/2025 at 3:12 PM, by Staff T, Registered Nurse, showed no documentation of external length of catheter measurements. On 12/05/2025 at 11:16 AM, Staff B, DNS said she did not see documentation of external catheter length for Resident 84 or arm circumference. Staff B said her expectation was that the nursing staff measure the external length on admission and weekly with dressing changes and show documentation of arm circumference on admission or insertion. Reference: WAC 388-97-1060(3)(j)(ii).

Based on observation, interview and record review, the facility failed to ensure oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 1 resident (Resident 73) reviewed for respiratory care and services. The failure to document when oxygen was administered, to check and replace empty portable oxygen cylinders, and ensure humidifier bottles contained fluid and were functional, placed residents at risk for respiratory compromise and/or unmet respiratory needs. Findings included . Resident 73 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 11/10/2025, showed the resident had diagnoses of heart failure and pulmonary hypertension (high blood pressure in the arteries connecting your heart to your lungs) and received oxygen therapy during the assessment period.Review of Resident 73's electronic medical record showed the following 11/04/2025 oxygen orders:-Oxygen 1-2 liters via nasal canula as needed, for shortness of breath. Notify the physician when resident is placed on oxygen. -Change humidifier bottle every week when oxygen is in use, and as needed.-Change oxygen tubing when it becomes visibly soiled. On 12/02/2025 at 11:57AM, Resident 73 was sitting in a wheelchair in their room doing pursed lip breathing (a technique where air is inhaled slowly through the nose and then exhaled slowly through pursed lips to slow down breathing and improve air exchange). Resident 73 had a nasal canula in place that was attached to a portable oxygen cylinder secured to the back of their wheelchair. Observation of the regulator showed it was set to deliver two liters of oxygen per minute, but the oxygen cylinder gauge registered zero PSI (pounds per square inch) which showed the oxygen cylinder was empty.On 12/04/2025 at 8:34 AM, Resident 73 was in a wheelchair in their room with a nasal canula in place that was attached to a portable oxygen cylinder secured to the back of their wheelchair. The oxygen cylinder regulator was set to deliver two liters of oxygen per minute. Observation of the oxygen cylinder gauge showed it registered zero PSI (empty). Resident 73 reported they could not feel any air blowing through their nasal cannula.On 12/04/2025 at 9:00 AM, upon request Staff KK, Registered Nurse, checked Resident 73's portable oxygen cylinder and stated, It looks like it is empty and indicated they would replace it. When asked if they checked Resident 73's portable oxygen cylinder to ensure it was not empty prior to transferring Resident 73 to it from the oxygen concentrator Staff KK explained that the nurse aides transferred the resident from the concentrator to the portable oxygen cylinder when they got Resident 73 up. When asked if nurse aides were allowed to administer medications and/or set the liter flow for a resident's oxygen Staff KK stated, No. Review of the December 2025 Treatment Administration Record (TAR) on 12/04/2025 showed Resident 73 had not received any supplemental oxygen in the month of December. Facility nurses had not signed that they administered oxygen to Resident 73.On 12/04/2025 at 9:37 AM, Staff KK confirmed Resident 73 used oxygen daily. When asked if any nurse had documented on the December 2025 TAR that they administered Resident 73 oxygen, Staff KK stated, no.On 12/09/2025 at 9:30 AM, observation of the humidifier bottle attached to Resident 73's oxygen concentrator showed it was empty.On 12/09/2025 at 9:34 AM, Staff E, Registered Nurse, confirmed Resident 73's humidifier bottle was empty and needed to be replaced.Review of the December 2025 TAR showed Resident 73's humidifier bottle was not changed from 12/01/2025 - 12/09/2025 despite an order to change weekly when oxygen was in use.Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to reevaluate the necessity and safety of bed rails/mobility bars for 2 of 2 residents (Residents 12 & 8) reviewed for bed rails. This failure placed residents at risk of accidents and a diminished quality of life.Findings included.Review of the facility policy titled Assistive Devices and Equipment, revision date of 2/2021, showed the facility was to assess the appropriateness for resident condition, personal fit, device condition, and staff practices, to decrease the risk of avoidable accidents associated with the devices and equipment.Resident 12Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia (decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems, reasoning issues, and personality changes). The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired. Review of Resident 12's falls care plan, revised on 11/20/2025, showed they were a high risk for falls related to limited mobility, incontinence, cognitive problems, gait/balance problems, history of falls, lack of impulse control, poor communication and comprehension, poor insight and judgement, psychoactive drug use, were unaware of safety needs, and hearing problems. In this care plan, 14 total falls were listed: 05/24/2025, 05/25/2025, 06/09/2025, 06/13/2025, 06/17/2025, 06/18/2025, 07/01/2025, 08/05/2025, 08/27/2025, 08/29/2025, 08/30/2025, 10/18/2025, 11/05/2025, and 11/14/2025. Review of Resident 12's electronic health record (EHR), showed Resident 12 had an initial evaluation for mobility bars done on 08/06/2025, which did not document any falls (although there was a section asking about falls on the form). No reevaluation was found.During an observation on 12/01/2025 at 1:09 PM, Resident 12's bed was observed with bilateral mobility bars on the top of the bed. Resident 8Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 8 was cognitively intact.Review of Resident 8's falls care plan, revised on 08/27/2025, showed they were a moderate risk for falls due to deconditioning, gait/balance problems. Recent falls were listed as 6/23-fall w/bruises and 6/26-NIF [no injury fall].Review of Resident 8's EHR, showed Resident 8 had an initial evaluation for the mobility bars done on 05/01/2025, which did not document any history of falls. No reevaluation was found. During an observation on 12/02/2025 at 8:29 AM, Resident 8's bed was observed with bilateral mobility bars on the top of the bed. During a joint interview on 12/08/2025 at 9:47 AM, Staff C, Assistant Director of Nursing/ Registered Nurse, and Staff J, Resident Care Manager/Licensed Practical Nurse, were asked about mobility bars. When asked if Resident 12 had any mobility bar assessments done after the initial evaluation, Staff C said their quarterly assessment for the MDS was done in November, continued looking in the EHR, then said they could not find any documentation of a reevaluation for the bed mobility bars. Staff C said mobility bars were to be reassessed quarterly and also confirmed this had not happened for Resident 8. During an interview on 12/08/2025 at 1:53, Staff B, Director of Nursing Services, said their expectation for bedrails/mobility bars, was for them to be reassessed quarterly. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure monthly pharmacist recommendations were carried out accurately and timely, for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. This failure placed residents at increase for accidents, unnecessary medication, complications, and a diminished quality of life.Findings included.Review of the facility policy titled Medication Monitoring Medication Regimen Review and Reporting, dated 01/2024, documented the nursing care center would follow up on the recommendations to verify that appropriate action had been taken, with recommendations acted upon within thirty calendar days or per facility specific protocols. For issues that required physician intervention, the provider was to either accept the recommendation or to document their rational of why the recommendation was rejected in the medical record.Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired, and had a history of falls.Review of Resident 12's pharmacy recommendation for July 2025, showed the pharmacist recommended directions for Resident 12's lidocaine patch order, for putting on in the morning and taking off at night, with a maximum amount of time on of twelve hours total. Review of Resident 12's November 2025 Medication Administration Record (MAR), showed the pharmacist recommendation was not followed, and Resident 12 was ordered to wear the lidocaine patch for twenty-four hours.During an interview on 12/03/2025 at 8:44 AM, Staff Q, Licensed Practical Nurse (LPN), confirmed Resident 12 was wearing their lidocaine patch for twenty-four hours a day. Review of Resident 12's pharmacist recommendation for November 2025, showed the pharmacist recommended a gradual dose reduction (GDR, decrease in dose) of Resident 12's antipsychotic medication. The pharmacist included a section to let the facility know the requirements of the GDR, CMS [Centers for Medicare and Medicaid Services] guidelines require that psychotropic medications undergo a gradual dose reduction (GDR) attempt in two separate quarters (with at least one month between the attempts) during the first year of initiation or admission; then annually thereafter, unless clinically contraindicated. Notes found on the GDR form showed the provider believed Resident 12 was a reasonable candidate for a cautious GDR attempt, as their behaviors had remained stable. There was no clinical rationale that documented why the GDR could not be attempted at the time. The form had a note that the Power of Attorney (POA, legal decision maker) rejected the GDR attempt. Review of Resident 12's additional pharmacist recommendation for November 2025, done in response to Resident 12's multiple falls (about 14 since admission), dizziness, and nose bleeds, showed the pharmacist gave multiple recommendations. The pharmacist documented that Resident 12 was receiving a dose of tamsulosin (a medication that relaxes muscles in the prostate and bladder neck to improve urine flow), that was double the general dosing and recommended the dose be decreased due to side effects of orthostatic hypotension (low blood pressure when standing after sitting or lying down), dizziness, headache, falls, and nose bleeds. The pharmacist also gave considerations for melatonin (sleep aide) and Resident 12's antipsychotic to be lowered. In the section that said it was to be completed by nursing staff/physician, no documentation was found on what the decision was or why no changes were made. The physician signed the form on 11/13/2025 and nursing signed on 11/14/2025. Review of Resident 12's MAR from 11/01/2025 to 12/08/2025, showed none of the recommendations for the above three medications had been implemented. During a joint interview on 12/08/2025 at 9:47 AM, Staff C, Assistant Director of Nursing/ Registered Nurse, and Staff J, Resident Care Manager/LPN, were asked about Resident 12. Staff C reviewed Resident 12's July pharmacist recommendation and said the lidocaine order had been updated. Staff C reviewed Resident 12's EHR further and confirmed the lidocaine patch was being applied twice a day. Staff J said the order showed it was on for twenty-four hours. When asked if a POA declination was a clinical indication for not performing a GDR, Staff C said yes, because of resident rights. When asked about Resident 12's pharmacist recommendation review that was requested due to falls, Staff C acknowledged there was not a discussion on the recommendations and there should have been. Staff C said they had checked it off because they have pharmacy do a medication review when they run out of fall interventions, and there currently were unable to find why Resident 12 was on the higher doses of tamsulosin. During an interview on 12/08/2025 at 1:53 PM, Staff B, Director of Nursing Services, said their expectation for following medication regimen review recommendations was for them to go to the medical provider or mental health provider and behavior meetings, then the provider makes the decision on if they agree and they would then follow the instructions. When asked if the team was recommending a GDR and the POA declined, if that met a clinical indication for not following the recommendation, Staff B said they did not know and would need to look into that before answering.No follow-up information was provided.Reference F658Reference WAC 388-97-1300 (1)(c)(iii) -1300 (4)(c)

Based on observation, interview and record review, the facility failed to ensure food was properly stored and labeled in refrigerators, food temperatures were checked without preventing cross contamination, and the resident snack refrigerators were monitored in accordance with professional standards for safe food service. These failures placed the residents at potential risk for food borne illnesses, and a diminished quality of life.Findings included .Initial RoundsOn 12/01/2025 at 10:50 AM, an unidentified item in the dairy refrigerator without a date on it was observed. Staff BB, Registered Dietician, said it was a cake and she could not find a date on it and threw it away. Also observed was a stick of butter partially used with the excess paper crumbled around it. When asked if there was a date on it, Staff BB said no and it should have been placed in a container. Staff BB placed the butter in a container and dated it before she placed it back in the refrigerator.On 12/01/2025 at 10:51 AM, in the refrigerator, along the back wall with the clock and electrical panel, a cup of undated dressing was observed. Staff BB took the cup of dressing out of the refrigerator and threw it away.On 12/01/2025 at 10:58 AM, a greenish substance was observed on the surface of peppers in the produce refrigerator. Staff BB said the peppers were molded and threw them away. On 12/03/2025 at 2:23 PM, Staff CC, Dietary Services Manager, said her expectations for the molding peppers was to double check and make sure they were rotating the produce, and she said she had educated the staff on this. Staff CC said the butter with crumbled paper around it should been placed in a clean container and properly labeled.Meal PreparationOn 12/03/2025 at 10:49 AM, Staff DD, Cook, wiped off the thermometer used to check food temperatures with the rag from the disinfectant bucket also used to wipe the counters, before she checked the temperature of the noodles. Staff DD placed the rag back in the disinfectant bucket. At 10:50 AM, Staff DD cleaned sink and counters with rag from disinfectant bucket just used to wipe off the thermometer. At 10:53 AM, Staff DD checked the temperature of the hamburgers with the thermometer, cleaned with the rag in the bucket of cleaning solution just used to wipe off the counters. At 12:09 PM, Staff DD wiped the counters by the stove and sink and then wiped the thermometer with same rag from the disinfectant bucket.On 12/03/2025 at 2:23 PM, Staff CC, Dietary Services Manager, said it was not sanitary to use the rag from the disinfectant bucket to wipe the thermometer when it was also used to wipe the kitchen counters. Staff CC said she would prefer they used alcohol wipes but if they were not available then they could use a separate disinfectant rag and bucket to wipe the thermometer when they checked the food temperatures. Resident Snack RefrigeratorOn 12/03/2025 at 2:50 PM, Staff E, Resident Care Manager/Registered Nurse, observed the thermometer in the resident snack refrigerator, by the [NAME] dining room and near the administrator's office. Staff E said it was 50 degrees and he said it should be below 41 degrees. When asked how long it has been that way, Staff E stated, I don't know. Staff A, Administrator, said they did not want to take any chances and would talk to maintenance and have the food thrown. On 12/03/2025 at 2:56 PM, Staff Y, Scheduling Coordinator, was observed emptying the freezer and refrigerator located near the [NAME] dinning room for residents. Staff Y said he planned to put up a sign that it was out of order.On 12/03/2025 at 3:47 PM, a sign was observed that said out of order and the temperature gauge read 50 degrees by the [NAME] dinning room (resident refrigerator). There was no food in the refrigerator or freezer. Both Staff Y and Staff A, Administrator, confirmed the thermometer was at 50 degrees. Staff Y said they removed all the food. Staff A said the temperature should have decreased by now, it had been long enough. WAC Reference 388-97-1100(3),2980

