Every finding on record at Avamere Rehabilitation of Burien

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a process to determine if a nursing home resident had mental health/intellectual disability needs which required further assessment and/or treatment) Level 2 referrals were accurate and submitted timely for 3 of 6 residents (Residents 4, 60, & 44) reviewed for PASRRs. This failure placed residents at risk of not receiving timely and necessary services to meet their mental health needs.Findings included.<Facility Policy>According to the facility's 08/2025 PASRR Completion Policy, the facility would make sure all admissions had the appropriate PASRR completed. <Resident 4> According to the 06/16/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 4 admitted to the facility on [DATE] with diagnoses of depression, bipolar, and post-traumatic stress disorder. The MDS showed Resident 4 received antidepressant medications during the assessment period. Review of Resident 4's health records showed a PASRR Level 1 was completed on 12/11/2025. The PASRR Level 1 showed Resident 4 had Serious Mental Illness (SMI) indicators, but a Level 2 PASRR evaluation was not indicated at that time due to exempted hospital discharge, and a Level 2 was to be completed if the discharge did not occur within 30 days. In an interview on 06/25/2026 at 1:50 PM, Staff C (Social Services Director) reviewed Resident 4's 12/11/2025 PASRR Level 1 and stated an exempted hospital discharge was when a resident was expected to stay in the facility for less than 30 days. Staff C stated Resident 4 should have had the PASRR Level 1 redone and referred for a Level 2 for SMI after 30 days, but they did not. Staff C stated Level 2 PASRR evaluations were important to identify mental health issues, provide recommendations, and obtain resources to assist the residents with their mental health needs while a resident at the facility and after discharge. <Resident 60> According to the 03/12/2026 admission MDS, Resident 60 admitted to the facility on [DATE] with multiple diagnoses including depression and post-traumatic stress disorder. The MDS showed Resident 60 received antidepressant medications during the assessment period. In an interview on 06/22/2026 at 9:27 AM, Resident 60 stated that they had times of being super depressed and had severe anxiety issues. Review of Resident 60's health records showed a PASRR Level 1 was completed on 03/04/2026. The PASSR Level 1 showed Resident 60 had SMI indicators, but a Level 2 PASSR evaluation was not indicated at that time due to an exempted hospital discharge, likely to require fewer than 30 days of nursing facility services. A Level 2 evaluation was to be completed if a scheduled discharge did not occur. Review of Resident 60's health records showed a PASRR Level 1 was completed on 06/19/2026, 107 days after admission to the facility, and indicated a Level 2 evaluation referral was required for SMI. In an interview on 06/24/2026 at 11:33 AM, Staff C stated that Resident 60 had SMIs and originally had an exempted hospital discharge because they were expected to be in the facility less than 30 days. Staff C stated the facility recently submitted a PASRR Level 2 evaluation referral, and the referral should have been submitted 30 days after admission, but it was done late. <Resident 44> According to the 06/02/2026 admission MDS, Resident 44 was admitted to the facility on [DATE] with diagnoses of anxiety disorder and hip fracture. The MDS showed Resident 44 received antidepressant medications during the assessment period. Review of Resident 44's records showed a PASRR Level 1 was completed on 06/15/2026, staff checked boxes indicating Resident 44 had anxiety disorder, mood disorder, and post-traumatic stress disorder as SMIs, and a Level 2 PASRR referral was required. In an interview on 06/25/2026 at 12:01 PM, Staff C stated it was very important to have an accurate PASRR Level 1 and 2. Staff C reviewed Resident 44's Level 1 PASRR and stated Resident 44's SMIs were not checked accurately. Staff C stated staff should have reviewed Resident 44's record and completed the PASRR Level 1 form accurately to provide appropriate services for Resident 44, but they did not. Reference: WAC 388-97-1915 (1).

Based on observation, interview, and record review, the facility failed to ensure expired medications, supplies, and nutritional supplements were removed from 1 of 1 medication rooms (Central Medication Storage Room). This failure placed residents at risk of receiving expired medications or other products, ineffective treatment, and diminished quality of life.Findings included .<Facility Policy>According to the facility's revised 11/2020 Storage of Medications policy, medications and biologicals were to be stored in a safe, secure, and orderly manner, and expired medications were to be returned to the dispensing pharmacy or destroyed.<Central Medication Storage Room> In an observation on 06/22/2026 at 8:24 AM, the following expired items and medications were found stored in the Central Medication Storage Room:A bottle of skin cleanser with an expiration date of 11/2024A bottle of vitamins with an expiration date of 04/2026Four boxes of skin barrier wafers (dressings used for an abdominal surgical opening to the colon, to protect surrounding skin and attach a collection bag) with expiration dates of 01/01/2026 and 06/01/2026Eight bottles of liquid nutritional supplements with expiration dates of 04/2026.In an interview on 06/22/2026 at 9:25 AM, Staff H (Registered Nurse) stated there should not be expired medications or products in the medication storage room because residents could receive expired medications, which could affect resident safety.In an interview on 06/26/2026 at 2:42 PM, Staff B (Director of Nursing) stated that expired medications should not be stored in the medication room because they could be accidentally administered to the residents and may result in adverse effects. REFERENCE: WAC 388-97-1300(2).

Based on observation, interview, and record review, the facility failed to ensure their medication error rate was less than five percent (%). Failure of 1 of 4 nurses (Staff F - Registered Nurse) to administer 6 of 31 medications at the scheduled time for 1 of 4 residents (Resident 31) observed during medication pass resulted in a medication error rate of 19%. This failure placed residents at risk for adverse side effects and/or reduced effectiveness by not receiving medications as prescribed.Findings included .<Facility Policy>Review of the facility's Medication and Treatment Orders policy, revised 11/2025, showed medications should be administered upon written order of an authorized prescriber and required staff to follow physician medication orders as written to ensure safe and effective medication administration.<Resident 31>Observation on 06/26/2026 at 7:18 AM showed Staff F prepared medications for Resident 31 that included the following:A medication to treat enlarged prostateA medication to treat depressionA medication to treat high blood pressureA medication to lower blood sugarA supplement to treat low vitamin B levelA vitaminIn an observation and interview on 06/26/2026 at 7:31 AM, Staff F entered Resident 31's room and administered the listed medications to Resident 31. Staff F stated they administered Resident 31's medications early so they would not be late administering medications to other residents.Review of Resident 31's Order Summary, dated 05/08/2026, showed physician orders directed staff to administer the listed medications every morning at 9:00 AM.In an interview on 06/26/2026 at 7:49 AM, Staff B (Director of Nursing) stated they expected nursing staff to follow physician's order as written. Staff B stated that staff nurses had one hour before and one hour after the prescribed time to administer medications. Staff B stated medications might work differently for each resident and administering them at the prescribed time was important to ensure their therapeutic effects. REFERENCE: WAC 388-97-1060(3)(k)(ii).

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a process to determine if a nursing home resident had mental health/intellectual disability needs which required further assessment and/or treatment) Level 2 referrals were updated timely with new mental health diagnoses for 2 of 6 residents (Residents 6 & 10) reviewed for PASRRs. This failure placed residents at risk of not receiving timely and necessary services to meet their mental health needs.Findings included.<Facility Policy>According to the facility's 08/2025 PASRR Completion Policy, the facility would make sure all admissions had the appropriate PASRR completed. <Resident 6> According to the 02/02/2026 Annual Minimum Data Set (MDS – an assessment tool), Resident 6 admitted to the facility on [DATE], was able to understand and be understood, and had active diagnoses including anxiety disorder, depression, and bipolar disorder (a mental health condition that causes extreme, cyclical shifts in mood, energy, and activity levels). Review of a Level 1 PASRR completed by hospital staff, dated 08/07/2019, showed Resident 6 had bipolar disorder, and did not require a PASSR Level 2 evaluation due to being stable on their medications and not showing indicators of Serious Mental Illness (SMI). Review of an 11/07/2024 progress note showed a psychiatric provider determined Resident 6 met criteria for a diagnosis of anxiety disorder. Review of Resident 6's medical records showed a diagnosis of depression was added on 04/24/2024 and a diagnosis of anxiety disorder was added on 06/05/2025. Review of Resident 6's records showed there was no updated PASSR Level 1 or PASSR Level 2 referral to include new SMI diagnoses. In an interview on 06/26/2026 at 8:13 AM, Staff C (Social Services Director) stated that they should have submitted a new PASRR Level 2 referral with Resident 6's new SMI diagnoses, but they did not. <Resident 10> According to the 06/03/2026 Annual MDS, Resident 10 had active diagnoses including anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder. The MDS showed Resident 10 received antipsychotic medication during the assessment period. Review of the revised 04/05/2024 Mood/behavior Care Plan (CP) showed Resident 10 had multiple behaviors related to diagnoses of bipolar disorder, anxiety disorder, and depression. The CP directed staff to notify social services for any change in Resident 10's behaviors. Review of Level 2 PASRR completed on 01/19/2016, showed Resident 10 had Major Neurocognitive disorder and posttraumatic stress, and did not show they had anxiety disorder, bipolar disorder, or depression checked as SMIs. Review of a contracted Mental health provider's 05/07/2026 progress note showed Resident 10 had diagnosis of anxiety disorder, bipolar disorder, and post-traumatic stress disorder. Review of Resident 10's record showed no updated PASRR level 2 form with current SMIs. In an interview on 06/25/2026 at 12:09 PM, Staff C reviewed Resident 10's record and stated they should have updated Resident 10's PASRR Level 2 with Resident 10's new SMI diagnoses, but they did not. REFERENCE: WAC 388-97-1975(7)(9).

Based on interviews, and record reviews, the facility failed to report and conduct thorough investigations to identify the root cause(s) and contributing factors for an accusation of staff to resident for 1 of 3 sample residents (Resident 4) reviewed for grievances. Facility failure to complete a thorough investigation placed residents at risk for potential abuse/neglect, negative health outcomes, and poor quality of life.Findings included.<Policy>According to the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, residents had the right to be free from abuse, including verbal and mental abuse. The policy showed the facility would protect residents from abuse by facility staff. The facility would maintain a culture of compassion and caring for all residents. The facility would identify and investigate any allegations of abuse and/or mistreatment. The policy showed the facility would investigate and report all allegations within the state required timeframe and the facility would protect all residents from any harm during the investigation.<Resident 4>According to the 06/12/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 4 had no memory impairment. The assessment showed Resident 4's preferred language for communication was English. The MDS showed Resident 4 exhibited no physical, verbal, or other behaviors toward others. The MDS showed Resident 4 had diagnoses of depression and post-traumatic stress disorder.In an interview on 06/22/2026 at 9:30 AM Resident 4 stated Staff E (Certified Nursing Assistant-CNA) displayed an attitude of not wanting to help residents with their needs. Resident 4 stated Staff E would roll their eyes when they asked for assistance. Resident 4 stated a couple of months ago Staff E spoke in a language other than English to another CNA and pointed and laughed at them. Resident 4 stated they reported to management but did not hear back regarding a resolution. Resident 4 stated Staff E had worked with them since the reported incident and continued to act like they did not want to do any work, and Staff E was rude, acting irritated, when Resident 4 asked Staff E for help with anything.Review of the facilities grievance logs showed Resident 4 reported Staff E on 04/21/2026 and again on 06/11/2026 for mistreatment. The facility provided investigation documents for both grievances which showed on 04/21/2026 Resident 4 had reported Staff E for poor customer service and on 06/11/2026 Staff E was being rude. The investigations did not show the accusations were not reported to state agency or include statements from Resident 4, Staff E, or any other residents. The investigations did not show Staff E was removed from caring for residents at the facility pending investigation or any disciplinary actions were taken.In an interview on 06/25/2026 at 1:13 PM, an anonymous employee stated they witnessed staff speaking in languages other than English inside the facility in resident care areas and at the nurse's station. The anonymous employee stated they were expected to speak English upon entering the facility and it was important because the facility was the resident's home and they understand English.In an interview on 06/26/2026 at 8:59 AM Staff A (Administrator) stated they provided all supporting documents for the 04/21/2026 and 06/11/2026 grievances. Staff A stated they did not have statements from Resident 4, Staff E, or other residents regarding the two grievances. Staff A stated there was no documentation of disciplinary actions for Staff E related to the incidents of mistreatment. Staff A stated they expected staff to speak in English upon entering the facility. Staff A stated they had in-serviced all staff in March 2026 to ensure staff were speaking English. Staff A stated it was important to speak English in the facility for resident's rights. Staff A stated they expected staff to interview Resident 4, Staff E, and other residents as part of a thorough investigation, but they did not.In an interview on 06/26/2026 at 10:02 AM, Staff C (Social Service Director) stated they should have obtained a statement from Resident 4, Staff E, and other residents regarding the 04/21/2026 and 06/11/2026 grievances but did not. Staff C stated all staff were mandatory reporters and were required to report allegations of mistreatment and verbal/mental abuse. Staff C stated it was important to conduct a thorough investigation when residents reported mistreatment to ensure all residents' safety.In an interview on 06/26/2026 at 11:10 AM Staff C stated, they dropped the ball on investigating Resident 4's grievances on 04/21/2026 and 06/11/2026. Staff C stated they expected staff to report allegations of abuse/neglect within two hours.In an interview on 06/26/2026 at 12:16 PM Staff D (Licensed Practical Nurse) stated they expected staff to speak in English in the facility. Staff D stated they had received complaints in the past from residents of staff speaking in languages other than English and they reported it to management. Staff D stated they expected staff to speak English unless in break room or off duty outside of the facility.Reference: WAC 388-97-0640(6)(a)(b)(c).

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintained and promoted resident rights and privacy for 1of 3 sample residents (Resident 56) reviewed during wound care. The failure to provide adequate privacy during the provision of care placed residents at risk for a diminished sense of self-worth and well-being. Findings included . <Facility Policy>According to the facility policy titled, Confidentiality of Information and Personal Privacy, revised February 2021, the facility would protect and safeguard resident confidentiality and personal privacy. The facility would strive to protect the resident's privacy regarding their accommodations, medical treatment, personal care and visits.<Resident 56>According to a 05/29/2026 Medicare 5 Day Minimum Data Set (an assessment tool), Resident 56 had a functional limitation to their left lower leg related to an amputation and was dependent on staff for toileting, personal hygiene, and rolling side-to-side in bed.Observation on 06/22/2026 at 11:02 AM showed Resident 56 was lying in their bed in their room. The window next to Resident 56's bed had vertical blinds with multiple missing slats, creating gaps in the window covering.Observation in Resident 56's room on 06/25/2026 at 10:39 AM showed Staff F (Registered Nurse) and Staff L (Licensed Practical Nurse - Wound Nurse) assisted Resident 56 to a side-lying position to assess and apply treatment to wounds on Resident 56's buttocks area. Resident 56's backside was exposed and facing the window. The observation showed another staff member visible through the gaps in the window blinds, walking back and forth outside the building in the parking lot.In an interview on 06/25/2026 at 10:58 AM, Staff F and Staff L stated they knew about missing slats in the window blinds and stated the facility was supposed to work on them, but they had not.In an interview on 06/25/2026 at 11:29 AM, Resident 56 stated the window blinds had been broken for a while, and no one had fixed them yet. Resident 56 stated they did not want anyone from outside to see them while they had no clothes on.In an interview on 06/26/2026 at 10:18 AM, Staff B (Director of Nursing) stated the privacy and dignity of residents was important to protect residents' rights. Staff B stated privacy should be provided during wound care, and the missing blind slats should be replaced to provide adequate privacy during resident care. REFERENCE: WAC 388-97-0180(1-4).

Based on observation, interview, and record review, the facility failed to ensure staff sanitize devices after use in accordance with Enhanced Barrier Precautions (EBP - infection control measure used to reduce the spread of multidrug-resistant organisms) for 2 of 3 sample residents (Residents 5 and 90) reviewed for skin conditions and failed to follow physician orders for 1 of 1 sample resident (Resident 14) reviewed for Transmission-Based Precautions (TBP) related to bed bugs. These failures placed residents at risk for the development and transmission of communicable diseases and an unsanitary environment.Findings included .<Facility Policy>According to the facility policy titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised February 2026, reusable items would be cleaned and disinfected or sterilized between residents included durable medical equipment, blood pressure cuff and thermometer to decrease risk for spreading the infection. The policy showed single resident use items would be used by only one resident and disinfected according to manufacturer's instructions between uses.According to the October 2025 facility policy titled, Isolation - Initiating Transmission-Based Precautions, when TBP was implemented, including Contact Precautions, the Infection Preventionist (IP) or designee would clearly identify the Personal Protective Equipment (PPE) to be used, explain to the resident and visitors the use of PPE, determine the appropriate notification on the room entrance door to inform staff and visitors of TBP, and ensure PPE was maintained outside the resident's room. <Resident 5> According to the 05/17/2026 admission Minimum Data Set (MDS - an assessment tool), Resident 5 was admitted to the facility with multiple pressure ulcers. Review of Resident 5's June 2026 Physician Orders showed a 05/11/2026 EBP order directed staff to wear Personal Protective Equipment (PPE) when performing high contact activities and to follow signage posted on Resident 5's door. Observation on 06/22/2026 at 9:32 AM showed an EBP sign posted on Resident 5's door with instructions for staff to follow before entering the room. Observation on 06/24/2026 at 8:29 AM showed Staff G (Licensed Practical Nurse) entered Resident 5's room, checked their blood pressure (BP) using a BP cuff, came outside, performed hand hygiene, put the BP cuff on top of the medication cart without sanitizing it, and started preparing medications for other residents. In an interview on 06/24/2026 at 8:31 AM, Staff G stated they should sanitize the BP cuff, but they forgot to clean it. Staff G stated it was important to clean the device after using it with residents on EBP to prevent spreading infection to other residents. In an interview on 06/25/2026 at 9:07 AM, Staff J (IP/Staff Development Coordinator) stated their expectation was that staff follow the signs posted outside resident's rooms to wear PPE before entering the room. Staff J stated staff should have sanitized the equipment they used for Resident 5 before leaving the room, but they did not. Staff J stated it was very important for staff to follow the instructions on the signs to prevent spreading the infection to other residents. <Resident 90> According to the 06/22/2026 admission MDS, Resident 90 admitted to the facility with a wound infection and a multidrug-resistant organism. Review of Resident 90's health records showed a 06/19/2026 physician order directing staff to implement EBP, wear appropriate PPE when performing high contact activities, and follow the precaution signage posted outside Resident 90's room door every shift. Observation on 06/22/2026 at 9:34 AM showed EBP signage posted on Resident 90's door instructing staff to follow EBP before entering the resident's room. Observation on 06/22/2026 at 9:36 AM showed Staff G entered Resident 90's room and checked their BP using a reusable BP cuff. After completing Resident 90's BP check, Staff G returned to the medication cart without cleaning or disinfecting the BP cuff. Staff G placed the BP cuff into their uniform pocket and continued administering medications to other residents. <Resident 14> Review of Resident 14's health records showed a 06/18/2026 physician order to maintain Contact Precautions for seven days for exposure to bed bugs. In an observation and interview on 06/22/2026 at 12:06 PM, Resident 14 stated staff took their electric wheelchair out of their room and placed it outside, but Resident 14 did not know why. Resident 14 had no TBP signage posted outside their room. Observations on 06/22/2026 at 12:06 PM, 06/23/2026 at 12:08 PM, and 06/24/2026 at 8:12 AM showed no TBP signage posted outside Resident 14's room. In an interview on 06/24/2026 at 8:18 AM, Staff I (Resident Care Manager 2) stated Resident 14 had an electric wheelchair brought into the facility with visible bed bugs. Staff I stated they removed the wheelchair and fumigated the room. Staff I reviewed Resident 14's physician orders and stated they should be on Contact Precautions per order, have a Contact Precaution sign posted outside of their room instructing all who entered the room to wear PPE and remove prior to exiting, and have a stocked PPE cart outside of their room. In an interview on 06/24/2026 at 8:23 AM Staff J stated they expected staff to place a Contact Precaution sign and PPE cart outside of Resident 14's room upon obtaining the physician order to maintain Contact Precautions but they did not. Staff J stated they expected staff to follow Contact Precautions according to physician's orders. REFERENCE: WAC 388-97-1320(1)(a)(2)(b)(5)(c).

