Every finding on record at Avamere Rehabilitation at Ridgemont

Based on observation, interviews and record reviews, the facility failed to ensure a safe discharge plan was in place for 1 of 2 residents (1) reviewed for discharges. The facility failed to develop a patient-centered discharge plan by the interdisciplinary team for 2 of 3 residents (1 & 2) reviewed for discharge planning. These failures placed residents at risk of unsafe discharge and unmet care needs.Findings included.<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia and a fracture to the tibia. The comprehensive Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and required substantial assistance or was dependent on staff for activities of daily living (ADLs).No comprehensive discharge care plan was included in the medical record.On 08/11/2026 at 2:56 pm, Resident 1's family member (FM) 1 said they were Resident 1's decision maker. FM 1 said there was miscommunication between her and the facility regarding Resident 1's discharge. FM 1 said promises were made and not kept by the facility. The discharge did not go as planned and Resident 1 ended coming home.Progress notes, dated 07/07/2026, documented Resident 1 reported some family issues regarding FM 2, who they believe does not like them. This was reported to Staff B, Registered Nurse (RN) and Director of Nursing (DNS).Progress notes, dated 07/10/2026, documented Resident 1 was experiencing family related stress related to FM 2.Social History, dated 07/14/2026, documented Resident 1 lived at home with their family and required assistance with ADLs, medication, housekeeping, groceries, and transportation. The history documented Resident 1 would be returning home with family support.Care conference notes, dated 07/14/2026, documented Resident 1 reported they did feel safe at home with FM 1 but felt uneasy when home alone with FM 2. The family feels this was related to the resident's diagnosis of dementia. The resident wanted to discharge home with family and community resources.Progress notes, dated 07/21/2026, documented Resident 1 was showing signs of agitation stating they were getting out of this place and I'm going to murder my family. The resident was placed on elopement (risk of leaving the facility unattended) precautions and the crisis hotline was contacted. Hydroxyzine (a medication used for anxiety) was started.Progress notes, dated 07/22/2026, documented a Notice of Medicare Non-Coverage (NOMNC- an official document given when Medicare coverage is about to end) was given to FM 1 with Staff C present. FM 1 said they felt unsafe with Resident 1 in the home. It was documented they would follow up with the family.Progress notes, dated 07/22/2026, documented Resident 1 wished to discharge back to the community with support of their family and community resources. Barriers to discharge included Resident 1's cognition and a possible urinary tract infection. The resident would require alternative placement due to memory and exit seeking. The discharge date was listed as 07/25/2026.Progress notes, dated 07/23/2026, documented FM 1 appealed Resident 1's NOMNC.Progress notes, date 07/24/2026, documented Resident 1 lost the NOMNC appeal. A call was made to discuss discharge plans. A voicemail was left.Progress notes, dated 07/26/2026, documented Resident 1 was transported home with FM 1 and home health services.On 08/11/2026 at 3:54 pm, Staff C, social services, said Resident 1 was given a NOMNC and the family appealed, which was lost. Staff C said their financial responsibility started on 07/25/2026. Staff C said he reached out to FM 1 regarding discharge plans, but he never received a return phone call. Staff C said there was no alternative discharge planning documented once FM 1 verbalized concerns about Resident 1 returning home. Staff C said he thought the concerns were related to an adult protective services (APS) report filed regarding FM 2 but could not be sure. Staff C said there was no comprehensive care plan related to the APS report or Resident 1's discharge.On 08/11/2026 at 4:20 PM, Staff B said she made an APS referral related to Resident 1's statements about FM 2. Staff B said she did interview family members and felt sure there were no concerns about FM 2. Staff B said she could not see in the medical record where this had been addressed or care planned. Staff B said she could see in the progress notes FM 1 reported concerns with Resident 1 returning home but could not see where alternative discharge plans had been addressed. Staff B said residents should have a comprehensive discharge care plan.<Resident 2>Resident 2 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease. The comprehensive MDS, dated [DATE], documented Resident 2 had no cognitive impairment and was dependent on staff with ADLs.No comprehensive discharge care plan was included in the medical record.On 08/11/2026 at 2:10 pm, Resident 2 was observed in their room. Resident 2 had an arm brace on their left arm/shoulder. Resident 2 said they were hoping to return home but needed more assistance at this time.Social History, dated 07/28/2028, documented Resident 2 lived at home with their family and required assistance with ADLs, medication, housekeeping, groceries, and transportation. The history documented Resident 2 will be returning home with family support.At 3:54 pm, Staff C said Resident 2 does not have a discharge care plan. Staff C said he could put one in now and there was no issue with missing a comprehensive care plan.At 4:20 pm, Staff B said she expects a comprehensive discharge care plan to be in place in the medical record.Reference WAC 388-97-0120(3)(a)

Based on interview and record review, the facility failed to ensure results of allegations/investigations were reported to the State Agency Hotline within 5 working days for 2 of 2 residents (1 & 2) reviewed for abuse and neglect. This failure placed residents at risk for potential unmet needs and decreased quality of life. Findings included .Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses of heart failure and diabetes mellitus. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had no cognitive impairment and was dependent on staff for some activities of daily living (ADLs).Incident Report, dated 03/16/2026, documented Staff D, Nursing Assistant (NA), stood at the end of Resident 1's bed and told them to stop stuttering. Then, slammed Resident 1's refrigerator door so hard the freezer opened. The allegation was reported to the State Agency on 03/16/2026. No evidence was provided showing a 5-day follow-up was submitted to the State Agency.On 04/13/2026 at 1:57 PM, Staff B, registered nurse (RN) and Director of Nursing (DNS), said she did not submit a 5-day follow-up for this allegation. Staff B acknowledged this should have been submitted to the State Agency. Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia and a urinary tract infection. The admission MDS, dated [DATE], documented Resident 2 had moderate cognitive impairment and was dependent on staff with ADLs.Incident Report, dated 04/01/2026, documented Resident 2's family had concerns about treatment of the resident by an unnamed staff member. The allegation statement documented the resident had bruising on their thigh shaped like a handprint. The allegation was reported to the State Agency on 04/01/2026. No evidence was provided showing a 5-day follow-up was submitted to the State Agency.On 04/13/2026 at 1:57 PM, Staff B, RN and DNS, said she did not submit a 5-day follow-up for this allegation. Staff B acknowledged this should have been submitted to the State Agency. Reference WAC 388-97-0640(5)(a)

.Based on interview and record review, the facility failed to provide a transfer notice and written bed hold notice at the time of transfer to the hospital, for 3 of 3 sampled residents (Resident 24, 73 & 2) reviewed for hospitalization. This failure placed residents at risk for not knowing their rights to transfers or of bed holds while in the hospital and a diminished quality of life.Findings included .RESIDENT 24Resident 24 was admitted to the facility on [DATE]. The 5 Day Minimum Data Set (MDS, an assessment tool) dated 09/05/2025, documented Resident 24 was cognitively intact.Resident 24 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The electronic health record (EHR) had no documentation Resident 24 was provided with a transfer notice or a bed hold notice at the time of the transfer. RESIDENT 73Resident 73 was admitted to the facility on 07/082025. The admission MDS, dated [DATE], documented Resident 73 was cognitively intact.Resident 73 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 73 had a second transfer to the hospital on [DATE] and did not return to the facility. The EHR had no documentation Resident 73 was not provided with a transfer notice or a bed hold notice at the time of either transfer.RESIDENT 2Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 2 was cognitively intact.Resident 2 had multiple hospitalizations in the past year on the following dates:09/08/2024-09/24/202405/09/2025-05/12/202505/26/2025-05/29/202508/28/2025-08/31/2025The EHR documented Resident 2 was not provided with a transfer notice or a bed hold notice for any of the listed transfers.On 09/10/2025 at 10:30 AM, Staff B, Director of Nursing Services, said when a resident is transferred to the hospital, they were sent with an emergency packet that included the transfer notice and the bed hold policy. In the event the resident was being sent to the hospital in an emergency, social services were responsive for reaching out the resident or the resident representative the following day to provide the bed hold notice and it would be documented in the EHR. When shown all the listed transfers above, Staff B said all transfer notices and bed holds should have been completed. Reference WAC 388-97-0120.