Based on observation, interview and record review, the facility failed to ensure residents' records were accurate and complete for 10 of 24 sampled residents (Resident 9, 81, 6, 52, 10, 26, 31, 7, 1, & 37) reviewed for resident records. The failure to document resident information accurately and completely, and/or correctly identify residents' primary care physician, placed the resident at risk for incomplete and inaccurate medical records and unmet care needs.Findings included .Resident 9 Resident 9 was admitted to the facility on [DATE], with diagnoses of dementia with psychotic disturbance (involves symptoms of hallucinations (seeing things not there) and delusions (fixed false beliefs)). Review of the Modification of Quarterly Minimum Data Set (MDS, an assessment tool), dated 10/04/2025, documented Resident 9 was severely cognitively impaired. Record review of Resident 9's progress notes, from 07/04/2025 through 07/17/2025, showed the following behaviors were noted. A behavior progress note, dated 07/04/2025, documented Resident 9 was seeing children that were not there (hallucinating). A behavior progress note, dated 07/05/2025, documented Resident 9 was experiencing hallucinations and hollering out. A nursing progress note, dated 07/10/2025, documented Resident 9 was visually hallucinating, yelling out, and believed someone else was in the room. A behavior progress note, dated 07/17/2025, documented Resident 9 was experiencing visual hallucinations and delusions. Review of the July 2025 behavior monitors, showed Resident 9 had behavior monitors for potential behaviors for antipsychotic use, the behaviors to be documented on by staff included 1. verbal aggression, 2. physical aggression, 3. hallucinations, and 4. delusions. Staff were to document the number corresponding with the behavior noted on the behavior monitor. Review of the behavior monitor for 07/04/2025 (when it was documented Resident 9 was hallucinating), showed staff had documented a + (positive) sign for that date but did not indicate a number for which behavior Resident 9 was positive for. Review of the behavior monitor for 07/05/2025 (when it was documented Resident 9 was hallucinating), did not indicate Resident 9 was having any of the four behaviors included on the behavior monitor. Review of the behavior monitor for 07/10/2025 (when it was documented Resident 9 hallucinating), did not indicate Resident 9 was having any of the four behaviors included on the behavior monitor. Review of the behavior monitor for 07/17/2025 (when it was documented Resident 9 was hallucinating and having delusions), did not indicate Resident 9 was having any of the four behaviors included on the behavior monitor. On 12/08/2025 at 1:13 PM, Staff B, Director of Nursing Services (DNS), said she would expect listed behaviors to be charted on the behavior monitor if they were observed and documented in a progress note. Staff B reviewed Resident 9's behavior monitor and confirmed the documentation from progress notes for 07/04/2025, 07/05/2025, and 07/10/2025 was not there. Staff B said the staff had documented a positive sign on the 07/17/2025 behavior monitor, but they should have included the corresponding number to indicate which sign Resident 9 was positive for. When asked if the missing documentation on the behavior monitors met her expectations, Staff B said no, it should have been put there. Resident 81 Resident 81 was admitted to the facility on [DATE], with an admitting diagnosis of acute respiratory failure with hypoxia (a sudden, severe condition where the lungs fail to get enough oxygen into the blood). The 5 Day MDS, dated [DATE], indicated Resident 81 had some difficulty making decisions regarding tasks of daily life in new situations only. Resident 81 was transferred to the hospital on [DATE]. Review of a single nursing progress note, dated 09/06/2025 and entered at 1:14 pm, documented the day's events leading up to Resident 81's hospitalization. The note showed Resident 81 was smiling in the morning, and documented vital signs (measurements, such as temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation [O2, percentage of oxygen in the blood]) were stable. Without a documented time, Resident 81 later declined a shower and stated he did not feel well. Without a documented time, the nurse documented vital signs remained stable, without recording what the vital signs were. The nurse then documented Resident 81 reported mild shortness of breath when lying flat, the head of the bed was elevated, and Resident 81 was supplied with oxygen at 2 liters per minute. Documentation showed the certified nursing assistant notified the nurse Resident 81 had called 911 from his room. The nurse documented they entered the room for further evaluation and Resident 81's oxygen was then 86% on the 2 liters of oxygen. The note then said emergency medical services crew had arrived at Resident 81's room. Review of Resident 81's vitals showed only two oxygen readings from 09/06/2025 as follows: 09/06/2025 at 7:33 AM, O2 at 92% on room air (morning vital signs) 09/06/2025 at 12:57 PM, O2 at 85% on room air (not a stable vital) The second stable set of vitals, reported in the nursing progress note, was not found. On 12/08/2025 at 1:02 PM, Staff B, DNS, said if a resident reported being short of breath and oxygen was applied, an oxygen reading should be taken and then documented in the record. Regarding the missing documentation of vital signs for Resident 81, Staff B said the nurse should have documented the vital signs. Resident 6 Resident 6 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 6 was cognitively intact, relied on staff for most cares and had an indwelling catheter (a thin tube that remained in the bladder to remove urine). Review of Resident 6's electronic health record (EHR), showed they were sent to the hospital for chest pains and possible urinary tract infection (UTI), from 11/04/2025 to 11/05/2025. The EHR had no follow-up documentation or discharge summary from Resident 6's hospitalization. A Nursing care progress note, dated 11/06/2025 at 2:59 AM, documented Resident 6 returned from the hospital with a diagnosis of UTI (urinary tract infection), but they were unable to obtain antibiotic until provider completed visit with Resident 6. On 12/08/2025 at 10:46 AM, when asked about Resident 6's hospitalization, Staff B, DNS, said the reason for Resident 6's admit was UTI with possible sepsis and the follow-up recommendations included urology and nephrology (specialists in urinary system and kidneys) referrals, to repeat CBC (common blood test that counts your blood's key cells) and UA (urinalysis to look for infection) and antibiotics to be continued. Staff B reviewed the EHR and said none of the recommendations had been followed up with. Resident 52 Resident 52 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment, dated 10/02/2025, showed Resident 52 was severely cognitively impaired, impaired with decision making, and dependent on staff for cares. Review of Resident 52's EHR, showed they were taking a blood thinner and had a side effect monitor for it. Review of Resident 52's progress notes from 10/25/2025 to 12/04/2025, showed blood was noted by nursing in Resident 52's urine on 11/11/2025, 11/22/2025, 11/23/2025, 11/24/2025, 11/25/2025, and 12/04/2025. Review of Resident 52's Treatment Administration Record for their blood thinner side effect monitor, from 11/01/2025- 12/02/2025, showed blood-tinged or frank blood in the urine was a potential side effect and staff had documented no complications noted. During an interview on 12/08/2025 at 12:08 PM, Staff C, Assistant Director of Nursing (ADON)/RN, when asked if a resident on a blood thinner who was having blood in their urine, if that should be recorded on their side effect monitor, said yes it should. Resident 10 Resident 10 was admitted to the facility on [DATE] with a diagnosis of acute pancreatitis (inflammation of the pancreas). The admission MDS, dated [DATE], documented the resident was cognitively intact and had a urostomy (surgically made hole for urine removal through the abdomen). Appointment Documentation On 12/01/2025 at 2:58 PM, Resident 10 said they were supposed to get a scan (computed tomography [CT]- an advanced imaging test that uses X-rays and a computer to create detailed, cross-sectional pictures of the inside of the body). They said they went to the appointment and were sent back because they needed a prescription, and the facility was working on rescheduling the scan. Resident 10's orders, dated 11/13/2025, showed:- Please dress resident in comfortable clothes without metal, for CT appointment on 11/24/2025 at 1:30 PM.- Clear liquid diet three hours before CT appointment on 11/24/2025 at 1:30 PM. A review of Resident 10's Progress notes, dated 11/24/2025, did not show documentation of the resident going to and coming back from a CT appointment. On 12/04/2025 at 2:13 PM, Staff C, ADON/RN, said she did not see any documentation of a CT appointment in the progress notes and her expectation was that the staff document when a resident leaves the facility for an appointment and returns. On 12/05/2025 1:12 PM Staff B, DNS, when looking at the EHR, said she did not see documentation, and she would expect the nursing staff to put in a note that said Resident 10 went for a CT. Primary Care Physician Documentation Review of Resident 10's EHR showed, Staff LL was the primary care physician. On 12/05/2025 at 12:48 PM Staff LL, Medical Director, was asked if she was the physician for this resident and she said no. Staff LL said she had never seen this resident. When asked why she was listed as the primary care physician for Resident 10, Staff LL stated, Because I am the medical director. Review of Resident 26's EHR, showed Staff LL was the primary care physician. Review of Resident 31's EHR, showed Staff LL was the primary care physician. Review of Resident 7's EHR, showed Staff LL was the primary carer physician. Review of Resident 1's EHR, showed Staff LL was the primary care physician. Review of Resident 37's EHR, showed Staff LL was the primary care physician. During an interview on 12/05/2025 at 1:38 PM, Staff LL, Medical Director, reported they were not the primary care provider for any residents at the facility. Reference F690 Reference WAC 388-97-1720 (1)(a)(i-iv)(b)(2)(a-m)

Based on observation, interview and record review, the facility failed to ensure staff followed standard precautions (common sense practices to prevent the spread of infection in healthcare) and enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug resistant organisms and precautions that are implemented when someone has chronic wounds or confirmed or suspected infections). Additionally, the facility failed to perform infection surveillance for 1 of 1 resident (Resident 52) reviewed for surveillance. This failure placed residents at risk of undetected infection, spread of infection, and a diminished quality of life. Findings included.STANDARD PRECAUTIONS During an observation on 12/02/2025 at 11:38 AM, Staff J, Resident Care Manager/Licensed Practical Nurse, gave Resident 74 insulin (medication injected via a needle, that regulates blood sugar) without wearing gloves. During an interview on 12/02/2025 at 11:51 AM, Staff J said they did not have to wear gloves while administering Resident 74's insulin, because it was administered with an insulin pen (a device with a needle, used to inject insulin with preloaded amounts of insulin). During an interview on 12/04/2025 at 1:31 PM, Staff R, Infection Preventionist/Registered Nurse (IP/RN), when asked if it met expectations that insulin was administered with an insulin pen and the nurse was not wearing gloves, said no, nurses were supposed to wear gloves. ENHANCED BARRIER PRECAUTIONS Review of the facility's policy titled Avamere Living-Enhanced Barrier Precautions, dated 03/21/2024, said in the purpose statement, The facility will implement Enhanced Barrier Precautions for residents with [ .] wounds requiring dressing changes [ .]. The guideline interpretation and implementation said, B. All residents with any of the following will be placed on EBP. 2) Wounds[ .] (Wounds generally include chronic wounds e.g. pressure ulcer, [ .]) Resident 24 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 11/19/2025, documented Resident 24 was cognitively impaired, was dependent on staff for all cares and admitted with an unstageable pressure ulcer (PU) on the right heel and moisture associated skin damage (MASD) on their coccyx (tailbone). During observation of wound care on 12/04/2025 at 10:53 AM, Staff T, RN, and Staff R, IP/RN, donned gloves, but no gowns, then uncovered and rolled Resident 24 onto their side. Staff T removed the old foam dressing and said the wound smelled like fish. Staff T cleansed with wound cleanser and then removed their gloves, sanitized their hands, and reapplied new gloves. Staff T patted the wound dry and applied foam dressing. Staff T confirmed two distinct open areas on buttock. On 12/04/2025 at 1:31 PM, when asked if Resident 24 should have been on EBP for wound care treatment, Staff R, IP, stated, It is not a massive pressure ulcer it is very superficial, it is a stage 2 pressure ulcer. It's so microscopic, tiny. Staff R confirmed Resident 24 admitted with a PU, but due to being open to air it doesn't need EBP. When asked if the wound was covered now and if Resident 24 required EBP at this time, Staff R stated, It is so insanely tiny, but probably. When asked if staff should wear personal protective equipment (PPE) during dressing changes, Staff R said for EBP yes. On 12/05/2025 at 11:15 AM, when asked when EBP was required, Staff K, Residential Care Manager (RCM), said when providing care to residents with open wounds, wounds that were draining and catheters. Observations were explained that Staff T, RN, and Staff R, IP/RN, only wore gloves during the wound care treatment. Staff K said that was not acceptable, both staff should have worn the appropriate PPEs. On 12/08/2025 at 10:46 AM, Staff B, Director of Nursing Services (DNS), was asked if they would expect Resident 24 to be on EBP due to required wound care treatments, Staff B said yes. Observations of no EBP signage or EBP cart outside Resident 24's room was reported and the observation of the wound care treatment was explained. Staff B said staff should have worn the appropriate PPE's, there should have been signage for the EBP with required PPE's available and that was not acceptable either. On 12/09/2025 at 12:02 PM, Staff A, Administrator, was told of the observation of Resident 24's wound care treatment. Staff A said both staff members should have been wearing appropriate PPEs for wound care treatment and there should have been EBP signage and PPEs available. INFECTION SURVEILLANCE Review of the facility policy titled, Infection Prevention and Control Program, revised 10/2018, showed it had multiple sections related to infection surveillance, including the following: surveillance, data analysis, outbreak management, and prevention of infection. The section on surveillance, showed surveillance tools would be used for recognizing the occurrence of infections, with a recording of their number and frequency, detecting outbreaks, and detecting unusual pathogens with infection control implications. The section on data analysis, showed the data obtained during surveillance would be used to oversee infections and spot trends. The infection preventionist would be responsible for collecting data from nursing units, categorizing each infection by body site, and recording the number of infections. The monthly rates could be plotted graphically or otherwise compared side-by-side to allow for trend comparison. The section on outbreak management, showed the facility would use specific criteria to differentiate sporadic cases from true outbreaks. The section on prevention of infection, showed staff were to identify possible infections or potential complications of existing infections, implement measures to avoid complications, educate staff and ensure proper infection prevention techniques, and have enhanced screening for possible significant pathogens. During a general infection control interview on 12/03/2025 at 11:23 AM, Staff R, IP/RN, was asked to explain their process for tracking and managing the spread of infections. Staff R said they tracked daily, that if someone was on an antibiotic or alert (facility had identified a potential safety or medical concern and was increasing observation and communication), such as for emesis (vomiting) or new cough, they would be placed on alert and Staff R would investigate to see if the doctor thinks it might be something (infectious). Staff R said their computer dashboard showed antibiotic and clinical alerts were listed, they looked at this every morning, tracked what was happening in current time, but also tracked the monthly look back. Resident 52 was admitted to the facility on [DATE] and had diagnoses of retention (bladder holds on to) of urine, obstructive and reflux uropathy (blockage in the urinary system that prevents normal urine flow), and dementia. Review of the Quarterly MDS assessment, dated 10/02/2025, showed Resident 52 was severely cognitively impaired, impaired with decision making, and dependent on staff for cares. Review of a nursing progress note, dated 11/06/2025, documented Resident 52 reported both pain and burning with urination, and they were placed on alert due to signs and symptoms of dysuria (painful or difficult urination). A second nursing progress note, dated 11/06/2025, documented Resident 52's urine was foul and slimy. Review of Resident 52's temperature log, showed they had a temperature taken on 10/18/2025 and not another until 11/15/2025. On 12/09/2025 at 11:13 AM, Staff R, IP/RN, said during an alert period, residents should have vitals taken once a day at a minimum, usually every shift. Regarding Resident 52's suspected infection and having their temperature taken on 10/18/2025 and not another until 11/15/2025, Staff R said she would have expected temperatures to be taken during that period. After reviewing the 11/06/2025 progress notes that indicated Resident 52 was having pain and burning with urination and was placed on alert for signs and symptoms of dysuria, Staff R was asked if Resident 52 was identified as a resident who had a suspected infection, Staff R said Resident 52 had many infections. Reference F686, F690Reference WAC 388-97-1320 (2)(a)

Based on interview and record review, the facility failed to ensure safety devices were consented for 1 of 2 residents (Resident 12) reviewed for safety devices/bed rails. This failure placed residents at risk of uninformed consent, increased chance of accidents, and a diminished quality of life. Findings included.Resident 12 was admitted to the facility on [DATE], with a diagnosis of dementia (decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems, reasoning issues, and personality changes). The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/2025, showed Resident 12 was severely cognitively impaired. Review of Resident 12's safety device assessment and consent form for their wander guard device (device worn on person or mobility aid that alarms when exiting certain doors), dated 06/05/2025, showed the device was being used to remind the resident to not leave the facility without assistance. Under potential risks (a section on the risks of using the assistive device), other was selected and staff wrote, Leaving facility without assist and injuring self. Under consent, staff documented they had obtained Verbal Consent from Resident.Review of Resident 12's safety device assessment and consent form for their bilateral mobility bars/bed rails, dated 08/06/2025, showed staff documented they had obtained Verbal Consent from Resident.During an observation on 12/01/2025 at 1:09 PM, Resident 12 was seen with bilateral mobility bars on the top of their bed. During an observation on 12/03/2025 at 11:15 AM, Resident 12 was seen with a wander guard on their wheelchair. During a joint interview on 12/08/2025 at 9:47 AM, Staff C, Assistant Director of Nursing/ Registered Nurse, and Staff J, Resident Care Manager/Licensed Practical Nurse, were interviewed about Resident 12. Staff C said if a resident showed signs of dementia, they would need to get consent from the Power of Attorney (legal decision maker) or primary emergency contact. Staff C said Resident 12 was not able to give informed consent, so their wife would need to be contacted. When asked if it was clear where they were consenting to have the wander guard placed, Staff C acknowledged the consent form did not say where. During an interview on 12/08/2025 at 1:53 PM, Staff B, Director of Nursing Services, said risk and benefits should be reviewed for informed consent, and residents unable to sign for themselves should not be signing consent. Reference WAC 388-97-0260,-1020(4)(a-b)

Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their comprehensive care plans for 4 of 22 sampled residents (Residents 1, 3, 8 & 81). The failure to initiate bowel care, identify and monitor non-pressure skin conditions, complete and document respiratory assessments, and evaluate daily weights and report significant variances to the physician, placed resident at risk for unidentified and/or avoidable decline, delay in treatment, pain/discomfort, unmet care needs and other potential negative health outcomes. Findings included . The facility's bowel care protocol dated 10/2020 documented, If a resident has not had a bowel movement for three consecutive days (must be medium or large), observe the following protocol after a physician order had been obtained.a. evening shift is to run a look back reportb. Evening shift to give milk of magnesia. If no results, thenc. Day shift to give the suppository. If no results, thend. Fleets enema will be given. If no results, complete a focused assessment of the abdomen and complete a digital exam and notify the Physician if needed.e. Suppositories and enemas are not to be given on night shift unless it is a resident's request. 1) Resident 1 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool) showed the resident was cognitively intact, had diagnoses of heart failure and kidney failure and received diuretic medication during the assessment period. Record review showed an order, dated 10/25/2025, order for daily weights. The order did not include weight variance parameters to indicate when physician notification was required. A nutritional problem care plan, revised 11/17/2025, directed staff to notify the physician and resident or representative of significant or severe weight loss or weight gain. Severe or significant weight loss or gain were not defined. Review of Resident 1's daily weight for November 2025 showed the following: a) 11/11/2025 weight- 265.1lbs; 11/12/2025 weight- 270.8 lbs. (+ 5.7 lbs. in 24 hours) b) 11/15/2025 weight -274 lbs.; 11/16/2025 weight- 278 lbs. (+ 4 lbs. in 24 hours, and + 13.1 lbs. in 6 days) c) 11/21/2025 weight- 279.6 lbs.; 11/22/2025 weight- 285 lbs. (+ 5.4 lbs. in 24 hours and + 19.9 lbs. in 11 days) Review of the electronic health record showed there was no documentation that the physician was notified of Resident 1's weight gain on the above referenced occasions. On 12/08/2025 at 2:36 PM, when asked if there was documentation the physician was notified of Resident 1's weight gain on 11/12/2025, 11/16/2025 or 11/22/2025 Staff B, Director of Nursing Services, said the physician should have been notified, but was unable to find documentation to show that it occurred. 2) Resident 81 was admitted to the facility on [DATE]. The 5 Day MDS, dated [DATE], indicated Resident 81 had some difficulty making decisions regarding tasks of daily life in new situations only. Resident 81 had an admitting diagnosis of Acute Respiratory Failure with Hypoxia (a sudden, severe condition where the lungs fail to get enough oxygen into the blood.) Resident 81 was transferred to the hospital on [DATE]. Resident 81 had an order, dated 09/05/2025, for Oxygen to be applied at 2 liters per minute via nasal canula as needed for shortness of breath/cyanosis (bluish or grayish discoloration of the skin, lips, or nail beds due to a lack of oxygen in the blood or poor circulation, signaling that tissues are not getting enough oxygen). Staff were instructed in the order to notify the MD (provider) once resident was on oxygen. Review of a nursing progress note for Resident 81, dated 09/06/2025 entered at 1:14 PM, documented Resident 81 was smiling in the morning and vital signs (measurements of essential body functions, such as temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation [SpO2 or O2, percentage of oxygen in the blood]) were stable. At some point later (time was not documented in the note) Resident 81 declined a shower and stated he did not feel well. The note then documented vital signs remained stable (the note did not specify the time this set of vital signs were taken or what the vital sign readings were at this point.) The note then documented Resident 81 reported mild shortness of breath when lying flat and the head of the bed was elevated, and Resident 81 was supplied with oxygen at 2 liters per minute (the note did not document that vital signs were taken when oxygen was applied, that a respiratory assessment was done, or that the provider was notified when oxygen was applied). The note then documented that the certified nursing assistant notified the nurse that Resident 81 had called 911 from their room (time was not noted). The note then documented that the nurse entered Resident 81's room for further evaluation and Resident 81's oxygen was then 86% on the 2 liters of oxygen. The note then said Emergency Medical Services crew arrived to Resident 81's room, report was provided to the crew, and Emergency Medical Services transported Resident 81 to the hospital for evaluation. The note then documented O/C (on call) Resident Care Manager notified of event. Review of the note showed that vital signs were reportedly done three times, the first being in the morning, secondly when it was charted vital signs remained stable, and the third time when Resident 81 was reevaluated. Further review indicated a set of vital signs taken at 12:57 pm indicated that Resident 81 had an oxygen reading of 85% on room air at that time, however oxygen level of 85% on room air would not indicate vital signs were stable. Record review showed only two oxygen readings from 09/06/2025 as follows: On 09/06/2025 at 7:33 am O2 at 92% on room air (morning vital signs) On 09/06/2025 at 12:57 pm O2 at 85% on room air (a critical and dangerous reading) On 12/08/2025 at 9:39 AM, Staff F, Registered Nurse, when asked what steps she would take if a resident reported feeling short of breath, Staff F said she would have the resident sit down and would check their pulse ox (oxygen level) and do a respiratory assessment, listen to the lungs, and if oxygen reading was below 90% she would put 2 liters of oxygen via nasal cannula on the resident. On 12/08/2025 at 1:02 PM, Staff B, Director of Nursing Services, when asked her expectations of staff actions when a resident reports shortness of breath, Staff B said they should do an assessment, get vital signs, listen to the lungs, take pulse ox, look for edema and once assessment is done call the doctor. Staff B said if the pulse ox was low, staff should put oxygen on the resident and notify the doctor they did that. When asked where the respiratory assessment would be documented, Staff B said in a progress note. When asked if staff should get an oxygen reading if a resident required the application of oxygen due to shortness of breath, Staff B said yes. When asked if staff did get a set of vital signs should they be entered into the record, Staff B said yes. When asked if a resident had an as needed order for oxygen with instructions to notify the MD after oxygen was applied when she would expect the MD to be notified, Staff B said at the time. When Staff B reviewed the progress note from the nurse on 09/06/2025, and was asked about the missing vital sign documentation, Staff B said the nurse should have documented the vital signs that were reportedly stable. When asked if a respiratory assessment was done, Staff B said the progress note did not say the nurse had listened to Resident 81's lungs and they should have. When asked if the provider should have been notified, Staff B said the provider should have been notified of the oxygen application. When asked if this met her expectations, Staff B said no, adding that the nurse should have put in two progress notes. On 12/09/2025 at 1:06 PM, Staff C, Assistant Director of Nursing, reviewed the 09/06/2025 nursing progress note and said the nurse who provided care that day had written the vital signs were stable and should have listed the vital sign readings in the progress note. Staff C said it would have been good to know what Resident 81's oxygen level was at the time they were put on oxygen. 3) Resident 3 was admitted was admitted to the facility on [DATE] with a diagnosis of cellulitis (deep bacterial skin infection causing red, swollen, painful, and warm skin) of right and left lower limbs. The admission MDS, dated [DATE], documented the resident was cognitively intact. Review of Resident 3's bowel movement record documented the resident had no bowel movement on 11/26/2025, 11/27/2025, 11/28/2025, 11/29/2025, 11/30/2025, and 12/1/2025. Review of Resident 3's November and December Medication Administration Record (MAR) did not show any documentation of the resident receiving PRN (as needed) bowel medications. On 12/04/2025 at 10:48 AM, Staff C, Assistant Director of Nursing/Registered Nurse, said while looking at Resident 3's electronic medical record (EMR) she did not see any progress notes of resident refusing PRN medications or that they were offered. Staff C said her expectation is that the bowel protocol be initiated and or the staff document that they offered PRN medications if they were refused. On 12/08/2025 at 12:33 PM Staff B, Director of Nursing, said while looking at Resident 3's EMR that the staff did not give any PRN medications and her expectation is that they start the bowel protocol. 4) Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE] showed Resident 8 was cognitively intact. During an observation and interview on 12/2/2025 at 8:28 AM, Resident 8 showed they had a bruise on their left forearm, said they had bumped something, and the bruises just happen. Review of Resident 8's electronic health record on 12/3/2025, showed there was no monitor in place for the bruise. During an interview on 12/5/2025 at 8:01 AM, Staff S, Registered Nurse, confirmed Resident 8 had a bruise on their forearm. When asked how long it had been there, Staff S said they did not know. When asked if they were doing any interventions for the bruise, Staff S said no they were not. During a joint interview on 12/8/2025 at 9:47 AM, Staff C, Assistant Director of Nursing/ RN, and Staff J, Resident Care Manager/Licensed Practical Nurse, were asked about Resident 8. When asked about Resident 8's forearm bruise, both Staff C and Staff J were unable to find any documentation on it. Staff C confirmed there was no mention of it on the skin assessments for the month of November, it was not on the care plan, and there was not an accident and incident report on it. Staff J assessed Resident 8's forearm, returned, and said there was a bruise on the upper forearm, over the size of a dollar coin, and described it as red and circular. Staff J said they would have expected monitoring of the bruise, and for it to have been documented on a skin assessment. Refer to F628 and F842 Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure supervision was provided in the bathroom as directed in the care plan for 1 of 4 sampled residents (1) reviewed for accident hazard. This failure placed residents at risk for injury and a diminished quality of life. This failure caused harm to Resident 1 when the resident was left unattended, on a shower chair, in the bathroom and experienced a fall and sustained a wrist fracture and forehead hematoma. Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 07/02/2023, documented Resident 1 had moderate cognitive impairment; required extensive assistance from one to two staff for bed mobility, transfers, and toileting; and had a history of falls. A Fall Risk Evaluation, dated 06/27/2023, documented Resident 1 was at moderate risk for falls. The care plan, dated 06/27/2023, documented Resident 1 was at moderate risk for falls. Interventions, initiated 06/27/2023, included, DO NOT leave unsupervised in bathroom/on bedside commode. An Alert Note, dated 06/28/2023 at 10:04 PM, documented Resident 1 was found on the floor in the bathroom. The resident reported after having a bowel movement she tried to get to the sink to wash up and lost her balance and fell . The CNA (certified nursing assistant) reported he had instructed Resident 1 to not attempt to transfer and to put on the call light if needing assistance. The resident was assessed for injury and found to have a bump on the right forehead, right knee, and reported right shoulder pain. The resident was transported to the emergency room . An X-ray exam finding, dated 06/28/2023 at 11:41 PM, documented Resident 1 had a nondisplaced transverse radial metaphyseal fracture (one of the two long bones in the forearm breaks close to the wrist) of the right wrist. A facility investigation report, dated 06/30/2023, showed a CNA statement that Resident 1 was left in the bathroom unsupervised; the resident was instructed to not attempt to transfer and use the call light if needing assistance. When staff returned to the bathroom to check on the resident, Resident 1 was found on the floor. On 07/05/2023 at 2:05 PM, Resident 1 was observed with a soft cast (splint and ace wrap) on the right arm from fingertips to past the elbow. Resident 1 said she was by herself for a short period of time in the bathroom. The resident said the staff member had to go do something. The CNA did say to not get up and to use the call light. Resident 1 said she fell while attempting to do something I thought I could do. Resident 1 stated, I had to learn a hard lesson in complying with the rules. At 3:06 PM, Staff D, CNA, said at the time of Resident 1's fall he had just completed the resident's shower, the resident was being transported back to her room, he left the resident in the shower chair in the bathroom, instructed the resident to not get up and to use the call light. Staff D said the resident verbally responded with understanding. Staff D said he then went to answer a call light and when he returned, about 2 minute later, he discovered Resident 1 on the floor. Staff D said he knew how residents were to be transferred and any safety precautions by what was on the Kardex (care directive from the care plan), what the residents can tell him and by asking other staff. Staff D said he had left Resident 1 in the bathroom before and was not aware the care plan directed staff to not leave the resident unsupervised. Staff D said he did not think Resident 1 would be able to get out of the shower chair and that she was alert and understood his direction by verbally responding okay. On 07/07/2023 at 3:00 PM, Staff C, Registered Nurse (RN) and Resident Care Manager, said residents were assessed on admission for fall risk, taking into consideration the resident's diagnoses, cognition, and history of falls. Interventions were then care planned to prevent falls. Staff C said staff should know what intervention were in place by the care plan and the Kardex. Staff C said Resident 1 was admitted on [DATE], fell on [DATE], and was not supposed to be left unattended, in a shower chair, in the bathroom. At 3:17 PM, Staff B, Director of Nursing Services and RN, said fall assessments were completed on all new admissions and based on cognition, history of falls and diagnoses. Those with increased risk of falls were expected to be placed near the nurse's station and not be left unattended in the bathroom among other interventions. Staff B said staff knew what fall prevention interventions were indicated for the resident by reviewing the Kardex. Staff B said her expectation was that staff read the Kardex. Staff B said Staff D was not following the care plan for Resident 1 when the resident fell , as Resident 1 was not supposed to be left in the bathroom unattended. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards when providing a one person transfer instead of the care planned two person transfer for 1 of 2 sampled residents (1) reviewed accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This failure caused harm to Resident 1 when transferred with one, rather than two, staff without the required lift, and sustained right ankle fractures, a left knee abrasion, and a skin tear with bruising to a left-hand finger. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including aphasia (a disorder that affects how one communicates and understands spoken and written language), and hemiparesis (inability to move one side of the body) of right (dominant) side following cerebral infarct (stroke). The quarterly Minimum Data Set, an assessment tool, dated 10/20/2022, documented Resident 1 had moderate cognitive impairment and required extensive assistance from two staff for bed mobility and transfers. The care plan focus for activities of daily living (ADL) care included transfer interventions, initiated 11/03/2017, staff were to use a sit to stand mechanical lift when transferring Resident 1, for optimal independence with decreased risk of falls. A Nursing Care Note, dated 10/24/2022 at 9:40 PM, documented during transfer from bed to w/c [wheelchair] res [resident] lost strength and slid to the floor. Aide was assisting res and lowered her to the ground. Another aide was called to room and res was assisted to bed. Assessed for injury, noted 3x3cm [centimeter] abrasion to L [left] knee and 1cm skin tear to L 5th finger. Cleansed and bandaged wounds. Res denies pain presently. Witnessed fall and did not hit head. Educate staff to use proper transfer equipment. Fax to PCP [primary care provider] to notify and for tx [treatment] orders. Placed on alert. Unable to notify POA [power of attorney] due to late hour. A Nursing Care Note, dated 10/25/2022 at 9:11 PM, documented faint bruising noted to L 5th finger and L knee after fall on 10/24/2022. Dressings intact. Awaiting further tx orders. A Nursing Care Note, dated 10/26/2022 at 12:05 PM, documented, Latent injury [discovered after the incident] assessed on patient this morning from her recent fall. Right ankle has swelling and bruising. Tender to the touch. Patient has difficulty trying to move ankle. Called on-call provider . who gave a verbal order to have patient get a scheduled x-ray of her right ankle. Inquired whether she should be sent via 911 and the provider ordered it to be scheduled. Order and requisition for STAT [immediately] x-ray given to scheduling to make an appointment as soon as possible. Called POA . to inform [them] of the swelling/bruising of right ankle and that we would be sending her to get an x-ray as soon as it was scheduled. An x-ray report, dated 10/27/2022 at 10:06 AM, documented, Impression: Distal fibula [ankle bone] and medial malleolar [end of shin bone on side of ankle] fractures are present . fracture lines extend in to the tibiotalar joint [ankle junction between distal tibia and fibula]. A Nursing Care Note, dated 10/27/2022 at 11:46 AM, documented, Patient went to scheduled x-ray this morning and image indicates a fracture of her right distal tibia and fibula. Order received from [provider] to send patient to the ER [emergency room ] for evaluation and treatment of fractures. Called and spoke with daughter . and notified [them] of the results and that [the resident] would be going to the ER. [They] had no questions at this time. A Nursing Care Note, dated 10/27/2022 at 5:04 PM, documented, Resident returned to facility via ambulance. Resident has right posterior short leg splint in place. No c/o [complaint of] pain or discomfort at this time, will continue to monitor. Resident needs F/U [follow-up] with ortho in one week. Transportation notified. A Physician's Order, dated 10/28/2022, documented the resident was to be non-weight bearing until the resident had follow-up with ortho regarding tibia/fibula fractures. A facility investigation report, dated 10/31/2022, documented the CNA (Certified Nursing Assistant) did not use a sit to stand lift to transfer the resident, instead attempting to transfer Resident 1 alone. A physician's order, dated 11/19/2022, documented a CAM (controlled ankle movement) boot was to be worn by Resident 1 twenty-four hours a day for safety. An orthopedic follow-up note, dated 12/15/2022, documented the resident was to continue to wear the CAM boot when not working with PT (physical therapy) and was upgraded to 5% toe touch weight bearing. On 12/16/2022 at 2:27 PM, Resident 1 was observed sitting in her wheelchair in the hall outside of her room. The resident was self-propelling the wheelchair with her left foot and arm, right foot with CAM boot was in place on footrest, and right arm was placed in brace fitted to chair. On 12/19/2022 at 7:52 PM, Staff D, CNA, said the resident did not like to use the sit to stand, and it was common knowledge she was a two person transfer and not a sit to stand. Staff D said she were unable to find another staff to assist, so she attempted to do a stand pivot transfer with the resident as she had done successfully many times. Staff D stated, We just didn't turn. I fell , and [the resident] landed on top of me. On 12/20/2022 at 11:05 AM, Resident 1's Family Member (FM) said the facility reported Resident 1 fell . FM said Resident 1 was dropped because she is paralyzed on the right side of her body and depends on staff to transfer her. FM stated, They have to transfer [the resident] with zero weight. FM said she had witnessed staff physically lifting Resident 1 under the arms when transferring, and stated, It seems they all transferred her differently. FM said Resident 1 had a bad knee scrape, and the ankle was black and blue with swelling. FM said she went to the orthopedic appointment with Resident 1 and was told there were three fractures. FM said she could tell Resident 1 was in pain due to wincing and facial expressions when the ankle was moved. At 3:45 PM, Staff C, Licensed Practical Nurse and Resident Care Manager, said staff knew how residents were to be transferred by the Kardex (care directives) and the care plan. Staff C said she was there the evening Resident 1 fell and the CNA transferring the resident did not use a sit to stand as directed in the care plan. Staff C said there were immediate injuries to the knee and finger noted, but she did not know until later that the ankle was fractured. Staff C said she monitored that care plans were being followed through observations. On 12/21/2022 at 10:07 AM, Staff E, CNA, said prior to the fall, the resident was a sit to stand lift for transfers, and Staff E did not recall the resident refusing to use the lift. Staff E said Resident 1 was currently required a Hoyer lift with two staff assist. At 11:26 AM, Staff B, Registered Nurse and Director of Nursing Services, said staff knew how to transfer residents by using the Kardex or the care plan. Updates were made by her or the RCMs. Staff B said she did random checks to monitor the care plan was being followed. When asked about Resident 1's fall on 10/24/2022, Staff B said the ankle injury was not immediately apparent due to it being the resident's affected side, but then bruising and swelling developed and the x-ray showed it was fractured. Staff B said the resident was sent to the ER. When asked what the facility investigation found as the reason for the fall, Staff B stated, The evening shift aide did not use the lift. She did not follow the Kardex. She was in a hurry and could not find anyone to assist. Staff B said her expectation was for staff to follow the Kardex. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review the facility failed to identify and provide needed care and services to meet the physical needs for 1of 2 sampled residents (#271) reviewed for quality of care when a residents weight was not obtained, [MEDICAL CONDITION] monitoring was not initiated and provider notification of change of status did not occur. These failures caused harm to resident #271 when his health declined, he experienced extended anxiety and confusion and was hospitalized . Findings Include . Resident #271 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record documentation showed the resident was alert and oriented x 4 (to person, place, time and situation) at the time of admission. <Weight> A Provider order, dated 08/24/18 at 3:06 PM, documented Check admission weight then every week. Every day shift every Wednesday for unspecified diastolic (Congestive) Heart Failure. The resident's (MONTH) (YEAR) Treatment Administration Record (TAR) directed staff to obtain vital signs, including weight monthly starting 08/24/18. TAR documentation showed no weight was obtained for Resident #271. The facility could not provide documentation that showed the resident was weighed during his 08/23/18 to 08/27/18 admit. On 10/23/18 at 5:47 PM, after reviewing the resident's medical record Staff A, Registered Nurse and Director of Nursing Services, said no weight had been documented for this admit. Staff A said nursing assistants were expected to obtain and document the resident's weight upon admit. <[MEDICAL CONDITION] monitoring> The Admission Nursing Data Base, dated 08/23/18, documented Resident #271 had 2+ . peripheral (indicating arms and legs) [MEDICAL CONDITION] (swelling caused by fluid retention) on the day of admit. The medical record showed no order(s) related to monitoring the resident's [MEDICAL CONDITION] and no parameters to direct facility staff when to contact provider. On 10/23/18 at 5:47 PM, Staff A said licensed staff were expected to do skilled charting every shift for the first 3 days of admission and the charting should include [MEDICAL CONDITION] monitoring results. Staff A stated Resident Care Managers were expected to initiate [MEDICAL CONDITION] monitoring on the resident's TAR and the monitoring should occur every shift (days, evenings and nights). Medical record documentation showed the resident admitted to the facility on the evening shift of 08/23/18 with [MEDICAL CONDITION] to the upper and lower extremities and abdominal area. Resident #271 was discharged on the night shift of 08/27/18 to the hospital when he declined. Licensed staff missed 11 of 13 opportunities to monitor the resident's [MEDICAL CONDITION] during his admission. WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure care to prevent the development of and monitoring to prevent the worsening of a facility acquired pressure ulcer occurred for 1 of 2 sampled residents (#66) reviewed for pressure ulcers. These failures placed residents at risk of pain, wound decline and a decreased quality of life. This caused harm to Resident #66. Findings include . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) stages include: Stage I: Intact skin with non-blanchable (redness remains when skin depressed) redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. (MONTH) indicate resident is at risk for developing a pressure ulcer. Stage II: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red/pink wound bed. Unstageable: Tissue loss in which actual depth of the ulcer is completely obscured by slough (moist devitalized tissue) and/or eschar (dark crusty tissue) in or covering the wound bed. Resident #66 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 10/01/18, documented the resident was cognitively intact, required extensive assistance with bed mobility, transfer, was at risk for pressure ulcer development and had no pressure ulcers. Resident #66's Admission Nursing Data Base, dated 9/24/18, documented the resident did not have a pressure ulcer. A nurses note, dated 10/2/18 at 6:03 AM, documented, resident reported increased pain at right heel; noted an approximate 5 centimeter (cm) reddened area on right heal. The Accident and Incident report for Resident #66's skin impairment, dated 10/01/18 and revised on 10/09/18, documented, .Right heel is blanchable and relief was obtained after heels were floated. Record review included the resident's (MONTH) (YEAR) and (MONTH) (YEAR) Treatment Administration Records (TARs) and showed the facility did not provide Resident #66 with wound care treatment and no wound related monitoring was in place between 10/03/18 and 10/17/18. A Wound Assessment Details Report, dated 10/04/18 at 9:24 AM, documented, Resident #66 had a Stage II pressure ulcer on the right heel. Documentation on 10/11/18 showed the right heel pressure ulcer was unstageable. On 10/16/18 through 10/18/18, multiple observations showed Resident #66 sitting up in his wheelchair, wearing non-skid socks with his feet flat on the floor. On 10/18/18 at 11:52 AM, when asked if Resident #66 had any pressure ulcers Staff L, Registered Nurse (RN), stated, No he does not, am looking at the orders and I don't see one, so no he does not. At 11:58 AM, Staff M, RN and Resident Care Manager (RCM), said Resident #66 developed a pressure ulcer to right heel. Staff M, stated, I think we have orders but they are in here incorrectly. After reviewing the resident's (MONTH) and (MONTH) TARs Staff M, said, I don't see where treatment was provided, it is not on the TARs. On 10/18/18 at 2:26 PM, Staff P, RN and Wound Care Nurse, said, Resident #66's right heel pressure ulcer was facility acquired and identified on 10/4/18 as a Stage 2 pressure ulcer. Staff P, said, an order for [REDACTED]. Staff P, said, on 10/11/18 the wound became unstageable and she requested doctors' orders via fax which did not go through. Staff P, stated, system failure. Staff P said there was no follow up to obtain the orders, and the wound had worsened. On 10/18/18 at 2:00 PM Staff A, RN and Director of Nursing Services, said it was her expectation staff follow the facility wound protocol. Staff A, said, Resident #66's pressure ulcer could have been prevented, orders should have been obtained timely, placed on the TARs and should have been care planned. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure necessary care and services were being provided to ensure the residents did not develop and/or worsen pressure injuries for 4 of 5 sampled residents (#1, 2, 3 & 5) reviewed for quality of care. The failures by a licensed nurse to document the pressure injuries and implement necessary interventions to prevent and/or heal pressure injuries in a timely manner caused harm to Resident #1, #2, #3 and #5 and represented an immediate jeopardy for all the residents who were dependent on staff members for transfers and bed mobility. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission assessment, dated 5/12/17, documented the resident was at risk for development of pressure injuries. The resident was alert, oriented and able to make his needs known. The resident had generalized weakness and was dependent on staff for assistance with activities of daily living including transferring, bed mobility and toileting. The resident did not have a pressure injury when the resident was admitted to the facility. The resident's care plan had interventions to ensure care and services were being met and prevent development of pressure injuries. On 6/29/17 at 1:45 p.m., Resident #1 was observed sitting in a wheelchair in the resident's room and was neatly groomed. The resident said he had a sore on his tailbone and was not able to recall how the injury occurred. Resident #1 stated the facility was not equipped to help someone like the resident who needed assistance with toileting. The resident said he had waited in soiled incontinent products up to an hour for staff assistance. The resident stated he looked at the clock on his wall when he waited and said help was especially slow during meals. The resident stated he was admitted without a pressure injury. At 2:15 p.m., Licensed Nurse (LN) B stated the resident had a pressure injury on the resident's tailbone. LN B indicated the pressure injury was a Stage III (full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia) and the wound measured 1.5 centimeter (cm) x 1.0 cm x 0.5 cm. LN B stated the wound was 50% beefy red in the center and had no odor. At 2:15 p.m., a skin observation with LN B showed the resident had a pressure injury on the resident's tailbone. The wound was approximately a dime sized, elongated shaped and about 0.5 cm in depth. The center of the wound was beefy red, yellow slough and pink on the perimeter of the wound. No fluid discharge was observed. The resident complained of pain when LN B palpated the wound. LN B packed the wound and covered it with a foam dressing. A progress note, dated 5/25/17 at 7:31 a.m., documented a nursing assistant reported the resident had a reddened area to the resident tailbone. A LN assessed the injury and notified the resident's physician the resident had an open area on the resident tailbone which measured 1.5 cm x 2.0 cm. The facility did not receive a new order for the resident and the resident was unaware of the pressure injury. A progress note, dated 6/7/17 at 5:27 p.m., a Resident Care Manager (RCM) documented the resident complained of his tail bone being sore. The resident was assessed and noted the pressure injury had increased in size to 3 cm x 1 cm x 1.2 cm in depth, maroon in color and had fluid discharge. The facility notified the resident's physician and the physician ordered to have the wound cleansed and the dressing changed every three days and as needed. A progress note, dated 6/23/17 at 3:11 p.m., a LN documented no mention had been made in the nursing report last two days regarding the sacral pressure ulcer and no orders had been placed in the resident's treatment chart for dressing changes. The resident was sent to the hospital for an evaluation of the wound. A progress note, dated 6/24/17 at 1:39 a.m., documented the resident returned to the facility and was diagnosed with [REDACTED]. Review of the record showed the facility did not have treatments in place to address the resident's pressure injury which was identified on 5/25/17 and no dressing changes were document until 6/7/17. The resident's record showed the facility provided six dressing changes (6/7/17, 6/15/17, 6/19/17, 6/21/17, 6/23/17 and 6/25/17) from 5/25/17 to 6/29/17. The resident had physician orders for wound care, dated 6/7/17, with instructions to clean wound to coccyx with normal saline, pack with [MEDICATION NAME] Ag, and cover with foam dressing. The dressing was to be changed every three days and as needed until resolved. Record review showed there were no dressing changes from 5/25/17 to 6/7/17, and received 6 of the 8 dressing changes ordered by the physician. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 5/21/17, documented the resident had memory problems, required assistance with activities of daily living including transfer, bed mobility, toileting and was at risk for development of pressure ulcers. Resident #2 did not have a pressure injury. The resident's care plan had interventions to ensure the resident did not develop a pressure injury including to float the resident's heels while in bed, complete skin assessment weekly and for staff to anticipate the resident's needs. On 6/29/17 at 6:10 p.m., Resident #2 was observed sitting in her wheelchair in the dining room and neatly groomed. The resident was not able to provide information related to the care and services she had received. At 6:20 p.m., LN B stated the resident had eschar that covered the resident's entire right heel and was unstageable. At 6:20 p.m., a skin observation with LN B showed the resident's right heel was covered with a dried, black, thick leathery skin layer with brown edges. The resident stated she did not recall how the injury occurred. Review of record showed a progress note, dated 6/9/17 at 3:08 p.m., the resident was found with a pressure injury measured 3 cm x 3 cm unstageable purple area on the resident's right heel. Staff were to ensure the resident's right heel was floated while in bed and not come into contact with the wheelchair. A progress note, dated 6/23/17 at 11:52 a.m., documented on 6/21/17 a wound was found the resident's right heel. On 6/23/17 the resident was assessed and a wound measured 3.5 cm x 3.0 cm unstageable pressure ulcer to the resident's right heel. The wound was hard, with black necrotic tissue covering the wound bed. A wound summary report, dated 6/28/17, documented the resident's right heel pressure ulcer was measured and was 2.4 cm x 6.20 cm, necrotic hard and unstageable. The facility became aware of the pressure injury on 6/9/17. The facility had no documentation and could not verify treatments were initiated and implemented to promote healing and prevent a worsening of the pressure injury. 3) Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's assessment, dated 4/20/17, documented the resident had memory problems, impaired cognition, dependent on staff for assistance with activities of daily living including transfers, bed mobility and toileting. The facility identified the resident was at risk for development of pressure injury. On 6/29/17 at 1:50 p.m., Resident #3 was observed sitting in his wheelchair and was not able to provide information related to the care and services the resident received. Review of the wound summary report showed on 5/9/17 the resident acquired a pressure injury on the right ischial tuberosity (buttock). On 5/9/17, the resident had a physician order for [REDACTED]. The Treatment Administration Record (TAR) documented the facility provided 13 dressing changes from 5/9/17 to 5/31/17. The facility did not change the resident's dressing for 10 days. On 5/31/17, the wound summary record showed the wound was measured at 2.0 cm x 1.5 cm x 2.5 cm and classified as a Stage II. On 6/21/17, the wound was measured at 1.7 cm x 1.9 cm x 1.8 cm and classified as a Stage III. On 6/28/17, the wound was measured at 1.2 cm x 1.94 cm x 2.2 cm. At 3:35 p.m., LN B said Resident #3 had a pressure injury on the resident's right buttock with fluid discharge. The wound bed was beefy red with yellow slough in the center and measured 1 cm x 1.5 cm x 2.5 cm. At 3:35 p.m., a skin observation with LN B showed the resident had a pressure injury on the right lateral buttock. The wound was approximately dime size, approximately 2.5 cm deep and was beefy red with yellow slough in the center. 4) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's assessment, dated 6/11/17, documented the resident had memory problems, impaired cognition, unable to make her needs known, dependent on staff members for assistance with activities of daily living including transfer, bed mobility and incontinent care. Resident #5 was at risk for development of pressure injuries and was admitted with a Stage II (partial thickness skin loss involving epidermis, dermis or both) pressure injury on her left buttock. The resident was end of life care and had been discharged from the facility. A progress note, dated 6/7/17 at 8:34 a.m., documented the resident was found with open areas on each heel, both measured approximately 1.0 cm in diameter. A progress note, dated 6/13/17 at 12:34 a.m., LN documented during morning care the resident was found with a Stage III pressure injury on the resident's right upper buttock. On 6/29/17 at 5:30 p.m., Nursing Assistant (NA) D stated the facility's computerized documentation system showed the care and services each resident required and guidance for the NAs. NA D said he reviewed the computer system each shift for changes in the residents' care plans and to ensure services were being met. NA D stated he looked at the residents' skin whenever he was providing care for the residents and reported skin problems to the LNs as soon as he was able. At 5:50 p.m., LN A stated staff members reported skin problems to the LNs. LN A said the LNs were responsible to assess the resident, document the characteristic of the wound/injury, location, size, complete an incident report, notify the resident's physician, and put in treatments to prevent further deterioration of the wound/injury. LN A said the assessments and treatments were to be done and/or put in place immediately. LN A stated the LN who assessed the resident was responsible for updating the TAR, verbally inform the care staff of the changes and notify the incoming LN during shift report. The Resident Care Coordinator (RCM) stated the LNs updated the care plans in the computerized charting system all the care directives and provided guidance for the NAs to follow. The RCM said the NAs were responsible for the care and services included in the computerized charting system. The Regional Nurse Consultant (RNC) and the Director of Nursing Services (DNS) were interviewed. The RNC stated Resident #1, #2, and #3 sustained pressure injuries and they were facility acquired. The RNC said the facility investigated the incidents and discovered the residents involved were under the care of LN B. The RNC stated the care staff reported the injuries to LN B who was responsible to assess the injuries, document the injuries in the residents' clinical records and the 24 hour report, notify the RCM/DNS, update the TAR, and initiate an incident report. The RNC said the facility investigations showed LN B consistently failed to follow the facility's pressure injuries guideline and did not provide the necessary treatments for the injuries. The RNC said the residents did not receive the necessary treatments in a timely manner. The RNC stated the RCM and DNS reviewed physician orders daily to ensure proper interventions were in place and did weekly skin audits to ensure treatments were effective. The RNC said the DNS and RCM monitored the LNs to ensure compliance. The facility failed to provide the necessary physician ordered treatments for the residents and failed to provide effective oversight of the LNs to assure physician orders and treatments were being implemented resulting facilty acquired pressure ulcers for Resident #1, #2, and #3 and the worsening of a pressure ulcer for Resident #5.