Based on observation, interview, and record review the facility failed to ensure 3 (Resident 21, 24, & 64) of 4 residents reviewed for dental services received the care and services they required to preserve their dental health. This failure placed the residents at risk for unmet dental needs and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 2001 Dental Services policy, the facility provided routine and emergency dental services to residents via a contract agreement with a licensed dentist, referral to a resident's personal dentist, referral to a community dentist, or other dental providers. The policy showed the facility's social services department would assist residents with dental appointments. <Resident 21> According to the 04/14/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 21 had clear speech with no memory loss, was understood, and able to understand others. In an interview on 05/13/2025 at 2:23 PM, Resident 21 stated they had some broken teeth for quite a while, recently with occasional pain. Resident 21 stated they were finally scheduled for a dental appointment on 05/14/2025. Record review showed a 02/03/2025 in-house dental consult for Resident 21 with recommendations for a referral for x-rays, evaluation, extractions, and upper and lower dentures. This consult was acknowledged by staff and uploaded into Resident 21's records on 03/07/2025. No further documentation was found regarding staff following up on the dental referral until 04/14/2025, over two months after the consult. In an interview on 05/19/2025 at 12:00 PM, Staff F (Social Services Director) stated it was their expectation follow up for dental referrals would occur as soon as possible to avoid worsening issues. Staff F stated they would expect staff to document when the referrals were made and attempt to schedule appointments promptly. Staff F reviewed Resident 21's records and was unable to locate documentation to indicate why the dental referral was not completed timely. <Resident 24> According to a 01/02/2025 Significant Change MDS, Resident 24 had clear speech with no memory loss, was understood, and able to understand others. This MDS showed staff assessed Resident 24 with obvious or likely decayed or broken natural teeth. Review of a 01/08/2025 dental Care Area Assessment (CAA) staff documented Resident 24 had broken, missing teeth, and required assistance with oral care needs. Staff documented they would proceed to the CP to ensure plans were in place to decrease risks. Review of a revised 04/09/2025 dental health CP showed directions to staff from 09/10/2024 to coordinate arrangements for dental care, transportation as needed/as ordered. In an interview on 05/12/2025 at 9:10 AM, Resident 24 stated they had one progressively worsening tooth, broken teeth, and missing teeth. Resident 24 stated they needed to go to the dentist for a long time. Review of a 10/28/2024 progress note showed Resident 24 was scheduled for an 11/18/2024 consult to address their outstanding dental concerns. Record review showed an 11/18/2024 in-house dental consult for Resident 24 with recommendations for a referral for x-rays and evaluation, and a note indicating the resident would like their teeth evaluated. The consult was uploaded to Resident 24's records on 12/01/2024. No further documentation was found regarding the dental referral until 04/08/2025, almost five months later, when Resident 24 was seen again by the in-house dentist with the referral requested a second time. In an interview on 05/19/2025 at 12:00 PM, Staff F stated their department had some turn-over with staff and some appointment referrals were not followed up on. Staff F reviewed Resident 24's records and stated their dental referral was not followed up timely. <Resident 64> According to a 07/11/2024 admission MDS, staff assessed Resident 64 with obvious or likely decayed or broken natural teeth. Review of a 07/18/2024 dental CAA showed staff documented Resident 64 had broken, missing teeth, and was at risk for a decline in oral health. Staff documented they would proceed to the CP to ensure plans were in place to decrease the risk. Review of a revised 07/24/2024 oral health CP showed directions to staff to coordinate arrangements for dental care and transportation as needed/as ordered. Record review showed a 11/18/2024 in-house dental consult for Resident 64 with recommendations for a referral for x-rays, evaluation, extractions due to broken, loose, and rotting teeth. Review of the provider progress notes showed on 12/09/2024, 01/02/2025, 01/12/2025, and 02/23/2025, the provider wrote directions for a dental referral for Resident 64. Review of a progress note on 05/07/2025 showed staff documented Resident 64 handed half of a broken tooth to staff during lunch. Record review showed no documentation the dental referral for x-rays, evaluations, and extractions for Resident 64 were followed up on by staff until staff followed up on the broken tooth on 05/08/2025, almost six months later. In an interpreted interview on 05/13/2025 at 1:52 PM, Resident 64 stated they had a broken tooth and had a hard time eating. In an interview on 05/15/2025 at 12:31 PM, Staff T (Medical Records Assistant) stated they were in that position since December 2024 and were responsible for making resident information packets when residents were scheduled for appointments. Staff T stated they did not hear of any dental concerns or appointments scheduled for Resident 64. In an interview on 05/19/2025 at 12:00 PM, Staff F stated in November 2024 a different staff member was assigned to follow up on appointments and things were missed. Staff F stated it was their expectation the dental referral for Resident 64 should have been but was not completed timely. REFERENCE: WAC 388-97-1060(1), (3)(j)(vii). .

<Resident 78> According to the [DATE] admission MDS Resident 78 had intact memory and admitted to the facility on [DATE]. Record review showed no AD documentation in Resident 78's chart. There was no documentation to demonstrate the facility offered Resident 78 assistance to formulate an AD. In an interview on [DATE] at 12:43 PM Staff F stated there should be a signed acknowledgement form on file showing Resident 78 was offered AD formulation assistance. Staff F stated they would look into the matter and provide whatever documentation they found. No further documentation was provided. REFERENCE: WAC 388-97-0280(3)(c)(i-ii). Based on interview and record review the facility failed to obtain and/or renew guardianship papers, and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 4 of 7 residents (Residents 42, 78, 3, & 27) reviewed for guardianship/advance directives. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care. Findings included . <Facility Policy> According to the facility's 2001 AD policy, when a resident admitted the facility would inquire as to their AD status. The policy showed if the resident did not have an AD, the facility would offer assistance to formulate one. If the resident had one or more ADs, the facility would obtain copies to place in the resident's record. The policy did not address the maintenance of guardianship papers. <Resident 42> According to a [DATE] Significant Change Minimum Data Set (MDS - an assessment tool), Resident 42 had severe memory impairment and multiple medically complex diagnoses including a stroke, dementia (a progressive impairment of memory and abstract thinking), and end-stage kidney disease. This MDS showed Resident 42 had a life expectancy of less than six months and required hospice (specialized care for individuals with a life expectancy of six months or less) services. Review of Resident 42's revised [DATE] AD Care Plan (CP) showed the resident had a legal guardian and indicated Resident 42 did not have the capacity for decision making regarding their healthcare. This CP gave directions to staff to review the ADs with the resident/family and legal guardian quarterly and as needed. Record review showed [DATE] guardianship court papers on file. These papers indicated they were only effective until [DATE], almost one year prior. No further guardianship paperwork was present in Resident 42's records. In an interview on [DATE] at 11:00 AM, Staff F (Social Services Director) stated it was their expectation guardianship papers were uploaded timely and not expired. Staff F stated it was important for ADs to be in place, in case something happened, and a resident could no longer make decisions on their own behalf. Staff F reviewed Resident 42's records and stated their guardianship papers were expired. <Resident 3> According to the [DATE] Quarterly MDS Resident 3 had severely impaired memory. Review of Resident 3's record showed the provider signed a Capacity for Medical Decision form on [DATE] indicating Resident 3 was not capable of making their own medical decisions. Review of Resident 3's record showed an [DATE] letter of guardianship. This letter showed it was effective until [DATE]. There was no current guardianship documentation. In an interview on [DATE] at 8:09 AM, Staff F reviewed Resident 3's record and stated their guardianship papers were expired. Staff F stated the facility did not have current guardianship papers on file for Resident 3. <Resident 27> According to the [DATE] Annual MDS Resident 27 had impaired memory. Review of Resident 27's record showed a provider signed a Capacity for Medical Decision form on [DATE] showing Resident 27 was not capable of making their own medical decisions. Review of the revised [DATE] AD CP showed Resident 27 did not have the capacity for decision making. This CP showed Resident 27's legal guardianship documentation expired and instructed staff to keep copies of guardianship documents in Resident 27's record. Review of Resident 27's record showed a [DATE] letter of guardianship that expired on [DATE]. Review of Resident 27's 2024 and 2025 clinical record showed no current guardianship paperwork. In an interview on [DATE] at 8:15 AM Staff F stated they did not have any current guardian paperwork for Resident 27.

Based on record review and interview, the facility failed to provide required liability notices for 1 of 3 residents (Resident 83) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage (NOMNC - a notification informing Medicare beneficiaries that their covered services will be terminated and provides information on their appeal rights) before Resident 83 was discharged from the facility, placed the resident at risk for not fully understanding their Medicare benefits and appeal rights. Findings included . <Resident 83> Record review showed Resident 83 was admitted to the facility on [DATE] and was discharged home on [DATE]. Resident 83's record showed the facility did not document they provided a NOMNC letter to Resident 83. Resident 83's record showed the facility provided a Nursing Home Transfer or Discharge notice to the resident on 01/25/2025. This notice showed the reason for the discharge was Resident 83's health was improved and they no longer needed the services provided by the facility. The 01/26/2025 Nursing progress note showed the facility's social service department arranged for Resident 83 to discharge home with home health, including physical and occupational therapy. The nursing note showed the facility provided medications and discharge papers to Resident 83 to go home with. There was no documentation showing that the facility provided a NOMNC letter to the resident. In an interview on 05/15/2025 at 2:59 PM, Staff F (Social Services Director) reviewed Resident 83's record and stated they did not provide a NOMNC letter to Resident 83. Staff F confirmed Resident 83 did not leave the facility against medical advice. Resident 83 was not available for the interview at this time. Reference: WAC 388-97-0300(1)(e),(5),(6).

Based on observation and interview, the facility failed to maintain a homelike environment for 5 of 5 units. The failure to ensure residents' windows were free of missing blind panels, resident rooms were free of wall scrapes, and handrails in hallways were in good repair left residents at risk for a diminished sense of privacy, and a less than homelike environment. Findings included . <Handrails> Observation of the facility's hallways on 05/13/2025 from 12:51 PM through 12:54 PM showed the handrail in the central hallway was missing the end piece. This left a sharp edge on the rail and not looked homelike rail. The handrail outside room [ROOM NUMBER] and room [ROOM NUMBER] were also missing their end pieces, were with sharp edges and did not look homelike handrails . <Wall Gouges> Observation on 05/12/2025 at 8:47 AM showed the wall behind the resident's bed in room [ROOM NUMBER]-2 had deep gouges that exposed drywall. Observation on 05/13/2025 at 9:52 AM showed the walls of room [ROOM NUMBER]-2 were scuffed, with gouges that exposed drywall. Observation of room [ROOM NUMBER]-2 on 05/13/2025 at 1:52 PM showed the wall by the window had significant gouging that removed paint and exposed drywall. Observation of room [ROOM NUMBER]-2 on 05/13/2025 12:54 PM showed several areas of the wall were not painted, including around the window. Observation of room [ROOM NUMBER]-2 on 05/13/2025 at 12:39 PM showed the wall was scuffed under window, leaving exposed drywall. The material cover of the chair in the room was torn. <Blinds> In an interview on 05/13/2025 at 12:45 PM Resident 74 expressed frustration the blinds of their window were missing vertical panels. Resident 74 stated this affected their sense of privacy. Resident 74's blinds were noted to miss several panels. Observations on 05/19/2025 from 9:21 AM to 9:28 AM showed vertical blind panels were missing in Rooms 21, 25, 48, and 50. In room [ROOM NUMBER] one vertical panel was broken. In room [ROOM NUMBER] one vertical panel was 3-4 inches shorter than the others and did not look homelike. <Interview> During environmental round on 05/23/2025 at 3:04 PM, Staff H (Maintenance Director) stated it was important to maintain a homelike environment for the facility's residents. Staff H stated keeping the facility clean and in good repair was important and confirmed the handrails, walls, and blinds needed to be repaired. REFERENCE: WAC 388-97-0880. .

Based on observation, interview, and record review the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled residents (Resident 44) reviewed for grievances. This failure placed residents at risk for emotional distress and a diminished quality of life. Findings included . <Facility Policy> According to the facility's January 2017 Grievance Policy, informal concerns should be forwarded verbally to the Grievance Official or a department supervisor. This person should then contact the resident with the concern, and the concerned resident had the right to obtain a written decision on the grievance if they chose. This policy showed immediate action would be taken to prevent any potential violations of resident rights. <Resident 44> According to the 02/25/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 44 had clear speech and was able to make themselves understood. The MDS showed Resident 44 had a moderate memory impairment and demonstrated no behavior. In an interview on 05/14/2025 at 12:51 PM Resident 44 stated they were having a bad day. Resident 44 stated they told their caregiver someone took their personal gallon bottle of hand soap and replaced the soap with a pack of wipes only. Resident 44 stated they did not feel clean with using the wipes for hygiene and was upset. Resident 44 stated someone took their soap a couple of days ago and no staff offered to help them fill out a grievance form. No gallon bottle of hand soap was observed in the room at this time. During observations on 05/14/2025 at 1:05 PM, Resident 44 was heard reporting their missing soap concerns to Staff P (Licensed Practical Nurse), who told the resident they could offer them wipes. Resident 44 stated they wanted the soap to wash their hands and stated for two days I have had dirty hands. Resident 44 stated they wanted to know who took the soap. In an interview on 05/16/2025 at 10:41 AM Resident 44 stated they were irritated because staff now took their washcloth, and they still did not hear back regarding their hand soap. Resident 44 stated a family member bought the soap and would be looking for it when they visited. In an interview on 05/16/2025 at 11:00 AM, Staff F (Social Services Director) stated paper grievances were stored in a binder in the administrator's office. Staff F stated if they heard of a resident grievance (including a missing item) they completed a form and took it to the administrator. Staff F said if the issue was not resolved the facility needed to replace the item. Staff F stated they expected a grievance form to be completed by facility staff if a resident raised a concern verbally. Staff F stated missing property should be resolved timely. In an interview on 05/19/2025 at 12:36 PM Resident 44 stated their soap was still not returned to them and they had not received any updates. In an interview on 05/19/2025 at 1:08 PM Staff D (Resident Care Manager) stated when staff learned of a missing item for a resident they should immediately start a grievance form. Staff D stated they were unaware of Resident 44's missing bottle of hand soap. In an interview on 05/19/2025 at 1:40 PM Staff P stated when a resident reported a missing item, they verify with the resident what was missing, when it was last seen, and inform the laundry department, they let the Social Services department know and complete a grievance form. Staff P stated they knew a bottle of sanitizer was removed from Resident 44's room, but they were unsure by whom. Staff P stated they explained to Resident 44 they could not keep sanitizer in their room, offered wipes as an alternative, and did not know Resident 44 had further concerns. Staff P stated they regarded this a safety issue rather than a grievance, so they did not process it as a grievance. In an interview on 05/19/2025 at 1:4 PM Staff D stated they would expect a nurse to begin the grievance process when a resident complained of a missing item. Review of an updated grievance log on 05/19/2025 showed no grievance was documented for Resident 44. In an interview on 05/19/2025 at 2:37 PM, Staff A (Administrator) stated they were the facility's Grievance Officer. Staff A stated their expectation when a resident brought forward a concern or grievance was for a resolution within five days. Staff A stated they expected staff to report to their manager when they learned of a grievance and offer to start a grievance form. If the resident stated a formal grievance process was not necessary, that would be documented. Staff A stated it was important to resolve grievances timely so the facility felt homelike to its residents. REFERENCE: WAC 388-97-0460. .

Based on observation, record review, and interview the facility failed to ensure residents were offered the opportunity to participate in a care conference for 2 (Residents 24 & 183) of 21 sample residents whose Care Plans (CPs) were reviewed, and failed to ensure resident CPs were updated as needed for 2 (Residents 22 & 48) of 21 sample residents. These failures placed residents at risk for unmet care needs, and frustration. Findings included . <Facility Policy> According to the facility's 2001 comprehensive, person-centered CP policy, the facility would, in conjunction with the resident and their family or legal representative, develop a comprehensive CP for each resident. The policy showed residents would be informed of their right to, and be provided with, advanced notice of care planning conferences. The policy showed assessment of residents was ongoing and CPs should be revised as needed with changes. <Care Conferences> <Resident 24> According to a 03/27/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 24 had no memory impairment, clear speech, was able to understand and be understood by others. In an interview on 05/12/2025 at 9:04 AM, Resident 24 stated they did not recall having any recent care conferences with staff to discuss their CP and goals. Record review showed a 01/07/2025 care conference evaluation signed as complete on 01/24/2025. No other care conference documentation was found after that date in Resident 24's records. In an interview on 05/19/2025 at 12:00 PM, Staff F (Social Services Director) reviewed Resident 24's records and confirmed Resident 24 should have, but did not have a care conference around the end of March 2025 when their MDS and CP were updated. <Resident 183> According to a 05/06/2025 admission MDS, Resident 183 was admitted to the facility on [DATE] with clear speech, and was able to understand, and be understood by others. In an interview on 05/13/2025 at 11:09 AM, Resident 183 stated they were frustrated and felt they were dumped at the facility and staff started feeding them pills. Resident 183 did not remember meeting with staff for a care conference after admission. Record review showed no care conference documentation in Resident 183's records. In an interview on 05/16/2025 at 6:55 AM, Staff D (Resident Care Manager - RCM) stated the process for care conferences was to include residents and/or their family in the care planning process and were to be completed within the first three days of admission and then quarterly thereafter, or as needed with changes. In an interview on 05/19/2025 at 12:00 PM, Staff F reviewed Resident 183's records and confirmed the resident should have, but did not have a care conference after their admission as required. <Care Plan Revision> <Resident 22> According to a 04/23/2025 Quarterly MDS, Resident 22 used a walker and a wheelchair for mobility and required partial assistance from staff to transfer to a chair. This MDS showed Resident 22 only received splint or brace assistance once during the seven-day assessment period. Review of a 04/24/2025 restorative progress note showed staff documented Resident 22's splint was discontinued due to the resident's continued removal of, and refusals to wear the splint. Record review showed the revised 12/12/2024 restorative program CP still identified a goal for Resident 22 to continue to wear their splints comfortably and without complication. Staff did not identify Resident 22's refusals to wear the splints or update and revise the goal after the splints were discontinued. In an interview on 05/19/2025 at 1:08 PM, Staff D stated their expectation was for staff to update and revise CPs with changes to make sure the CP reflected the resident's current condition. Staff D stated Resident 22's CP should have been but was not updated to reflect the resident's splint refusals<Resident 48> According to the 05/01/2025 Significant Change MDS, Resident 48 was admitted to the facility on [DATE], had diagnoses including an enlarged prostate and had an indwelling catheter (a small flexible tube inserted into the bladder through the urethra to drain urine). Observations on 05/12/2025 at 10:23 AM, 05/13/2025 at 1:17 PM, and on 05/15/2025 at 9:34 AM showed Resident 48 was lying in their bed with an indwelling urinary catheter in place. In an interview on 05/15/2025 at 9:34 AM, Resident 48 stated they had an indwelling catheter in for a long time because they could not urinate on their own. Review of the physician orders showed a 04/25/2025 order directing the nursing staff to provide indwelling catheter care every shift to Resident 48 and change the catheter as needed. Review of the revised 05/08/2025 Alteration in Elimination CP showed Resident 48 had a suprapubic catheter (a different type of catheter that drains urine through a whole in the lower abdomen rather than the urethra) and instructed staff to provide suprapubic catheter care per facility protocol, rather than an indwelling catheter. In an interview on 05/19/2025 at 12:42 PM, Staff D (RCM) reviewed Resident 48's record and confirmed Resident 48 had an indwelling catheter. Staff D stated the CP was not accurate. Staff D stated they expected CPs to be accurate so the staff could provide better care for the residents. REFERENCE: WAC 388-97-1020 (2)(f), (4)(b), -1020 (5)(b). .