.Based on interview and record review the facility failed to ensure psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had an adequate indication for use, the specific target behaviors (TB) the medication was implemented to treat were identified and monitored, gradual dose reductions (GDRs) were performed and resident responses accurately assessed and documented, non-drug interventions were identified and attempted prior to administration of as needed (PRN) psychotropic medications, and staff monitoring for medication adverse side effects occurred for 3 of 5 residents (Residents 13, 44 & 26) reviewed for unnecessary medications. These failures detracted from staff's ability to assess the effectiveness of psychotropic medication(s), need for ongoing use and presence of medication adverse side effects (ASEs). This placed residents at risk for receiving unnecessary medications, unidentified or delayed identification of ASEs, and a diminished quality of life.Findings included . 1) Resident 13 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/08/2025, showed the resident had moderate cognitive impairment, diagnoses of dementia, anxiety disorder (feelings of worry or fear that are persistent), and psychotic disorder (mental health condition characterized by a loss of touch with reality, leading to significant disturbances in thoughts, perceptions, and behavior), and received anti-depressant and anti-psychotic medications during the assessment period. Review of the electronic health record (EHR) showed Resident 13 had the following psychotropic medication orders:a) A 09/10/2024 order for citalopram (an anti-depressant) daily for anxiety disorder.b) A 11/07/2024 order for mirtazapine (an anti-depressant) daily at bedtime for depression and protein-calorie malnutrition. c) A 11/04/2024 order for quetiapine (an anti-psychotic) 50 milligrams (mg) twice a day at 8:00 AM and 8:00 PM, and an additional order from 07/15/2025 for quetiapine 25 mg daily at 2:00 PM for dementia with moderate psychotic disturbances. The order included documentation that Resident 13's quetiapine was reinstated to 25 mg at 2:00 PM from 12.5 mg secondary to a failed GDR. An alteration in cognition care plan, revised 05/23/2025, showed Resident 13 received quetiapine for dementia with agitation. The TBs were identified as yelling, calling out, using profanity, swinging hands and refusing care. Review of the September 2025 Treatment Administration Record (TAR) showed the antipsychotic behavior monitor identified the TBs for the use of quetiapine as refusal care, agitation, and mentions of death or disaster. These TBs were inconsistent with the TBs identified on Resident 13's care plan. Review of the anxiety disorder care plan, initiated 04/30/2025, documented Resident 13 received hydroxyzine (an antihistamine) for anxiety and had identified TBs of yelling, calling out, using profanity, and swinging hands. The same TBs that were identified for the use of quetiapine. Review of the 04/02/2025 hydroxyzine order, showed it was to be administered twice a day for itching, not for anxiety disorder. An at risk for depression care plan, initiated 04/30/2025, showed Resident 13 received mirtazapine and citalopram for dementia with confusion. This was inconsistent with the physicians' orders which documented the citalopram was ordered to treat anxiety disorder and the mirtazapine to treat depressive disorder with protein-calorie malnutrition. Specific TBs were not identified for the use of mirtazapine and citalopram. Both medications had the same TBs identified which were hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxiety or health-related complaints, and tearfulness. Review of the July, August and September 2025 Medication Administration Record (MAR) and TARs, showed Resident 13's anti-depressant behavior monitors were all blank. Additionally, the anti-depressant behavior monitors did not identify distinct TBs each medication was intended to treat. Instead waking up agitated, combativeness, and making negative statements were identified as the TBs for the use of both medications, which were inconsistent with the TBs identified on the care plan. Review of a Psychotropic Drug and Behavior Review, dated 07/07/2025, showed Resident 13 received citalopram and mirtazapine for anxiety disorder, not dementia with confusion as care planned or depression with protein-calorie malnutrition as documented in the mirtazapine order. The psychotropic review interdisciplinary team recommended a GDR of Resident 13's 2:00 PM dose of quetiapine from 25 mg to 12.5 mg. Review of the EHR showed a GDR of Resident 13's 2:00 PM dose of quetiapine from 25 mg to 12.5 mg was ordered on 07/11/2025 and implemented on 07/12/2025. Review of the nurses notes between 07/12/2025 - 07/14/2025 showed there were three nurses notes on 07/12/2025, two on 07/13/2025 and two on 07/14/2025 (day shift) that addressed Resident 13's GDR of quetiapine. All seven nurses' notes documented that the resident had no adverse effects to the GDR and/or demonstrated no behaviors and/or was pleasant and cooperative with care. A nurse's note dated 07/14/2025 at 4:15 PM, documented Resident 13 had increased mood swings, a short temper, and increased anxiety when staff were unable to answer their call light immediately. The note indicated the nurse requested Resident 13's quetiapine be increased back to 25 mg secondary to a failed GDR. A nurse's note dated 07/14/2025 at 4:25 PM, documented an order was obtained to reinstate quetiapine to 25 mg secondary to failed GDR. Review of the July 2025 TAR showed no behaviors were documented on the anti-psychotic behavior monitor between 07/12/225 -07/14/2025 (the period of the GDR). Review of the EHR showed the only documentation that Resident 13 demonstrated a TB was in the 07/14/2025 nurses note in which the resident indicated their frustration was related to call light response time. During an interview on 09/11/2025 at 9:31 AM, Staff B, Director of Nursing Services (DNS), acknowledged that Resident 13's physicians orders, care plans, consents and the psychotropic drug and behavior reviews documented conflicting indications for the use (diagnoses) for hydroxyzine, mirtazapine and citalopram, the specific TBs medications were implemented to treat were not identified or were inconsistent, and staff failed to complete behavior monitoring for mirtazapine and citalopram in July, August and September 2025. Staff B said the indication for use and the specific TBs a medication was initiated to treat should be clearly and accurately identified, documented and consistently monitored. Staff B indicated the lack of behavior monitoring could detract from staff's ability to determine effectiveness of the medication and need for continued use. When asked if Resident 13 exhibiting one episode of increased anxiety and/or agitation (associated with frustration about call light response) was sufficient to determine the quetiapine GDR had failed Staff B, DNS, stated, No. 2) Resident 44 was admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident had diagnoses of anxiety disorder, depressive disorder and unspecified dementia, and was severely cognitively impaired. Resident 44 had a physician's order, dated 05/15/2025, for Trazadone (an antidepressant), given once daily at bedtime for insomnia. The EHR documented no side effect monitoring for the Trazadone order. On 09/10/2025 at 10:30 AM, Staff B, DNS, said staff should have been documenting if side effects were or were not observed for Resident 44's Trazadone. 3) Resident 26 was admitted to the facility on [DATE] with diagnoses of severe dementia with agitation and anxiety disorder. Review of the Admissions MDS, dated [DATE], showed they had severely impaired cognition (mental processes), had behaviors of rejection of care and verbal behaviors that affected others, and were taking antianxiety, antidepressant, and antipsychotic medications. Review of Resident 26's EHR, showed they had a behavior monitor in place for dementia/anxiety, but no other behavior monitor order was found for what behaviors each medication was treating. Resident 26's antidepressant medication, being given for antianxiety purposes, did not have consent, behavior monitor orders, or adverse side effect orders. For Resident 26's antipsychotic medication, being given for dementia with behaviors, they did not have orders for behavior monitors or adverse side effect monitors. For Resident 26's anticonvulsant medication (medication that primarily treats seizures but can also treat anxiety), prescribed for antianxiety purposes, they did not have behavior monitors or adverse side effects. Resident 26's anticonvulsant/antianxiety mediation had an as needed order. Review of the MAR/TAR from 09/01/2025 to 09/07/2025, showed it was given on 09/01/2025, 09/02/2025, 09/04/2025, 09/05/2025, 09/06/2025, 09/07/2025. Resident 26's anticonvulsant/antianxiety as needed order did not include an NPI monitor to track that NPI was given before the as needed medication. During an interview on 09/09/2025 at 1:57 PM, Staff E, Resident Care Manager, was asked to review Resident 26's EHR for NPI usage for their as needed anticonvulsant/anxiety medication for 09/02/2025, 09/06/2025, and 09/07/2025. Staff E confirmed there was no NPI usage found in the documentation for the three dates. Staff E was unable to find consent for the antidepressant medication, was unable to find behavior monitors specific to what each medication was treating, and was unable to find side effect monitors for the three medications reviewed. Reference WAC 388-97 -0620 (1)(a) -1060 (3)(k)(i) .

.Based on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated in accordance with accepted professional standards of practice, and expired medications were discarded for 1 of 2 medication rooms and 1 of 2 medication carts (300 Hall medication room and medication cart) that were observed. These failures placed residents at risk to receive expired medications and negative health outcomes.Findings included . 300 Hall Medication CartObservation of the 300-hall medication cart on 09/10/2025 at 2:40 PM with Staff K, Licensed Practical Nurse (LPN), revealed the following expired and/or undated medications:1) Resident 37's glargine insulin pen (prefilled injection device containing a long-acting type of insulin used to manage blood sugar level) was opened and undated. Review of the pharmacy quick reference guide showed glargine insulin pens were to be discarded 28 days after opening.2) Resident 62's atropine eye drops had an open date of 08/22/2024. Review of the package insert showed the eye drops were to be discarded 180 days after opening.3) Resident 4's card of Ondansetron was expired, with a discard date of 08/25/2025.On 09/10/2025 at 2:40 PM Staff K, LPN, confirmed the above medications were opened and undated or past their discard dates and needed to be disposed of. 300 Hall Medication RoomObservation of the 300-hall medication room on 09/10/2025 at 2:47 PM with Staff K, LPN, revealed the following: 1) Resident 80's Humulin R insulin pen was opened and undated, which was verified by Staff K, LPN. Review of the pharmacy's quick reference guide showed Humulin R insulin pens should be discarded 28 days after opening.Reference WAC 388-97-1300(2).

Based on observation and interviews, the staff failed to maintain infection control practice by transporting linen covered and performing hand hygiene when delivering clothes from room to room in 4 of 4 hallways (100, 200, 300 and Transitional Care (TC)) observed. These failures placed all residents at risk of an infection and diminished health.Findings included.On 09/07/2025 at 12:44 PM, Staff J, Laundry Aide, was observed delivering personal clothes down the 100 hallway from a rolling basket style cart with a stack of clothes layered onto each other inside the cart. The cart contained personals and was uncovered. Staff J was observed delivering resident clothes to room [ROOM NUMBER] and then 105. Staff J, touched the hangers in room [ROOM NUMBER] and took them out of the room and hung them on the cart. Staff J did not perform hand hygiene before going into room [ROOM NUMBER] where Staff J brought out empty hangers. Staff J was not observed performing hand hygiene before going into room [ROOM NUMBER] where they assisted the resident in finding their clothes and removed the hangers and brought them out of the room. Staff J was not observed performing hand hygiene as they came out of the room, before they grabbed clean clothes and went into room [ROOM NUMBER]. Staff J was not observed performing hand hygiene when coming out of room [ROOM NUMBER]. Staff J brought hangers out of room [ROOM NUMBER], took a blanket into room [ROOM NUMBER], and did not perform hand hygiene. On 09/09/2025 at 10:57 AM, Staff I, Laundry Aide, was observed transporting towels and clothing protectors and draw sheets in a basket with wheels down the 300 hallway to the linen closet that connects TC and the 300 rooms to the 100 and 200 rooms. The linen cart was not covered. Staff I said they were transporting linen from the laundry room to the linen closet. On 09/09/2025 at 2:38 PM, Staff G, Environmental Services Supervisor, said that he saw Staff I transporting the linen uncovered and said, I saw it and I have already given [Staff I] an in-service. Staff G said the linen should have been covered with a sheet and it was not covered. Staff G said when staff were going from room to room delivering resident's clothes, the staff should hand sanitize between rooms when delivering the personal items.On 09/11/2025 at 8:55 AM, Staff I, was observed coming out of the laundry room with a basket on wheels, transporting linen uncovered to the clean linen closet in the hallway that connects TC and the 300 rooms to the 100 and 200 rooms.On 09/11/2025 at 8:55 AM, Staff I was observed transporting the linen cart, uncovered down the TC hallway, outside the laundry room. On 09/11/2025 at 9:17 AM, Staff B, Director of Nursing Services, said there should be a sheet placed over the cart as staff were transporting and delivering personals and linen in the hallways.On 09/11/2025 at 10:14 AM, Staff I was observed transporting resident clothing in a cart, uncovered, down TC hallway to the 300 hallway.Reference WAC 388-97-1320 (1) (c), (3)