Based on interview and record review, the facility failed to utilize required assistive gait belt devices for 1 of 3 sampled residents (#1) reviewed for adequate supervision. This failure resulted in harm to Resident #1 when a fall incurred with forehead lacerations and fractured spine and placed all residents at risk of the diminished care and services. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple health conditions including traumatic subdural (bleeding in the brain from trauma), repeated falls on 12/28/16 and 1/9/17, difficulty walking and muscle weakness. Resident #1's Minimum Data Set, a comprehensive assessment tool, dated 12/11/16, indicated Resident #1 required extensive assistance of two (2) persons for transfers. Resident #1's care plan, dated 12/05/15, and revised 02/08/16, noted Resident is high risk for falls. Interventions included 1 person stand pivot with all transfers and do not leave unsupervised. Emergency Department (ER) records dated 1/9/17 showed Resident #1 sustained a fall at the facility resulting in a large, gaping, full thickness 10 cm laceration to forehead and a T1 transverse process fracture (broken bone in spine). In-service education, dated 1/19/17, for Safe Transfers, reveaked: All transfers that are not mechanical or independent require use of a gait belt. On 1/20/17 at 12:20 p.m., Nursing Assistant (NA) A stated on 1/09/16, while assisting Resident #1 with transferring from a shower chair to a wheelchair, Resident #1 fell forward hitting his/her head on a laundry basket and the floor. NA A stated Resident #1 was supported from behind and a gait belt (assistive gait belt device used to steady, help balance during transfer of residents from one position to another) was not used during the transfer. NA A indicated the gait belt was used for all transfers during the shower until the last transfer from shower chair to the wheelchair when NA A forgot to use it. NA A stated, Without the gait belt I could not control (Resident #1's) fall. Review of In-service records after the fall, dated 12/20/16, indicated, Topic: Fall Safety; Gait Belts are to be used when ambulating a resident that is not independent and during all transfers unless otherwise directed by the care plan/Kardex. On 1/20/2017 at 10:50 a.m., the Staff Development Coordinator (SDC) stated NA A had been working independently in the facility for approximately 4 weeks when Resident #1 fell during the transfer. The SDC stated, I'm unaware of what training NA A has received .NA A should have used a gait belt for the transfer. NA A failed to receive adequate supervision and training when s/he did not utilize a gait belt to assist the resident during transfers. Refer to F 498.