<Resident 44> According to a 02/25/2025 Annual MDS, Resident 44 had clear speech and was able to understand, and be understood by others. This MDS showed Resident 44 required substantial assistance from staff to stand, needed set up assistance for personal hygiene, and had no rejection of care during the assessment period. Review of a revised 09/20/2024 Self Care Performance CP showed Resident 44 had limited mobility related to weakness and impaired balance. This CP gave directions to staff to provide physical assistance with shaving. Observations on 05/12/2025 at 1:58 PM showed Resident 44 with a patch of long hairs on their chin. In an interview at this time, Resident 44 stated they liked to have their chin shaved so it felt smooth. Resident 44 stated they could tell when their chin hair grew out and indicated in the past staff assisted them to shave. Resident 44 was observed two days later, on 05/14/2025 at 12:51 PM with the same unshaven chin hair. Review of Resident 44's May 2025 ADL documentation from 05/01/2025-05/19/2025, showed staff documented they provided shaving daily during that time. In an interview on 05/19/2025 at 10:41 AM, Staff N (CNA) stated they were expected to provide assistance with shaving, if required, any time a resident was observed with hair growth. Staff N stated shaving should not only be done on shower days. Staff N stated they did not notice Resident 44 had hair growth during the current shift and did not offer to assist with shaving. Observation on 05/19/2025 at 12:36 PM showed Resident 44 with new hair growth on their chin. In an interview at that time, Resident 44 stated they were shaved once but not shaved once but their chin hairs regrew as they did not get assistance to shave since. In an interview on 05/19/2025 at 1:08 PM, Staff D (Resident Care Manager) stated it was their expectation staff provide shaving assistance as needed every shift when they saw hair growth. Staff D stated personal hygiene was important for residents to feel good about themselves and how they look. Staff D stated Resident 44 should have but was not provided shaving assistance daily as directed on their ADL records. REFERENCE: WAC 388-97-1060(2)(c). Based on observation, interview, and record review the facility failed to assist residents with Activities of Daily Living (ADLs - personal hygiene, grooming, bathing, eating etc.) for 2 of 6 residents (Residents 70 & 44) reviewed who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's 03/2018 revised Supporting ADLs policy showed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This policy showed if residents with an impaired ability to think or memory loss disorders resisted care, staff should attempt to identify the underlying cause of the problem and not assume the resident rejected care. This policy showed staff should reapproach the resident or have another staff member offer the care needed. <Resident 70> According to the 04/22/2025 Significant Change Minimum Data Set (MDS - an assessment tool) Resident 70 readmitted to the facility on [DATE] after a fall with a right arm fracture. The MDS showed Resident 70 did not reject care during the assessment period. The MDS showed Resident 70 was dependent on staff for toileting, transferring, personal hygiene including shaving, oral care and bathing. According to the 04/21/2025 revised ADL Self Care Deficit Care Plan (CP) Resident 70 was non-weight-bearing on their right arm and required one-person physical assistance for dressing, transferring from the bed to a wheelchair, and personal hygiene including brushing hair, brushing teeth, and shaving. The CP directed staff to assist the resident to get up in their wheelchair for all meals and report refusals to a licensed nurse. Observations on 05/12/2025 at 2:09 PM and on 05/14/2025 at 8:40 AM showed Resident 70 lying in their bed, dressed, and with facial hair. In an observation and interview on 05/14/2025 at 10:47 AM, Resident 70 was in their wheelchair in front of the nursing station,with obvious facial hair. When asked if staff offered them assistance to shave their facial hair, Resident 70 stated, No. I used to do everything but not anymore since I broke my arm In multiple observations on 05/15/2025 at 8:21 AM, 10:50 AM, and at 12:51 PM, Resident 70 was in their bed in a hospital gown. Resident 70 stated they waited for staff to dress them and get them in their wheelchair for lunch, but it did not happen. In an interview on 05/15/2025 at 1:07 PM, Staff P (Licensed Practical Nurse) stated Resident 70 needed assistance with all ADLs including getting out of bed. Staff P stated they did not get a report from staff that Resident 70 refused care that morning. In an interview on 05/15/2025 at 1:13 PM, Staff O (Certified Nursing Assistant - CNA) stated they did not shave Resident 70 that morning or dress them. Staff O stated they should provide morning care to Resident 70 and get them up in their wheelchair for meals, but they did not. In an interview on 05/16/2025 at 12:02 PM, Staff B (Director of Nursing) stated they expected staff to provide morning care to every resident including oral care, shaving, dressing, and getting them in their wheelchair as residents allowed, but did not.

Based on observation, interview, and record review the facility failed to ensure 1 of 2 residents (Resident 24) reviewed for vision and hearing services received the care and services they required to maintain their vision. The failure to provide follow through with a needed follow up appointment placed Resident 24 at risk for worsening vision, and frustration. Findings included . <Facility Policy> According to the facility's 2001 Sensory Impairment policy, the physician would identify and order the appropriate consultations needed to help manage the causes, complications, and risks for residents with sensory impairments. <Resident 24> According to a 03/27/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 24 had multiple medically complex diagnoses including a stroke with cortical blindness (a condition with loss of vision due to damage in the visual processing areas of the brain). This MDS showed Resident 24 had highly impaired vision. Review of the 05/17/2024 and 01/08/2025 visual function Care Area Assessments showed staff documented Resident 24 had highly impaired vision and was at risk for safety issues, distress, and isolation related to their impaired vision. Staff documented they would address this concern in Resident 24's Care Plan (CP) to ensure plans were in place to decrease the identified risks. Review of a revised 01/03/2025 impaired vision CP showed directions were provided to staff to arrange for consultation with eye care practitioners as required. In an interview on 05/12/2025 at 9:00 AM, Resident 24 stated they lost their eyesight about a year ago after they had a stroke. Resident 24 stated the last time they went to the eye doctor was over six months ago when they were informed they were blind. Review of a 04/26/2024 nursing progress note showed staff documented Resident 24 had an appointment for an eye exam that day, had a follow up appointment, and would let the next shift and scheduler know. Record review showed a 05/15/2025 records request form was sent from the facility to the eye specialist clinic requesting the after-visit summary from Resident 24's 04/26/2024 appointment. On 05/22/2024 the clinic responded and sent the documents to the facility, which included information showing Resident 24 needed a six-month follow-up visit. The documents were added to Resident 24's records on 05/30/2024. In an interview on 05/27/2024 at 11:05 AM, the eye specialist clinic stated Resident 24 did not return since their 04/26/2024 appointment. The specialist stated Resident 24 was scheduled for their six month follow up visit on 10/25/2024, but did not show up. No documentation was found in Resident 24's records regarding the missed appointment. In an interview on 05/19/2025 at 1:08 PM, Staff D (Resident Care Manager) stated follow-up appointments were important for continuation of care. Staff D reviewed Resident 24's records and was unable to find further information regarding the missed six-month vision follow-up appointment. REFERENCE: WAC 388-97-1060(3)(a). .

Based on observation, interview, and record review the facility failed to ensure mechanical lifts (lift devices used to help transfer residents who cannot bear their own weight from surface to surface) were maintained in safe working order for 2 of 2 mechanical lifts. The failure left residents at risk for unsafe transfers, falls, and injury. Failures included . <Facility Policy> According to the facility's undated Equipment Safety and Functionality Expectations policy, staff must inspect all equipment prior to use. The policy showed for mechanical lifts, safety clips must be present and attached securely prior to use, and wheels function and can lock. <Resident Council> During a Resident Council meeting on 05/16/2025 at 1:08 PM, Resident 35 expressed a concern with the facility's mechanical lifts. Resident 35 stated some of the pins (spring-loaded locking clips on the hooks of the lift where the sling in which the resident is seated for transfer is connected - a safety clip. These spring-loaded locking clips helped ensure the sling does not disconnect when the resident is not suspended.) were missing. Resident 35 stated some of the other spring-loaded locking clips no longer worked as they should because the spring mechanism did not work. Resident 35 stated they needed a mechanical lift for transfers and seeing the missing or non-functional pins made them feel unsafe. Observation on 05/16/2025 at 1:55 PM showed the mechanical lift nearest Resident 35's room (located outside room [ROOM NUMBER]) was missing one of the six spring-loaded locking clips. Additionally, this mechanical lift had two spring-loaded locking clips that did not spring shut, confirming the concern Resident 35 raised at Resident Council. The brake of the left rear wheel of the lift was missing the rubber mechanism that allowed the brake to be deployed with the use of a foot. The brake would not engage. Observation on 05/16/2025 at 2:01 PM showed the mechanical lift on East wing hallway near room [ROOM NUMBER] was missing two spring-loaded locking clips. In an interview on 05/16/2025 at 2:34 PM, Staff A (Administrator) stated they would provide the user manual for the facility's mechanical lifts. Staff A reached out to Staff H (Maintenance Director) to obtain it. On 05/16/2025 at 2:46 PM Staff H joined the interview. Staff H stated they checked the mechanical lifts monthly. Staff H stated sometimes the spring-loaded locking clips failed and needed replacement. Staff H showed the checklist they used to check the mechanical lifts monthly. Staff H stated they received no reports residents had a safety concern related to the lifts. Staff A stated both lifts would be removed from the floor until they were in full working order. In an interview and observation on 05/16/2025 at 3:10 PM, Staff A noted the missing pins and brake panel from a lift still located in the resident hallway, over an hour after the lift safety concern was identified, and stated the lift would be removed from the floor until repaired. Observation on 05/19/2025 at 9:47 AM showed a rented mechanical lift being used on the floor. REFERENCE: WAC 388-97-1060(3)(g). .

Based on observations, interviews, and record review the facility failed to reassess the resident for bowel and bladder needs or provide the necessary care and services to ensure bowel and bladder continence was improved for 1 of 2 residents (Resident 47) reviewed for bowel and bladder needs. This failure left the resident at risk for unmet care needs, avoidable incontinence, and embarrassment. Findings included . <Facility Policy> According to the facility's April 2018 Urinary Incontinence policy, nursing staff would assess residents and document the circumstances related to incontinence. The physician would identify potentially treatable medical conditions and address causes related to urinary incontinence. The policy showed facility staff would identify environmental interventions and assistive devices such as grab bars, urinals (bottles male residents can urinate in), bedside commodes, and walkers to facilitate toileting. Based on the assessment and causes of the incontinence, staff would provide scheduled toileting, prompted voiding, or other interventions to try to improve the resident's continence status. <Resident 47> According to the 04/08/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 47 admitted to the facility on [DATE], had no memory impairment, and was able to make their own decisions. This MDS showed Resident 47 was always incontinent of bowel and bladder during the assessment period and was dependent on staff for toileting needs. Observation on 05/12/2025 at 11:12 AM and on 05/13/2025 at 1:23 PM showed Resident 47 lying in bed. In an interview on 05/13/2025 at 1:23 PM, Resident 47 stated they used incontinence briefs for bowel and bladder needs since admitting to the facility. Resident 47 stated when they were in the hospital they successfully used a urinal to urinate. Resident 47 stated they knew when they needed to urinate but they could not walk to the bathroom. Record review showed the 01/08/2025 Urinary incontinence Care Plan (CP) directed staff to assist Resident 47 with the toilet upon rising, before and after meals, at bedtime, and as needed. The CP instructed the staff to keep a urinal within reach because Resident 47 used a urinal in bed. In a joint interview on 05/14/2025 at 11:00 AM, Staff C (Assistant Director of Nursing), Staff E (Resident Care Manager), and Staff M (Resource Nurse) stated Resident 47 was alert and able to make their needs known. Staff E stated Resident 47 was always incontinent of bowel and bladder. Staff E stated staff should assess the resident's bowel and bladder needs and initiate interventions like a urinal or a bedside commode to facilitate toileting. In an interview and observation on 05/14/2025 at 11:15 AM, Staff M confirmed there was no urinal in Resident 47's room. Staff M discussed urinal use with Resident 47. Resident 47 stated they would use a urinal while in bed. On 05/14/2025 at 11:33 AM, Staff C stated they should have reassessed Resident 47's bowel and bladder status and start a scheduled toileting program, but they did not. In an interview on 05/16/2025 2:32 PM, Staff B (Director of Nursing) stated staff should reassess to ensure Resident 47 received the necessary care they required. REFERENCE: WAC 483.25-1060 (3)(c). .

Based on observation, interview, and record review the facility failed to ensure medications were stored, returned, and/or discarded when expired for 1 of 3 medication carts (Middle Medication Cart) and 1 of 1 medication rooms observed. The failure to ensure unneeded medications were returned to the pharmacy upon resident discharge and to ensure medications carts were secured when not in use by a nurse placed the residents at risk for receiving unauthorized, compromised, and/or ineffective medications. Findings included . <Facility Policy> According to the facilty's revised November 2020 Storage of Medications policy, discontinued, outdated, and deteriorated drugs and biologicals must be retumed to the dispensing pharmacy or destroyed. The policy showed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) that contained drugs and biologicals must be locked when not in use and unlocked medication carts must not be left unattended. <Medication Room> Observations of the medication room on 05/12/2025 at 9:41 AM with Staff P (Licensed Practical Nurse) showed a vial of Tuberculosis (TB - a highly contagious respiratory disease) testing solution in the refrigerator. The vial had an open date of 04/11/2025 and more than 30 days passed since the vial was opened. Staff P stated staff should have, but did not remove and discard the TB vial once it expired. The following observations in the medication room were made with Staff P on 05/12/2025 at 9:45 AM: - five vials of a blood thinning medication that expired 04/30/2025 - two containers of blood collection needles that expired 10/31/2024 - two containers of blood collection needles that expired 11/30/2024 - one box of oil-based dressings that expired 10/2024 - one tube of a wound gel that expired 04/2025 - two one-gram boxes of protein wound powder dressings that expired 06/2024 - one one-gram box of protein wound powder dressings that expired 09/2024 In an interview at this time, Staff P stated the expired medications and supplies should have been but were not discarded and removed from the supply area in the medication room. Observation of the contents of a filing cabinet in the medication room were made with Staff P on 05/12/2025 at 10:05 AM. This filing cabinet contained: - a bag with at least 12 bottles of medications for a resident who discharged on 07/11/2024, 10 months previously. - nine bottles of medication for a resident who discharged on 10/13/2024, seven months previously. - eight medication cards for a resident who discharged on 12/10/2024, five months previously. In an interview at this time, Staff P stated it was their expectation the medications would be removed promptly and either returned or destroyed upon a resident's discharge. Staff P stated the medication found in the filing cabinet should be removed. <Middle Medication Cart> <Unsecured Medication Cart Keys> Observation on 05/12/2025 at 9:36 AM showed the keys of the middle medication cart were left hanging in the lock of the narcotic drawer with no staff in the area. At 9:37 AM, Staff Q came to the cart and realized they left the keys in the cart. Staff Q stated I should have locked that. When asked if the keys should be left in the cart, Staff Q stated, at least you were there. <Expired Medications> Observations of the middle medication cart on 05/12/2025 at 10:22 AM with Staff Q (Registered Nurse) showed a long-acting insulin pen (medication used to manage blood sugar levels) with an open date of 04/12/2025. In an interview at this time, Staff Q stated the insulin pen expired 28 days after opening and should have been removed from the cart on 05/10/2025, two days previously. In an interview on 05/19/2025 at 11:08 AM, Staff B (Director of Nursing) stated it was their expectation for expired medications and supplies to be removed from the medication room and carts. Staff B stated the nursing staff should not be using them. Staff B stated discharged residents' medications should be discarded or returned to the pharmacy within the first week of discharge to decrease the risk for possible medication errors and to avoid possible financial burdens for the residents. WAC: REFERENCE 399-97-1300(2),-2340. .

Based on observation, interview, and record review the facility failed to: ensure staff followed contact precautions (a type of isolation precaution used to prevent the spread of infections transmitted by direct or indirect contact) for 1 resident (Resident 183) of 1 reviewed for contact precautions; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear and gowns used to prevent exposure to infectious materials) for one supplemental Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms in long-term care settings) room (room [ROOM NUMBER]); ensure staff used appropriate Hand Hygiene (Staff R); ensure the facility was free of uncleanable surfaces; ensure urinals (plastic bottles used to pass urine for resident with mobility issues) were sanitary. These failures placed residents at risk for exposure to and development of infectious diseases. Findings included . <Facility Policy> Review of a revised August 2019 facility, Isolation- Initiating Transmission-Based Precautions [TBP - a set of infection control measures designed to prevent the spread of infectious diseases] policy, showed TBPs would be initiated when a resident was at risk of transmitting an infection to other residents. This policy showed when TBP precautions were implemented, the infection preventionist would provide and oversee the process. <Contact Precautions> <Resident 183> According to the 05/06/2025 admission Minimum Data Set (an assessment tool), Resident 183 had diagnoses including an acute bone infection in their left ankle and foot, amputation of their left toes, and a skin infection to their left leg. This MDS showed Resident 183 required antibiotic medication during the assessment period. Record review showed Resident 183 had a 05/02/2025 order for contact precautions due to a multidrug-resistant organism wound infection to their left leg. The order showed staff must follow the posted signage outside of the room. Observation on 05/12/2025 at 8:34 AM showed Resident 183's room (room [ROOM NUMBER]) had a Contact Precautions sign at the door directing anyone entering the room to perform Hand Hygiene (HH) upon entry and before leaving. This sign showed that in addition to HH, all staff entering the room must also put on gloves and a gown prior to entering the room. The sign showed staff should remove the gown and gloves and perform HH again before exiting the room. At that time, Staff Q (Registered Nurse) was observed to be in the room wearing a surgical mask but no gown or gloves. This nurse stood at the resident's bed as they gave the resident their morning medications. Observations on 05/12/2025 at 8:39 AM showed Staff Q exit Resident 183's room, without performing HH, went into the kitchen, and returned with a cup of coffee to deliver to the resident. Staff K (Infection Preventionist) stopped Staff Q and told them to use PPE. Staff Q then grabbed a gown and took it with them into the room and put it on while walking to the resident's bedside. Observations during meal service on 05/12/2025 at 11:57 AM showed Staff U (Certified Nursing Assistant) enter Resident 183's room to deliver their lunch tray. Staff U did not use the required PPE as directed on the door for contact precautions. Once inside the room, Staff U put on gloves, did not put on a gown, and emptied Resident 183's urinal. After emptying the urinal, Staff U removed their gloves, washed their hands, and began moving items on Resident 183's bedside table. Staff U then used the remote control to adjust the bed and then left the room without performing HH. Staff U picked up another lunch tray and delivered it to room [ROOM NUMBER] and touched their bedside table, moved their television, came out and closed the door, and then performed HH. Observations on 05/12/2025 at 12:10 PM showed Staff S (Dietary Manager) entered room [ROOM NUMBER] without putting on a gown or gloves or performing HH as directed by the contact precautions sign posted at the door. Staff S was observed to touch Resident 183's tray ticket while in the room. Staff S was then observed leaving the room, without performing HH, entered the main dining room, and moved a meal cart. Staff S then adjusted the menus in their plastic holders in the dining room. Upon exiting the dining room, Staff S was noted to touch the handrail and go into the kitchen. <EBP> Observations during meal service on 05/12/2025 at 11:54 PM showed room [ROOM NUMBER] had an EBP sign placed outside the door. This sign directed everyone entering the room to perform HH before entering and when leaving the room and directed staff to wear gloves and gowns before close contact with the resident. Staff U delivered a lunch tray to the resident in room [ROOM NUMBER], moved up their bed, and physically assisted the resident with positioning, without wearing a gown or gloves. Staff U then exited the room, and without performing HH, took a cup from the food cart, used the main coffee pot to fill the cup, and reentered room [ROOM NUMBER]. In an interview on 05/16/2025 at 11:28 AM, Staff K stated it was their expectation that staff follow the directions posted on the precaution signs at resident doors. Staff K stated the required PPE was an important part of reducing the risk of disease transmission. Staff K stated for a resident on contact precautions, staff were required to put on a gown and gloves at the door, prior to entering a resident's room. Staff K stated staff should not go in a room to drop things off, without putting on the proper PPE first if a resident was on contact precautions. Staff K stated for EBP, staff were expected to put on a gown and gloves prior to providing any close contact with residents. Staff K stated all staff should perform HH before entering, providing care, after care, touching resident items, and upon exiting a room. Staff K stated HH was important to reduce and prevent disease transmission. <Uncleanable Surfaces> Observations on 05/13/2025 at 12:39 PM showed a chair with a leather-like cover near the window in room [ROOM NUMBER]. The leather-like fabric cover of the chair was peeled and torn with uncleanable material showing through. In an interview on 05/29/2025 at 3:04 PM, Staff H (Maintenance Director) stated they removed the chair from the resident's room because it was not cleanable and did not look homelike. <Hand Hygiene> Observation on 05/14/2025 at 1:22 PM showed Staff R (Housekeeping) placed their housekeeping cart in the hallway outside a nurse's station, entered the nursing station, took a nail clipper from their pocket and clipped their fingernails at the nurse's station. They put the nail clipper in their pocket, went out in the hallway, and moved their housekeeping cart to the janitor room in east wing hallway. Staff R came back to the nursing station, blew their nose, threw the tissue in a trash can, and went to clock out for the day. Staff R did not perform HH. Observation on 05/15/2025 at 10:45 AM showed Staff R walking in the east wing hallway and filing their fingernails. In an interview on 05/19/2025 at 12:43 PM, Staff K stated Staff R should not clip their fingernails at the nursing station. Staff K stated Staff R should wash their hands after they placed their housekeeping cart in the janitor room and before touching the time clock as it was an infection control issue. <Urinals in Trash Cans> Observation in room [ROOM NUMBER]-1 on 05/12/2025 at 10:45 AM and 12:46 PM showed Resident's urinal was hanging inside a trash can. Observations in room [ROOM NUMBER]-1 on 05/12/2025 at 10:54 AM and on 05/13/2025 at 12:35 PM showed Resident's urinal was hanging inside a trash can next to the resident's bed. In an interview on 05/19/2025 at 12:47 PM, Staff K stated residents' urinals should not be placed inside the trash cans, that was infection control issue. Staff K stated the facility staff should keep resident's urinals clean, and in a bag, but not in the trash cans. REFERENCE: WAC 388-97-1320 (1)(c), (2)(b), (5)(c). .