.Based on observation, interview and record review the facility failed to provide bowel care in accordance with physician orders and the facility bowel protocol for 2 of 6 residents (Residents 6 & 36) reviewed for bowel management, to replace tube feeding syringes every 24 hours as ordered for 1 of 1 resident (Resident 79) reviewed for tube feeding, and to ensure non-pharmacological interventions (NPIs, non-medication interventions aimed to decrease pain) were attempted prior to administration of as needed (PRN) pain medication for 2 of 5 residents (Residents 44 & 26) reviewed for unnecessary medications. These failures placed residents at risk for unmet care needs, possible complications, and a diminished quality of life.Findings included.Review of the facility's Living Bowel Care Protocol policy, dated October 2020, showed if a resident did not have a bowel movement (BM) for three days (must be a medium or large BM) the following would occur.a) The evening shift nurse would administer Milk of Magnesia (MOM).b) If there were no results from MOM, the day shift nurse would administer a Dulcolax suppository.c) If there were no results from the Dulcolax suppository, a Fleet enema would be administered. d) If there were no results from the Fleet enema, the nurse would complete a focused abdominal assessment and digital exam and notify the physician if needed.BOWEL PROTOCOL 1) Resident 6 was admitted to the facility on [DATE] and had a diagnosis of constipation. The Annual Minimum Data Set (MDS-an assessment tool), dated 08/07/2025, documented the resident was cognitively intact. A review of the electronic health record (EHR) documented Resident 6 did not have a BM from 08/12/2025 – 08/16/2025 (5 days). Resident 6 had orders for:- Bisacodyl Oral Tablet, Polyethylene Glycol Powder and 2 Senna Tablets twice a day for constipation- Milk of Magnesia (MOM) every 24 hours as needed for no BM x3 days- Polyethylene Glycol Powder as needed for constipation no BM x3 days- Bisacodyl Rectal Suppository as needed for constipation once daily for no BM x3 days and MOM ineffective- Mineral Oil Rectal Enema as needed for constipation for no bm x3days and MOM and Bisacodyl suppository ineffective A review of August 2025 Medication Administration Record (MAR) documented Resident 6 refused MOM on 08/15/2025. On 09/10/2025 at 10:33 AM, Staff E, Resident Care Manager (RCM) said Resident 6 did not have a BM from August 12th – 16th and they refused the MOM on August 15. Staff E said the nursing staff should have reapproached Resident 6 and offered MOM again, completed a bowel assessment, and notified the provider. Staff E said it should have been documented in a progress note. On 09/11/2025 at 9:17 AM, Staff B, Director of Nursing Services (DNS), said the nursing staff should have documented the refusal in a progress note and performed an abdominal assessment. 2) Resident 36 was admitted to the facility on [DATE]. Review of the resident's physicians' orders showed the following bowel care orders: - MOM, as needed, if no BM for three days, dated 11/01/2023. - Dulcolax suppository, as needed, if MOM was ineffective, dated 11/01/2023. - Fleet mineral oil enema, as needed, if Dulcolax suppository was ineffective. May repeat two times, dated 08/09/2024; and - Dulcolax tablets- administer two tablets every 24 hours as needed for constipation, dated 03/31/2025. Resident 36's July and August 2025 bowel records showed they went from 07/27/2025 – 08/01/2025 (6 days) without a BM. Review of the July and August 2025 Medication Administration Records (MARs) showed Resident 36 was administered Dulcolax two tablets on 07/30/2025 at 8:43 PM. The bowel record showed Resident 36 had no results from the Dulcolax and continued without a BM for the remainder of 07/30/2025, 07/31/2025 and 08/01/2025. No further as needed bowel medications were administered. Review of Resident 36's EHR showed there was no abdominal assessment documented between 07/27/2025 – 08/01/2025. On 09/11/2025 at 9:31 AM, when asked if facility nurses provided Resident 36 bowel care in accordance with the physicians' orders and facility bowel protocol, Staff B, DNS, stated, No, not that I see. Staff B said when Resident 36 did not have results from the Dulcolax tablets administered on evening shift, a Dulcolax suppository should have been administered on day shift. TUBE FEEDING SYRINGE 3) Resident 79 was admitted to the facility on [DATE] and had a diagnosis of pancreatic cancer and aftercare following surgery on the digestive system. On 09/09/2025 at 5:48 AM, it was observed that a 60 cubic centimeter (cc- a unit of volume) syringe in a graduated container was dated 09/06/2025 at the bedside of Resident 79. On 09/09/2025 at 8:00 AM, it was observed at Resident 79's bedside a syringe dated 09/06/2025 in a container. On 09/09/2025 at 8:05 AM, Staff H, Licensed Practical Nurse (LPN), said the syringe was dated 09/06/2025 and she would throw it away. Staff H said the syringe should be changed every day. On 09/11/2025 at 9:17 AM, Staff B, DNS, said a syringe and graduated container that was being used for tube feeding should be replaced every 24 hours. NON PHARMACOLGICAL INTERVENTIONS 4)Resident 44 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 44 was severely cognitively impaired. Resident 44 had an order for tramadol; 50 milligrams as needed for pain. The order also instructed staff to provide NPIs to reduce pain and document effectiveness, as followed: 1-Repositioning, 2-Relaxation, 3-Diversional Activities, 4-Food/Beverage, 5-Blanket/Sweater. The August 2025 Treatment Administration Record (TAR), documented Resident 44 was given Tramadol 25 times, with no NPIs attempted or documented. The September (1st-9th) 2025 TAR documented Resident was given Tramadol 5 times, with no NPIs attempted or documented. On 09/10/2025 at 10:30 AM, Staff B, DNS, said the order was entered incorrectly; it should have said non-pharmacological interventions. Staff B said staff were not documenting NPIs and should have been when administering PRNs. 5) Resident 26 was admitted to the facility on [DATE] with a diagnosis of severe dementia with agitation. Review of the Admissions MDS, dated [DATE], showed they had severely impaired cognition (mental processes), and were receiving both scheduled and as needed pain medication. Review of Resident 26's EHR, showed they were receiving an as needed opioid pain medication. Review of Resident 26's MAR/TAR, showed the as needed opioid pain medication was given on 09/06/2025 and 09/07/2025 without any NPIs documented. During an interview on 09/09/2025 at 1:57 PM, Staff E, RCM, acknowledged there were no NPIs documented in Resident 26's chart related to the two as needed administrations listed above. Reference WAC 388-97-1060 (1)-1060 (3)(k)(i) .

Based on interview and record review, the facility failed to ensure residents with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for catheter removal and coordination with urology occurred timely for 1 of 3 residents (Resident 1) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including stroke and kidney disease. The Minimum Data Set (MDS), an assessment tool, dated 04/11/2025, showed the resident was severely cognitively impaired, dependent for activities of daily living and had indwelling urinary catheter. On 04/10/2025 at 2:12 PM, Collateral Contact 1 (CC 1), said they had expressed ongoing concerns about Resident 1's catheter. CC1 said the urine in the catheter bag was frequently red in color and there was sludge (mixture of solid and liquids) in the bag too. CC1 said they had brought it to the attention of the facility staff for a couple of weeks. CC1 said they were frustrated with the facility's lack of response to their concerns regarding the urine and catheter, so they contacted the Urology (medical specialty focused on the urinary tract) office to request an appointment. Resident 1's care plan, dated 08/19/2024, showed the resident had an indwelling catheter for obstructive uropathy (a blockage in the urinary tract obstructs the flow of urine). Resident 1's medical provider notes showed the following: 12/27/2024- Today I noted recurring hematuria (blood in urine) associated with the indwelling catheter. No catheter tugging noted on examination of the foley. Requested clarification regarding urologic follow-up status through the nursing staff. 01/10/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-Hematuria, a recurrent problem, has a permanent indwelling foley. Requested clarification regarding urologic follow-up status through the nursing staff. 01/27/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-Hematuria, a recurrent problem, has a permanent indwelling foley. Requested clarification regarding urologic follow-up status through the nursing staff. Hematuria, follow up with urology. 01/30/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-Hematuria, a recurrent problem, has a permanent indwelling foley. Requested clarification regarding urologic follow-up status through the nursing staff. Hematuria, follow up with urology. 01/31/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-Hematuria, a recurrent problem, has a permanent indwelling foley. Requested clarification regarding urologic follow-up status through the nursing staff. Urology follow up as scheduled or directed. 02/04/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-Hematuria, a recurrent problem, has a permanent indwelling foley. Requested clarification regarding urologic follow-up status through the nursing staff. Urology follow up as scheduled or directed. 02/18/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-continue indwelling foley catheter, urology follow up as scheduled or directed. 03/18/2025- Physical exam- Has foley catheter draining reddish colored urine. Assessment-continue indwelling foley catheter, urology follow up as scheduled or directed. 03/25/2025- spoke with the resident's daughter, concern that he does not need a foley catheter. In reviewing the notes, a foley catheter was placed in the hospital due to severe diaper rash and since left the hospital and was placed on hospice was left in place. However, several months later he graduated from hospice, and they did not discuss foley removal at that time. Resident 1's progress notes, dated 03/25/2025, showed the facility had spoken to the resident's daughter and urology and an appointment was scheduled for 04/16/2025. The note showed the Urologist wanted the catheter changed prior to the appointment and a urinalysis (urine test for infection) obtained. Review of Resident 1's electronic medical records on 04/23/2025, showed no documentation of communication and/or follow-up with the urology office prior to 03/25/2025. Resident 1's progress note, dated 03/31/2025, showed the facility staff changed the resident's catheter and the urine was red. The note showed the resident was sent to the emergency room . Resident 1's hospital records, dated 04/07/2025, showed the resident was brought to the emergency room with hematuria after replacing a foley. Records showed the resident with diagnosis of catheter associated urinary tract infection. The records showed the resident received intravenous (medication administered through the vein) antibiotics (medication to treat infection) in the hospital. On 04/23/2025 at 12:28 PM, Staff A, Director of Nursing, said the facility reviewed indication for indwelling catheters at least quarterly. Staff A said they would expect a resident with an indwelling catheter to have a medical indication for use and attempts to remove the catheter and proceed with voiding trials unless medially contraindicated. Staff A said after reviewing Resident 1's medical records the resident was sent to the hospital in August of 2024 and the hospital placed an indwelling catheter. Staff A said when the resident returned to the facility they were placed on hospice and the catheter was left in place. Staff A said the resident came off hospice in December of 2024. Staff A said there was no documentation the facility assessed the resident for removal of the catheter and/or consulted with urology. Staff A said if the provider assessed the resident and requested clarification from nursing regarding urologic follow up, it should have occurred. Reference WAC 388-97-1060 (3)(c)