Based on observation, interview and record review the facility failed to provide adequate pain relief for 2 of 3 residents (#49, 75) reviewed for pain. This failure caused harm to Resident #49 as evidenced by her continued and consistent report of pain to a level of eight out of ten, (with zero being no pain), for greater than two months. It was also determined the facility failed to hold a blood sugar lowering medication when the resident's blood sugar was low for 1 of 5 residents (#25) reviewed for medication administration. It was also determined the facility failed to provide adequate wound care to 1 of 3 residents (#38) reviewed for non-pressure wounds. These failures placed all residents at risk for receiving inadequate care and services. Findings include: <Resident #49> Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool showed the resident was cognitively intact, had several episodes of feeling down, depressed, or hopeless and had little interest or pleasure in doing things several times during the 14 day look-back period used for this assessment. The resident required extensive assistance with all ADL's except eating. The resident did not receive scheduled pain medication but had received non-medication interventions for pain and PRN, as needed, pain medication within 5 days of this assessment. The resident rated her pain as being five out of ten. On 10/10/16 at 1:39 p.m., Licensed Nurse (LN) G, the Resident Care Manager (RCM), documented the Resident c/o (complaint of) back pain to nurse and RA, believes her current w/c (wheelchair) cushion is no longer effective and is causing pain. AM nurse to fax physician for OT eval and treat orders due to pain. A nurse progress note dated 10/11/16 at 3:21 p.m. showed LN B documented the resident would like a new w/c cushion because the present cushion is not very comfortable . and the Resident Care Manager (RCM) was aware. Multiple record reviews between 11/8/16 and 11/16/16 showed no documentation that revealed staff had followed up on the documented resident request for a new cushion. On 11/8/16 at 10:18 a.m., the resident stated her bottom was hurting from sitting in her wheelchair. She declined having staff lay her down stating I would just like this chair to be more comfortable. On 11/9/16 at 10:14 a.m., review of the residents Pain Care Plan, last updated on 11/11/16, showed the resident had chronic pain, including pain in bottom. The goal was for the resident to verbalize satisfaction with her pain management by not vocalizing or grimacing due to pain. Interventions included Assess for pain with each interaction. Ask resident frequently if they are having pain. Staff were also directed to provide diversional activities and provide a quiet environment when the resident had episodes of increased pain. There was no intervention that guided staff to investigate ongoing or unresolved reported pain. On 11/9/16 at 10:03 a.m. Resident #49 was sitting in her wheelchair and stated her bottom hurt. The resident adjusted her position in the chair and said that would help the pain for a while. At 2:04 p.m., after shifting her weight in her chair, the resident said her bottom had been uncomfortable. On 11/10/16 at 11:42 a.m., while sitting out by the nurse's station where multiple staff walked by, the resident said she was not sure if a cushion was on her chair but her bottom hurt and she would like to be able to sit longer. She stated she did not like going to bed too early in the evening but she often did because it gets too painful. The resident did not have a recliner, liked being out with people and said she would like to be able to be comfortable in her wheelchair all day and not have to go to bed because of the pain. The resident was shifting her weight and had a furrowed brow. Review of the residents Pain Level Summary on 11/10 at 11:20 a.m., showed the Residents pain level was between five and eight out of ten (5-8/10), on eight out of 11 monitoring's in August, 13 out of 13 in September and 10 out of 11 in October. At 12:10 p.m. the Director of Nursing (DNS) stated no staff had informed her Resident #49 was having difficulty with her current wheelchair cushion, there was an extra ROJO (specialized to assist in preventing pressure related sores) cushion available and she would have it placed on the resident's chair. MAR documentation showed the resident received a new ROJO cushion on 11/10/16 around 3:00 p.m. Facility pain monitoring between 11/10 at 4:00 p.m. and 11/14 at noon showed the resident reported a pain level of zero out of ten 23 of 24 assessments with the residents highest pain level reported as two out of ten on one occasion. On 11/14/16 at 11:25 a.m., the resident stated she liked the new cushion and has not had any bottom pain since it was placed in her wheelchair. At 11:29 a.m. the DNS stated if a resident consistently reported five out of ten pain she would expect staff to have done a thorough review to determine the root cause of the pain, already considered the cushion might be the cause and acted on making any needed changes to the non-medication interventions for pain relief, like replacing the cushion. On 11/15/16 at 11:05 a.m. and 11/16/16 at 10:07, the resident stated she had no pain in her bottom and she really liked the new wheelchair cushion. The facility failed to adequately investigate the root cause of Resident #49's ongoing pain and follow through on the residents request for a new wheelchair cushion, without surveyor intervention. This failure caused the resident to experience unresolved pain for at least 3 months. <Resident #75> Resident #75 was admitted to the facility in June of 2015. According to Resident #75's MDS dated [DATE], the resident required limited assistance with ADLs. The MDS also documented the resident had occasional pain with a pain intensity of 5 on a scale of 1 to 10. On 11/8/16 at 3:55 p.m., when asked if she had been experiencing pain and/or discomfort, Resident #75 stated, Yes. I have pain in my shoulder and I am supposed to be getting cream put on at night but they don't always come in and do it. Resident #75's care plan was reviewed which did not have specific interventions related to pain management and only documented a potential for dental pain. The care plan did not address the resident's shoulder pain or history of a [MEDICAL CONDITION] that occurred at the facility. Review of the resident's MAR indicated [REDACTED]. On 11/15/16 at 3:12 p.m., LN C, a resident care manager, indicated there should be a care plan for pain and said she would do one. The LN then asked the resident's nurse to conduct a pain assessment. At 3:14 p.m., LN D entered Resident #75's room and asked the resident about her pain. The resident indicated she had pain in her shoulder and sciatica pain (pain going down the leg from the lower back). When the LN expressed he had not been aware of sciatica pain, Resident #75 stated, I have had it for five years. LN D asked how often she had the pain and if it interfered with her sleep. The resident indicated her pain occurred mostly at night and did interfere with sleep at times. She described the pain as mild to moderate. At 3:20 p.m., Resident #75, I don't like to bother them (nurses) and call them in here. Review of the resident's MAR indicated [REDACTED]. . <Resident #25> Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, showed the resident was moderatly to severely cognitively impaired and required extensive assistance with ADL's. On 11/15/16 at 10:00 a.m., Resident #25's November 2016 Medication Administration Record [REDACTED] On 11/7, 11/8, 11/13, and 11/13 at 5 p.m., the resident's blood sugars were 87, 86, 68, and 90 and 45 units of 500 unit/ml insulin was given subcutaneously on each occasion. Later that night, at approximately 12:00 a.m., on 11/8, 11/9, 11/13, and 11/14, the blood sugars on the MAR indicated [REDACTED]. On 11/15/16 at 2:38 p.m., Licensed Nurse (LN) G confirmed the above understanding of the documentation was correct. When asked what she would expect a nurse to do in regard to the insulin with the resident's blood sugars being what they were, she stated, I would expect, as a prudent nurse, they would have held the insulin if the blood sugar was less than 100. On 11/15/16 at 11:10 a.m., LN C, when asked, in general, at what blood sugar should a nurse hold insulin, she stated, In general - anything less than 100. In addition, when asked what she would expect for Resident #25 stated, I would expect there to be parameters and those to be followed. When asked what the parameters were for this resident, she looked and stated, I don't see where the physician wrote hold parameters. (Medical Director (MD)) is here if you'd like to talk to him about it. On 11/15/16 at 11:18 a.m., the MD was told that documentation showed Resident #25 was receiving insulin despite low blood sugars and asked if there were parameters for when to hold insulin. He said he would have to look at the chart. LN G was nearby and the MD asked her to check the chart. She was unable to find parameters and stated, It looks like they dropped off when the orders were changed. MD said that he would enter some parameters. On 11/15/16 at 2:38p.m., LN G confirmed that the resident did not have parameters and said, Yes, I faxed over a request to his office to see if we could get parameters for all his patients. <Resident #38> Resident #38 was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #38's Admission Nursing Data Base, completed 8/11/16, documented the resident had two wounds identified, one on the bottom of each foot. The left foot wound was documented as 3 centimeters (cm) by 2 cms and was described as stage 4 (full thickness wound reaching down to bone). The wound to the bottom of the right foot was described as a dried blister and no measurements were provided. Review of Resident #38's August Treatment Administration Record (TAR) documented no treatment was provided to the left foot ulcer until 8/21/16, 10 days after Resident #38 was admitted . The TAR documented the wound received treatment on 8/21/16 and 8/22/16. On 8/23/16 a new order was received to change the left foot dressing every 3 days. The TAR documented no dressing change occurred on 8/23/16 or 8/26/16 as ordered. No treatment was documented for the right foot until 8/24/16, 13 days after Resident #38 was admitted to the facility. On 11/14/16 at 3:39 p.m., Resident #38's wounds to the bottom of the right and left feet were observed with LN A. The areas appeared as callouses with small open areas. The wounds did not show any obvious signs or symptoms of infection. On 11/14/16 at 4:49 p.m., LN C, Resident #38's nursing care manager, was unable to answer any questions regarding the lack of wound care for the resident upon admission. LN C indicated she would have to look into why wound care was not documented for Resident #38. LN C stated, there is a progress note from 8/14/16 that documented staff changed the dressing. The Nursing Progress Note, dated 8/14/16 at 3:27 p.m., documented RLE (right lower extremity) needs to be seen by MD possible dressing applied to wound. A Nursing Progress Note, dated 8/16/16 at 11:08 p.m., documented, Resident has wounds to bil (bilateral feet). No wound care orders at this time, MD faxed for orders, awaiting response. In a follow up interview, LN C stated, The wound care- I haven't gotten to the bottom of that yet and agreed it was concerning that Resident #38 did not have wound care provided to the [MEDICAL CONDITION] until 10 days after admission to the facility.