Based on interview and record review, the facility failed to ensure level I Preadmission Screening and Resident Reviews (PASRRs - a mental health screening required to be completed prior to admission to a skilled nursing facility) were accurate prior to admission for 2 of 7 residents (Residents 50 & 133). These failures placed residents at risk for inappropriate placement, unmet mental health needs, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's July 2024 PASRR policy, all newly admitting residents would have a Level I PASRR screening prior to admission to the facility. The policy showed all potential admissions identified with a positive Level I PASRR must be evaluated by the state authority through the Level II process and be approved for admission prior to admitting. <Resident 50> According to a 01/23/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 50 had multiple medically complex diagnoses including anxiety, depression, and Post Traumatic Stress Disorder (PTSD), and required the use of psychotropics (medications that affect mental function, mood, and behavior). Record review showed Resident 50 admitted to the facility on [DATE] from the hospital with a 01/14/2025 Level I PASRR. Section 1 of this PASSR showed the resident was marked as having no Serious Mental Illness (SMI) indictors. The last section of the form showed Resident 50 did not require a level II evaluation as they did not show indicators of an SMI. Review of the 01/17/2025 Clinical Summary hospital record showed Resident 50 actively received psychotropic medications and had SMI indicators prior to and upon admission to the facility. In an interview on 05/19/2025 at 12:11 PM, Staff F (Social Services Director) stated accurate Level 1 PASRRs were important as they defined what mental health services a resident would be provided based on the resident's mental health. Staff F stated it was their expectation a Level 1 PASRR would be accurate upon admission to the facility and stated the admissions coordinator was responsible for obtaining them prior to admission. In an interview on 05/22/2025 at 12:00 PM, Staff L (Admissions Coordinator) stated they were responsible for checking and obtaining the Level 1 PASRR prior to a resident's admission to the facility. Staff L stated it was their expectation a Level 1 PASRR was accurate, and if the resident had an SMI, a Level 2 evaluation would be completed prior to admission to the facility. Staff L reviewed Resident 50's admission Level 1 PASRR and stated it was inaccurate. <Resident 133> According to the 05/07/2025 admission MDS, Resident 133 had a moderate memory impairment and admitted to the facility on [DATE]. The MDS showed Resident 133 had a diagnosis of depression and took an antidepressant medication. Review of the 05/01/2025 Level I PASRR showed Resident 133 had no Serious Mental Health (SMI) indicators. This PASRR did not include Resident 133's depression diagnosis. In an interview on 05/19/2025 at 12:22 PM Staff F stated it was the facility's responsibility to review the Level I PASRR completed by the hospital for accuracy. Staff L stated the 05/01/2025 Level I PASRR lacked Resident 133's depression diagnosis and was inaccurate. REFERENCE: WAC 388-97-1915 (1)(2)(a-c). .

Based on observation, interview, and record review the facility failed to protect resident's rights to be free from abuse when facility policies and procedures to monitor and identify psychological harm were not implemented for 1 of 3 residents (Resident 2) reviewed for abuse. Resident 2 experienced psychological harm and fear when they were verbally abused by a staff member. This failure placed all residents at risk of psychological abuse, and a diminished quality of life. Findings included . Review of the facility Abuse Prevention Policy and Procedure, dated 07/01/2020, directed staff to initiate investigations as soon as a report of abuse was received to rule out or identify abuse and investigations would be completed within five days. Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 09/2022, directed staff to interview the abused resident, reporter, other residents, involved staff, witnesses, physician, and resident representatives when completing an investigation of abuse. The policy showed there would be an assessment and monitoring of the abused resident for emotional support. The policy showed any employee who was accused of abuse was placed on leave with no resident contact until the investigation was completed. The resident would be protected from retaliation from the abuser and would be kept informed of the progress of the investigation. The 3/06/2024 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 2 was diagnosed with a stroke with paralysis on their left side and required two person maximum assistance for transfer and physical assistance from staff for showers. Resident 2 was assessed as cognitively intact and able to make their own decisions. A 03/13/2024 facility report to the state agency showed on 03/13/2024 Resident 2 was being assisted to stand by two staff, started to fall, when one staff said, God damn it, mother fu**er and Resident 2 was pushed onto their bed and the two staff proceeded with a bed bath instead of a shower. In an interview on 03/18/2024 at 3:40 PM, Resident 2 stated It was my shower day and they came about 6:00 AM, I was still half asleep and they tried to lift me up and told me to stand. Resident 2 stated there were two caregivers present and Resident 2 started to stand but because of their stroke it was difficult. Resident 2 stated I tried to stand, but they pushed me down and said mother fu**er you are going to break my back. Resident 2 stated I was shocked that they were swearing and they were upset. I did not do anything wrong. I was afraid. They yelled at me and swore and did not even apologize. They just gave me a shower in bed, who does that? They took a washcloth and put it above my face and squeezed water over my head. I was not covered and I was cold and my bed was wet. When Resident 2 was asked how the caregivers made them feel, Resident 2 stated I am afraid that they will come back, and my next shower they will be angry at me because I told on them. Resident 2 was observed with a grimace on their face, eyes wide and had a trembling voice when they stated they were afraid. When asked about what happened after the fall and the shower in bed, Resident 2 stated a nurse came to look at their skin and interviewed them about the incident. Resident 2 stated they were afraid to report the caregiver for pushing them and swearing. Resident 2 stated If it was that easy for [them] to swear at me, there might be others [residents] not capable of complaining, I think [they] could do that to other [residents]. When Resident 2 was asked if the nurses followed up on the days following the fall, Resident 2 said no one talked to them after the first interview Resident 2 stated no one told me anything about an investigation or what happened to the caregivers. Resident 2 stated I am afraid the [caregiver] will come back and be angry at me because I reported them. Resident 2 stated they did not want that caregiver to provide care to them any longer. In an interview on 03/18/2024 at 4:10 PM, Staff D (Resident Care Manager) stated a skin assessment and interview was completed with Resident 2. Staff D stated after an incident a resident should be placed on alert charting to monitor and document for any signs of harm. Staff D stated they thought they placed Resident 2 on monitoring and alert charting. Staff D looked at Resident 2's progress notes and stated documentation was not there to show Resident 2 was monitored for harm after the incident. In an interview on 03/18/2024 at 4:45 PM, Staff A (Administrator) stated an investigation was started, the caregivers were removed from the schedule and were asked to write a statement. Staff A stated Resident 2's allegation could not be substantiated as abuse. Staff A stated the two caregivers returned to work the next day. In an interview on 03/19/2024 at 1:05 PM with Staff A and Staff B (Director of Nursing), Staff B stated they removed the two caregivers from the building on 03/19/2024 and asked them to write a statement of the incident. Staff B stated they did not interview either of the caregivers. Staff B stated both staff returned to work the next day, before the investigation was completed. Staff B stated education or training was not provided before returning to working with residents. Staff A and Staff B were asked if anyone followed up with Resident 2 after the incident. Neither Staff A nor Staff B knew if there was follow up with Resident 2. Staff A and Staff B stated staff was expected to place residents on alert charting to monitor and document the resident status after an incident. Staff A and Staff B were asked if Resident 2 was monitored for harm after the incident was reported, neither Staff A nor Staff B knew if Resident was harmed. Staff A and Staff B were asked to provide the documents of the investigation, Staff B stated the investigation was not finished and the documents were not available. In an interview on 03/20/2024 at 11:41 AM, Staff A stated they would send the incident report. The incident report and documents were not provided until 03/20/20204 at 3:30 PM. Staff A stated their expectation was that both caregivers would be educated to the incident prior to returning to work. Staff A stated Resident 2 should have been monitored for psychosocial harm and documentation of monitoring should be in the medical record. Staff A stated monitoring was not done, but monitoring was important so harm could be identified and interventions could be implemented for the resident's safety. REFERENCE: WAC 388-97-0640(1).

Based on interview and record review the facility failed to follow transfer and discharge requirements for 2 of 2 residents (Residents 4 & 3) reviewed for transfer and discharge requirements. The failure to identify a resident's inability to make complex decisions, coordinate care with the Resident Representative (RR), the physician, and the receiving hospital and provide adequate documents for a safe care transition, placed cognitively impaired residents at risk for harm, unmet care needs, delay in care, lack of advocacy from their RR, and diminished quality of life. Resident 4 experienced psychological harm, applying the reasonable person concept, when they were transported by a taxi driver to the hospital ER, were not able to talk or explain to hospital personnel why they were there or what care they needed, had no advocate present to assist with the transfer, and the facility staff did not contact the ER to provide background information/medical history, and received multiple diagnostic tests that were possibly not required. Findings included . <Facility Policies> The 08/2018 Transfer or Discharge, Emergency policy showed if an emergency transfer or discharge to a hospital was necessary, the facility would notify the attending physician, notify the receiving facility, prepare a transfer form to send with the resident, notify the representative, assist in arranging transportation. The 12/2016 Transfer or Discharge Documentation policy showed When a resident is transferred or discharged , details will be documented in the medical record and appropriate information will be communicated to the receiving health care facility. The policy directed staff to document the basis for transfer or discharged in the medical record including, the specific resident needs that cannot be met, the facility's attempt to meet those needs, the receiving facilities services that are available to meet those needs. The policy directed staff to document notice was provided to the resident/representative and a summary of the resident's overall medical, physical, and mental condition. The policy directed a resident transferred or discharged for any reason the receiving facility will receive communication on the basis for transfer/discharge, including specific resident needs that could not be met, facility's attempt to meet those needs, the receiving facility's services available to meet those needs, and all necessary information and documentation to ensure a safe and effective transition of care. <Resident 4> The 03/16/2024 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 4 was admitted on [DATE] for rehabilitation after a stroke. Resident 4 was assessed to have unclear speech, rarely/never understood, and sometimes understood others. Resident 4 was not able to use their dominant right side extremities, was unable to speak, was unable to complete a cognitive exam. The MDS showed the staff's cognitive assessment concluded Resident 4 had severe cognitive impairment and could never/rarely make decisions regarding the tasks of daily life. The MDS showed Resident 4 had no delirium, behaviors, or refusals of care. The 03/13/2023 Speech Language Evaluation showed: Resident 4 had a complete loss of speech from their stroke, impaired hearing comprehension, impaired verbal language skills, impaired motor speech, impaired speech intelligibility, and impaired communication exchange in daily activity. Resident 4 was oriented to person only (without awareness of place, time, and situation), had impaired thinking and impaired problem-solving skills. Resident 4's memory was impaired, short-term, long-term, and procedural memory was not assessed due to the impairment. Resident 4 was assessed by the speech therapist to have barriers that would impact discharge, specifically related to cognitive impairment. The 03/12/2024 Care Plan (CP) showed Resident 4 was dependent on staff for dressing, hygiene, showering, mobility in bed, and transfers from one surface to another. Resident 4 used a wheelchair for all mobility and was dependent on staff for mobilization of the wheelchair. The CP showed Resident 4 did not have a plan for behavior interventions. Review of the 03/16/2024 3:37 PM nursing note showed Resident 4 was forcibly trying to get out of the facility entrance and was combative with staff. Staff C (Resident Care Manger) spoke with Resident 4, determined they wanted to leave the facility, contacted the primary representative (RR1), left a voice message for the secondary representative (RR2), and arranged a public taxi to transport Resident 4 to the ER. The facility was unable to provide documentation of why Resident 4 wanted to leave the facility, alternatives offered to meet Resident 4's needs and safety in the facility, reporting the incident to, or involving the physician in, possible resident medical changes, and the details regarding emergent medical or non-medical need to necessitate the transfer to an ER. The facility could not provide documentation of the required information including special instructions or precautions for ongoing care or care plan goals or any other documentation to ensure Resident 4 had a safe and effective transition of care. Review of the 03/16/2024 ER documents showed Resident 4 was dropped off at the curbside by a public taxi, no family members, representatives, or advocates were present, with unclear documentation as to why Resident 4 was sent to the ER. The hospital records showed multiple attempts were made by the hospital staff to call the family and the facility without success. Resident 4 was non-verbal and unable to provide a medical history. After multiple diagnostics the hospital documented Resident 4 was determined to be at their baseline. Resident 4 was admitted to the hospital for placement to a long-term care setting with a diagnosis of failure to thrive and concern for elderly abuse. In an interview on 03/19/2024 at 3:50 PM, Resident 4's RR1 stated they had multiple missed calls on their cell phone from the facility. RR1 answered a call from Staff C who stated Resident 4 was no longer welcome at the facility, argued with a nurse when trying to exit the facility, and the facility was sending Resident 4 to the hospital. RR1 stated they told Staff C they were at work and asked Staff C to hold on the phone. When RR1 came back to the phone, Staff C hung up the phone. RR1 stated they were not provided any details of what occurred and was not part of making decisions for Resident 4's transfer. RR1 stated Staff C did not ask permission or try to solve the problem and was just trying to get [Resident 4] out of there. RR1 stated Resident 4 would not be going back to the facility. In an interview on 03/19/2024 at 4:11 PM, with Collateral Contact, (ER Nurse) who received Resident 4 from the ER triage, stated a taxi dropped Resident 4 off outside the ER and left. Resident 4 had some papers and written on one of the pages was a note summarized as Hi my name is (Name), I left (facility) against medical advice (AMA), please help me. The CC saw a signed AMA form. The CC tried to communicate with Resident 4 thru writing and determined Resident 4 could not hold a pen or write with either their right dominant hand or their left hand. The CC stated Resident 4 was not able to state why they were at the ER or where they came from or how the ER was supposed to help them. In an interview on 03/19/2024 at 4:36 PM, Resident 4's RR2 stated they received a voicemail on 03/16/2024 from Staff C. The cell phone voicemail was transcribed into text and was provided as a document. The documented message stated Resident 4 wanted to leave the facility, Staff C stated they could not keep them at the facility, Staff C could not reach RR1 and wanted someone to come pick up Resident 4, Staff C stated they tried calling the hospital and the hospital would not take Resident 4, Staff C stated they tried to get an ambulance company to transport Resident 4 to the hospital but there was no medical necessity for transport, Staff C stated Resident 4 was going to leave the facility and they would rather not put them out on the street and could not keep Resident 4 at the facility as it was not a prison. In an interview on 03/20/2024 at 11:59 AM, Staff A (Administrator) stated Resident 4 answered yes and no questions by nodding or shaking their head but was non-verbal. Staff A stated the MDS assessment showed Resident 4 was unable to complete specific cognitive tests and did not determine Resident 4's cognitive capacity. Staff A stated the AMA incident was not reported to the state agency, was not on the facility incident reporting log, an incident investigation was not initiated, the discharge documentation was not thorough. Staff A stated they needed to collect more information on the incident. Staff A stated Resident 4 was assisted by Staff C to get a public taxi and Resident 4 was sent with paperwork to the local ER. Staff A reviewed the incident details and stated Resident 4 had an unsafe discharge. In an interview on 03/22/2024 at 10:44 AM, Staff C stated on 03/16/2024 Resident 4 was at the facility exit door trying to leave. Resident 4 was wearing a gown and in a wheelchair and throwing punches at staff. Staff C stated they talked with Resident 4 to try to understand what was going on. Staff C stated that Resident 4 wanted to leave the facility and offered to help them do so safely. Staff C stated they called RR1 multiple times. When Staff C reached RR1 they explained Resident 4 wanted to leave, was very upset, and Staff C did not have a discharge plan for Resident 4. Staff C stated RR1 agreed to have Resident 4 sent to the ER by taxi. Staff C stated they tried calling RR1 again to provide an update and was not able to reach RR1. Staff C stated they pushed Resident 4 out of the locked facility door and the taxi driver had a wheelchair transport van. Resident 4 was placed in the taxi van and strapped in by the driver. Staff C provided the taxi driver with an envelope that contained contact information for Resident 4, a list of medications, and the AMA form to give to the ER staff. Staff C stated they wrote on the documents that Resident 4 requested to go to the ER, was discharged AMA from facility. Staff C did not send an escort for Resident 4's safety. Staff C stated they did not call the ER after Resident 4 left in the taxi. Staff C stated they did not discuss with the ER Resident 4's care needs, the situation of why they were being transported, and did not follow up to ensure Resident 4 arrived at the ER in the public taxi. Staff C stated they should have called the ER staff to discuss why Resident 4 went to the ER. In an interview on 03/22/2024 at 10:59 AM, Staff A stated they understood the discharge of Resident 4 was not safe. Staff A stated there should have been a call to the ER to transfer care and inform the ER of the incident. Staff A acknowledged the facility's failed practice. <Resident 3> A 03/15/2024 Significant Change MDS showed Resident 3 was admitted on [DATE] with a urinary tract infection, kidney failure on dialysis, bowel incontinence, and urine retention with an indwelling catheter to the bladder. Resident 3 required physical assistance from staff for all mobility, hygiene, toileting and catheter care. A review of the 03/25/2024 nursing note showed Resident 3 had an antibiotic resistant UTI and was positive for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). A review of the 03/25/2024 nursing notes showed no documentation of an assessment of Resident 3's change in condition which required a transfer to the hospital emergency room . A review of the 03/25/2024 facility to hospital transfer form showed Resident 3 was sent to the emergency room for altered mental status. A 03/25/2024 facility report to the state agency by Staff A (Administrator) showed Resident 3 was given their roommate's medications, became heavily sedated, and was transported emergently to the hospital. Review of the 03/25/2024 facility investigation summary showed Resident 3 was administered a potent medication for opioid dependance, a blood pressure lowering medication, an antianxiety medication, and four other medications not prescribed to Resident 3. Review of the 03/25/2024 9:26 AM nursing note showed Staff C attempted to contact the hospital ER for 30 minutes and was unable to give report to hospital ER staff to hand off care safely. In an interview on 03/27/2024 at 1:26 PM, Resident 3's RR stated they arrived at the facility on 03/25/2024 to visit Resident 3. The RR stated they were told Resident 3 was sent to the hospital earlier that morning because Resident 3 was given their roommate's medications in error. The RR stated none of Resident 3's contacts were notified of the transfer to the hospital or the medication error. In an interview on 03/27/2024 at 4:57 PM, Staff C stated nurses are expected to make a call and provide report of the resident status to the receiving facility. Staff C stated they did not connect with hospital staff and did not provide information to the hospital ER staff to transfer care of Resident 3's care. In an interview on 03/27/2024 at 4:57 PM, Staff A stated nurses are expected to notify the Resident's representative and the hospital staff when transferring a resident to the hospital. Staff A stated there was no documentation to show the RR for Resident 3 was informed of the emergency transfer to the hospital as expected. Staff A stated Staff C should have, but did not, contact the hospital staff to provide a verbal transfer of care. Refer to F760- Residents are Free from Significant Medication Errors REFERENCE: WAC 388-97-0120(3)(a)(b).

Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 3), reviewed for medication administration was free from a significant medication error. Resident 3 experienced harm when a staff nurse, who had not completed the facility required competency review for medication administration, did not follow standard practices for medication administration when they administered potent medications belonging to another resident to Resident 3 which resulted in the resident entering a comatose state (a life-threatening change of condition), emergency transfer to the hospital, and admission to the intensive care unit. These failures placed all residents at risk of harm, significant injury, and potential death. Findings included . Review of a facility policy titled Administering Medications, dated 04/2019, showed medications are administered in accordance with the prescriber's orders. The nurse staff administering medications would verify the resident's identity before giving medications using the photo in the medical record or verifying the resident identity with other facility staff. The nurse staff would check the medication label to verify the right resident, right medication, right dosage, with time and right route before giving the medication. Medications ordered for a particular resident may not be administered to another resident. New nurse staff are not permitted to prepare or administer medication until they have been oriented to the medication administration system used by the facility. The charge nurse must accompany new nurse staff on the medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned. A 03/25/2024 facility report to the state agency by Staff A (Administrator) showed Resident 3 was given their roommate's medications, became heavily sedated, and was transported emergently to the hospital. Review of the 03/25/2024 facility investigation summary showed Resident 3 was administered a potent medication for opioid dependance, a blood pressure lowering medication, an antianxiety medication, and four other medications not prescribed to Resident 3. In an interview on 03/27/2024 at 4:20 PM, Staff F (Licensed Practical Nurse) stated they went into Resident 3's room, woke the resident from sleeping, placed the medication cup on the bedside table, asked Resident 3 to verify their name, started a conversation, then Resident 3 took the cup of medications and swallowed them. When finished Resident 5 (the roommate to Resident 3) asked about when they would receive their medications. Staff F asked their name and identified the medication error. Staff F reported to Staff E (Resident Care Manager) who told Staff F to monitor Resident 3. Staff F told Staff D (Resident Care Manager) about the specific medications administered in error. Staff D immediately assessed Resident 3 as difficult to arouse and called 911 for emergency medical services. In an interview on 03/27/2024 at 4:50 PM, Staff C (Staff Development Coordinator) stated Staff F was a new employee, had two training days on the medication cart with other nurse staff, and did not have a competency review completed before independently administering medications to residents. Staff C provided Staff F's timecard and stated Staff F worked five shifts independently before the medication error occurred on 03/25/2024. Staff C stated all nurses should have a competency review prior to independently administering medication. In an interview on 03/27/2024 at 5:00 PM, Staff A and Staff C acknowledged the wrong medications were given and Resident 3 had a life-threatening decline in condition related to the significant medication error. Refer to F622- Transfer and Discharge Requirements. REFERENCE WAC: 388-97-1060(3)(k)(iii).