Based on interview and record review, the facility failed to obtain clarification for treatment and assess timely for prompt intervention, a surgical incision under the dressing for 1 of 3 residents (Resident 1) reviewed for wound care. Resident 1 experienced harm when their surgical incision dehisced (opened back up), became necrotic (dead/devitalized tissue) and showed signs of infection after 19 days without observation of the incision below the dressing assessment. This failure placed residents at risk for medical complications and a decreased quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including diabetes, heart and kidney disease. The Minimum Data Set, an assessment tool, dated [DATE], showed the resident required assistance with their activities of daily living. Resident 1's progress note, dated [DATE], showed Resident 1 was scheduled for a L [left] toe amputation (surgical procedure to remove a body part) on [DATE] related to necrosis and several unsuccessful rounds of antibiotic treatments and wound care. Resident 1's After Visit Summary, dated [DATE], showed post-operative discharge instructions that included to remove the dressing after 72 hours and redress with light gauze dressing at least every other day. The after-visit summary showed they were to call the medical provider if they had redness, tenderness or signs of infection around the surgical site. Facility designated physician order, for Resident 1, dated [DATE], showed orders to leave the dressing to left great toe in place until follow-up appointment on [DATE]. The order expired/was discontinued on [DATE], leaving no remaining treatment orders in place. Resident 1's surgeon's office visit note, dated [DATE], showed staff removed the bandage from the left amputation site, sutures were intact, no drainage, warmth or erythema (redness) at the site. The note showed sterile gauze was applied to the site and wrapped with kerlix (type of bandage) and the patient was instructed to call for any signs of infection or concerns. Review of Resident 1's Treatment Administration Record from [DATE] through [DATE], showed no documentation of a dressing change to the left great toe and/or monitoring/assessment of the left great toe surgical site. Review of Resident 1's progress notes from [DATE] thru [DATE], showed no dressing changes to the left great toe and/or monitoring/assessment of the left great toe surgical site. Review of Resident 1's physician orders from [DATE] through [DATE], showed no orders for dressing changes to the left great toe and/or orders to keep dressing in place. Resident 1's weekly skin assessments, dated [DATE] and [DATE], showed the left great toe amputation dressing was intact, and the dressing was to remain in place until follow up appointment with the surgeon (dressing change orders ended [DATE] after which new orders should have been obtained). The skin assessments did not document the dressing on the surgical incisions was removed or any visualization of the incision site occurred. Review of Resident 1's surgeon's office visit note, dated [DATE], retrieved from EPIC (an electronic record system outside of Resident 1's facility medical record), by Staff A, Resident Care Manager (RCM) on [DATE], showed the left great toe amputation site with residual cellulitis (skin infection) and an order for Keflex (antibiotic). Resident 1's weekly skin assessment, dated [DATE], showed the left great toe amputation dressing was intact but there was no assessment of the surgical incision beneath the dressing. Resident 1's progress note, dated [DATE] (9 days after surgeon's visit) and the first time documentation showed facility staff assessed the resident's incision since the amputation on [DATE], documented the resident's wound/incision to their left dorsal hallux (great big toe), had a scant amount of drainage with a slight foul odor. Resident 1's facility medical provider notes, dated [DATE], showed the provider examined Resident 1's surgical site on the left great toe and it was necrotic, foul smelling, with purulent (thick, milky fluid) drainage and wound dehiscence (a partial or total separation of an incision). The notes showed the provider advised the resident they needed to go the hospital for intravenous (administered into the vein) antibiotics and wound debridement (medical procedure to remove dead and infected tissue) but the resident declined to go and chose to remain at the facility and stay comfortable. On [DATE] at 1:48 PM, Staff A said they entered the order on [DATE] for the dressing to remain in place until the follow up appointment with the surgeon and expected there would be new dressing orders at the [DATE] follow up appointment. Staff A said Resident 1 went to their follow up appointment with the surgeon on [DATE] and returned with no paperwork. Staff A said they expected when residents returned from appointments without paperwork, the expectation was to call the doctor's office to ensure there were no new orders and/or instructions. Staff A said there was no documentation in the medical record that this took place. On [DATE] at 3:24 PM, Staff B, Director of Nursing, said the system for monitoring and assessment of wounds was during dressing changes, documenting in the progress note and weekly during skin assessments. Staff B said they reviewed Resident 1's medical record and saw documentation the resident had a dressing on the left great toe, but no documentation of a physician's order for a dressing after [DATE], no monitoring and/or assessment of the surgical site and no documentation the staff changed the left toe dressing between the surgeon's follow up appointments. Staff B said they expected that during Resident 1's weekly skin assessment that staff should have assessed the resident's skin to include the left great toe surgical incision, and a surgical incision should be followed by the RCM until healed. Staff B said the staff should have contacted the physician for clarification of the wound care. Staff B said that did not happen. WAC Reference [DATE] (1)

Based on observation and interview, the facility failed to provide a clean, comfortable and homelike environment on 1 of 4 hallways (200 hall). The failure to ensure hallway carpeting was clean and in good repair and resident rooms were mopped and free of sticky substances, placed resident at risk for a diminished quality of life, and resulted in a less than homelike environment. Findings included . On 08/21/2024 at 10:28 AM, observation of the 200-hall carpet showed an approximately 30-foot-long vertical cut right down the middle of the hallway carpet, and multiple five to eight feet long, horizontal cuts in the carpet running side to side across the hallway. Each of the vertical and horizontal cuts were covered with duct tape. At 10:30 AM, when asked about the state of the carpet, an anonymous staff member stated, oh you noticed that [carpet in disrepair]. I can't stand it. The staff member indicated the carpet had been in that state for a few years. On 08/22/2024 at 11:55 AM, when asked about the environment, Resident 65 stated, [The hallway carpet] is disgusting. I find it insulting. Do I find it homelike? What? No! When I first saw it, I thought they must be replacing it, but no. At 3:12 PM, Staff D, Maintenance Director, explained that for greater than two years prior, the carpet on the 200 hall had been bunching up resulting in potential tripping/safety hazards. Staff D said he had to cut the carpet to try and stretch the carpet in the areas where it was bunching up. After the bunched-up areas were addressed, the cuts in the carpet were covered with duct tape and bids were obtained for replacement of the carpet. According to Staff D, the facility then went through several Administrators. Staff D said with each change in administration, Staff D had to obtain a new bid for replacement of the carpet which had continuously set the project back. Staff D stated, I know I have told the [state] survey team for a few years that the carpet was going to be replaced because it was, but like I said then the administrators would change, and the carpet [replacement] quote process would start over. At 3:21 PM, when asked if the facility had a work order or had moved beyond just obtaining bids Staff D, stated, No. Reference WAC 388-97-0880 (1)

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 63) reviewed for communication and sensory and who required assistive devices for vision or hearing were assisted with application of their glasses. Failure to ensure their glasses were in good repair and applied to the resident daily precluded the resident from reading the activity calendar and menus independently and placed them at risk for feelings of diminished self worth and decreased quality of life. Findings included . Resident 10 admitted to the facility on [DATE]. Review of the 07/09/2024 Quarterly Minimum Data Set (MDS, an assessment tool), showed the resident's vision was adequate with the use of corrective lenses. A self care deficit care plan, revised 08/24/2023, showed the resident wore glasses during waking hours, as well as at night as the resident would often wake up and read. Staff were directed to keep the resident's glasses within reach for independent use, and make sure the glasses were clean. On 08/22/2024 at 11:30 AM, Resident 10 was observed lying in bed without their glasses in place. The resident's glasses were observed in a kidney basin on a three drawer chest located on the other side of a divider curtain. The glasses were not in the resident's sight or reach. The glasses were observed to only have one lens in place. The other lens was lying in the bottom of the basin. Resident 10 said they did not know where their glasses were currently at but indicated they had been broken. Resident 10 said staff were aware but No one does anything! When asked if they required their glasses for activities of daily living, the resident said they used them for reading. Similar observations were made on 08/23/2024 at 1:41 PM, 08/26/2024 at 11:19 AM and 1:43 PM and 08/27/2024 at 12:09 PM. On 08/27/2024 at 1:05 PM, Staff C, Resident Care Manager, confirmed Resident 10's glasses were in a kidney basin on the other side of the divider curtain, not within the residents field of vision or within reach. Staff C then looked around the room and found two more sets of glasses, each pair also only had one lens. Staff C said they had not been informed that the resident's glasses were broken. When asked if facility staff should have identified this when they performed the daily cleaning of the glasses, Staff C said yes. Reference WAC 388-97-1060 (2)(a)

Based on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 5 of 8 residents (Residents 65, 32, 25, 10 and 13) reviewed for bowel management. The failure to initiate bowel care in accordance with physician's orders placed residents at risk for pain/discomfort, nausea, decreased appetite and a diminished quality of life. Findings included . Review of the Avamere Living Bowel Care Protocol, dated 10/2020, showed if a resident had not had a bowel movement (BM) for three consecutive days (must be medium or large), Evening shift would administer: a) milk of magnesia (MOM) b) if no results from MOM, day shift would administer a bisacodyl suppository. c) if no results from the suppository, a fleets enema would be administered. If no results from the enema a focused examination of the abdomen and a digital exam and notify the physician. 1) Resident 65 admitted to the facility on [DATE]. On 08/22/2024 at 12:02 PM, Resident 65 reported a long history of constipation and stated, It's one of those things I have to deal with. Review of the July and August 2024 bowel record showed the resident went the following periods without a BM: 7/11/2024 - 07/21/2024 (11 days) and 8/10/2024 - 08/12/2204 (4 days.) Review of the July and August 2024 Medication Administration Record (MAR) showed facility staff failed to administer as needed bowel medication after three days of no BM as ordered. On 08/27/2024 at 2:28 PM, when asked if on the above referenced occasions facility nurses provided as needed bowel care as ordered Staff B, Director of Nursing Services (DNS), stated, No. 2) Resident 32 admitted to the facility on [DATE]. On 08/22/2024 at 2:02 PM, Resident 32 said they struggled with periodic constipation. Review of the August 2024 bowel record showed the resident went from 08/08/2024 - 8/12/2024 (4 days) without a BM. Review of the August MAR showed facility staff failed to administer Resident 32's as needed bowel medication after three days of no BM as ordered. On 08/27/2024 at 2:36 PM, when asked if on the above referenced occasion facility nurses provided as needed bowel care as ordered Staff B, DNS, stated, No. 3) Resident 10 admitted to the facility on [DATE]. Review of the July and August 2024 bowel record showed the resident went the following periods without a BM: 07/27/2024 - 7/29/2024 (3 days), and 08/07/2024 - 08/11/2024 (5 days). Review of the July and August 2024 MAR showed facility staff failed to administer Resident 10's as needed bowel medication after three days of no BM as ordered. On 08/27/2024 at 2:36 PM, when asked if on the above referenced occasion facility nurses provided as needed bowel care as ordered Staff B, DNS, stated, No. 4) Resident 25 admitted to the facility on [DATE]. Review of the June 2024 bowel record showed the resident had no BM from 06/19/2024 - 06/22/2024 (4 days.) Review of the June 2024 MAR showed facility staff failed to administer as needed bowel medication after three days of no BM as ordered. On 08/27/2024 at 2:37 PM, when asked if facility nurses provided as needed bowel care to Resident 25 as ordered Staff B, DNS, stated, No. 42960 5) Resident 13 was admitted to the facility on [DATE] with diagnoses including Parkinsons (neurodegenerative brain conditions that causes motor symptoms) and bipolar disorder (characterized by both manic and depressive episodes). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 08/06/2024 documented the resident was cognitively intact and was dependent to needing moderate assistance with activities of daily living (ADLs). Resident 13's physician orders showed to give 2 tablets of Bisacodyl (a stimulant laxative) 5 MG (miligrams) by mouth every 24 hours as needed for constipation and no bowel movement (BM) on the 3rd day. The Bowel Record for 07/24/2024 - 08/22/2024 documented Resident 13 did not have a BM on 08/03/2024, 08/04/2024, 08/05/2024, and 08/06/2024. The Medication Administration Record for August 2024 documented Resident 13 received a Dulcolax Suppository (a stimulant laxative suitable for the fast relief of occasional constipation) 10 MG on 08/07/2024. On 08/26/2024 at 1:04 PM, Staff C, Resident Care Manager, said Resident 13 went 4 days without a BM and the bowel protocol should have been implemented on 08/06/2024. On 08/27/2024 at 11:11 AM, Staff B, DNS, said his expectation was for the staff to follow the bowel protocol and the resident receive a bowel medication on the 4th day without a BM or document in a progress note that the resident refused. Reference WAC 388-97 - 1060 (1)