Based on observation, interview and record review, it was determined that the facility failed to identify, evaluate and analyze risks associated with falls, and failed to implement adequate supervision to prevent falls for 2 of 5 (#48, #5) current sampled residents reviewed for accidents. This failure caused harm to Resident #48 when they had a fall and sustained a hip fracture. This failure placed all residents at risk for falls and injuries. Findings include: 1) Resident #48 originally admitted to the facility on [DATE] and recently re-admitted on [DATE] after sustaining a fall and hip fracture in the facility. Other medical [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive impairment, required extensive assistance with Activities of Daily Living (ADLs) and had impaired balance. A Fall Risk Evaluation, dated 6/24/16, documented the resident was at moderate risk for falls, exhibited loss of balance while standing and required hands-on assistance to move from place to place. A physician order [REDACTED]. When auto-lock brakes are applied to a wheelchair, the brakes are automatically engaged when weight is not applied to the seat (i.e. the resident begins to stand up). If the resident is already standing and going to sit down, the wheelchair brakes would be automatically engaged until the resident's weight was fully in the wheelchair. Resident #48's ADL care plan, initiated 11/15/14 and revised 11/17/14, documented the resident required one person assistance with toilet use. Resident #48's Falls care plan, documented an intervention dated 11/24/14, Resident to wear non-skid foot wear at all times. <6/24/16 Fall> Review of the Resident's Medical Record documented the resident fell on [DATE] around lunchtime. The facility investigation documented the resident had, shoes in place (unclipped as she often chooses to wear them so). The investigation included an intervention to prevent further falls that was documented as, Plan: Resident teaching, use call system to summon assist from staff for needs, resident in agreement. No other interventions were documented to prevent falls for Resident #48 who had severe cognitive impairment and would likely not remember to use the call light, despite education provided by staff. The investigation did not identify the resident's shoes as a risk factor despite them being unclipped during her fall. <10/22/16 Fall> Review of Resident #48's medical record documented the resident had a subsequent fall on 10/22/2016 at 3:03 a.m. and sustained a hip fracture. According to the facility investigation, finalized 10/26/16, the resident was attempting to transfer from the toilet to the wheelchair. Facility staff heard the resident fall and found her laying on her left side in front of the toilet. The facility investigation did not indicate if the auto lock brakes were in place to the wheelchair at the time of the fall. The Accident/Incident Interview, completed by Nursing Assistant (NA) O and dated 10/22/16, documented, She calls in the section marked 'what time did you last check the resident?' which indicated the resident had not been checked on during NA O's shift, which began at 10:00 p.m., 5 hours prior to the fall. In the section marked 'how long had the resident been up?' NA O documented, unsure, she is independent for the most part. The facility investigation documented, The Resident was wearing mary jane type shoes with 2 inch heel . reasonable to conclude fall occurred due to self-transfer with heeled shoes that possible foot turned causing impaired balance and fall. The facility did not provide adequate supervision to Resident #48 on the night shift of 10/22/16 and the facility failed to identify this may have been a contributing factor to the injury fall. The facility failed to ensure auto-lock brakes were in place to the resident's wheelchair and failed to identify this as a possible contributing factor to the resident's fall. The facility failed to ensure Resident #48 had safe footwear in place, despite that being part of the resident's care plan. Observations throughout the survey period showed the resident did not have auto-lock brakes in place to her wheelchair, as ordered by the physician. On 11/9/16 at 3:09 p.m., Resident #48 was asleep in her bed. The wheelchair brakes were not on and auto-lock brakes were not observed in place to the wheelchair. On 11/10/16 at 9:37 a.m., Resident #48 was sitting in her wheelchair. The wheelchair brakes were not on and auto-lock brakes were not in place to the wheelchair. On 11/14/16 at 2:28 p.m., Resident #48 was in bed asleep. The wheelchair brakes were not on and auto-lock brakes were not in place to the wheelchair. At 4:28 p.m., when asked what measures were in place to prevent Resident #48 from falling, NA J was unable to state any specific fall interventions. At 4:30 p.m., when asked what interventions were in place to prevent Resident #48 from falling, Licensed Nurse (LN) G stated, She is receiving physical and occupational therapy and we removed the shoes. They had a buckle that she was refusing to let staff buckle and that contributed to her fall. LN G indicated staff gave verbal cues to the resident to use the call light, auto-lock brakes were in place to the wheelchair, and the wheelchair should be placed by her bed. At 4:36 p.m., LN G examined Resident #48's wheelchair and agreed it did not have auto-lock brakes in place. LN G agreed Resident #48's care plan was not being followed. At 5:33 p.m., the Director of Nursing Services (DNS) stated Resident #48 did not have auto-lock brakes on her wheelchair since February of 2016 when she was seen by therapy for a new wheelchair. Auto-lock brakes were unable to be applied to the new wheelchair. On 11/15/16 at 10:58 a.m., when asked why the unsafe shoes were not addressed before the injury fall on 10/22/26, the DNS responded, The shoes had not presented as a problem at that time. The facility failed to ensure appropriate supervision and fall prevention interventions were in place for Resident #48. This caused Resident #48 harm when she fell in the bathroom and broke her hip. 2) Resident #5 admitted to the facility in 2013 with multiple medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool dated 9/15/16, documented the resident required extensive physical assistance with ADLs and had limited range of motion on one side of both the upper and lower extremity. On 11/14/2016 at 10:35 a.m., Resident #5 was sitting in a wheelchair in the hallway. The left side of the wheelchair/arm rest was not in place. The DNS walked by and stated, I will get the nurse manager. The DNS returned with LN G and stated, He needs an arm rest. At 2:35 p.m., Resident #5 was sitting in his wheelchair in his room alone and eating lunch. No arm rest was in place on the resident's left side. The over-bed table, containing the resident's food, was on the resident's left side approximately one foot from the resident. Resident #5 was using his right hand to reach across and lean towards the tray table on his left to pick up his food. The resident looked like he could easily fall off the left side of his wheelchair as he leaned to reach his food. At 2:54 p.m., when asked if Resident #5 was safe without an armrest, the DNS stated, He should have an armrest. Facility staff failed to ensure Resident #5's wheelchair was in safe, working order. Not having an arm rest to the left side, the resident's weak side, placed Resident #5 at risk for a fall and/or injury.

Based on observation, interview and record review it has been determined the facility failed to consult the physician immediately of an incident involving 1 of 7 current sampled residents (Resident #1) which resulted in a significant injury requiring physician interventions. This failure resulted in harm when a resident spilled hot liquid into his lap causing 2nd and 3rd [MEDICAL CONDITION] the physician was not consulted timely regarding needed treatment. Findings include: Facility investigation dated 5/19/16 documented the following: Resident #1 spilled hot chocolate on himself on 5/19/2016. Licensed nurse (LN) 1 was notified and reportedly observed wetness and brown staining on Resident #1 ' s upper thighs and peri (groin) area. Later in the shift, the LN 1 was informed resident had some redness and a blister to upper thigh. LN 1 noted in progress notes that it was observed to be a 3 cm x 2 cm reddened area with centrally located with fluid filled sac 2 cm x 1.5 cm x 1 cm. LN 1 documented that skin prep was applied to the area and left open to air. LN 3 and the Director of Nursing ( DNS) became aware of [MEDICAL CONDITION] wound rounds on 5/20/16. LN 1 informed them that it had happened the day before. Pictures submitted with facility incident report document [MEDICAL CONDITION] right and left thighs, and scrotum. It was not evident that after viewing the significant burn wounds on Resident #1 that either the DNS or LN 3 consulted the physician on the seriousness of the wounds to ensure that proper medical assessment and treatment was obtained. There was no telephone call to the physician to discuss the seriousness of the burn injuries or to request a physician see the resident. While this complaint investigator was onsite on 6/16/16 the following interviews, observations and record reviews were completed: At 12:59 p.m., via telephone interview, Physician Assistant (PA), stated, I saw the fax the on the 23rd (of May) notifying me of the incident and the reddened area and blister and that skin prep was used on the blister. Then I received a fax on May 27th from LN 2 indicated there was concern [MEDICAL CONDITION] looking worse. I was able to speak with LN # 4 to get a complete report on the status of the burns; LN 4 reported The wounds are not healing and there is necrosis in the wounds, as well as [DIAGNOSES REDACTED] and tenderness around them. At that time I gave orders to get a wound culture, start an antibiotic and new wound care orders and to monitor wounds closely. Then I saw (the resident) Wednesday June 1st. I was shocked at the severity of the burn, as the original fax did not indicate it was a significant burn. I should have been notified immediately by phone. The facility failed to consult with the physician timely and advocate for the resident to be seen urgently despite the severity of the burn wounds. Subsequently, the burn wounds continued to deteriorate. Refer to F 309

Based on interview and record review, it has been determined the facility failed to thoroughly investigate resident to resident altercations for 1 of 8 residents ( Resident #2) reviewed for investigations and failed to timely report a burn injury to Resident # 1 for 1 of 1 resident reviewed for a thermal injury. The facility did not report several physical altercations to a state agency or take all necessary corrective actions as required to prevent recurrence, and did not report to the state agency in a timely manner when a resident received significant burn injury. Findings include: Resident to Resident Altercations Resident #2 is a [AGE] year old admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2 ' s record showed multiple occasions of resident being the instigator of multiple resident to resident altercations. Progress note entries included: 4/15/16- Resident #2 agitated and combative kicking and hitting staff; attempting to bite, kicked another resident; MD was called and no med adjustments , said if continues send to emergency room . Investigation into this incident was not completed. 4/25/16-Resident #2 was going up hallway in wheelchair and started hitting another resident, separated residents. 5/11/16-Resident #2 propelled wheelchair to another female resident in dining room and struck her with open hand across the face; separated residents. 5/12/16-Resident #2 rolled her wheelchair next to another resident and started striking her. Residents separated and taken to each of their rooms. Mental health evaluation was requested. 5/13/16-Resident #2 moved her wheelchair next to another resident and started striking her and yelling at her. The residents were separated. An Investigation was not completed. 6/8/16 at 12:30 p.m. -Resident #2 was in dining room for lunch and was sitting at the table next to another resident. Residents exchanged words and yelled at each other, and slapped each other on the arms; situation diffused by removing resident to another area. 6/09/16 at 1230- In DR, another resident was sitting at the table where this resident sits for lunch every day; there again was an exchange of words between the two residents and they started hitting each other on the arms, both residents were separated and placed on alert for further monitoring of any concerns. An Investigation was not completed. On 6/17/16 at 12:42 p.m. when discussing what interventions have been attempted to assist Resident #2 in managing physical altercations, the social service director (SSD) stated We talk to her, but she doesn ' t remember, to keep hands to herself, we ' ve changed rooms, we are running out of places to put her. She is right by the nurses ' station to keep an eye on her. Aside from 1:1, redirecting is all we have done. Further, SSD stated She (Resident #2) has not been on 1:1 since she came here. When asked why theses resident to resident incidences were not called in to state agency, SSD stated We didn ' t report it as there were no injuries. The facility records did not indicate that any of the residents who had been on the receiving end of the resident to resident altercations had been monitored for evidence of psychological harm. In the Washington State Nursing Home Guidelines AKA The Purple Book on page 25 there are reporting directions to facilities. The directions to facilities for Physical abuse without bodily injury or psychological harm indicates the facility can solely log these incidents in the required State Reporting Log if there is no injury of psychological harm. But it also gives the additional information in the double asterisk at the bottom of page 25 that states In general there is a presumption that abuse has occurred whenever there has been some type of impermissible, unjustifiable, harmful, offensive, or unwanted contact with a resident. This presumes that instances of abuse of any resident (whether comatose, cognizant, or not) cause physical harm, pain or mental anguish. The facility had no information regarding monitoring the resident recipients of the resident to resident abusive acts to demonstrate that there was no psychological harm to the residents. Resident Burn Injury Resident #1 ' s burn injury occurred 5/19/16 and was not reported to state agency until 5/26/16, 7 days after the injury occurred. This was not a timely notification to the state agency.

Based on interview, observation and record review, the facility failed to ensure 1 of 7 current sampled residents (Resident #1) received services that are provided according to accepted standards of clinical practice. This failure caused harm to Resident #1 who had spilled hot liquid in his lap. Licensed nurse (LN) 1 did not provide basic first aid, but put a treatment on [MEDICAL CONDITION] was not ordered by a physician and likely caused further damage to the resident ' s skin. Findings include: Facility investigation dated 5/19/16 documented the following: Resident had spilled hot chocolate on himself and the Nursing Assistant (NA) 2 who was present dabbed the resident ' s lap with a clothing protector. LN 1was notified and reportedly observed wetness and brown staining on Resident #1's upper thighs and peri (groin) area. LN 1 instructed NA 2 to change Resident # 1's clothing. Later in the shift the LN was informed resident had some redness and a blister to upper thigh. LN 1 noted in progress note that it was observed to be a 3 cm x 2 cm reddened area with centrally located with fluid filled sac 2 cm x 1.5 cm x 1 cm. LN 1 documented that skin prep was applied to the area and left open to air. While this complaint investigator was onsite on 6/16/16 the following interviews, observations and record reviews were completed: At 2:18 p.m. observed wounds with the Physician Assistant. Left leg had a red open area, right thigh had black center with green drainage, and scrotum had frank red blood with open area down the center. Resident complained of tenderness in these areas Lab report for culture of wounds dated 5/27/16 came back on 5/31/16 and indicated wounds were positive for [MEDICATION NAME] faecalis and [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). Resident #1 was placed on contact isolation precautions. On 6/17/16 at 2:30 p.m. when Licensed Nurse (LN) 1 was asked about this incident, LN 1 stated, I was outside the dining room when a staff member told me that Resident #1 had spilled hot cocoa on himself. I saw the liquid on his pants, so we took him to his room to look at his skin and there was no redness, so I told the aide to just change his clothes. A little bit later the aide came and told me there were redness and a blister on his right upper thigh. I applied skin prep to keep the blister intact at that time. The next day another blister to the other leg occurred. I then did the incident report and sent a fax to the MD to notify. When asked why skin prep was applied, the LN 1 stated, I didn ' t get an order from the doctor because we typically put skin prep on a blister. We use skin prep to prevent them from bursting. I have since learned that it probably wasn ' t a good idea since the skin prep keeps the heat in. When asked if other first aid interventions were provided, LN 1 stated, it didn ' t occur to me that ice or a cool cloth was needed. I guess I should have done that. When asked why MD was faxed and not called LN1 stated, Normally we would call; I don ' t remember why I didn ' t. The facility failed to provide basic first aid when resident # 1 spilled hot liquid into his lap. LN 1 failed to notify an RN for a timely, thorough assessment. LN provided treatment of [REDACTED]. LN 1 failed to notify MD immediately for interventions or notify immediate supervisor of incident.

Based on interview, observation and record review, the facility failed to provide or obtain immediate necessary care and services for 1 of 7 current sampled residents ( Resident # 1). This failure resulted in harm when the resident spilled hot liquid into their lap causing 2nd and 3rd degree burns, which subsequently resulted in a multi-drug resistant infection to the wounds. Findings include: Facility investigation dated 5/19/16 documented the following: Resident #1 had spilled hot chocolate on himself and the NAC who was present dabbed the resident ' s lap with a clothing protector. Licensed Nurse (LN) 1 was notified and reportedly observed wetness and brown staining on Resident #1 ' s upper thighs and peri (groin) area. Later in the shift the LN 1 was informed resident had some redness and a blister to upper thigh. LN 1 noted in progress note that it was observed to be a 3 cm x 2 cm reddened area with centrally located with fluid filled sac 2 cm x 1.5 cm x 1 cm. LN 1 documented that skin prep was applied to the area and left open to air. LN 3 and d DNS became aware of [MEDICAL CONDITION] wound rounds on 5/20/16 and were notified by LN 1 it had happened the day before. Pictures submitted with facility incident report documenedt [MEDICAL CONDITION] right and left thighs, and scrotum. The faciilty faxed the physician office on 5/20/16 according to LN 1, instead of calling. Physician Assistant (PA) did not see the fax about the burn until 4 days after the burn injury occured. The first FAX was not seen by the PA until 5/23/16. The faciilty faxed the physician again on 5/27/16 as [MEDICAL CONDITION] worse. The PA gave orders but the wounds described as 2nd and 3rd [MEDICAL CONDITION] not visualized the the PA until 6/1/16. PA was shocked at the severity of the burn, as the original fax did not indicte it was a significant burn and should have been notified immediately by phone. Nursing staff viewing the wounds failed to call the physician and advocate that the resident be seen by a specialist or the local emergency department even as the burn wounds worsened. While this complaint investigator was onsite on 6/16/16 the following interviews, observations and record reviews were completed: At 2:18 p.m. observation of the wounds with PA, revealed that the left leg had red open area, right thigh had black center with green drainage, scrotum had frank red blood with open area down the center. Resident complained of tenderness in these areas Lab report for culture of wounds dated 5/27/16 came back on 5/31/16 and indicated wounds were positive for [MEDICATION NAME] faecalis and [MEDICAL CONDITION]-Resistant Staphylococcus [MEDICAL CONDITION]. Resident was on contact isolation precautions. Failure to receive prompt first aid treatment and to call and consult with the physician caused a delay in treatment. This failure caused resident undue pain and suffering that was preventable had appropriate treatment been initiated immediately and put all residents at risk for not receiving thorough and timely assessments and/or treatments of health needs.