Based on observation, interview, and record review, the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of splint use and monitoring impacts of blood thinners and sleep medications for 4 of 20 residents (Residents 191, 60, 85, & 44) reviewed for quality of care. Resident 191 experienced harm when their left hand became swollen and self-reported a severe level of pain when the facility failed to implement measures to monitor the resident's circulation and blood flow to their broken left arm after wound treatment and reapplication of the hard splint. These failures placed residents at risk for unmet needs, decline in medical status, and a decreased quality of life. Findings included . <Splint/Cast> <Facility Policy> Reveiw of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, showed the nursing staff would assess and document a resident's significant risk factors for developing pressure ulcers including immobility. The policy showed the impact of specific treatment choices made by the resident/resident representative would be reviewed. <Resident 191> According to the facility census, Resident 191 was admitted to the facility on [DATE] for skilled nursing and rehabilitation services following hospitalization . The 02/16/2024 hospital discharge summary showed Resident 191 was discharged to a skilled nursing facility with a splinted left arm after sustaining a left radial (forearm bone) fracture. Review of the facility's 02/16/2024 Admission Nursing Database showed Resident 191 was assessed to be alert, oriented with intact memory, and had clear speech during communication. The skin assessment of this record showed Resident 191 has a skin tear on their left forearm. On 02/20/2024 at 11:31 AM, Resident 191 was observed lying in bed, their left arm in a half-cast fiberglass (a hard plaster material) splint wrapped in a cotton dressing and secured by an elastic bandage; the left arm was resting on top of the resident's chest area. Resident 191 stated they had a bad fall, landed on their left arm and broke it. Resident 191's left hand was observed to have two rings on their fingers; a cloth sling was tucked on the left side the resident (partially lying on the sling) and was not supporting the fractured arm. When asked if the resident was aware they were lying on the sling, Resident 191 stated it was supposed to help the staff to have something to hold on to during repositioning in bed but they [staff] did not use it [cloth sling] anyways .they just yank my arm whichever way they want and it really hurts . Review of Resident 191's medical records on 02/20/2023 showed the 02/16/2024 Admission Nursing Database (head-to-toe assessment) completed by the admission nurse did not identify the presence/use of a left arm splint. The facility records did not show any monitoring for swelling and/or blood circulation of Resident 191's left hand/fingers. Resident 191's baseline Care Plan (CP) did not capture the presence/use of a left arm splint and the risks involved with having an immobilization device in place. The CP showed no indication for use of the cloth sling or any staff instructions on how to use and apply the sling correctly. In an interview on 02/22/2024 at 8:40 AM, Staff W (Admissions Nurse) stated they conducted the head-to-toe assessment during admission and were responsible for creating the baseline (CP). When asked how the staff determine what needed to be included in the CP, Staff W stated they based the resident's CP from their initial assessment of the resident and from there, the staff would pick and choose from the CP library which was built-in the facility's electronic health records software. The 2023 February Treatment Administration Record showed a 02/16/2024 order to perform daily treatment and dressing change to Resident 191's left forearm fall-related skin tear and to place the splint back in place after wound care. In an observation and interview on 02/22/2024 at 9:14 AM, Resident 191 was in bed and the cloth sling was off, and scrunched to the side; their left hand was swollen (almost twice the size of their right hand) and purplish in color. The two rings on the resident's left fingers appeared tight on the knuckles. Resident 191 stated the nurse who applied the splint put in on too tight. Resident 191 stated their left hand turned pale, cold, and swollen throughout the night and was very painful and they could not extend their arm out without causing severe pain. Resident 191 stated they told the nurse on duty in the morning who adjusted/loosened the splint for them but the swelling had not yet subsided. Resident 191 stated they did not want to remove their rings because of their fear of losing them. In a joint observation and interview on 02/22/2024 at 9:23 AM, Staff K (Licensed Nurse) saw the condition of Resident 191's left hand and stated having a splinted/casted arm was a high risk condition because a resident could lose their arm if not assessed or monitored accordingly. When asked if there was any indication to monitor Resident 191's left hand for swelling, Staff K stated there should be, but there was none. Staff K stated it was important to have monitoring in place because swelling was hard to track if not recorded in the resident's medical record, .swelling could happen pretty fast and was dangerous for a splinted/casted arm. Staff K stated there were no indications to elevate Resident 191's left arm to help decrease the swelling; there were no instructions written specifically for the use of the cloth sling; and that Resident 191 was not presented with the risk and benefits for wanting to keep their rings on which could further impair circulation and potentially severe the resident's limb. In an interview on 02/22/2024 at 8:58 AM, Staff H (Resident Care Manager) stated the baseline CP was important to be complete, accurate, and identify the needs of newly admitted residents so the nursing staff could provide safe care. Staff H referred to the baseline CP initiated for Resident 191 on admission and stated the presence of a left arm splint was not captured. Staff H stated there was no assessment or monitoring in place to check for Resident 191's skin for pressure points or the resident's left hand/fingers for any changes in color, movement, sensation, or blood return on the nail beds to ensure Resident 191 had adequate blood flowing to their left arm from being splinted. 46479 <Anticoagulant (AC) Monitoring> <Facility Policy> According to the November 2019 Anticoagulation - Clinical Protocol facility policy, residents on AC therapy would have a person-centered CP that included possible signs and symptoms of bleeding, and food and drug interactions. The policy showed the physician would order measures to address any complications, including holding or discontinuing the AC medication as indicated. <Resident 60> Review of Resident 60's 02/22/2024 Physician Order (PO) summary showed a 12/20/2023 PO for an AC to be administered to Resident 60 twice daily. This medication was prescribed for Resident 60's irregular heart rhythm. There was no assessment or additional orders to monitor for adverse side effects such as bleeding or bruising. Review of Resident 60's 04/06/2023 Comprehensive CP showed no CP related to Resident 60's use of the AC medication. There were no goals, interventions, or directions for staff to monitor Resident 60 for adverse side effects. There were no instructions for staff to follow if Resident 60 had an adverse reaction to their AC medication. In an interview on 02/27/2024 at 10:49 AM, Staff E (Resident Care Manager - RCM) confirmed Resident 60 did not have orders or a CP to monitor Resident 60 and their use of the AC medication. Staff E stated it was important to monitor residents who took AC medications to ensure the dosage was appropriate and to monitor residents for adverse side effects. Staff E stated nurses should be monitoring residents for bleeding and bruising. 45941 <Resident 85> According to the 02/05/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 85 had diagnoses including heart failure. This MDS showed Resident 85 used an AC during the assessment period. Observations on 02/20/2024 at 11:18 AM, and on 02/22/2024 at 10:29 AM showed Resident 85 had a faded bruise on their right hand. Resident 85 stated they had bruises on their hand for a while related to the AC medication. Review of the February 2024 Medication Administration Record (MAR) showed Resident 85 received the AC medication as ordered for an abnormal heartbeat. Review of the CP showed there was no CP for AC medication for Resident 85. In an interview on 02/26/2024 at 1:56 PM, Staff G (RCM) reviewed Resident 85's record and stated there should be a PO from the provider to monitor Resident 85 for bleeding and bruises but staff did not obtain one. Staff G stated CPs for all high-risk medications were very important to direct staff to provide care for the resident but they did not have CP for AC medication and to monitor the side effects. In an interview on 02/27/2024 at 2:33 PM, Staff B (Director of Nursing) stated there should be a PO to monitor Resident 85 for any new bruising related to AC medication and a CP developed for AC medication monitoring but did not. 47836 <Resident 44> According to the 12/29/2023 Quarterly MDS, Resident 44 had a diagnosis of an irregular heartbeat. This MDS showed Resident 44 received AC medication during the assessment period. Review of the February 2024 MAR showed Resident 44 received AC medication two times daily. Review of the 12/23/2023 at high risk for readmission d/t polypharmacy CP showed Resident 44 was on a high-risk AC medication with an intervention to monitor high risk medications. This CP did not specify what to assess or monitor regarding AC medication use. Review of Resident 44's February 2024 POs showed an active order for an AC medication to be administered twice daily. There were no indications to assess or monitor for signs and symptoms of active bleeding related to AC medication use. Review of Resident 44's February 2024 MAR showed they had received the AC medication twice daily. During an interview on 02/26/2024 at 10:13 AM, Staff E stated Resident 44 was receiving an AC medication and they were not monitoring for signs of active bleeding, but they should to ensure Resident 44 was not having adverse side effects from the medication and staff would know how to care for her while on a blood thinner medication. <Sleep Medications> <Resident 85> Review of the February 2024 POs showed Resident 85 received a medication for sleeping daily. Review of the February 2024 MAR showed no documentation to assess and/or monitor the sleeping hours to determine if the medication was effective or not. In an interview on 02/26/2024 at 1:56 PM, Staff G reviewed Resident 85's record and stated there should be indications to monitor Resident 85's hours of sleep to determine if the medication was helpful, but there was none. Staff G stated the monitoring of a resident's sleeping hours was very important to identify if the medication was effective, but they missed that. Refer to F655- Baseline Care Plan. Refer to F842- Resident Records - Identifiable Information. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to ensure 3 of 5 sampled residents (Residents 32, 10, & 17) reviewed for Pressure Ulcers (PUs)/Pressure Injuries (PIs), received prescribed pressure reducing measures and repositioning on a consistent basis. Resident's 32 and 10 experienced harm when they developed facility acquired PUs. This failure placed all residents at risk for PI/PU development, and a diminished quality of life. Findings included . <PU Staging Guide> Review of the facility provided guided titled, Gentell PI Staging and Care Plan Considerations, dated 2019, showed a PI/PU was defined as damage to the skin and underlying tissue usually over a bony prominence. The guide showed PI/PUs could present as intact skin or an open ulcer and might be painful, and these injuries occurred as a result of intense and /or prolonged pressure or pressure in combination with shearing. A Deep Tissue Pressure Injury (DTPI) presented as intact or non-intact skin that was non-blanchable deep red, maroon, or purple discoloration, or epidermal (outer, protective layer of skin) separation revealing a dark wound bed or blood-filled blister. Stage II PU was defined as a partial thickness loss of skin with exposed dermis (sensitive connective tissue layer under the outer layer of skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. A Stage III PU was defined as full thickness loss of skin, in which fat tissue was visible in the ulcer and rolled wound edges were often present. Slough and/or eschar might be visible and obscure the extent of tissue loss which would then be defined as an Unstageable PU. <Facility Policies> Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, showed nursing staff and the practitioner would assess and document an individual's risk factors for developing PIs/PUs such as immobility, recent weight loss, and a history of PUs. The policy showed the nurse would describe and document a full assessment of a PU including location, stage, length, width, and depth, and the provider would assist the staff in identifying the type of PI/PU. Review of the facility policy titled, PI Overview, revised March 2020, showed PI/PU referred to damage to the skin and/or underlying soft tissue usually over bony prominence. A PI would present as intact skin and could be painful. A PU would present as an open ulcer, the appearance would vary depending on the stage and could be painful. PI/PU's occurred as a result of intense and/or prolonged pressure or pressure in combination with shear. Shearing occurred when layers of skin rubbed against each other or when the skin remained stationary, and the underlying tissue moved and stretched and angulated or tore the underlying capillaries and blood vessels causing tissue damage. DTPI presented as a persistent non-blanchable deep red, maroon, or purple discolored area of skin. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealed a dark wound bed or blood-filled blister. Pain and temperature change often preceded skin color changes. Review of the facility policy titled, [Facility] Living - Weekly Skin Audit Guidelines, revised 08/25/2020, showed weekly skin audits would be completed on all residents by a licensed nurse. This policy showed that all new PI's required implementation of weekly wound assessments to be done by a licensed nurse <Resident 32> According to the 01/18/2024 Admission/5-day Minimum Data Set (MDS- an assessment tool), Resident 32 admitted to the facility on [DATE], had no memory impairment and had diagnoses including diabetes (high blood sugar), malnutrition, and depression. According to this assessment, Resident 32 required extensive assistance with bed mobility and was at risk for developing PUs. According to the 01/12/2024 nursing admission skin assessment, Resident 32 admitted with no PU. A 01/12/2024 Braden scale (a tool identifying the risk for forming PUs) showed Resident 32 was at high risk for developing PUs. The 01/12/2024 Skin Care Plan (CP) showed Resident 32 had the potential for alteration in skin integrity. Nursing interventions included instructions to staff to keep skin clean and dry, report any new skin impairments to nurses, and for nurses to complete weekly skin assessments. Review of a nutritional assessment, dated 01/16/2024 upon admission, completed by the Registered Dietitian (RD), showed Resident 32 was at high risk for skin break down. A 01/19/2024 Care Conference note showed Resident 32 stated my butt hurts when sitting up in the chair. A 01/23/2024 weekly skin audit showed Resident 32's skin was intact and Resident 32 had no PUs. Review of the 01/30/2024 Nursing Progress Note (NPN) showed Resident 32 had an open area that measured as 1.0 cm (centimeter)X 0.5 cm X 0.5 cm on their tailbone area. This note showed Resident 32 preferred to lay on their back and did not want to be on their sides due to shoulder pain. A 01/30/2024 Physician Order (PO) directed staff to apply a barrier cream to Resident 32's buttocks after every incontinent episode. Review of the February Treatment Administration Record (TAR) showed Resident 32 received treatment to their buttocks as ordered. On 02/01/2024 the Skin CP was revised to include a small open area to Resident 32's tailbone. Interventions included an air mattress. A 02/12/2024 PO directed staff to cleanse a wound, apply medication, and cover with a dressing daily. This order did not specify the site for the wound treatment. The 02/19/2024 PO directed staff to apply a treatment to the open wound on Resident 32's tailbone area. Review of the Resident 32's records showed the resident's tailbone wound was assessed by a contracted wound provider on 02/18/2024 now measuring 0.6 cm X 0.3 cm X 0.1 cm. The wound provider recommended that staff reposition Resident 32 every two to three hours per facility protocol and recommended an RD evaluation for interventions. Observations on 02/20/2024 at 9:39 AM, 11:57 AM, and 2:11 PM, on 02/21/2024 at 9:04 AM, 11:30 AM, and 1:52 PM, on 02/22/2024 at 8:10 AM, 10:23 AM, and 1:33 PM, on 02/23/2024 at 8:51 AM, 11:07 AM, and at 1:20 PM showed Resident 32 lying on their back on airmattress in their bed. In an interview on 02/21/2024 at 10:23 AM, Resident 32 stated they had a sore on their bottom. Resident 32 stated they did not want to get up in their wheelchair (w/c) because their bottom hurt. Resident 32 stated,staff were too busy to help me to get up in w/c and reposition me in my bed. In an interview on 02/22/2024 at 11:07 AM, Staff I (Certified Nursing Assistant - CNA) stated they tried to reposition Resident 32 in bed at times but Resident 32 refused to be on their side. Staff I stated they did not document the refusals. Staff I stated they should have documented the refusals and notified the RCM. Observation on 02/27/2024 at 12:52 PM showed Staff P (Licensed Practical Nurse- Wound Nurse) providing wound care to Resident 32. Resident 32's tailbone wound was covered with a bordered gauze dressing. Staff P removed the dressing, assessed the wound that measured 2.0 x 0.5 x 0.3 cm. The wound had mild clear color drainage with no odor. Staff G (Resident Care Manager - RCM) joined the wound nurse to assess the wound. Staff G stated the wound base was covered with slough (dead cells) and was a Stage 3. In an interview on 02/26/2024 at 1:29 PM, Staff G stated they expected staff to reposition residents every two to three hours in bed and in their w/c to reduce the risk for PUs. Staff G stated staff should document if residents refused care and notify RCM and Social Services to follow up. Staff G Stated they knew Resident 32 was at high risk for developing PUs but staff missed implementing interventions to prevent PUs. Staff G stated they did not follow the contracted wound provider's recommendations on 02/18/2024 to reposition Resident 32 or obtain an evaluation from the RD. Staff G stated they should have notified the RD about Resident 32' PUs but they did not. In an interview on 02/26/2024 at 2:16 PM, Staff Q (RD) stated they assessed residents upon admission, quarterly and as needed. Staff Q stated they reviewed residents with weight loss and PUs issues in a weekly nutrition meeting with nurse managers. Staff Q stated they were unaware of Resident 32's PU and did not assess Resident 32 after they developed a PU. In an interview on 02/27/2024 at 2:28 PM, Staff B (Director of Nursing) stated monitoring, early identification of skin impairments, and implementing PU prevention timely were important to maintain skin integrity and to prevent new PUs from developing. Staff B acknowledged the nurses did not follow the instructions for preventative measures which resulted in Resident 32's new PU on their tailbone. Staff B stated it was very important for staff to update resident's CPs according to the assessment, to follow the provider's recommendations, and to ensure residents were free from new PUs and pain related to PUs, but they did not. 47836 <Resident 10> According to the 01/26/2024 Quarterly MDS, Resident 10 was able to make themselves understood and was able to understand others. The assessment showed Resident 10 required physical assistance with moving to and from a lying position, turning side to side, and positioning their body while in bed. Resident 10 required maximal assistance with lower body dressing and putting on/taking off footwear. The MDS showed Resident 10 had a diagnosis of weakness or complete paralysis of one side of their body, affecting their dominant right side. According to the MDS, Resident 10 was at risk for developing PUs. Review of a 11/15/2023 PO for Resident 10 showed an order to complete weekly skin assessments. These PO's showed a 02/08/2024 order that directed staff to monitor Resident 10's right second medial toe blood filled scab every shift, this being the first notation of the wound in Resident 10's records. A PO initiated on 02/13/2024 directed nursing staff to treat Resident 10's right medial second toe wound. These orders did not show any pressure reduction methods in place for Resident 10's toe. Record review of Resident 10's revised 12/12/2023 at risk for impaired skin integrity CP, showed Resident 10 would not develop new skin breakdown. This CP showed interventions for a LN to complete weekly skin checks, and for staff to provide assistance with repositioning. This CP did not have the right second toe medial PI documented on it. The CP did not identify the right great toe positioning that caused constant pressure to the second toe therefore they did not have interventions in place to reduce the pressure to this area. Review of a 01/10/2024 weekly skin assessment showed Resident 10's skin was intact and showed Resident 10 had no skin irregularities. Review of a 02/14/2024 weekly skin assessment showed Resident 10 had a skin irregularity to their right medial second toe and the irregularity was not new. This skin assessment only noted a skin irregularity to Resident 10's right second toe but did not document an assessment of the wound itself to include measurements, color, if there were any signs of infection or drainage noted. Review of Resident 10's weekly skin assessments showed the skin assessment was not completed, as ordered by the Physician, on 01/17/2024, 01/24/2024, 01/31/2024, and 02/07/2024. Observations on 02/21/2024 at 8:53 AM, 10:48 AM, and 12:22 PM, on 02/22/2024 at 9:02 AM, 11:51 and AM, 02/23/2024 at 9:13 AM, 02/27/2024 at 8:45 AM, and 1:54 PM, and on 02/28/2024 at 12:53 PM showed Resident 10 lying in bed on their back with the head of the bed elevated 90 degrees and blankets draped over their toes. On 02/21/2024 at 12:48 PM Resident 10 stated they had a wound that developed to their right second toe which caused them pain at times. A wound care observation and interview on 02/27/2024 at 10:52 AM showed Resident 10 lying in bed on their back. Staff F (Licensed Practical Nurse) stated Resident 10's right big toenail was pressed against the right second medial toe causing pressure to the right toe where the wound had developed. The right second medial toe wound measured 1.3 cm wide by 2 cm in length and presented as a circular dark purple area with open skin rolled around the wound edges. Staff F stated Resident 10 often refused care and stated refusals should be documented in Resident 10's medical records, and staff should notify the RCM of refusals. Staff F stated they did not document the refusals but should have. Staff F stated the RCM was aware of Resident 10's frequent refusals of care. Review of Resident 10's records showed a 02/27/2024 provider note stating they were informed of a new wound to Resident 10's right second toe on 02/26/2024 and that it appeared their right great toenail had rubbed the right second toe causing the DTPI. This note showed Resident 10 was at risk of delayed wound healing due to unstable blood sugars and right-sided hemiplegia (weakness or complete paralysis of one side of their body.) During an interview on 02/26/2024 at 10:09 AM Staff E (RCM) stated Resident 10's weekly skin assessments were not completed on 01/17/2024, 01/24/2024, 01/31/2024, and 02/07/2024, but they should have been. Staff E stated the weekly skin assessments were important to prevent new skin issues and note any skin issues before they caused the resident to develop a PI/PU. Staff E stated Resident 10's right great toe turned toward their second toe causing the toenail to press into the side of the second toe. Staff E stated there was not any pressure reduction methods in place between Resident 10's right great toe and their second toe prior to development of the PI, but there should have been. Staff E stated they placed the original PO for the wound treatment but was unable to state when the PI developed due to the incomplete weekly skin assessments and no NPN's documenting when the wound developed. Staff E stated Resident 10 did not have a CP for their right second toe medial PI, right sided hemiplegia, or adult failure to thrive (lack of motivation/ability to perform Activities of Daily Living (ADLs) on own with impaired physical function, malnutrition, depression, and cognitive impairment being the 4 main symptoms), but they should have so staff knew how to care for Resident 10. During an interview on 02/26/2024 at 11:43 AM Staff A (Administrator) stated there was no investigation logged or completed for Resident 10's facility acquired PI, but there should have been. During an interview on 02/27/2024 at 11:13 AM Staff E stated they investigated Resident 10's records further because they thought it was the podiatrist that cut their toe when trimming Resident 10's toenails. Staff E stated the podiatrist did not cut the resident, and the wound was a PI caused by the toes pressing together. 46479 <Resident 17> Review of the 09/21/2023 Quarterly MDS showed Resident 17 had no memory impairment and diagnoses included a brain bleed with impaired mobility to one side of their body, end stage kidney failure, and diabetes. The assessment showed Resident 17 was at risk for developing PUs and did not have any current PUs. Review of a 02/07/2024 Significant Change MDS showed Resident 17 developed one Unstageable PU and one DTPI. <Heel DTPIs> Review of a 01/03/2024 incident report showed Resident 17 complained of pain to their right heel. The incident report showed staff identified a wound measuring 1.0 cm by 1.0 cm. A 01/04/2024 NPN showed Resident 17 had a DTPI to their right heel. A 01/09/2024 Physician progress note showed resident with a new [DTPI] to left inner heel . [left lower extremity] was directly on the edge of calf bolster (a device used to protect a resident's legs from injury while in a wheelchair). This progress noted showed Resident 17 had conflicting appointments during the time the facility's contracted wound team was in the facility and the physician instructed the RCM to contact wound team for a consult at a non-conflicting time. There were no progress notes indicating facility staff contacted the wound team for a consult. There were no assessments in Resident 17's record indicating Resident 17 was assessed by the contracted wound team as ordered by the provider. A 01/11/2024 PO instructed staff to provide treatment to Resident 17's left lateral heel. Review of Resident 17's revised 01/12/2024 CP showed Resident 17 had a skin tear to their right lateral heel. This CP showed Resident 17 would wear bilateral foam boots at all times. This CP did not identify a right heel DTPI or any skin impairment related to Resident 17's left heel. The CP did not instruct staff to assess, measure, or document the condition of the right heel. The CP directed staff to provide the treatment as ordered and did not have an intervention to include the facility's contracted wound team in Resident 17's care. Review of Resident 17's wound and skin assessments showed a 02/02/2024 weekly skin audit. This audit showed [left] heel continued with treatment . There were no other wound or skin assessments in Resident 17's record indicating staff were monitoring and assessing Resident 17's right and/or left heel. Review of a 02/15/2024 PO directed staff to cleanse Resident 17's left lateral heel, apply a medicated treatment and cover with a bandage. The diagnosis for this PO was indicated as a DTPI for the right lateral heel. There were no clarifying POs in Resident 17's record to indicate if Resident 17 had a DTPI to the right heel, left heel, or both. In an interview on 02/27/2024 at 11:55 AM, Resident 17 stated they obtained the DTPI on their right heel from it resting on their wheelchair footrest. Observation on 02/28/2024 at 11:27 with Staff C (Regional Nurse Consultant) showed Resident 17 lying in bed on their back. Staff C removed Resident 17's socks. There was no dressing observed to Resident 17's right or left heel. A small, nickel sized darkened discolored area was noted to Resident 17's right lateral heel and a large, golf ball sized darkened discolored area was noted to Resident 17's left lateral heel. Both of Resident 17's feet were observed to be dry and had large pieces of flaky skin. Staff E peeled large pieces of skin from the discolored area to Resident 17's left heel. Underneath the dry skin, a large, darkened discolored area remained. Staff C pressed on the discolored area of Resident 17's left heel and could not determine if the area was blanchable (process to determine if there is adequate blood flow to compressed skin) or not. At that time, Resident 17 stated they had no feeling in their left foot and could not feel Staff C pushing on their foot. In an interview on 02/28/2024 at 11:50 AM, Staff C stated they could not determine what the area on Resident 17's left foot was. Staff C stated the area needed to be evaluated by the facility's contracted wound team. Staff C stated all DTPI's and areas of skin impairment should be measured and assessed per the facility's policy. Staff C confirmed there was missing documentation regarding monitoring, measuring, and assessing Resident 17's right and left heel. <Tailbone PU> Review of a 01/08/2024 incident report showed Resident 17 was found to have a 4 cm by 8 cm open area to their tailbone area. Review of Resident 17's revised 01/12/2024 CP showed Resident 17 had an unstageable open area to their tailbone. The CP showed Resident 17 was provided with an air mattress for pressure relief, Resident 17 was to turn and reposition every two to three hours, and staff were to provide the treatment as ordered. The CP did not identify how the PU would be monitored. A 02/11/2024 PO instructed staff to cleanse the tailbone wound daily, apply a medicated dressing, and cover with a foam bandage. Review of Resident 17's skin and wound evaluations showed an evaluation was completed on 01/09/2024 and showed the tailbone PU area measured 12.9 cm, was 6.2 cm long and 3.3 cm wide. The evaluation was incomplete and did not address the location of the wound. The next evaluation was not completed until 01/29/2024, nearly three weeks later, and showed the PU increased in size with the area measuring 24.6 cm, length was 9.4 cm and width was 4.2 cm. The remaining evaluations were completed on 02/06/2024 and 02/15/2024. Record review on 02/28/2024 showed no further evaluations were completed for Resident 17's tailbone PU. In an interview on 02/27/2024 at 12:10 PM, Staff E stated the tailbone PU was evaluated weekly on Mondays. Staff E confirmed there were missing assessments and stated maybe the resident was out, maybe we missed [the assessments]. Staff E stated the contracted wound team assessed Resident 17's PU by looking at the weekly photographs and measurements obtained by Staff E. Staff E stated the contracted wound team called Staff E at the end of the day on Monday's with recommendations for Resident 17's wound. Staff E stated the recommendations were not formally documented. Staff E could not provide any documentation showing the contracted wound team assessed Resident 17's PU. In an interview on 02/28/2024 at 12:26 PM, Staff C confirmed there was no record of the contracted wound team assessing or evaluating Resident 17's PU. Refer to F609 - Reporting of Alleged Violations Refer to F610 - Investigate/Prevent/Correct Alleged Violation REFERENCE WAC: 388-97-1060 (3)(b).