Based on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice for 3 of 3 residents (Residents 16, 48 & 74) reviewed for IV therapy. The failure to ensure IV orders included routine monitoring of IV insertion sites, flush orders, weekly changes of IV dressings and needleless injection caps, and initial and then weekly measurements of IV catheters external length and the residents arm circumferences, placed them at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . <Facility Policy> Review of the facility's Vascular Access Device (VAD) Dressing Change, Needleless Connector Change, Flushing and Locking, and Peripheral Midline Catheter policies, dated 08/2021, showed VADs included PICCs, non-tunneled catheters (subclavian, jugular, femoral), Tunneled catheters, and implanted venous ports. Staff were directed to: a) Perform VAD dressing changes every seven days and as needed. b) Measure VADs external length upon admission/during the initial assessment, weekly with dressing changes, upon suspicion of a change in length or if signs or symptoms of complications were present. c) Measure the upper arm circumference of residents with Peripherally inserted central catheters (PICCs) or peripheral midline catheters, upon admission and/or with the initial assessment and then at least weekly. d) Change needleless connectors upon admission; at least every seven days; after blood draws; and any time the integrity of the needleless connector is in question. e) Specific flush/lock orders must be obtained, documented, and submitted to the pharmacy. f) Monitor the IV insertion site for signs and symptoms of infection or infiltration each shift. 1) Resident 16 admitted to the facility on [DATE]. Review of the 5-day Minimum Data Set (MDS, an assessment tool) showed the resident had a diagnosis of osteomyelitis (bone infection), had IV access via a midline, and received IV antibiotic therapy. An Admission Nursing Database assessment, dated 08/07/2024, documented Resident 16 had IV access via a midline (a tube that is placed into a vein, usually in the arm. The catheter is then moved through the vein until the tip sits at the level of your armpit and away from the shoulder) to the right upper arm for antibiotic therapy related osteomyelitis of the left tibia and fibula (lower leg bones). Resident 16's comprehensive care plan showed the type and location of the resident's IV access, goals of antibiotic therapy and care instruction for management of the IV site were identified or addressed in the plan of care. Review of Resident 16's physicians' orders showed a 08/08/2024 order for Ceftriaxone (an antibiotic) two grams IV daily, infuse over 30 minutes for osteomyelitis. No IV maintenance and monitoring orders were in place. The August 2024 Medication and Treatment Administration Records (MAR, TAR) showed there was no documentation that facility staff had: a) Monitored the IV insertion site for signs and symptoms of infection or infiltration. b) Performed weekly midline dressing changes. c) Measuring the midline external length weekly. d) Measured the resident's right arm circumference weekly. e) Performed midline flushes. There was no direction related to the type, amount and frequency of midline flushes. f) Changed the resident's needleless injection caps at least weekly. 2) Resident 48 admitted to the facility on [DATE]. Review of the 5-day MDS, dated [DATE], showed the resident had a wound infection, IV access and received IV medications. A 07/27/2024 re-admission nurse's note documented the resident had a midline to their left upper arm and were to receive IV Daptomycin (an antibiotic). Resident 48's comprehensive care plan (CP) showed it did not address the presence, type, and location, of the Resident 48's IV access. No instruction was provided to staff about how to assess, monitor, and care for the resident's IV access. Review of Resident 48's physicians' orders showed the following 07/30/2024 IV orders: -IV Daptomycin daily. - Midline IV catheter: replace administration sets for intermittent use every 24 hours. - Midline IV catheter: Check placement sterile transparent dressing every shift. The August 2024 MAR and TAR showed there was no documentation to show facility staff had: a) Monitored the IV insertion site for signs and symptoms of infection or infiltration. b) Performed weekly midline dressing changes. c) Measuring the midline external length weekly. d) Measured the resident's right arm circumference weekly. e) Performed midline flushes. Nor was there direction related to the type, amount and frequency of midline flushes. f) Changed the resident's needleless injection caps at least weekly. On 08/26/2024 at 3:27 PM, Staff B, Director of Nursing Services (DNS), said Resident 16's and 48's IV orders were incomplete and should have included the maintenance and monitoring orders identified in the facility's IV policy. Staff B said facility nurses should have identified the IV orders were incomplete and clarified them but failed to do so. 46793 Resident 74 admitted to the facility on [DATE]. The Admission MDS, dated [DATE], documented Resident 74 was cognitively intact. Resident 74 was admitted to the facility with a PICC line. The Electronic Health Records shows no order for monitoring and maintenance of the PICC line. On 08/26/2024 at 3:27 PM, Staff B, DNS, said Resident 74's IV orders were incomplete and should have included the maintenance and monitoring orders identified in the facility's IV policy. Staff B said facility nurses should have identified the IV orders were incomplete and clarified them but failed to do so. Reference WAC 388-97-1060 (3)(j)(ii)

Based on observation, interview and record review, the facility failed to assure residents received foods in the appropriate form and/or nutritive content as prescribed by a physician for 5 of 36 sampled residents (Resident 57, 22, 10, 52 & 74) reviewed for diet requirements. Failure to ensure residents' received physician ordered therapeutic diets or portion sizes placed residents at risk for medical complications or nutritional deficits. Findings included . Review of the breakout menu for the lunch meal on 08/26/2024 showed residents on a: a) Regular diet was to receive an #8 scoop of apple crisp. b) Residents on a soft bite sized diet (SB6) or minced and moist diet (MM5) were to receive a #12 scoop of apple crisp. c) Residents on a pureed diet (PU4) were to receive a #10 scoop of apple crisp. d) Residents on limited carbohydrate, limited fat, limited salt, or limited potassium/phosphorus diets, were to receive a #16 scoop of apple crisp. Additionally, residents on a low potassium/phosphorus (renal) diets were to receive lemonade in lieu of milk and spiral pasta in lieu of cubed steak. <Prepping> On 08/26/2024 at 10:22 AM, Staff L, Cook, was observed preparing pureed chicken. Staff L poured an un-measured amount of chicken from a metal container into the robot coupe blender and pulsed the blender five times. Staff L then obtained an un-measured amount of hot water from the spigot and proceeded to pour an unmeasured amount into the blender with the chicken. The mixture was then blended for 1 minute. Staff L, then stopped and looked and added an unmeasured amount of thickener to the mixture and blended it for 30 seconds. Staff L again observed the mixture and added an additional unmeasured amount of thickener before pulsing the mixture. The mixture was then poured from the blender into a strainer to remove any excess fluid. The chicken mixture was then poured into a metal steam table bin and placed it on the steam table. At 10:35 AM, Staff L followed a similar process when preparing the pureed asparagus. An unmeasured amount of asparagus was put into the blender and blended for 10 seconds. Staff L then added an unmeasured amount of thickener from an un-graduated plastic cup and blended the mixture for an additional 10 seconds before pouring it into a metal steam table bin and placing it on the steam table. At 12:32 PM, when asked if dietary staff were to follow a written recipe when preparing pureed foods, Staff E, Food Service Director (FSD) stated, Yes, and indicated staff were expected to follow the recipe and measure out the amount of thickener, seasoning, etc. as directed in the recipe to maintain nutritional content, palatability, and appropriate texture. <Plating/Serving> On 08/26/2024 at 10:46 AM Staff M, Dietary Aide, was observed plating peach crisp (substituted for apple crisp). Staff M placed one #16 scoop of peach crisp into each desert container and covered them with lids. Staff M then placed a desert on each of the staged trays in preparation for tray line. At 11:45 AM, observation of the steam table showed dietary staff failed to prepare spiral pasta for the residents on renal diets, garlic green beans which was to be served with the alternative meal of lemon pepper chicken and wild rice; apple crisp as it was unavailable and replaced with peach crisp; and no butter was available to provide residents with their vegetables. At 11:46 AM, Staff E, FSD, confirmed the facility was out of the following lunch menu items- butter, garlic green beans, apple crisp and failed to prepare spiral pasta, which was to be served to residents on renal diets in lieu of the cubed steak. <Lunch Tray Line> Observation of lunch tray line from 11:47 AM - 12:32PM, showed Staff O, Cook, prepare the following: 1) Resident 57's was on a regular, limited carbohydrate diet, with additional instruction to provide extra sauce and gravy. Staff O, failed to provide extra sauce/gravy. 2) Resident 22 was on a regular, limited salt, soft and bite sized diet, with small portions. Staff O served the resident a regular large protein diet. 3) Resident 10 was on a regular, soft and bite sized diet, with small portions. Staff O served the resident regular portions. 4) Resident 52 was on a regular, limited phosphate, sodium and potassium (Renal) diet. Staff O did not provide the resident spiral pasta as none was prepared. Additionally, the menu showed residents on renal diets were to receive lemonade in lieu of milk. However, beverages were not provided by dietary staff and floor staff provided beverages when delivering the tray. Observation on 8/26/2024 at 12:47 PM, Resident 52's room tray was observed with an open, empty container of 2% milk on their tray. No lemonade was present. 5) Resident 74 was on a regular high calorie, high protein diet. Staff O served a regular diet. The resident was not provided whole milk or butter (the facility was out of butter). At 12:15 PM, Staff O explained that a high calorie diet usually entailed providing whole milk, extra butter etc. to maximize caloric intake. When asked if the facility had whole milk or butter available, Staff O stated it was not available. At 12:17 PM, Staff E, FSD, acknowledged the serving size of the peach crisp was incorrect for all residents on regular, regular texture diets, as well as for residents on minced and moist, soft and bite sized, and pureed diets, which called for a #12 and #10 scoop of peach crisp respectively. When asked about the above referenced deviations from resident's ordered diets Staff E, FSD, checked the dietary computer and confirmed the list of diets that was provided remained accurate and confirmed the above observed errors. Staff E said it was the expectation that residents' therapeutic diet orders be followed. Reference WAC 388-97-1200(1)