Based on observation, interview and record review it was determined the facility failed to provide psycho/social support and interventions to 2 of 3 (Resident #1, #2) experiencing grief and loss. This failure caused harm to the residents for not initiating increased support for loss and grief of their loved ones. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's spouse was admitted to the facility on [DATE] as a terminal patient and onto hospice services. Resident #1 was informed of his wife's status when she was admitted to the facility. Review of Resident #1's social services care plan indicated on 5/10/16 the resident was care planed for a focus on, anticipatory grieving: resident's wife is terminally ill. Interventions listed on Resident #1's care plan indicated, Allow time for the resident to grieve, and offer support as needed. Encourage the expression of feelings as required. Resident might not always be able to communicate sorrow/grief, so be on the alert. On 05/11/16 Resident #1 was observed in the hallway and appeared confused asking the State Surveyor, 'why he had to move away from the dead lady?' Resident #1 further indicated that he was moved from his room away from his wife and did not understand why. Review of Resident #1's records indicated on 5/11/16 Resident #1 was moved from his former room that was across the hall from his wife, to a different room that was down a very long hallway. Records indicated there is no change to care plan to monitor for change in behavior due to room change. On 5/11/16 at 10:06 a.m.; Resident #1 was later observed in the hallway and when asked how he was doing, the resident became tearful and stated, I can't even talk, gesturing to his throat, as though he was attempting to not cry. Resident #1 stated, my wife is about this (gestured with his fingers) far from never never land. Resident #1 continued on indicating how sad he was about losing his wife and began to cry. On 5/12/16 Resident #1 was observed to be leaving his wife's room and was observed to be very tearful. The resident removed his hat, hung his head very low and was observed to wipe tears from his eyes. The state surveyor stopped and spoke with Resident #1 for several minutes to comfort him, he then continued on down the hall, still tearful. Licensed Nurse (LN) A was observed to stop at the resident's wheelchair and state, How ya' feeling? Resident #1 stated, Well I am barely on the edge. LN A continued, Well I am your nurse, so let me know. I hope you feel better soon. LN A was observed to walk away. Resident #1 was observed to continue to still be tearful. The resident was observed on multiple occasions to be at his wife's bedside, and observed to be very tearful and upset. On 5/12/16 LN A indicated that if a resident is on alert for signs or symptoms of grief she would monitor a resident's appetite, elevated heart rate and for any signs of sadness. When asked if Resident #1's behavior and comment moments before was possibly related to grief, LN A indicated that it likely was and that she was going to go back and talk to him when she was done delivering paperwork. On 05/12/16 at 12:53p.m.; the Social Services Director (SSD) indicated that Resident #1's daughter was very attentive to the resident's needs when she was in the building. When asked how she as Social Services is reaching out to the resident and monitoring for signs and symptoms of grief, the SSD indicated that she will go in and say hello, SSD further indicated that he (Resident #1) knew her, but not emotionally. SSD indicated there is a Chaplin that does come to the facility for the residents, but she did not know when he comes and that he was in the building this day, but did not know who he was seeing or why. When asked if she knew if the Chaplin was going to visit with Resident #1, SSD indicated she did not know and had not spoken to the Chaplin. SSD indicated the only plans in the making for when the resident's wife dies is that he will remain at the facility and his daughter will return to California. SSD did not indicate as to any plans for psycho/social support. SSD indicated the resident was moved rooms as it was feared him being too close to his wife's room would cause anxiety and confusion. The facility failed to increase psycho-social support for Resident #1 during the transition and loss of his spouse. Resident #1 was observed on several occasions' to be tearful and overcome with grief with staff present and offering no psycho-social support. <Resident #2> Resident # 2 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. On 05/11/16 at 1:40 p.m.; Resident #2 stated, They won't let my son come see me anymore. The resident further stated, There was a ruckus and my son who is just sticking up for me got in trouble with the 'big wigs' here. The resident was observed to become tearful and stated, he wasn ' t even allowed to visit me on Mother's Day. When the resident was probed to see if the resident wanted her son to visit, Resident #2 stated, Of course I do! We live together and he does his best to take care of me. Why would they do this to a [AGE] year old woman? Record review of Resident #2's care plan indicated there were no interventions in place to provide increased emotional support, or a psychosocial care plan for grief and loss of visitation of the resident's son. On 05/11/16 the Social Services Director (SSD) indicated there was no care plan in place for psychosocial. SSD stated, You're right there is no psychosocial problem on the care plan. On 05/11/16 at 6:00 p.m.; the Administrator (ADM) indicated there had not been any follow up communication with Resident #2's son. The ADM indicated there is a no trespass order against Resident #2's son that the ADM had petitioned into place with no expiration date. The ADM stated, There will be no discussion until further notice (with the resident's son). On 05/12/16 record review indicated a No Trespassing order was petitioned by the ADM on 04/26/16 at 3:49 p.m. This order makes it a crime for Resident #2's son to enter the facility. The expiration date for the trespass order was noted as never. The facility failed to attempt to reconcile or advocate for the resident by re-assessing the situation with Resident #2's son. The facility failed to increase interventions to prevent further psychosocial harm to the resident experiencing grief and loss of visitation from her son.

Based on interview and record review the facility failed to ensure the timely monitoring and assessment for the use of [MEDICATION NAME] (anti-coagulant) for 3 of 11 (#'s 3,4,& 5) residents reviewed. These failures placed the residents at risk for increased bleeding or blood clots and caused actual harm to Resident #3 who suffered from bleeding and elevated INR (measurement of how long it takes blood to clot). Findings include: All interviews took place 3/28 or 3/29/2012 Resident #3 was admitted to the facility 1/4/12. She had [DIAGNOSES REDACTED]. She was on medications to include [MEDICATION NAME] to treat the [MEDICAL CONDITION]-fibrillation. On 3/2/12 physician orders [REDACTED]. On 3/7/12 the INR was checked and the value was 2.7 (therapeutic is generally considered to be between 2 and 3). There was no evidence found in the medical record the physician had been notified of the INR on 3/7/12. There was no order found to indicate when the INR should be re-checked. On 3/17/12, according to the Interdisciplinary Progress Notes (IPN)written at 9:00 a.m., the Resident had a large "funny looking" bowel movement. The LN (licensed nurse) tested the stool for occult blood which was positive and then did a finger stick INR which was 8 (abnormally high). The LN then notified the physician and sent the resident to the hospital for further evaluation and treatment. The IPN dated 3/17/12 at 11:00 a.m. reported the resident had been admitted to CCU and was given blood. The resident did not return to the facility. Resident #4 was admitted to the facility 3/21/12. She had [DIAGNOSES REDACTED]. On 3/23/12 physician orders [REDACTED]. Recheck the INR 3/26/12. On 3/26/12 the INR was 1.0. The results were reportedly faxed to the physician, but there was no response to the fax and no new orders noted. There was no order for the INR to be rechecked. Resident #5 was admitted to the facility 3/9/12. She had [DIAGNOSES REDACTED]. On 3/17/12 physician orders [REDACTED]. There was an INR done on 3/21/12 which was 2.2. The PT/INR/[MEDICATION NAME] (Warafin) Flow Sheet in the medical record indicated the physician was notified. There was a line drawn through the box under dose change and in the box under Next Date PT/INR was written, "No order will ask MD." There was no evidence the physician was aware of the INR and there was no order found for when the INR should be rechecked. In an interview with the Director of Nursing (DNS) she stated the laboratory sent the results of the INR directly to the physician. She said nursing was to send it to the physicians and ensure an order was received to either change the [MEDICATION NAME] dose or continue the prior dose. Also orders were to be received for when the INR was to be rechecked. The DNS agreed it was a problem and on 3/29/12 was beginning in-services on a new procedure to monitor and assess INRs and [MEDICATION NAME]. .

Based on observation, record review and interview, the facility failed to ensure significant medication errors did not occur for 3 of 11 (#'s 3, 4, & 5) residents reviewed. Resident #'s 3, 4 & 5 received [MEDICATION NAME] (anti-coagulant) without current orders. This failure placed Resident #'s 4 & 5 at significant risk for receiving the wrong dose of medication and caused actual harm to Resident #3 when she suffered an elevated INR (the measurement of how long it takes blood to clot) and was sent to the hospital for treatment. Findings include: All interviews took place 3/28 or 3/29/2012 Resident #3 was admitted to the facility 1/4/12. She had [DIAGNOSES REDACTED]. She physician ordered medications to include [MEDICATION NAME] to treat the [MEDICAL CONDITION]-fibrillation. On 3/2/12 physician orders [REDACTED]. On 3/7/12 the INR was checked and the value was 2.7 (therapeutic is generally considered to be between 2 and 3). There was no evidence found in the medical record the physician had been notified of the INR on 3/7/12. There was no order to continue [MEDICATION NAME] at 4mg daily. Review of the Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"funny looking" bowel movement. According to the Interdisciplinary Progress Notes (IPN) dated 3/17/12 at 9:00a.m., the LN (licensed nurse) tested the stool for occult blood which was positive and then did a finger stick INR which was 8. The LN then notified the physician and sent the resident to the hospital for further evaluation and treatment. The IPN dated 3/17/12 at 11:00a.m. reported the resident had been admitted to CCU and was given blood. The resident did not return to the facility. Resident #4 was admitted to the facility 3/21/12. She had [DIAGNOSES REDACTED]. On 3/23/12 physician orders [REDACTED]. Recheck the INR 3/26/12. On 3/26/12 the INR was 1.0. The results were reportedly faxed to the physician, but there was no response to the fax and no new orders noted. Review of the Residents MAR indicated [REDACTED]. When interviewed LN - A stated she was unaware an order was needed to continue the [MEDICATION NAME] dose after an INR was drawn. She called the physician and received new orders for the [MEDICATION NAME] and an order to re check the INR. During an interview with Residential Care Manager (RCM) she said orders were necessary after an INR was done to either continue with prior dose or change the dose of [MEDICATION NAME] and she would look into what happened with the orders for Resident #4. Resident #5 was admitted to the facility 3/9/12. She had [DIAGNOSES REDACTED]. On 3/17/12 physician orders [REDACTED]. There was an INR done on 3/21/12 which was 2.2. The PT/INR/[MEDICATION NAME] (Warafin) Flow Sheet in the residents' medical record indicated the physician was notified. There was a line drawn through the box under dose change and in the box under Next Date PT/INR was written, "No order will ask MD." There was no evidence the physician was aware of the INR and there was no order found for when the INR should be rechecked. There was no documentation found in the IPN to indicate the physician had been notified or asked about the [MEDICATION NAME] or when the next INR should be drawn. In an interview with the Director of Nursing (DNS) she stated the laboratory sent the results of the INR directly to the physician. She said nursing was to send it to the physicians and ensure an order was received to either change the [MEDICATION NAME] dose or continue the prior dose. Also orders were to be received for when the INR was to be rechecked. The DNS agreed it was a problem and on 3/29/12 implemented a new procedure to monitor and assess INRs and [MEDICATION NAME]. She stated all nurses would be in-serviced.