Based on interview and record review, the facility failed to ensure supervision was provided to residents at the care level they were assessed to require for 2 of 3 residents (Resident 66, & 31) reviewed for falls. Resident's 66, who had a change in condition and increased weakness, experienced harm when they fell when left unsupervised resulting in a fractured right hip and to Resident 31, who required extensive assistance from staff with toileting, was left on the toilet without supervision resulting in a fall with a skin tear and left foot fracture. These failures placed all residents at potential risk for avoidable falls, injuries, and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Assessing Falls and Their Causes, revised March 2018, showed residents must be assessed upon admission and regularly afterward for potential risk of falls and that any relevant risk factors must be addressed promptly. This policy showed appropriate interventions taken to prevent future falls would be recorded in the residents Electronic Health Record (EHR). Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, revised July 2017, showed the Incident Reports (IR) for the facility would be reviewed by the Safety Committee for trends related to accidents or safety hazards in the facility and to analyze any individual resident vulnerabilities. <Resident 31> According to the 01/24/2024 Admission 5 Day Minimum Data Set (MDS- an assessment tool), Resident 31 admitted to the facility on [DATE], and was assessed with no memory impairment, and demonstrated no rejection of care. Resident 31 received pain medications, antianxiety (AA), and antidepressant (AD) medications on seven of seven days during the assessment period. Resident 31 had a history of falls. The MDS showed Resident 31 used a wheelchair (w/c) for mobility and required extensive assistance from staff with toileting and one person assistance with transferring from bed to w/c and w/c to bed. During the admission assessment, a fall risk evaluation was completed on 01/18/2024 with a score of 12, showing Resident 31 was a fall risk. Review of the 01/18/2024 Fall Care Plan (CP) showed Resident 31 was a fall risk related to a history of falls, AA, and AD medications. Nursing interventions instructed staff to keep Resident 31's call light within reach, keep their bed in the lowest position except during care, and update the fall risk assessment post fall and quarterly. The CP directed staff, Do not leave the resident unsupervised in bathroom (BR)/on bedside commode. Review of the undated Kardex (communication guide for CNAs about individual resident's needs) directed staff Do not leave the resident unsupervised in BR/on bedside commode. Review of a 01/27/2024 provider note showed Resident 31 was a fall risk and recommended staff keep Resident 31's bed in the lowest position to decrease the risk for injury related to falls. Observations on 02/20/2024 at 10:21 AM and 1:18 PM, on 02/21/2024 at 8:50 AM, 10:02 AM, and 1:20 PM, on 02/24/2024 at 10:22 AM and 2:43 PM showed Resident 31 lying in their bed. The bed was not observed in the lowest position and was 24 inches from the floor (standard bed height). In an interview on 02/22/2024 at 8:50 AM, Resident 31 stated they needed help to go the BR for bowel movements (BM). Resident 32 stated sometimes they had to wait for more than 35 minutes to get help. Resident 31 stated a couple of weeks ago, I fell in the BR and broke my toe. Resident 31 stated their broken toe was very painful at times and pain medications helped to relieve their pain. Review of the 02/07/2024 Nursing Progress Note (NPN) showed Resident 31 was observed lying on the floor in the BR with a skin tear to their left elbow measuring 1.0 centimeter (cm) X 2.0 cm and posterior left forearm measured 1.5 cm X 2.5 cm. Resident 31 denied any pain at that time. Staff notified the Physician and provided first aid to Resident 31. Review of the investigation showed Resident 31 had a fall on 02/07/2024 at 7:05 PM in the BR in their room. In a statement, the assigned Staff S (Certified Nursing Assistant - CNA) documented Around 7:01 PM, Staff S put the resident in the BR to use the toilet, gave the call light to call the staff when finished and Staff S waited outside the BR door for privacy. Around 7:05 PM Staff S heard a scream and went to see the resident in the BR. Staff S noticed Resident 31 lying on the floor inside the BR with skin tears on left arm and elbow. The 02/08/2024 investigation note showed Resident 31 was alert, forgetful, and required education on safety, transfers, and call light usage. A copy of the 02/08/2024 left foot X-rays report attached with the investigation showed Resident 31 had a non-displaced fracture at the base of their left great toe. There was no documentation in Resident 31's record showing Resident 31 complained of foot pain or staff communication with the provider about the foot pain which resulted in a Physician Order (PO) for an X-ray on 02/08/2024 related to left toe fracture. Review of the 02/09/2024 PO directed staff to splint (a device to support and protect the broken bone) Resident 31's left great toe by taping second toe to their great toe, to check capillary refill the toenail beds every shift, and to keep splint intact for 21 days. Observations on 02/21/2024 at 11:00 AM, 02/22/2024 at 12:23 PM, and 02/23/2024 at 3:33 PM showed no splint taped Resident 31's left second toe to their left great toe. In an interview on 02/23/2024 at 11:23 AM, Staff J (Licensed Practical Nurse - LPN) stated Resident 31 refused to have the splint on their left great toe and Staff J documented the refusals on treatment administration record. Staff J stated they did not document the communication with the provider in Resident 31's record. Staff J stated they should have documented in Resident 31's record but they did not. Staff J stated they did not notify the RCM and Social Services (SS). In an interview on 02/26/2024 at 2:19 PM, Staff H (Resident Care Manager) stated Resident 31 had poor safety judgement and was forgetful at times. Staff H stated the CP instructed staff not to leave the resident alone in the BR, but staff left the resident unsupervised in the BR and caused Resident 31 to have a fall with fracture. When Staff H was asked about the documentation about Resident 31's left toe fracture, Staff H reviewed Resident 31's record and stated they did not document Resident 31's complaint of foot pain or communication with the provider for an X-ray order. Staff H stated they were unaware of Resident 31's refusals of left great toe splinting as ordered by the provider. Staff H stated staff should have notified the RCM, SS, and the provider and documented in Resident 31's record, but they did not. In an interview on 02/27/2024 at 2:38 PM, Staff B (Director of Nursing - DNS) stated they expected staff to assess the resident at admission, post fall and quarterly and update the CP as needed. Staff B stated to update and follow the CP was very important to provide the necessary care to residents. Staff B stated the facility was aware of Resident 31's fall risk and left the resident alone in the BR and caused a fall with fracture. Staff B stated staff should not have left the resident alone in the BR. 47836 <Resident 66> According to 12/09/2023 Significant Change MDS, Resident 66 was assessed to have moderate memory impairment. The assessment showed Resident 66 had difficulty with hearing. The MDS showed Resident 66 had diagnoses of right hip fracture, history of unspecified falls, hemiplegia (weakness or complete paralysis of the entire one side of the body) affecting their left side, repeated falls, and generalized muscle weakness. The assessment showed Resident 66 required maximum assistance with transfers from chair to bed and bed to chair since diagnosis of Covid -19 (a highly contagious respiratory illness) and Shingles (a contagious painful, burning skin rash). Review of Resident 66's Activity of Daily Living CP revised on 10/17/2023 showed Resident 66 required one person assistance with dressing, transfers, and mobility. Resident 66's communication CP dated 10/03/2023 showed Resident 66 preferred communicating face to face, speaking clearly and concisely with the TV off, and limiting other background noises due to hearing deficit. Resident 66 was assessed to be a high fall risk related to history of falls with serious injury and incontinence on 10/03/2023 with interventions to keep bed in lowest position and resident required one person assist with all transfers. Resident 66 had a 10/16/2023 AD medication CP with an intervention to monitor for unsteady balance. Resident 66's Restorative Nursing Program CP dated 11/17/2023 showed they required one person assist and walker with ambulation (prior to significant change). Resident 66 had a Covid-19 CP dated 11/27/2023 showing they were on isolation precautions and to keep their door closed. Review of Resident 66's NPNs showed an 11/27/2023 provider note stating Resident 66 was a high fall risk and their reason for admission was due to falls. An 11/28/202 skilled NPN showed Resident 66's gait was unsteady, they had poor balance, and they were positive for Covid and were on isolation precautions. A 12/01/2023 NPN showed Resident 66 was on isolation precautions for positive Covid 19 and Shingles. A 12/07/2023 NPN showed Resident 66 had returned from the hospital after the surgical repair of the right hip fracture. Review of an 11-29-2023 Fall Risk Assessment showed Resident 66 was confined to a chair and oriented, required hands on assistance to move from place to place, was unable to independently come to a standing position, and required an assistive device such as a wheelchair. This fall risk assessment showed Resident 66 had one to two falls within the last six months and scored 13 which defined them as a moderate fall risk. Review of a 12/01/2023 fall IR showed Staff FF (CNA) went to answer Resident 66's call light that was on and asked them what they needed from the doorway. Staff FF was in the hallway outside of Resident 66's room putting on personal protective equipment due to Covid -19 isolation precautions when they heard a loud noise. Resident 66 was observed to be on the floor near their bed. The CNA notified the nurse on duty who went to assess Resident 66 immediately and noted the call light was within reach but not used or on. The IR showed Resident 66 had predisposing complications of gait imbalance (unsteady) while walking and recent illness (Covid 19 and Shingles). The IR showed the fall was unwitnessed. During an interview on 02/21/2024 at 8:38 AM Resident 66 stated they had a fall on 12/01/2023 breaking their right hip which required surgical repair. Resident 66 stated they required two CNAs for assistance at the time due to general weakness from Covid and that two CNAs had helped them to the sink. Resident 66 stated they were standing at the sink while the two CNAs went outside of their room into the hallway when their legs got tangled up and they fell . Resident 66 stated the CNA and nurse came back into the room after they fell . During an interview on 02/26/2024 at 9:09 AM Staff E (RCM) stated when a resident was assessed to be a fall risk, they expected staff to remain with the resident during cares, especially standing. If there was a concern that a resident, who was assessed to be a high fall risk and had a history of falls with serious injuries, would attempt to self-transfer they would implement a one-to-one caregiver to always stay with the resident. Staff E stated Resident 66 was positive for Covid and Shingles just prior to their fall and had experienced a change in condition causing them to have an increase in general weakness overall which should have been updated on Resident 66's CP to direct staff to stay with them while standing and providing care, but it was not. During an interview on 02/27/2024 at 9:19 AM Staff R (CNA) stated they were expected to stay with resident that were assessed to be a high fall risk while providing cares. Refer to F609 - Reporting of Alleged Violations Refer to F610 - Investigate/Prevent/Correct Alleged Violation REFERENCE WAC: 388-97-1060 (3)(g).