Based on interview and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 11 of 11 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life. Findings included . On 08/21/2024 at 1:02 PM, Resident 3 said they had a family member open another bank account for them because they could not withdraw money from their personal funds account on the weekends. On 8/26/2024 at 9:37 AM, Staff H, Licensed Practical Nurse (LPN), said she did not know the process if a resident wanted to withdraw money from their personal funds account over the weekend or after hours. At 9:40 AM, Staff C, LPN Resident Care Manager, said she did not know how a resident could withdraw funds from their Personal Funds account on the weekends and she said she would contact the business office to find out. At 9:50 AM, Staff I, Receptionist, said residents could withdraw money from their Personal Funds account through activities on the weekends but did not now know how they could withdraw money from their account if activities was not there. At 9:51 AM, Staff G, Business Office Manager, said there was a sign for residents with personal funds that said, Front Desk Resident Banking Hours 8:00 AM - 4:30 PM Monday - Friday Saturday & Sunday See Activities and when asked what the residents should do when activities was not in the building she acknowledged the sign needed to be changed. On 8/27/2024 at 11:42 AM, Staff A, Administrator, said they would educate staff on how residents could withdraw money from their personal funds account on the weekend and after hours. Reference (WAC) 388-97-0340 (1)(2)(3)

Based on interview and record review, the facility failed to provide residents a written notice detailing the reasons for discharge/transfer and to provide a copy of the notice to the state Ombudsman office as required for 2 of 2 sampled residents (Resident 27 & 75) reviewed for hospitalization s. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds. Findings included . Facility policy, titled, Transfer or Discharge Notice, dated March 2021, documented Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Resident 27 was admitted to the facility on [DATE]. The Admission Minimal Data Set, (MDS, an assessment tool) date 07/23/2023, documented Resident 27 was severely cognitively impaired. Resident 27 was hospitalized from 07/23/2024 until their return on 07/29/2024. The Electronic Health Record (EHR) showed no documentation of a transfer notice or Ombudsman notification. Resident 75 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 75 was cognitively intact. Resident 75 was hospitalized from 06/08/2024. The EHR showed no documentation of a transfer notice or Ombudsman notification. On 08/26/2024 at 1:15 PM, Staff C, Resident Care Manager, said they did not have a copy of the transfer notice or Ombudsman notification for either resident. When asked if a transfer notice/Ombudsman notification should have been completed, Staff C said yes. At 1:18 PM Staff N, Social Services Director, stated, I am responsible for the Ombudsman notification, and provided a copy of the Ombudsman notification list of transferred residents for June and July 2024. Resident 27 nor Resident 75 were on the list. Staff N said both residents should have been on the transfer list to the Ombudsman. Reference WAC 388-97-0120 (2) (a-d) .

Based on interview and record review, the facility failed to provide Care Conferences (a conference where staff and residents/families talk about life in the facility, review the progress of resident and make adjustments, as needed, to their care), for 1 of 2 sampled residents (Resident 13) reviewed for provision of care conferences, and failed to ensure care plans were reviewed, revised, and accurately reflected resident care needs for 4 of 21 sample residents (Residents 16, 48, 63, & 8) reviewed for care plan timing and revision. These failures placed residents at risk of not feeling involved in the development of their plan of care, unmet needs, and a diminished quality of life. Findings included . <Care Plans> 1) Resident 48 admitted to the facility on [DATE]. Review of the 5-day Minimum Data Set (MDS, an assessment tool), dated 07/22/2024, showed the resident had intravenous (IV) access via a midline and received IV medications. A 07/27/2024 re-admission nurse's note documented the resident had a midline (a tube that is placed into a vein, usually in the arm. The catheter is then moved through the vein until the tip sits at the level of your armpit and away from the shoulder) to their left upper arm and were to receive IV Daptomycin (an antibiotic). Resident 48's comprehensive care plan (CP) showed no care plan was developed that addressed the presence, or type and location of the Resident 48's IV access. No interventions were developed and/or implemented that directed staff how to assess, monitor, and care for the IV access. On 08/26/2024 at 3:27 PM, Staff B, Director of Nursing Services (DNS), said the location and type of IV access and maintenance and monitoring instructions should be care planned. When asked if they were Staff B stated, No. 2) Resident 16 admitted to the facility on [DATE]. Review of the 5-day MDS, dated [DATE], showed the resident had IV access via a midline and received IV medications. An Admission Nursing Database assessment, dated 08/07/2024, documented Resident 16 had IV access via a midline to their right upper arm for antibiotic therapy related osteomyelitis (bone infection) of the left tibia and fibula (lower leg bones). Resident 16's comprehensive CP showed no care plan was developed that addressed the type and location of the Resident 16's IV access. On 08/26/2024 at 3:27 PM, when asked if the type and location of Resident 16's IV access was care planned Staff B, DNS, stated, No. 3) Resident 63 admitted to the facility on [DATE]. Review of the 5-day MDS, dated [DATE], showed the resident had a diagnosis of obstructive sleep apnea (OSA, a sleep-related breathing disorder where people repeatedly stop and start breathing while they sleep) and did not use a continuous positive airway pressure (CPAP, a machine that uses mild pressure to keep the breathing airways open during sleep) machine or Bilevel Positive Airway Pressure (BiPAP, a non-invasive ventilation therapy used to treat sleep apnea, respiratory failure, and other breathing disorders) machine. On 08/06/2024 an order directed staff to apply CPAP at bedtime per set settings and remove in the AM. A CPAP therapy CP, revised 08/06/2024, directed staff to encourage resident to use their CPAP or BiPAP, but failed to identify which one the resident was to receive. The CP did not identify the CPAP settings or provide instruction for the cleaning and maintenance of the CPAP mask and machine, or identify the CPAP had a humidifier chamber, which needed to be checked and filled. On 08/26/2024 at 3:31 PM, Staff B, DNS, said Resident 63's CP should have identified the type of non-invasive ventilation the resident was to receive (CPAP vs. BiPAP) and provided resident specific care instructions related to their CPAP machine. 4) Resident 8 admitted to the facility on [DATE]. Review of the Significant change MDS, dated [DATE], showed the resident had impaired functional Range of Motion (ROM) to one upper and one lower extremity and did not receive restorative nursing services. Review of a self-care deficit CP, revised 06/13/2024, showed staff were to provide passive ROM to both upper and lower extremities, times fifteen repetitions and perform hand hygiene and gentle stretching of the resident's left hand, before applying a left-hand splint in the am. The care plan did not identify what joints and planes should be ranged or the frequency at which staff should provide the programs (e.g. daily, six times a week etc.) On 08/27/2024 at 2:38 PM, Staff B, DNS, stated the frequency at which the ROM program was to be provided, should have been care planned but was not. 42960 <Care Conferences> Resident 13 was admitted to the facility on [DATE] with diagnoses including Parkinson (neurodegenerative brain conditions that causes motor symptoms) and bipolar disorder (characterized by both manic and depressive episodes). The Quarterly MDS, dated [DATE], documented the resident was cognitively intact and felt it was very important to have family involved in discussions about their care. On 08/22/2024 at 10:55 AM, Resident 13 said they had not had a care conference recently. Review of the electronic health record (EHR) showed a care conference was conducted on 08/03/2023. On 8/26/2024 at 2:36 PM, Staff K, Social Services Coordinator, said Resident 13's last care conference was over a year ago in August 2023. Staff K said Resident 13's care conferences did not happen as often as they should have and Staff K said they had no excuses. On 8/27/2024 at 11:11 AM, Staff B, DNS said the expectation was for the care conferences to be done quarterly. Staff B said there was a note contacting the family to set up a care conference on 03/14/2024 but no further documentation after that. Reference WAC 388-97 -1020(2)(c)(d)

Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) to include providing oral care and assistance with shaving for 2 of 2 residents (Residents 63 and 10) reviewed for ADL's. The failure to assist dependent residents with oral care and shaving, placed residents at risk for embarrassment, dental caries, powerlessness and a diminished quality of life. Findings included . 1) Resident 63 admitted to the facility on [DATE]. Review of the 05/09/2024 Admission Minimum Data Set (MDS, an assessment tool), showed the resident was dependent on staff for oral hygiene and had no obvious or likely cavities or broken natural teeth. An ADL self-care care plan, initiated 05/20/2024, showed staff were directed to set Resident 63 up to self-brush, and staff were to assist to complete. On 08/21/2024 at 1:52 PM, Resident 63's family member said the resident was always clean shaven prior to admitting to the facility and systematically cleaned his hands and face after meals and brushed his teeth after breakfast. The resident's family member said they had informed staff on multiple occasions but stated, they are not doing it. Resident 63 was observed with a very short facial hair (beard/mustache.) When asked if he was assisted to brush his teeth after breakfast as requested, Resident 63 stated, Never. At 1:58 PM, Staff J, Certified Nursing Assistant (CNA) entered the room. Resident 63's family member asked if they had been brushing his teeth after breakfast and shaving him daily. Staff J, CNA, stated, No, not as often as I would like to honestly, but I try [to]. On 08/27/2024 at 1:41 PM, Staff C, Resident Care Manager (RCM), said facility staff should be assisting Resident 63 with brushing his teeth after breakfast and shaving daily, per Resident 63's preference. 2) Resident 10 admitted to the facility on [DATE]. On 08/22/2024 at 11:30 AM, Resident 10 was observed with several long curly hairs on their chin and a significant amount of hair on their upper lip. Similar observations were made on 08/23/2024 at 1:41 PM, 08/26/2024 at 11:19 AM and 1:43 PM. On 08/27/2024 at 12:09 PM, when asked it was their preference to have hair on their upper lip and chin, Resident 10 stated, No, I just don't have anything to remove it with. On 08/27/2024 at 1:05 PM, Staff C, RCM, confirmed staff should have been offering/assisting Resident 10 with shaving as needed, but had not recently done so. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to ensure non-invasive mechanical ventilation via continuous positive airway pressure machines (CPAP, an external device that provides a fixed pressure to keep breathing airways open while you sleep) was provided in accordance with accepted professional standards of practice for 2 of 2 residents (Resident 25 & 63) reviewed for respiratory care. The failure to ensure active CPAP orders were in place and complete, to include the prescribed pressure settings, type of mask (e.g. nasal pillows, nasal mask, full face mask) to be used, direction to check and refill the humidifier reservoir, and the solution to be used to refill it, placed residents at risk for ineffective assisted ventilation and unmet respiratory needs. Findings included . 1) Resident 25 admitted to the facility on [DATE]. Review of the 01/17/2024 Annual Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of chronic lung disease and obstructive sleep apnea (OSA, refers to apnea syndromes due primarily to collapse of the upper airway during sleep) and required non-invasive mechanical ventilation via a CPAP machine. An alteration in respiratory status care plan (CP), with a target date of 10/02/2024, showed the resident was to wear their CPAP during hours of sleep. The CPAP pressure settings should be set at 12-20 cm H2O per the 04/28/2023 pulmonologist recommendations. On 08/22/2024 at 10:32 AM, Resident 25 was observed with a CPAP machine and an opened and undated gallon, container of distilled water. The gallon container was approximately two thirds full. On 08/26/2024 at 9:03 AM, the opened and undated gallon container of distilled water remained present on the bedside table but was now only 1/2 full. Resident 25 stated, They poured it into the [CPAP] machine, it moistens the air. Review of Resident 25's physician's orders and August 2024 Medication and Treatment Administration Records showed there was no order for Resident 25 to use a CPAP, or any direction to staff to clean the machine, validate the pressure settings or assist with its application. Review of Resident 25's order history showed there was a CPAP order in place from 11/05/2023 - 05/13/2024, at which time it was discontinued. Review of the electronic health record showed no documentation was present that indicated an order was received to discontinue the CPAP. Provider notes, dated 05/23/2024 and 06/28/2024, showed they documented Resident 25's CPAP remained in use. On 08/26/2024 at 2:53 PM, when asked if Resident 25 had an order to wear a CPAP during hours of sleep Staff B, Director of Nursing Services (DNS), stated, No. When informed the resident's CPAP order fell off on 05/13/2024, despite the provider notes documenting it was still in use Staff B, DNS, said they would look into it. No further information was provided. Additionally, Staff B confirmed when staff opened a container of distillied water, it should be dated, as it should be discarded 2-4 days after opening. 2) Resident 63 admitted to the facility on [DATE]. Review of the Admission/ 5-Day MDS, dated [DATE], showed the resident had a diagnosis of obstructive sleep apnea and required non-invasive mechanical ventilation via a CPAP machine. A CPAP/BiPAP therapy related to obstructive sleep apnea CP, revised 08/06/2024, showed staff were to encourage CPAP/BiPAP use during hours of sleep. The CP did not identify whether Resident 63 used a CPAP or a BiPAP, nor did it identify the what the pressure settings should be, direct staff on when, how and what to use for cleaning the machine. Resident 63 had 06/08/2024 orders for: a) CPAP therapy per set settings at bedtime for OSA. Place at bedtime and remove in AM. b) Wash CPAP mask, reservoir, and machine every morning after removal. Let air dry. c) Clean and Wash CPAP tubing every Week. The orders did not identify what the prescribed pressure settings were for the CPA, identify what the CPAP mask and tubing were to be cleaned with daily, or on a weekly basis (e.g. soap and water, a vinegar mixture etc.), nor was there instruction to staff to check or refill the CPAP humidifier reservoir. Additionally, the solution staff was to refill the humidifier reservoir with was not identified. On 08/26/2024 at 2:53 PM, Staff B, DNS, said the CPAP orders should have identified what the CPAP mask and tubing was to be cleaned with, provided direction to staff to check and refill the humidifier reservoir as needed and identified that the reservoir should be filled with distilled water only. Staff B acknowledged the CPAP orders were incomplete and indicated facility nurses should have identified the incomplete order set and clarified the orders but failed to do so. Reference WAC 388-97-1060(3)(j)(vi)

Based on interview and record review, the facility failed to provide medication administration consistent with professional standards of nursing practice for 2 of 5 residents (Resident 1 and 2) reviewed for quality of care. This failure placed residents at risk for unmet care needs, diminished quality of life and potential for medical complications. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated, 11/01/2023, showed Resident 1 was cognitively intact. On 01/11/2024, at 1:02 PM, Resident 1 said they had not received their melatonin (medication to help with sleep) when Staff A, Licensed Practical Nurse (LPN), worked. Resident 1's physician's orders showed the resident had an order, dated 11/01/2023, for one melatonin per day for sleep. Review of a facility investigation, dated 12/15/2023, showed Resident 1 made an allegation against Staff A, LPN. The results of the investigation showed the facility removed Staff A from caring for Resident 1 following the allegation on 12/15/2023. Resident 1's December 2023 Medication Administration Record (MAR), dated 12/1/2023 through 12/31/2023, showed melatonin was administered by Staff A on 12/16/2023, 12/21/2023 and 12/25/2023. Resident 1's January 2024 MAR, dated 01/01/2024 through 01/31/2024, showed melatonin was administered by Staff A on 01/01/2024, 01/02/2024, 01/05/2024, 01/06/2024 and 01/07/2024. On 01/11/2024 at 2:46 PM, Staff A, said they had not provided care and/or medication administration to Resident 1 since the 12/15/2023 incident. Staff A said the nurse on another unit was assigned to Resident 1 when Staff A worked on the resident's unit. Staff A said when they completed their MAR documentation at the end of the shift and Resident 1's melatonin was not signed off, they would sign that the medication had been administered. When asked if Staff A verified Resident 1 received the melatonin, Staff A said they had not. On 01/11/2024 at 2:47 PM, Staff B, Director of Nursing Services (DNS), said they expected the Licensed Nurses to sign the MAR when they administered medications. Staff B said Staff A should not have signed for medications they had not administered. <RESIDENT 2> Resident 2 was admitted on [DATE]. The quarterly MDS, dated [DATE], showed the resident was cognitively intact. On 01/11/2024 at 1:09 PM, Resident 2 said they received their medications timely except for when the evening nurse had not administered their medications. Resident 2 said they had reported it to management. Review of a facility investigation, dated 01/02/2024, showed Resident 2 had complained to staff they had not received their evening medication on 12/30/2023. The investigation found Staff C, Registered Nurse (RN), had documented on the MAR they administered Resident 2's medications on 12/30/2023 but had failed to administer the medications to Resident 2. Resident 2's MAR administration history, showed Staff C signed they administered Resident 2's pain medication on 12/30/2023 at 9:58 PM. Resident 2's Narcotic Record, showed no pain medication had been distributed on 12/30/2023 by Staff C. On 01/11/2024 at 3:06 PM, Staff B, DNS, said they expected the licensed nurses to document the medications they administered in the MAR. Staff B said Staff C should not have signed for medications they did not administer. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview and record review, the facility failed to provide assessment, care planning and interventions to prevent a pressure injury (bed sore) from developing for one of three sampled residents (1) reviewed for pressure injuries. This failure caused harm to Resident 1 when the resident had a change of condition and developed an avoidable, advance stage wound on the sacrum (tail bone). Findings included . National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guidelines, dated 2019, documented strong positive evidence that individuals with limited mobility and limited activity had high potential for pressure injury. NPIAP documented strong positive evidence that, for individuals at risk of pressure injuries, prevention strategies should include 1) individualized repositioning schedule, and 2) repositioning with consideration to the level of activity, mobility and ability to independently reposition. Facility policy, Skin Management Guideline, dated 07/22/2016, documented nurses were to assess risk factors for development of pressure injury when residents were admitted , during quarterly assessment, change in condition and as needed. The risk assessment tool included evaluation of sensation, moisture, mobility, activity, friction and shear and nutrition. The Guideline stated interventions would be added to the care plan as indicated. The Skin Management Guideline documented nurses were to complete a head-to-toe skin assessment on admission. Resident 1 was admitted [DATE]. The Minimum Data Set (MDS), an assessment, dated 12/21/2021, documented Resident 1 was at low risk for development of pressure ulcers and was not on a turning and repositioning schedule. The MDS documented Resident 1 was alert, oriented and eating independently. Progress notes showed Resident 1 was transferred to a special care facility for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Re-admission nursing note, dated 02/01/2022, documented Resident 1's nursing assessment of skin could not be accomplished as resident was combative. Documentation of re-attempts to assess Resident 1's skin was not found. Re-admission risk assessment for development of pressure injury was not found. Progress note, dated 02/01/2022, documented Resident 1 was yelling, talking nonsensical, random words repetitively .topics only she may understand. Dietician progress notes, dated 02/10/2022, documented Resident 1 had a significant weight change from 139.6 pounds to 125.8 pounds in two months. Skin integrity care plan for Resident 1, revised 02/04/2022 (after resident was readmitted ), documented no new problems or interventions. The care plan documented Resident 1's refusal to be turned and repositioned. No intervention was documented in the care plan to address Resident 1's refusal of turning and repositioning ongoing. Care plan identified a targeted behavior for refusal of care but an intervention specific to this behavior was not found. Provider progress note, dated 03/11/2022, documented Resident 1 had altered mental status and was reported to be lethargic, sleepy, sedated, excessively fatigued and difficult to arouse. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, dated 03/13/2022, documented Resident 1 had an open wound at her sacrum (tail bone). Wound consultant progress note, dated 03/15/2022, documented the sacral wound was caused by Resident 1's recent altered mental status and reduced compliance with overall care. The wound consultant described the wound as pressure induced deep tissue damage. On 03/25/2022 at 12:58 PM, Resident 1 was observed lying on her back in bed. Resident 1 stated, I have a sore on my bottom. Can you please look at it?. On 03/25/2022 at 1:45 PM, when asked how the wound developed, Staff E, Licensed Practical Nurse, indicated Resident 1 had a change in mental status and was not drinking, turning, or moving. Staff E indicated residents should be repositioned every two hours. Staff E stated no one reported that they were not able to reposition Resident 1. Staff E indicated the expectation was that an aide would report that the resident refused so nurse could intervene. On 03/25/2022 at 2:53 PM, Staff C, Registered Nurse (RN), Unit Manager, stated if a resident was unable to turn themselves the aide would need to turn them every two hours. On 03/30/2022 at 10:50 AM, Resident 1's sacral wound was observed during treatment by Staff E. The wound bed was observed to be yellow. Staff E stated the wound bed was covered 75% with yellow slough (mass of dead tissue). On 03/30/2022 at 11:00 AM, Staff B, RN, Director of Nursing Services stated the expectation was that Resident 1 would be turned and repositioned by aides when the resident had a change in mental status, was sleepy and not moving in bed. Staff B indicated the wound may have been avoided if the resident was offloaded (repositioned). Staff B indicated turning and repositioning was a professional standard of nursing care. Staff B said, We could have done better as a team. We can't change it but going forward . Reference WAC 388-97-1060(3)(b)