Based on observation, interview and record review, the facility failed to provide assistance with nail care for 5 of 10 current sampled residents (#s 20, 111, 37, 6, 3) residing on all three units reviewed for personal care and showers for 9 of 14 current sampled residents (#s 201, 202, 85, 140, 64, 37, 3 and 13) reviewed for personal hygiene. The failure of the facility to provide basic hygiene services demonstrated harm to residents who depended on staff to assist them to obtain their highest well-being and quality of life. Findings include: <Nail Care> 1) Resident #20's Minimum Data Set, (MDS), an assessment tool, dated 5/20/11 documented the resident required extensive assistance with personal hygiene to include grooming. On 6/24/11 at 11:14 a.m., observed Resident #20 to have one quarter inch long fingernails with dark substance under both thumbnails, and the fourth and fifth fingernails on his left hand. The resident stated the dark material under his nails was "old Poligrip (denture adhesive)" as he pointed to the Poligrip box on his bedside table. The resident demonstrated he used his thumbs and fingers to push up on his top dentures allowing overflow of the Poligrip to seep under his nails. He said the staff used a wooden stick located in his shaving kit to remove the old Poligrip. The resident said he had to ask staff to trim and clean his nails as the staff do not do it on a regular basis. 2) Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE] documented the resident required extensive assistance with personal hygiene to include grooming. On 6/29/11 at 12:20 p.m., the resident's fingernails on the right hand were observed to have brown material under them. When brought to the attention of Licensed Nurse (LN) A, she stated the nursing assistants cleaned the resident's fingernails, if the resident was a diabetic, the LN cleaned the nails. As the LN looked at the resident's hand, the resident stated, "My nails are dirty." At 12:45 p.m., Nursing Assisstant (NA) H stated she was assigned to care for the resident that shift and had not noticed the resident's nails. The NA stated, "She digs." Resident #s 37, 6 and 3 were observed to have long and/or dirty fingernails which are described below under showers. <Showers 100 Hallway> According to the facility document "C.N.A. (Certified Nursing Assistant) Standards of Care," dated 12/11/10, "Shower residents 1 to 2 times a week as scheduled of their choice." 1) Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was alert, oriented and able to make her needs known. On 6/23/11 at 2:39 p.m., the resident stated, "I am suppose to have a shower every week, but, it has been once every four weeks or more than that. I worry about my feet getting toe jam and my hair getting dirty. I should have it on Monday but they usually get too busy to get around to it." Resident was observed to have oily hair which was slicked back away from her face. Record review revealed during the time frame 1/13/11 through 6/28/11 Resident #140 remained continuously at the facility and received assistance to shower on 2/7/11, 2/21/11, 3/22/11, 3/28/11, 5/26/11, 6/21/11, 7/29/11 and 7/4/11. During the same timeframe, documentation revealed the resident refused showers on 2/14/11, 3/14/11, 4/4/11, 4/11/11, 4/18/11, 4/21/11, 5/02/11, 5/05/11, 5/16/11, 5/23/11 and 6/20/11. On 6/30/11 at 9:00 a.m., the resident was observed to be lying on her bed. Her hair was oily and slicked back away from her face. Her fingernails were observed to be long with debris underneath the nails. The resident stated, "I know when I first came here I did get a shower initially, then it seemed I did not get one for a long time. I was told I would get a shower once a week, but that has not happened. I used to take a shower everyday when I was at home and wash my hair. They brush my hair back, but, I would like to wear it in a bob... I was thinking about going into the shower and washing my hair by myself. I have reminded the NA's about my weekly shower. It does make me worry about how my hair looks and how clean my feet are." On 7/6/11 record review revealed Resident #140 had a podiatry (foot doctor) visit on 7/5/11. The podiatrist documented "The following nails are discolored, hypertonic (abnormal thickening of the nail plate) and dystrophic (misshapen or partially destroyed nail plates.) Right: #1, #2, #3, #4, #5. Left: #1, #2, #3, #4, #5. These nails are painful upon palpation and margins are inflamed. Nails are at risk of catching on shoes, bed sheets and socks." At 12:30 p.m., Resident Care Manager (RCM) D stated skin checks were completed weekly for all residents which included looking at the resident's feet. During review of Resident #140's weekly skin assessment with RCM D for the months of 4/11, 5/11 and 6/11, there was no documentation, information or referrals made regarding the condition of the resident's feet. RCM D stated, "I am not sure how the treatment nurse missed the whole toenail issue, the podiatrist consult was requested by her physician when we informed her of the bathing schedule." At 1:00 p.m., Director of Nursing Service (DNS) stated, "The resident's feet should be checked. I have done several in-services with staff...they are told specifically to look at the toe nails." When asked who was responsible to ensure resident care was actually being done in regards to Resident #140's personal care and skin assessments the DNS replied, "I am ultimately responsible for everyone in house." 2) Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was unable to make his care needs known. On 6/22/11 at 6:30 p.m., Resident #64 was observed sitting in his wheel chair, at the dining room table with his head down, sleeping. The resident wore a flannel shirt and a clothing protector that had food on it from the evening meal. His hair was tossed and his thick beard and moustache were observed to have food and particulate matter in them. At 7:15 p.m., outside of Resident #64's room was a photograph of him revealing a well groomed man, holding his head up smiling with a moustache and short, trimmed beard. RCM D stated the photograph of Resident #64 "was taken about a year ago." When asked about the resident's current appearance RCM D stated, "He refuses care a lot, but residents are shaved or offered to be shaved on their shower days." Two days later, on 6/24/11 at 9:30 a.m., Resident #64 continued to have a thick beard and moustache. RCM D stated, "He usually gets his beard and moustache trimmed in the beauty shop however, he has been refusing." At 10:00 a.m., the DNS was asked about Resident #64's appearance, she stated "he gets his beard shaved and trimmed in the beauty shop." Documentation was requested from the DNS regarding Resident #64's beauty shop shave and haircut schedule. No documentation was provided. On 6/28/2011 at 10:15 a.m., Resident #64 was observed with food particulates in his beard around his mouth. When asked if he needed a shave the resident stated, "yes, I do." Record review revealed during the time frame 1/02/11 through 6/28/11 the resident had remained continuously in the facility and had not received a shower over the past 6 months. During the same time frame, documentation revealed the resident refused to take a shower on 1/5/11, 3/2/11, 4/4/11, 5/18/11, 6/1/11, 6/22/11 and 6/25/11. During the same time frame, documentation revealed the resident had a bed bath on 1/12/11, 2/5/11, 3/12/11, 3/30/11, 4/16/11, 5/7/11 and 5/11/11. On 6/30/11 at 2:10 p.m., NA F stated the directives for care the NA ' s follow are listed on the "Resident Status Sheet (computer generated care directive)." When asked to review what care directives were assigned for Resident #64, there were no directives indicating the assistance he required for nail care, shaving, showers, and personal hygiene including grooming. NA F stated " those tasks were not on the NA care directive. " On 7/6/11 at 12:30 p.m., RCM D was asked how Resident #64 did not receive a shower for six months, stated "that shouldn't have happened, we should have tracked him. We didn't have a tracking system until this survey, and he had refused showers quite a bit." At 1:00 p.m., the DNS stated the facility did have a tracking system for showers prior to the survey, "we have the nurse aide flow sheets for tracking the showers." When asked how that information was communicated to the RCM's the DNS reported resident concerns were discussed at stand up (a daily morning meeting) and a new nursing policy and procedure book was to be reviewed by all nurses last April. "I am ultimately responsible for everyone in house." 3) Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was unable to make her care needs known. Upon the surveyor entering the room, Resident #37 was observed lying in bed, the head of her bed slightly raised, the bedspread, blanket and top sheet were observed on the floor by the left side of her bed. The resident's legs and incontinent brief were exposed. Her eyes were matted, her hair was not combed and food debris was around her mouth. Resident #37 was eating food, with her left hand which had long fingernails with brown debris and particulate matter underneath the nails. The resident's right hand was contracted and her right arm immobile, the long fingernails of her right hand dug into her palm. At 7:30 a.m., LN C entered the resident's room and stated the resident always ate with her hands as she liked to eat sandwiches and other finger foods. LN C said this way she was able to eat more independently. LN C was asked to look at Resident #37's fingernails and LN C stated "they are awful." LN C proceeded to trim Resident #37's fingernails and clean her right, contracted hand. While cleaning the inside of the resident's contracted, right hand, observable debris and particulate matter fell on to a white washcloth that had been placed underneath it. LN C stated the NA's were responsible for trimming and cleaning the resident's nails twice a week during the resident's shower. LN C stated the LN's were responsible for ensuring resident care was provided. Record review revealed during the time frame 06/01/11 through 6/28/11 the resident remained continuously in the facility and had one shower on 6/01/11. During the same time frame, documentation revealed the resident refused to take a shower on 06/22/11. During the same timeframe, documentation revealed the resident had a bed bath on 06/15/11. 4) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE]documented behavior symptoms to include, hitting, kicking, biting, scratching and screaming significantly interfered with staff's ability to provide care. The resident required extensive assistance to complete personal hygiene tasks to include grooming and bathing. Review of the "Resident Status Sheet" (directives to the NA's for providing care) revealed there were no documented interventions, approaches or directions for the NA's to provide care to the resident ensuring the resident's needs were met despite her behavioral issues. On 6/24/11 at 2:35 p.m., Resident #6 was observed sitting in a wheel chair by the dining room with her hair uncombed, her fingernails were long, and she had facial hair. Four days later, on 6/28/11 at 12:05 p.m., Resident #6 was observed to have oily hair with flakes of white matter on her head, in her hair and on her shoulders. Record review revealed during the time frame 1/02/11 through 6/28/11 Resident #6 remained continuously at the facility and received assistance to shower on 3/8/11, 3/18/11, 3/22/11, 4/8/11, 4/12/11, 4/22/11,4/26/11, 5/13/11 and 5/20/11. During the same timeframe, documentation revealed the resident refused taking a shower on 1/5/11, 1/21/11, 2/4/11, 2/22/11, 3/1/11, 3/2/11, 3/25/11, 4/15/11, 4/19/11, 5/03/11, 5/27/11, 5/31/11 and 6/17/1. On 6/28/11 at 12:06 p.m., RCM D when provided the documentation Resident #6 had not received a shower from 1/2/11 through 3/8/11 and from 5/20/11through today stated "she refused and we were not tracking showers." 5) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3 required extensive assistance to complete personal hygiene tasks to include grooming and bathing. Resident #3 was non-verbal and unable to make her needs known. During the survey 6/22/11 through 7/8/11, Resident #3 was observed on several occasions to be sitting in her wheel chair, in the hallway, by the nurse's station and/or dining room. Her hair was so oily it looked wet, her fingernails were long, jagged and underneath her finger nails there was debris she had facial hair on her upper lip and chin. Review of the"Resident Status Sheet" (directives to the NA's for providing care) did not include any interventions or approaches to use to that were known to be or that may be effective in ensuring resident care needs were being met. There were no directives for shaving resident #3 or for instruction to provide hair and nail care. Record review revealed during the time frame 1/02/11 through 6/28/11 Resident #3 remained continuously at the facility and received assistance to shower on 1/20/11, 2/3/11, 3/5/11, 3/16/11, 4/12/11, 4/14/11, 4/25/11, 4/26/11, 5/8/11, 5/23/11, 5/30/11, 6/6/11, 6/20/11,6/25/11, 6/28/11 and 6/29/11. During the same timeframe, documentation revealed the resident refused a shower on 5/12/11. On 6/26/11 (twenty days after Resident #3's last documented shower) at 2:15 p.m., when asked about her wet looking hair NA F stated "it's not wet, it's dirty." On 6/29/11 at 11:10 a.m., RCM D and the DNS stated if a resident refused a shower, the NA told the LN. To ensure the resident was refusing, the LN was then to offer the resident a shower. The RCM stated, "I can't tell you if this truly occurred on the unit. If the resident refused, it should be documented and offered again the next shift and/or the next day." In reference to the resident's receiving a bed bath in place of a shower, the DNS and RCM D concurred that a bed bath was not considered or counted as a shower and should not be given in place of a shower. If a resident refused a shower than a bed bath would be offered. The surveyor reviewed Resident #'s 201, 202, 85, 140, 37, 6, 64, 111 and 3 shower records with Resident Care Manager (RCM) D and the Director of Nursing Service (DNS). Despite several refusals by the residents to receive showers, there was no documentation in the any of the residents' records of any communication and/or interventions initiated addressing the resident's resistance to personal care/showers. At 11:28 a.m. the DNS stated, "I check BMs (bowel movement) and weights but not showers." At 11:32 a.m., when asked if residents were asked the reason for their refusals, RCM D shook her head and stated, "No." The DNS stated there was nothing specific in the facility's NA policy and procedure manual for assessing resident preferences such as likes, dislikes or choices. At 11:45 a.m., the DNS reported an investigation would be initiated regarding resident's infrequent showers. On 7/7/11, the DNS provided documentation of their own investigation substantiating Resident # ' s 3, 6, 37, 64 and 140 showers were not being provided per facility policy. <Showers 200 Hallway> 1) Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#13 required total assistance to complete personal hygiene tasks to include grooming and bathing. Resident #13 was non-verbal and unable to make her needs known. Review of the "Resident Status Sheet" (directives to the NA's for providing care) did not include interventions or approaches to use that were known to be effective in ensuring resident care needs were met. There was no documentation for providing guidance for personal hygiene care for Resident #13. Record review revealed during the time frame 5//31/11 through 6/28/11 Resident #13 remained continuously at the facility and received assistance to shower on 6/11/11and 6/18/11. During the same timeframe, documentation revealed the resident refused a shower on 6/01/11. <Showers 300 Hallway> 1) Resident #201 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] indicated the resident required extensive assistance with personal hygiene to include grooming. The resident was not interviewable. The resident's bathing detail report during the time frame of 6/17/11 through 6/28/11 indicated the resident remained continuously in the facility and did not receive a shower. During the same time frame, documentation revealed the resident refused a shower on 6/21/11, four days after admission to the facility. No other refusals of showers was documented. 2) Resident #202 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] indicated the resident required extensive assistance with personal hygiene to include grooming. The resident was not interviewable. The resident's bathing detail report during the time frame of 6/13/11 through 6/28/11 indicated the resident remained continuously in the facility and did not receive a shower. During the same time frame, the resident received a bed bath on 6/27/11, 14 days after admission to the facility. During the same time frame, a refusal was documented on 6/24/11, 11 days after admission to the facility. No other refusals of showers or bed baths was documented. 3) Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] indicated the resident required extensive assistance with personal hygiene to include grooming. The resident was not interviewable. The resident's bathing detail report during the time frame of 3/1/11 through 6/28/11, indicated the resident remained continuously in the facility and did not receive a shower. During the same time frame, the resident received a bed bath on 3/7/11, 3/9/11, 3/24/11, 3/31/11, 4/25/11, 4/29/11, 5/9/11, 5/23/11, 6/13/11 and 6/27/11. During the same time frame, a refusal was documented on 5/12/11, 5/14/11, 5/16/11, 5/19/11 and 6/20/11. No other refusals of showers or bed baths was documented. On 6/29/11 at 7:20 a.m., NA H stated residents received showers twice a week. If a resident refused, the NA let the nurse know. NA H stated, "Sometimes the nurse can talk them into it." The NA said if the resident still refused, the resident received a shower on their next scheduled date. The NA said the resident was not re-approached during the next shift to offer a shower. At 11:25 a.m., RCM A stated when a resident refused a shower, her expectation was to give the resident a bed bath. She stated the resident should not have to wait until their next scheduled shower day. At 11:50 a.m., RCM B stated residents were supposed to receive showers, "Two times per week." She stated if the resident refused, "We need to give them some space and re-approach 10-15 minutes later." The RCM stated the nursing assistants let the nurse know if a resident refused a shower and it was documented in the care tracker (facility computer program). RCM B said the information was passed on during shift change and the resident was re-approached at least once during the next shift. On 7/6/11 at 1:40 p.m., the DNS stated the shower policy was one to two times per week. If the resident refused, the nursing assistant was supposed to report it to the charge nurse, who would then assess the resident. If the refusal continued, the shower was supposed to be rescheduled. If a shower was missed due to staffing, it should be rescheduled on the next shift. .

Based on observation, interview and record review, the facility failed to provide adequate supervision and ensure safety measures were implemented to decrease the likelihood of avoidable falls for 2 of 6 current sampled residents (#s 202 & 93) reviewed for accidents. This failure caused harm to Resident #202, who experienced an unwitnessed fall with injury and placed residents at risk for avoidable injuries. Findings include: 1) Resident #202 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 6/21/11 indicated the resident was moderately impaired with cognitive skills. The resident required extensive assistance with bed mobility and transfers. Review of hospital records revealed the resident had a stroke and while recovering, the resident fell and sustained a left hip fracture. On 7/1/11 at 10:20 a.m., a non-facility staff member reported seeing Resident #202 on the floor, near the bed. No alarm was heard at the nurse's station indicating the resident was not sitting in the chair. At 10:25 a.m., Resident Care Manager (RCM) B stated the resident had been sitting in the cardiac chair which was tilted back, prior to the fall. She said the resident had Parkinson's symptoms (movement related symptoms including tremors, shaking).The resident was taken to the hospital by ambulance. During random observations from 6/24, 6/27, 6/28, 6/29, /30 and 7/1/11, revealed that the resident who was of small frame was not supported well in this angular chair. The cardiac chair itself was covered in material that made it slippery. Staff failed to assess and observe the resident's risk which included dementia with Parkinson-like features ), impaired balance and coordination in relationship to this slippery covered chair. Upon retrun from the hospital after the fall, the facility continued to place the resident in this same chair. There was some recognition that the slippery surface may have contributed to the fall. However, the facility failed to take appropriate immediate action to change the surface of the chair to make it more secure and to decrease the liklihood of the resident from slipping off the chair again. The Resident Status forms (care delivery guide for nursing assistants) dated 6/28/11, 7/1/11 and 7/5/11 indicated safety devices documented, "cardiac chair (A chair which can be adjusted to a fully reclined bed), full body slide board for transfers." No safety interventions for use while the resident was in the cardiac chair were documented. The facility failed to develop safety measures to prevent falls when Resident #202 was in the cardiac chair, despite a history of a recent fall resulting in a substantial injury, [DIAGNOSES REDACTED]. Former Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her falls risk assessment dated [DATE] documented she was alert, had no history of falls, walked with an assistive device and required safety reminders. Review of the resident's record revealed on 5/17/11 at 3:00 a.m., the resident had a non-injury witnessed fall in her room. The resident was "having delusions, seeing people that are not there." The resident's falls risk assessment was updated documenting the resident was confused and being treated for [REDACTED]." Safety interventions to be implemented included for the resident to wear non-skid footwear in bed, to not leave the resident alone in the bathroom or on commode, alarm in bed and in wheelchair. According to the facility's investigative report, corrective action to prevent similar occurrences was to place a motion sensor and a lipped mattress. On the same day, Resident #93 had another fall occur, approximately 8 hours later, at 4:15 p.m. The second fall was an un-witnessed injury fall. The progress note documented the resident was found face down on the floor in her room with "rt (right) eyebrow lacerated (cut) ...appeared non-responsive." The resident was transferred to the emergency room and returned with stitches to her right eyebrow. According to the facility's investigative report, the motion sensor and the pressure alarms were not in place. On 7/7/11 at 7:25 a.m. Licensed Nurse (LN) A stated after the first fall on 6/17, she updated the falls risk assessment to include for the resident to have pressure alarms in bed and in the wheelchair. At 7:47 a.m. NA L stated he knew Resident #93 was a falls risk and placed the motion sensor alarm on the table directly in front of the resident as she sat in the wheelchair. NA L stated as far as he knew the motion sensor was working and should have gone off with any movement. The NA said he went on break and returned to be told the resident fell and the sensor alarm did not sound. NA L stated the resident did not have a pressure alarm in place because there was not a doctor's order for the pressure alarms. In review of the resident's record, a fax to the doctor requesting an order for [REDACTED]. The doctor's returned fax with the order for the pressure alarms was received at 1521 (3:21 p.m.), several hours after the first fall whereby the falls risk assessment was updated with interventions of applying pressure alarms in bed and the wheelchair to alert staff of the resident's movement.