Based on observation, interview, and record review the facility failed to ensure residents were protected from COVID-19 (Coronavirus - a contagious disease). (1) The facility did not have a system in place to ensure staff followed Infection Control (IC) practices to prevent exposure to or the spread of COVID-19. (2) The facility failed to ensure 15 (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9,10,13,18,19, 20, and 21) of 15 Residents who were actually and/or potentially exposed residents to COVID-19 infection were isolated and/or placed in quarantine to prevent the spread of Coronavirus. (3) The facility failed to investigate incidents of Coronavirus infections in the facility and conduct a root-cause analysis and identify where a breech in IC practices occurred in order to remedy actual or potential areas of concern and prevent further COVID-19 transmission to the residents. (4) The facility failed to ensure staff used required Personal Protective Equipment (PPE) when providing care during a COVID-19 outbreak for seven of seven staff members. As of [DATE] these failures caused 24 residents to acquire the COVID-19 virus and placed all other residents at risk for infection with COVID-19. These failures resulted in harm to two residents (6, 13), and caused 24 residents to acquire the virus placing them at risk for serious illness and death. At least two residents, Resident (6 and 13) were hospitalized . And the virus contributed to the death of resident (13). Findings include . Failure to ensure prompt quarantine Review of the facility's [DATE] Infection Control Policy and Procedure read: The Infection Control Preventionist (ICP) will conduct an ongoing surveillance for Health Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative measures. The policy also instructed the ICP to, Determine which residents received direct care from HCP (Health Care Personnel) and had unprotected exposure to HCP who worked with symptoms of COVID-19 or in the 48 hours prior to symptom onset. Review of the daily staffing schedule showed, Staff N, Nursing Assistant Certified (NAC), provided resident care on the night shift on [DATE], [DATE], and [DATE]. On the night of [DATE], Staff N received the results of a positive COVID-19 test. On [DATE] Staff N notified Staff L, Staffing Coordinator (SC) of the COVID-19 positive result. Staff L notified Staff B, Director of Nursing Services (DNS) about Staff N's COVID-19 positive test result on [DATE]. Review of the facility NAC schedule and assignment sheet showed three days prior to testing positive for the COVID-19 infection, Staff N provided care to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 on [DATE], [DATE], and [DATE]. Review of Residents' clinical records and infection control records showed no documentation the facility identified these residents or any potential staff in the facility that could have been actually/potentially exposed to Staff N within two days prior to Staff N's positive results for COVID-19 infection. Staff B, in an interview on [DATE] at 11:00 AM, was asked what steps the facility took to prevent the spread of the COVID-19 infection when the facility was alerted to Staff N's positive COVID-19 results. Staff B stated they could not confirm the facility took any steps, like quarantining exposed residents, to prevent the spread of the COVID-19 infection. Staff B in the [DATE] 11:00 AM interview was asked to provide documentation that the facility identified Residents (Resident 1, 2, 3, 4, 5, 6,7, 8, 9 and 10) that were actually/potentially exposed and subsequently placed on quarantine precautions. Staff B was unable to provide any documentation. Staff B stated quarantining actual/potentially exposed residents was not done. Thus, the facility did not implement infection control practices. Investigation and Root cause analysis Review of the facility's [DATE] and [DATE] COVID-19 infection line list showed the facility was in a COVID-19 infection outbreak on [DATE]. By [DATE] the facility identified 24 Residents and 20 staff members tested positive for the COVID-19 infection. Two of these residents, Resident 6 and 13 were hospitalized . One resident, Resident 13, died . Resident 6 (a resident who was provided care three days in a row by staff N who tested positive for COVID -19) remained hospitalized . Review of the local health care authority's [DATE] documents to the facility showed the facility was in outbreak status as of [DATE] as defined by two or more staff or one resident with a positive COVID-19 test. The facility's December COVID-19 line list showed four staff were identified as COVID-19 positive on [DATE]. On [DATE] at 11:00 AM, Staff D, Infection Control Preventionist (ICP), was asked to provide the documents to support the facility identified how the COVID-19 infection started and spread throughout the facility (root cause). Staff D stated, they did not investigate to find the root cause of the infection outbreak in the facility. Staff D stated they were focused on organizing the COVID-19 unit and did not investigate the root cause of the infection. Staff D stated they were new to the role of ICP and unfamiliar with how to perform a root cause analysis. On [DATE] at 12:00 PM Staff A, facility Administrator, stated, they thought the investigation was to be conducted at the end of the outbreak. Failure to Maintain Infection Control Practices The facility's [DATE] Infection Prevention and Control Program showed .policies and procedures are utilized as the standards of the infection prevention and control program. The infection prevention and control committee, Medical Director of Nursing Services, Infection Preventionist and key clinical administrative staff review the infection control policies at least annually. The review will include: Assessment of staff compliance with existing policies and procedures as needed. Review of infection control records showed the facility had no documentation staff were monitored for compliance and competency with personal protective equipment (PPE, masks, respirators, gowns, gloves .) either before or after the [DATE] outbreak started. Also, there was no documentation to show the facility assessed staff activities on an ongoing basis including to ascertain sustained compliance and competence with PPE usage, hand hygiene/washing/sanitizing, social distancing, and disinfecting after the outbreak began. In an interview on [DATE] at 10:00 AM, when asked when the facility conducted monitoring for staff ability to implement infection control practices, Staff D did not answer and stated they did not get to that task yet. On [DATE] at 1:00 PM, when Staff C, Staff Development (SD), was asked to provide records of the facility's infection control monitoring, Staff C was unable to provide any documentation and stated, infection control monitoring was done, but not documented. Transmission Based Precautions According to the signage associated with the facility's infection control program and provided by the facility, staff were instructed to implement transmission based precautions (TBP) for each of the different isolation categories. According to the quarantine precaution sign, staff were to wear a respirator (tight fit tested N-95 mask), eye protection (face shield or goggles) and gown and gloves when providing care and services. The signage for droplet precautions instructed staff to wear an N-95 respirator, a gown and gloves when entering a resident's room that was COVID-19 positive. According to the facility's local LHJ recommendations issued to the facility on [DATE] related to use of PPE in part read: Appropriate PPE use is important for reducing transmission of COVID-19. Staff should wear gown, gloves, fitted N-95 respirators, and eye protection for each interaction with a COVID-19 positive resident or quarantined resident. Correct donning (put on) and doffing (put off) PPEs was important to ensure staff do not spread the virus to other residents and staff. On [DATE] at 7:30 AM, Staff G and Staff H, NACs, were observed Assisting Resident 1 and Resident 2 to eat breakfast. According to the facility's [DATE] staffing records and COVID-19 line list, Residents 1 and 2 were exposed to the COVID virus by Staff N on [DATE], [DATE] and [DATE]. According to the facility policy, the current Center for Disease Control and the LHJ exposed persons with or without symptoms of the COVID -19 virus should be in quarantine. There was no quarantine sign on the door instructing staff to wear PPEs specific for quarantine. Staff G and Staff H were not wearing specific required PPE (N95 mask, isolation gown and gloves) appropriate when providing care for potentially exposed residents, or residents on quarantine. On [DATE] at 2:45 PM Staff I , CNA, was observed entering Resident 3's and 4's room. Staff I was wearing a surgical mask not a respirator, was not wearing eye protection, a gown or gloves as instructed in the facility policy for infection prevention or the sign on the door. Staff I proceeded to assist Resident 3 with personal care, collection and disposal of soiled linen on the floor. Observation on [DATE] at 3:30 PM, of the sign on Resident 3's and Resident 4's door showed these residents were on quarantine precautions. The sign directed staff to don an N95 respirator, eye protection and a gown and gloves if providing care and services to the resident and prior to entering the room. On [DATE] at 8:30 AM, Staff H was observed wearing a surgical mask rather than the required N-95 respirator while assisting Resident 2 (a potentially exposed resident to Coronavirus) to eat breakfast meal. This room did not have the required quarantine sign posted to instruct staff on what PPEs to wear when working with a resident who was exposed to COVID-19 positive staff. In an interview on [DATE] at 7:30 AM, when asked why they didn't don appropriate PPE prior to assisting Resident 1 and Resident 2 to eat, Staff H stated, they were not aware Resident 1 and Resident 2 were on quarantine precautions as no one notified them. In an interview on [DATE] at 10:30 AM Staff C stated Residents 1 and 2 should have been in quarantine. And staff should use all required PPE (N95 mask, gown and face shield) prior to providing care for Resident 1 and Resident 2. Staff N95 Fit Testing and Improper Mask Usage According to the [DATE] Facility Respiratory Protection Program (RPP) Policy, employees who are required to wear tight-fitting respirators be fit tested ; prior to being allowed to wear any tight-fitting respirator. Additionally, the RPP administrator would document and maintain copies of fit test records for all employees covered under the program. Observation on [DATE] at 2:30 PM showed Staff K entering a resident room, wearing an N95 respirator on top of a surgical mask and provide care to Resident 17 and Resident 18. In an interview on [DATE] at 2:35 PM, when asked why they were wearing a surgical mask over a surgical mask, Staff K did not answer. Observation on [DATE] at 2:40 PM showed Staff J wearing a surgical mask over another surgical mask. When asked, Staff J did not answer. Observation on [DATE] at 3:45 PM showed Staff F, Registered Nurse (RN) who was assigned to a positive COVID -19 unit and a non-COVID-19 unit wearing an N95 mask over a surgical mask while providing resident care for COVID-19 positive residents and non-COVID-19 residents. In the interview on [DATE] at 3:50 PM, Staff F stated, they wear an N95 mask over a surgical mask to ensure adequate protection from contracting COVID-19. Staff F stated they got the information from the radio and television. On [DATE] at 2:45 AM Staff I, was observed wearing a regular surgical mask not an N-95 respirator while providing care for Resident 3 who was on TBPs for quarantine. Observation of signage on the entrance to Resident 3's room instructed staff to wear an N-95 respirator, a face shield and a gown when providing care for Resident 3 who was on transmission-based precautions. On [DATE] in the interview at 3:00 PM, Staff E, NAC, a staff member who was assigned to provide on the job training, said, they reported for work late and found Staff I, a newly hired NAC already on the floor providing resident care in a quarantine room. Staff E stated, they were not aware if Staff I was/wasn't fit tested for N95 mask. In an interview on [DATE] at 3:45 PM Staff I stated they were not fit tested for an N95 respirator. Staff I stated they did not know they needed to wear a special mask (N95) while providing care for Residents in a quarantine room. In an interview on [DATE] at 7:30 AM, Staff H stated, they were not fit tested for an N95 respirator before working with residents. Staff H stated, they used N95 masks when providing care for residents who were on quarantine precautions or was positive for COVID-19. When Staff C was asked how they determined what specific N95 was appropriate for their use, Staff C stated that, they used any mask with N95 printed on the mask. During an interview on [DATE] at 10:00 AM Staff C stated they would expect staff to wear the N95 respirator when providing care for residents who were potentially exposed and were in quarantine. Staff C stated that, Staff H should have been fit tested for an N95 respirator prior to providing resident care during the facility COVID-19 outbreak. During an interview on [DATE] at 10:30 AM Staff C was unable to provide proof of Staff H's and I's fit testing record and acknowledged Staff I and H were not fit tested for N95 respirators. REFERENCE: WAC [DATE](1)(a)(2)(a).