Based on interview and record review, it was determined that the facility failed to ensure that the resident environment was free of accident hazards for 1 of 8 residents (#1) reviewed. Failure of the nursing assistant to ensure the wheelchair brakes were locked caused harm when Resident #1 attempted to independently transfer, fell , and sustained a fracture to the left subcapital femoral neck (left hip). Resident #1 admitted to the facility from the hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The minimum data set (MDS), and assessment tool, dated 2/3/14 identified the resident required extensive assist of two people for toilet use and transfers. The MDS dated [DATE] identified Resident #1 had a brief interview for mental status (BIMS) score of 5, which indicated severe cognitive impairment. The care plan dated 1/21/14 identified the resident had short term memory loss, was forgetful and required the use of simple one step instructions. The care plan documented the resident was at risk for falls due to weakness and required frequent visual checks with reminders not to transfer independently. The care directive (a care guide for nursing assistants) updated on 2/3/14, documented the resident required stand by assist of two people for transfers. Review of the facility's investigation dated 2/19/14 revealed the nursing assistant (Staff B), assisted the resident to the restroom. According to Staff B's witness statement, Staff B locked the brake to the right side of the wheelchair, and she thought the resident locked the brake to the left side of the wheelchair per their normal routine. The resident put on her call light when finished. According to staff B, when she walked down to help the resident get back in the chair, she witnessed the resident trying to self-transfer, the chair moved from under the resident and the resident fell back. According to Staff B's witness statement she looked at the brakes and the left brake (the resident locked) of the wheelchair was pushed, but not all the way, and the chair moved to the left side. Following the fall, the resident was sent to the hospital for further evaluation and treatment. Review of the hospital's medical imaging report revealed the resident sustained [REDACTED]. The facility's investigation concluded, per the resident's usual routine to lock the left brake, but did not fully lock, caused the wheelchair to move and the resident to lose balance and fall. On 3/24/14 at 12:15 p.m., during an interview, the licensed nurse (Staff J) reported according to her investigation it was the resident's normal routine to lock one side of the wheelchair while staff locked the other side of the wheelchair. When asked, Staff J stated she interviewed several nursing assistants, a licensed nurse (Staff K) and a nursing assistant (Staff F) who stated it was the normal routine to lock the brake of one side of the wheelchair and for the resident to lock the other side. Review of the investigation revealed Staff K's witness statement which documented, in part, "in the past while transferring, the resident would lock the left side of the wheelchair and I would lock the right." Individual interviews conducted with nursing assistants (Staff D), (Staff E) and (Staff F), stated they locked both brakes for the resident, and it was not their usual routine to have the resident lock the left side and for them to lock the right or vice versa. On 3/21/14 at 1:55 p.m., during an interview, Staff D reported she had to constantly remind the resident to lock the wheelchair brakes because the resident did not remember. Staff D reported there were times she would return to assist the resident, and the resident would have self-transferred back to the wheelchair from the toilet. When asked, Staff D stated she did not have the resident lock one side while she locked the other, and for safety she would always check to ensure the wheelchair brakes were locked before leaving. On 3/21/14 at 2:12 p.m., during an interview, Staff E reported the resident was not good about locking her wheelchair brakes and needed reminding. When asked, Staff E stated she would lock the wheelchair brakes for the resident and did not have the resident lock one side while she locked the other. Staff E stated there were times she would return and the resident would have self-transferred back in the wheelchair from the toilet. Staff E stated for safety she would lock the wheelchair brakes for the resident before leaving the resident in the restroom. On 3/24/14 a 12:16 p.m., during an interview, Staff F reported she locked the brakes to the wheelchair when the resident would transfer. When asked, Staff F stated she did not have the resident lock one side of the wheelchair brake while she locked the other. Staff F stated for safety she would just lock them both. On 3/24/14 at 12:03 p.m., during an interview, the physical therapist (Staff G) reported the resident was not consistent with locking her wheelchair brakes. On 3/24/14 at 12:24 p.m., during an interview, the Administrator (Staff A) was informed of the above findings. Staff B assisted the resident to the restroom and documented it was routine for the resident to lock one side of the wheelchair brake while she locked the other. According to the care plan, the resident was forgetful and required reminders not to independently transfer. Staff B left the resident in the bathroom unattended with the wheelchair, and failed to ensure the wheelchair brakes were locked. When the resident attempted to independently transfer, the wheelchair moved and the resident fell . Failure of the nursing assistant (Staff B) to ensure the wheelchair brakes were locked, caused harm when Resident #1 fell and sustained a left hip fracture when attempting to independently transfer to the unlocked wheelchair.

Based on observation, interview and record review it was determined that the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing for 1 of 8 residents (#1) reviewed for necessary care and services. This failure caused harm to Resident #1 who had increased pain not treated according to the physician's orders [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE]. The resident had multiple [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS), an assessment tool, dated 8/28/13 identified the resident received as needed (prn) pain medication for shoulder pain. The MDS indicated the pain frequency was rare, and the pain did not make it hard for the resident to sleep at night and did not limit the resident's day to day activities. Pain intensity was scored at "3" on a 0-10 pain scale. According to the quarterly MDS, dated [DATE], the resident's shoulder pain worsened. The quarterly MDS dated [DATE], identified the resident received prn pain medication, and received scheduled pain medication within the last five days of the MDS assessment. The previous MDS identified the resident used only as needed pain medication. According to the 11/15/13 MDS, the resident had frequent pain and the previous MDS noted pain to be rare. The current MDS assessment revealed the resident's shoulder pain made it harder to sleep, and limited day to day activities when before the pain did not make it harder to sleep and the pain did not limit day to day activities. A numeric scale had not been used for this assessment, but documented "moderate" for pain intensity. On 2/5/14 at approximately 2:45 p.m., Resident #1 observed in room sitting upright in the wheelchair watching television. During observation and interview, the resident stated the left shoulder pain became worse about a month and a half ago and she is not able to use her arm like before. Review of the record revealed the physician saw the resident on 11/13/13 and documented, in part, the resident's left should is hurting, and has decreased range of motion. On 11/13/13 the physician ordered [MEDICATION NAME] (pain medication) to be given routinely in addition to the prn [MEDICATION NAME] and prn Tylenol, noting that the resident did not take the [MEDICATION NAME] as much and may be helpful if taken more regularly. The physician's plan for this visit directed staff to get a physical therapy evaluation for the left shoulder and try having the [MEDICATION NAME] scheduled at bedtime, and as needed every six hours. Review of the faxed document received by this complaint investigator on 2/14/14, revealed a physician's orders [REDACTED]." On 2/5/14 at 1:45 p.m., during an interview, the resident care manager (Staff B) stated when orders for physical therapy are written, the order is noted by nursing, and given to therapy who will communicate findings directly with the physician. After reviewing the resident's record, Staff B confirmed the order was noted by nursing on 11/13/13 and given to therapy. Review of the record revealed therapy did a rehab "screen" versus an "evaluation" after receiving the physician's orders [REDACTED]. Review of the record revealed the resident had a "rehabilitation screen" dated 11/15/13, which documented, "patient was screened this date for shoulder pain noted by nursing. Patient is able to use (b) bilateral (UE) upper extremities evenly noted throughout (ADL) activities of daily living. Patient has been seen in the past for shoulder pain and is noted long standing per chart. No treatment warranted at this time. Patient reports she does well with pain medication, will re-screen in future if patient continues or decreased (fxnal) functional use is noted." On 2/5/13 at 12:59 p.m., during an interview, the rehab director (Staff A) reported nursing provides therapy with physician orders [REDACTED]. Staff A stated a screen does not require a physician's orders [REDACTED]. When asked, Staff A stated if a physician orders [REDACTED]. During a review of the record with the complaint investigator, Staff A confirmed a physical therapy evaluation had not been done, and stated the resident had a rehabilitation screen, and unable to find documentation that the physician had been notified that a screen was done versus an evaluation. When asked, Staff A stated she does not keep a copy of physician orders [REDACTED]. Review of the record revealed the physician saw the resident on 1/15/14 for a two month follow up and documented in part, the resident's hands are numb-the resident will drop things, and the left shoulder is still hurting a lot. I ordered physical therapy for the left shoulder, and never heard from the therapist, so not sure if the resident had that. The physician's plan for this visit directed staff to get an x-ray, and consider an orthopedic referral for possible joint injection and continue current pain medication for ongoing shoulder pain, possible arthritis and possible frozen shoulder. An x-ray report dated 1/16/14, revealed, "There is a [MEDICAL CONDITION] humeral neck with impaction, and angulation, which appears to be chronic." The orthopedic physician saw the resident on 1/20/14 with recommended orders for steroid injections, and physical therapy. Review of the record revealed a faxed note dated 1/21/14 to the primary care physician (69 days after the physical therapy evaluation had been ordered), which documented, "physical therapy did a screen on the resident versus an evaluation prior to possibly picking resident up if needed. Per screen resident was at her baseline, range of motion/shoulder pain since admission and felt not necessary to treat." The primary care physician replied to the fax via a faxed note dated 1/21/14, "I had been wondering why it wasn't done like I requested. Now ortho has requested physical therapy as well, so is it going to be done like I wanted in the first place?" On 2/5/14 at approximately 1:45 p.m., when asked, the resident care manager (Staff B), stated nursing is responsible to ensure orders are carried out, and confirmed there is no current system in place for nursing to ensure therapy implements the physician's orders [REDACTED].