Based on interview and record review, the facility failed to ensure an environment that was free from accidents and that a resident received supervision for one (Resident 1) of four sample residents reviewed for accidents. The facility failed to implement interventions to prevent further falls for Resident 1. This failure resulted in harm when Resident 1 repeatedly fell , and on the third fall fell out of the wheelchair and sustained a contusion to the face and an extensive hematoma to the left side of the head that required an emergency room visit for treatment. Findings include: Facility's Fall Policy Review of the facility's 07/2009 policy for fall prevention entitled Resident Safety and Prevention of Accidents showed that: Standards The facility will utilize a systematic approach to the resident safety that includes the following: Identification of specific resident risks of potentially avoidable accidents including but not limited to falls (including falls out of bed); [CONDITION(S)] (smoking or other; resident behaviors that place a resident at risk for altercations; unsafe wandering; elopement; injuries including (entrapment) from assistive devices (including side rails, hoyer lifts, walkers, wheelchairs and other devices .All accidents and incidents are investigated for cause and interventions implemented. all accidents and incidents are reviewed daily at stand up meetings .Implementation of action plans and specific resident interventions to address potential risks and actual problems .Identification of the need for supervision (resident specific and environmental) as a means for accident prevention. Resident 1 According to the annual Minimum Data Set (MDS-an assessment tool) dated 07/28/2021, Resident 1 admitted to the facility on [DATE] with medically disabling conditions including extensive bilateral lower extremity wounds and major loss of tissue to the lower extremity and generalized weakness to the lower extremity. This MDS identified the resident required physical assistance of staff for all Activities of Daily Living (ADLs), including mobility, transfers, and toileting. Fall 1 Review of the Incident Investigation Report (IIR) dated 10/20/2021 showed on 10/2021 at 9:30 PM, Resident 1 had an unwitnessed fall in the resident's room. According to the IIR, the resident was found sitting on the floor next to the bed and the wheelchair. The resident said they were watching television when they fell asleep in their wheelchair and fell out of the wheelchair to the floor. The resident sustained a bump to the forehead measuring 4 CM x 4 CM. Further review of this IIR, showed the root cause of the resident's fall was due to falling asleep in the wheelchair and not in the bed. The staff also documented the resident's repeated failure to call for assistance before attempting to self transfer as a reason for the fall. This was despite the fact staff and the resident said the resident fell asleep and fell . On 11/23/2021 at 2:00 PM, in the interview, Staff I, Certified Nurse's Aide (CNA) who regularly provided care for Resident 1 stated, Resident 1 frequently self-transferred without asking for assistance. This staff provided no information about the resident's sleep patterns. Review of Resident 1's CP did not show staff revised Resident 1's CP promptly following this fall with interventions to prevent this from recurring. An intervention to encourage Resident 1 to nap in bed was initiated on 10/25/201, five days after the fall. Fall 2 Review of the IIR dated 10/23/2021 showed, on 10/23/2021 at 2:15 AM (three days after the first fall on 10/20/2021), Resident 1 experienced a fall from the wheelchair while attempting to pack belongings in readiness for a planned discharge home. Review of this investigation showed staff concluded the resident's medical diagnoses from extensive wounds and major loss of tissue to bilateral lower extremities resulted in generalized weakness to the resident's lower extremities and contributed to the resident's fall from the wheelchair. The resident did not sustain any injuries from this fall. This investigation report showed the cause of the fall was due to the resident's perseveration with the imminent discharge from the facility. Review of the 10/20/2021 investigation report showed the facility concluded that to prevent further falls, staff were to assist the resident with packing at the time of discharge. Further review of the investigation report did not show the facility addressed the resident's generalized weakness to the lower extremities to prevent further falls. Review of Resident 1's CP did not show revised interventions to prevent the resident from falling. Fall 3 Review of the IIR dated 11/10/2021, showed, on 11/10/2021 at 9:00 PM, Resident 1 fell again from the wheelchair and hit their face on the concrete floor, sustaining substantial bruising, contusion to the face and a hematoma to the right side of the head, when the resident fell asleep in the wheelchair. The resident was transferred to the hospital the following day on 11/11/2021 for further evaluation, after the resident experienced a change in condition. According to Resident 1, interviewed on 11/19/2021 12:30 PM, they were experiencing increased pain to the head and face. The resident stated they didn't feel well. The facility transferred Resident 1 to the hospital where the resident was diagnosed with extensive contusion (three quarters) to the face and a large hematoma to the right side of the head. Review of this investigation dated 11/10/2021 showed the root cause analysis documented; the resident was noted with pillows placed behind the back of the wheelchair causing the resident's hips to be placed at the edge of the wheelchair resulting in a fall. This investigation also documented; the resident did not have the ability to correct the positioning when the hips were positioned at the edge of the wheelchair. This investigation included, the resident frequently self-transferred without assistance from staff and indicated the resident was to be evaluated by physical therapy staff for a tilt-n-space wheelchair, which would allow the resident's hips to sit back further in the wheelchair preventing the resident from pitching forward while sitting in the wheelchair, to prevent further falls. Record review and interview on 11/15/2021 at 3:00 PM (five days since the resident's fall with substantial injuries), showed, the resident was not evaluated for the tilt-n-space wheelchair as indicated in the investigation's plan for fall prevention. Review of Resident 1's CP did not show staff revised Resident 1's CP to reflect measures staff were to take to prevent the resident from falling as indicated in the investigation report. On 11/15/2021 at 4:00 PM in the interview, Staff D, Physical Therapist (PT) stated, they were unable to complete Resident 1's evaluation for the tilt-n-space wheelchair as they did not work on the weekend. On 11/15/2021 at 4:30 PM, Staff C the Director of Rehabilitation acknowledged the resident needed to be evaluated immediately after the incident or immediately after the order was received from the doctor to prevent further accidents. Review of IIRs dated 10/20/2021, and 11/10/2021 did not show staff explored why Resident 1 fell asleep in the wheelchair and not in the bed. Review of the resident's medical record showed staff did not assess the resident to determine the resident's preferred bedtime, to ensure the resident was assisted to the bed at the preferred bedtime or hours of sleep. There was no assessment of the resident's sleep patterns and no monitoring of the resident's hours of sleep. This documentation was requested on 11/19/2021 but no documentation was received. Staff I stated, in an interview on 11/15/2021 at 2:00 PM, the resident frequently refused to sleep in the bed and stayed up and fell asleep in the chair at late hours. On 11/15/2021 at 4:00 PM, Staff B did not know Resident 1's preferred bed time and acknowledged the facility did not assess Resident 1's preferred bedtime as indicated in the facility's Resident Rights - self Determination policy and procedure, which instructed staff to assess residents on admission for their preferences/choices including preferred bedtime. This policy also instructed staff to ensure the resident's CP would be updated to reflect preferences and choices quarterly and as needed. Despite the staff's awareness of the resident's choice not to use the call light for assistance to transfer, keeping extra cushions behind the wheelchair, multiple incidents to self-transfer, and poor safety awareness Resident 1's CP did not show revised interventions to address how staff were to ensure the resident's supervision and safety. On 11/19/2021 at 12:30 PM, the Resident Care Manager (RCM) stated, the Director of Nursing Services (DNS) was responsible for completing IIRs and develop interventions to prevent recurrence. After Staff H, Resident Care Manager printed and reviewed Resident 1's CP, they acknowledged the CP was not revised to reflect preventative measures to prevent resident falls other than the first intervention dated 10/25/2021. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure residents were protected from COVID-19 (Coronavirus - a contagious disease). (1) The facility did not have a system in place to ensure staff followed Infection Control (IC) practices to prevent exposure to or the spread of COVID-19. (2) The facility failed to ensure potentially exposed residents were isolated in a prompt manner. (3) The facility failed to ensure employees screened as having one or more symptoms of COVID-19 did not expose other residents and staff, or follow up on questionable employee symptoms. (4) The facility failed to prevent staff from working between sets or units, increasing the likelihood for the spread of COVID-19 between staff and other residents. (5) The facility failed to conduct a root-cause analysis and identify where a breech in IC practices occurred in order to remedy actual or potential areas of concern and prevent further COVID-19 transmission to the residents. These failures placed the residents and staff at risk for infection with COVID-19, displacement to another nursing home, and death. On 08/06/2020, the facility was notified of an Immediate Jeopardy related to Infection Control. On 08/21/2020, the validation of the IJ removal occurred through observations and review of records, including staff education, audits, staff schedules, employee screening logs, policies and procedures, and medical records. Findings included . FAILURE TO CONDUCT A ROOT-CAUSE ANALYSIS Review of a COVID-19 Policy and Procedure, updated 07/20/2020, showed the facility would develop and implement strategies to reduce the risk of resident and staff exposure to COVID-19, to include processes for visitors and staff screening and restrictions, training and education of staff, and environmental cleaning and disinfection. This policy showed that, during COVID-19 outbreaks in the facility or the surrounding community, the facility would practice social distancing and cancel group activities, instruct residents to remain in their rooms as much as possible and to maintain at least six feet apart from one another. This policy also showed the facility would provide training for all employees to include hand hygiene, use of Personal Protective Equipment (PPE - gloves, mask, gown, face shield), types of precautions, and environmental cleaning and disinfection, and that training may include observations of staff during provision of care. On 08/19/2020 at 2:07 PM, Staff B, Director of Nursing Services confirmed 12 residents participated in a smoking group activity through 07/31/2020. Review of a 05/08/2020 policy titled CORONAVIRUS (COVID-19) MANAGEMENT showed that COVID-19 was thought to spread via droplets requiring close contact with others for a prolonged period of time and that, Droplets generally travel only short distances (approximately six (6) feet or less) through the air. If close contact occurs while not wearing all PPE, healthcare personnel may be at risk for infection. This policy also showed, We do not yet know how long COVID-19 remains infectious in the air. Review of a revised 10/05/2017 Smoking Policy and Procedure did not address how the staff would prevent COVID-19 transmission during smoking, to include social distancing, sanitation of smoking supplies like smoking aprons, lighters, e-cigarettes/vaping, storage, or use of PPE. Review of a 07/27/2020 Occurrence Report showed, On 7/17/20 resident (Resident #1) with temperature of 100.1, uncontrolled jerking arm and leg, unresponsive, stiff and wide open fixed eye that lasted for two minutes. Provider in house who saw resident and ordered stat (immediate) labs, COVID 19 test and to quarantine resident. This report showed that on 07/17/2020, the resident was placed in a single room, and on Transmission Based Precautions (TBP - used when contact with the resident, their body fluids, or their environment presents a substantial transmission risk despite adherence to standard precautions), and resulted positive with COVID-19 infection on 07/21/2020. This report also showed that, All residents with possible exposure due to Resident's (sic) smoker placed on Droplet/Contact precautions (a TBP) on 07/21/2020, and that on 07/23/2020, the facility instructed staff to start wearing face shield in addition to mask for all staff while in the building. This report showed that on 07/24/2020, Staff H, Activities Aide, resulted positive for COVID-19 infection and that, This particular positive staff (tested [DATE]) works in the Activity Department with multiple contacts with residents and supervise (sic) smokers It is highly probable that the resident positive with COVID 19 on 07/21/2020 may be infected by an exposure from the Activity Staff whom she came in contact with during smoking or doing activity in room. Review of a 07/31/2020 Occurrence Report addendum, completed 14 days after the initial case of COVID-19 symptoms, showed, (Resident #1) is a supervised smoker. (Staff H) supervises smoking most of the time and has multiple contacts with residents including 1:1 activities. (Resident #1) has not gone outside of the facility for any appointments. She has been in the facility with no outside visitors since March 2020. It is highly probably (sic) that (Resident #1) may have been infected by an exposure to the Activity Aide with whom she had multiple contact with during smoking or 1:1 visits. Review of the Occurrence Report and addendum did not show the facility evaluated potential breeches in IC practices or processes in place like visitors and staff screening, environmental cleaning and disinfection, appropriate use of PPE, compliance with social distancing, hand hygiene or sanitation, or current group activities. In an interview on 08/03/2020 at 3:13 PM when asked what measures were taken to prevent COVID-19 transmission during smoking sessions, Staff H stated, What we did was only a certain amount of residents could come out at a certain time. Make sure they are masked when they come out of their rooms, sanitize their hands and then we put the apron on and give them the ashtray along with the six feet distance. After they are done everything is sanitized from the ash trays and their hands and wipe down the aprons. When asked who was also designated to take the residents out to smoke apart from Activities Staff, Staff H stated, Concierge and also nursing at 6:30 PM. When asked if she had to come closer than six feet from the resident, Staff H stated, Only when lighting their cigarettes. Staff H stated a designated lighter was being used by Activities Staff to light the cigarettes for all the residents. When asked if the facility had asked her how she thought the COVID-19 transmission occurred, Staff H stated, That's a good question. I couldn't even tell you. They haven't asked me. When asked if any other group activities took place, Staff H stated, Bingo on Friday. Only a certain amount of residents came to the dining room, only a certain number, and then everything is sanitized. In an interview on 07/31/2020 at 3:31 PM, when asked if the facility continued with a Smokers Group from February through July, Staff I, Activities Director, stated, Yes, when we learned they were positive we stopped it. Staff I also stated, We had the six feet apart and made a schedule no more than six people at a time, but also we would be able to accommodate eight but to be safe we just did six (residents). Staff I stated, Everybody had assigned aprons. Cigarettes and lighters were in a plastic zipper bag, and that sometimes Activities Staff assisted the residents to light their cigarettes. Staff I stated the residents had their own lighters and that smoking supplies were kept at the Nurses Station. Staff I stated the residents were taken out to smoke four times daily and that Activities Staff supervised all but the evening smoke break at 6:30 PM, which some breaks were supervised by the nursing department or the concierge. When asked if she ever had to come closer than six feet of the resident when she supervised smoking, Staff I stated, Yes, we do because we have to help to wheel them in and to wheel them out and anybody you had to help light a cigarette, but not all the time. Staff I added, It (the COVD-19 outbreak) just happened. It's so sad. When asked if she had any idea how COVID-19 was transmitted to the resident or if the facility had asked for her input into the outbreak analysis, Staff I stated, I have no idea and No, they didn't interview me. In a joint interview with Staff C, Infection Preventionist/Registered Nurse (IP/RN) and Staff B on 08/06/2020 at 1:32 PM, when asked how the facility ensured the residents who smoked were protected from COVID-19 exposure, Staff C stated, The first thing we did was to make sure they have the right to smoke, and that there is a risk involved, and their consent to participate. Review of 07/21/2020 Risk and Benefit forms for Residents #4, #5, #6, #7, #8, #9, #10, #11, and #12 showed, Issue: Continuing to smoke after being exposed to a COVID-19 diagnosis. The form showed no documentation of steps the facility would take to ensure residents were protected from COVID-19 during smoking. The form showed the question Changes made to plan of care was blank for Resident #4, #7, #8, #9, #10, #11, and #12. A No was indicated for Resident #5 and #6. Review of the resident Care Plans showed, Notice of smoking suspension on 08/11/2020 due to facility COVD outbreak. Interventions to prevent COVID-19 infection were not included in any of the care plans. Eight of the 12 residents who smoked contracted COVID-19. On 08/26/2020 at 9:22 AM, when asked if any risks and benefits to continue smoking were reviewed with the residents at the time the COVID-19 pandemic ensued and the facility allowed the high-risk group activity to continue, Staff A, Administrator, stated The facility provided for social distancing from the start of the pandemic. There were no risks and benefits done at that time because limiting smokers was thought to be adequate. All other facilities that we were aware of continued to allow smoking. When asked if the risks and benefits form showed how the facility protected the residents when it allowed a high risk group activity to continue and, if not on the form, where would those interventions be found, Staff A stated, No care plan changes were made at the time. All residents wanted to continue to smoke. In the continued joint interview with Staff B and C on 08/06/2020, when asked what was the maximum amount of residents allowed to smoke at once, Staff C stated, We have up to 8 residents, up to six, sometimes we have three or four. When asked how the facility ensured the residents who participated in the smoking group were protected from COVID-19, Staff C stated, We have the smoking materials and products kept in a box which is zip locked where everyone has their lighters and cigarettes and contained separately. Hand sanitizers are used for the residents and they grab their own cigarettes out after hand sanitizing and they have aprons and are disinfected after smoking. Each ash tray is individually used and then the supervisor would take those ash trays and dump it into cigarette bin and sanitized again and locked up. Aprons are taken away after sanitized and hung back. The supervisors were wearing gowns and masks. When asked if the smoker's group continued after suspecting Resident #1 of COVID-19 infection, Staff C stated, The minute we find out Resident #1 is positive we stopped the smokers group on July 21st (four days after suspected of COVID-19). When asked if the smokers group resumed, Staff C stated, The RCMs (Resident Care Managers) reassessed the smokers to make sure they can hold and light it for themselves and restarted the smoking group on 07/28/2020. Review of a NOVEL CORONAVIRUS 2019 SURVEILLANCE LOG showed, 7/21/20 All residents with possible exposure due to Resident's (sic) smoker placed on Droplet/Contact Isolation precautions. This log showed resident #1 was transferred to another nursing home. When asked how IC practices or processes changed to prevent further spread of COVID-19 when Resident #1 was suspected and then identified as positive for COVID-19, Staff C stated, Wearing a mask was already in place. Review of the log showed on 07/24/2020, (Resident #2) and staff tested positive for COVID-19 . positive staff notified of her result and self-isolated. This log showed the resident was transferred to another nursing home. When asked how IC practices or processes changed to control the spread of COVID-19 in the facility when the second resident and first staff case were identified on 07/24/2020, Staff C stated, Staff self-isolated and face shields started being used and that was for all the staff. Review of the log showed on 07/27/2020, Two staff results came back positive. Both positive staff members home on self-isolation. Review of the log showed on 07/28/2020, 1 (One) symptomatic resident . received positive result today and transferred to (another nursing home) the same day. Review of the log showed on 07/29/2020, Results came back positive and all 3 three residents) were transferred to (another nursing home) on the same day. Review of the log showed on 07/30/2020, 15 (fifteen) residents and 9 (nine) staff member results were positive for COVID-19. All positive residents were placed on Special Droplet/Contact isolation. Staff members who were notified of their results and isolating themselves at home. Full PPE, Universal, to be worn by all staff during care and when entering resident rooms. When asked what processes changed to address the spread of COVID-19 on 07/30/2020, Staff C stated, Exactly what we were doing with the face shield. On July 30th we became totally PPE, a gown was added, and each and every room is considered as a COVID room and full gown before entering. Review of the log showed on 07/31/2020, 5 (five) staff member results came back positive for Covid-19. Staff members notified and isolating at home. When asked if IC processes changed on 07/31/2020, day 14 after the first initial symptoms of COVID-19 and when an additional five staff members resulted positive, Staff C stated, No changes, full PPE. When asked if all communal activities had stopped, Staff C stated, Smoking going on. Staff C failed to demonstrate the facility conducted or considered an analysis of how and why COVID-19 was spreading, to include a review of employee symptoms, staff allocation, staff competency and compliance with IC practices, and review of current group activities. By 08/06/2020, the facility had a total of 31 residents and 19 staff infected with COVID-19. In this joint interview on 08/06/2020 at 1:32 PM with Staff B and C, when asked if the analysis and investigation of the COVID-19 outbreak was complete, Staff B stated, Yes, and that no further information was forthcoming. FAILURE TO MONITOR INFECTION CONTROL PRACTICES Review of facility records showed audits were completed on staff PPE Competency Validation on March 25, 2020. This review showed no additional monitoring of staff compliance and competency with PPE usage was conducted until after the outbreak started, four months later. Also, there was no documentation to show the facility assessed Activities Staff on an ongoing or regular basis after March 25, 2020 to ascertain sustained compliance and competence with PPE usage, hand hygiene, social distancing and disinfecting of smoking materials. In an interview on 08/06/2020 at 9:22 AM, when asked when was the last time she recalled being assessed for IC practices for COVID-19 prevention, Staff H stated, I'd say the last time they did it was two or three weeks ago, a date range coinciding when the outbreak occurred. In the continued joint interview on 08/06/2020 at 1:32 PM with Staff B and C, when asked how the facility ensured staff complied with IC practices for COVID-19 prevention recommendations, to include Activities Staff during smoke breaks, Staff C stated, First of all, we do surveillance daily. We (IP and DNS) make sure people follow the right way of using PPE and handwashing and sanitizers. That's daily and ongoing. We did have a PPE video that we watched and a return demo (demonstration) that we did at the beginning of the outbreak of the COVID and it included the whole house (staff) including therapists, everybody. They watched the video and then after that we asked one by one to do a return demo. When asked when the last time staff competency and compliance was conducted, Staff C stated, March 25 (2020), and Then after that it's a random thing we have been doing with staff and new hires. No further documentation was provided by Staff B or C to show the facility monitored staff competency and compliance with IC practices for COVID-19 prevention between March 25, 2020 and July 23, 2020. FAILURE TO ENSURE PROMPT ISOLATION OF RESIDENTS Review of a NOVEL CORONAVIRUS 2019 SURVEILLANCE LOG showed that on 07/21/2020 the facility placed all residents with possible exposure to Resident #1 on Droplet/Contact precautions (a TBP). In an interview on 08/06/2020 at 1:32 PM, when asked if the facility already knew who was likely exposed to Resident #1 when she showed signs or symptoms of COVID-19 infection on 07/17/2020, Staff C stated, The only thing that triggered right away was the smoking. We didn't know exactly, but the people that are suspected is her roommate. They (the roommate) was put on quarantine. When asked if other residents who participated in the smoking group should have been quarantined on 07/17/2020 instead of four days later, Staff C stated, No. At that moment we don't know if they're going to be positive or not. Staff C acknowledged other residents who participated in the smoking group should have been quarantined on 07/17/2020 due to their potential exposure to COVID-19. Review of a facility infection surveillance map received 07/31/2020 showed a cluster of COVID-19 infections between Rooms 47 to 56 located in the North Unit. By 07/31/2020, 21 residents had become infected with COVID-19 in the facility. Of those 21 infected residents, 15 lived in the North Unit (where three residents who participated in smoking resided), one lived in the East Unit (where four residents who participated in smoking resided), two lived in the West Unit (where four residents who participated in smoking resided, including Resident #1) and three lived in the Medicare Unit (where one resident who participated in smoking and also Resident #2, the second positive resident case, resided). FAILURE TO ADDRESS STAFF MOVEMENT BETWEEN RESIDENTS In this continued interview of 08/06/2020 at 1:32 PM, when asked how the facility allocated staff with positive COVID-19 cases in the building, Staff C stated, Yes, we try our best as possible to make sure people stay in one unit but sometimes they have to float. We try to contain all the staff to working one unit as much as possible. We do our diligence that floating does not happen but if it does, it's a very small chance that the staff is floated. When asked if nursing staff were also assigned to supervise the smoking group, Staff C stated, Yes, it's assigned on our schedule. No records were provided by the facility to show which and when nursing staff were assigned to supervise the smoking activity. Review of staff schedules between 07/17/2020 and 07/31/2020 showed the facility allowed a pattern of staff working from one job description to another (shower aide to nursing assistant, restorative aide to nursing assistant, treatment nurse to floor nurse) or work between sets or units of residents that did not participate in the smoking group, to other sets or units with potentially exposed residents or residents who participated in the smoking group (07/17/2020, 07/18/2020, 07/19/2020, 07/20/2020, 07/21/2020, 07/22/2020, 07/24/2020, 07/25/2020, 07/26/2020, 07/27/2020, and 07/30/2020). By 07/30/2020, 17 staff had tested positive for COVID-19 infection, including a Treatment Nurse (Staff F) who floated to the floors, both Restorative Aides (Staff J and K), both shower aides (Staff L and M), and nursing assistants noted to work between sets or units or duties (Staff N, Staff O, Staff P, Staff Q). In addition, a facility policy dated 05/08/2020 and titled CORONAVIRUS (COVID-19) MANAGEMENT showed that for residents suspected with COVID-19, The facility will keep a log of all persons who care for or enter the rooms or care area of these patients. An observation on 07/27/2020 at 8:30 AM showed Resident #3 (roommate of Resident #1 who showed signs and symptoms of COVID-19 on 07/17/2020 and resulted positive on 07/21/2020) was on isolation. Review of a staff tracking log for Resident #3 showed no documentation the facility monitored staff coming in and out of the room for six days between 07/22/2020 and 07/27/2020. In addition, this tracking log showed a start date of 07/04/2020 when there was no COVID-19 outbreak in the facility. For Resident #2, who was suspected of COVID-19 infection and placed on isolation until 07/27/2020, the tracking log showed a start date of 07/09/2020, when there was no COVD-19 outbreak in the facility. Similarly, the tracking log for Resident # 1 also showed a start date of 07/04/2020, when there was no COVD-19 outbreak in the facility. Review of the tracking logs showed the same handwriting across every single shift. The tracking logs did not show non-nursing staff who could have possibly entered the rooms throughout the time of isolation, like housekeepers, kitchen staff, social workers or activities staff. In this continued joint interview with Staff B and C on 08/06/2020 at 1:32 PM, when asked why the tracking logs had a start date prior to the outbreak, the same handwriting every single day and shift, and only included nursing staff, Staff B stated they did not use any tracking logs and she had them created by a staff member when the Surveyor requested them. When asked if the facility tracked staff in and out of suspected COVID-19 resident rooms as stated in their 05/2020 policy, Staff B stated, We do not have a time log to show who went in and out. We don't have actual logs in writing. When asked if the facility should have tracked staff movement, Staff B stated, We just created it (the log), and acknowledged staff movement in and out of suspected COVID-19 resident rooms was not monitored. FAILURE TO ENSURE EMPLOYEE HEALTH AND SCREENING In an interview with Staff B and C on 08/06/2020 at 1:32 PM, when asked what was expected from staff when they felt ill at home, Staff C answered, The expectation is first of all not to come to work, stay at home. It's all about self quarantine. When asked what the facility would do if an employee reported they were sick at work, Staff C answered, Immediately their temp is checked, put on a mask and sent home. Right away sent home. When asked how low grade temperatures were addressed by the facility, Staff C stated, Anything above 99 has to be looked at and they will call me and try to figure out what's going on. They call me and I check it out, and if I am not available then there is the DNS or the RCMs or the nurses on night shift. When asked where the follow-up for temperatures above 99 degrees was documented, Staff C stated, The follow up assessment is documented on the same screening sheet. Staff C added, I don't recall having any problems. They (the screening logs) are reviewed daily by me. Review of an undated facility employee screening procedure showed, If employee/Visitors have a temp (temperature) or answer yes to any of the questions, provide them with a mask and have them exit the facility. This procedure did not identify what qualified as a temperature. Review of the screening logs asked the screener to Check Temperature but did not show when a temperature should be questioned in order to determine whether to send the staff home or not. Review of education records dated 03/17/2020 and 05/11/2020 showed Medical Records staff, Unit Secretaries and a Nursing Assistant employed as a Staffing Coordinator, were trained on employee screening for COVID-19 signs/symptoms. Review of employee screening logs showed the facility identified Staff H with COVID-19 symptoms of Cough and Headache on 07/23/2020. This screening log instructed the employee to answer if they were Asked to Go Home (if yes to any of the screening questions). Y/N (Yes/No). Staff H indicated N. In an interview on 08/06/2020 at 9:22 AM, when asked if she was trained on what to do if she was sick, Staff H stated, Yes, somewhere around June (2020). When asked if she had been ill preceding the time of the outbreak, Staff H confirmed she started feeling sick in the late afternoon or evening of 07/22/2020, but reported to work on 07/23/2020. Staff H stated she experienced mostly cough, a little chest phlegm, then it got worse with fatigue and shortness of breath. When asked if she had reported her symptoms to her supervisor, Staff H stated, I told (Staff I), and she told me if I feel worse, let her know and Staff C. Staff H stated she left work around 3:30 or 4:00 PM. Review of employee pay roll hours showed Staff H reported to work at 7:11 AM and left at 3:40 PM on 07/23/2020. Staff H stated she resulted positive for COVID-19 the following day on 07/24/2020. In an interview with Staff I on 08/05/2020 at 12:17 PM, when asked if Staff H reported to her she was sick on 07/23/2020, Staff I stated, She said she had a kidney stone and that her back was hurting. She said she had some allergies [REDACTED]. She had a runny nose, sniffling, and (Staff H) said 'It's just my allergies [REDACTED]. Staff I also resulted positive for COVID-19 on 07/30/2020. Review of other July 2020 employee screening logs showed temperatures 99 degrees and above, and lower than usual body temperatures (below 97 degrees) with no documentation to show facility follow-up, and lack of screening on days worked: Review of payroll hours showed Staff R, Certified Nursing Assistant (CNA) worked 07/04/2020, 07/09/2020 and 07/18/2020, Staff X, CNA, worked on 07/09/2020, 07/17/2020 and 07/18/2020, and Staff S, Cook, worked on 07/01/2020, 07/02/2020, 07/08/2020, 07/09/2020, 07/10/2020, 07/12/2020, 07/15/2020, 07/16/2020, 07/19/2020, 07/20/2020, 07/22/0220, 07/26/2020, 07/27/2020, 07/29/2020 and 07/30/2020 and no information was documented on the screening log for those days. Staff with low-grade temperatures included: Staff U, RN, on 07/07/2020; Staff V, Licensed Practical Nurse (LPN) on 07/13/2020; Staff W, RN, on 07/07/2020, 07/08/2020, 07/13/2020, 07/14/2020, 07/16/2020, 07/21/2020, 07/30/2020, and 07/31/2020; Staff CC, RN, on 07/10/2020; Staff DD, Dietary Staff, on 07/21/2020, 07/23/2020, and 07/26/2020; Staff EE, CNA, on 07/26/2020 and 07/30/2020; Staff FF, CNA, on 07/04/2020; Staff GG, LPN, on 07/07/2020 and 07/27/2020; Staff HH, Therapist, on 07/27/2020; Staff II, CNA, on 07/07/2020 and 07/20/2020. Staff with lower than usual body temperatures and no follow-up included: Staff Y, Admissions, 95.3 on 07/01/2020 and 94.7 on 07/08/2020; Staff Z, Dietary Director, 91.0 on 07/03/2020 and 92.2 on 07/22/2020; Staff AA, Dietary Staff, 95 on 07/03/2020, 94 on 07/07/2020, 95 on 07/09/2020, 94 on 07/10/2020, 94 on 07/21/2020 and 93 on 07/26/2020; Staff J 93.8 on 07/22/2020; Staff BB, Dietary Staff, 79.5 on 07/23/2020. Staff T's, CNA, answers to the screening questions were illegible, some with check marks and others blank or with a line across, and Staff DD's screening log also showed he answered with a scribbled line across the COVID-19 screening questions instead of a Yes or No between 07/07/2020 and 07/30/2020, with no follow-up by the facility to ensure COVID-19 signs and symptoms were not present. ADDITIONAL OBSERVATION An observation on 07/27/2020 at 8:30 AM showed signage next to Resident #2's room that showed, Special/Droplet/Contact Precautions. The door to her room was open, contrary to the sign saying, Keep Door Closed. In an interview on 07/27/2020 at 8:40 AM, when asked why the resident was on precautions, Staff E, LPN stated, She was exposed to her roommate (Resident #1). When asked if the door should be closed as instructed by the signage, Staff E, LPN, stated, Yes, it should be closed. The facility failed to follow its 05/08/2020 COVID-19 policy to, Place a patient with suspected COVID-19 on isolation . isolate him/her in a private room with the door closed. FAILED TO IMPLEMENT AN INFECTION CONTROL QAPI PROCESS A 03/20/2020 QAPI (Quality Assurance Performance Improvement) Plan showed, the QAPI program will aim for safety and high quality with all clinical interventions and service delivery . by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. In an interview on 08/18/2020 at 1:04 PM, when asked what tools and monitoring systems the facility developed and implemented to ensure sustained and effective IC processes with the advent of the COVID-19 pandemic, Staff A stated, First, the IC policy was reviewed and implemented. We spent a lot of time on what to do when there is an outbreak. Updated the facility exposure plan in March 2020, the COVID-19 checklist, the Department of Health also assessed us in April 2020. Developed the screening log, the cleaning logs rounds, daily team meetings, tracking of PPE supplies. When asked how the facility ensured sustained compliance with IC practices for prevention of COVID-19 infection, Staff A stated, I know he (Infection Preventionist) had PPE observations in June (2020). When asked if the COVID-19 pandemic was considered a high risk or problem-prone issue that the facility should have known about and ensured sustained compliance, Staff A stated, That's what we are talking about, status meetings a couple times a month, and those should be in with the QAPI, that's how we review our systems, and review our screening logs. There wasn't a lot of evidence of him (the IP) looking at that. When asked if the lack of monitoring staff compliance and competency with IC practices detracted the facility from identifying and correcting potential or actual IC issues, Staff A stated, Yes. In an interview on 08/28/2020 at 8:11 PM, Staff C confirmed a total of 53 out of 92 residents and 29 staff had contracted COVID-19 since 07/21/2020. Six residents had since passed away. REFERENCE: WAC 388-07-1320(1)(a)(c).

Based on interview and record review, the facility failed to provide catheter-related services for four (#13, #14, # 15 and #16) of four residents reviewed for indwelling Foley catheter (a flexible tube inserted into the bladder through the urethra) use. For Resident #13, the facility failed to ensure the resident did not develop worsening of a previously identified skin issue with the use of an indwelling catheter. Failure to monitor the impaired skin integrity to the penis, to include placement of a catheter strap as directed by the provider, resulted in Resident #13 developing a urethral erosion, a complication from using an indwelling catheter. Findings included . A facility policy dated 01/09/2019 and titled Catheters - Indwelling Urinary showed the facility would monitor residents who utilized indwelling catheters for changes in condition. The preventative measures included, Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. Resident #13 Review of a 08/26/2019 admission skin assessment for Resident #13, showed staff identified a cath (catheter) insertion site with [MEDICATION NAME] (tear or break in the skin) open (sic) mid shaft of penis. This assessment did not show any measurements associated with the [MEDICATION NAME] opening. Review of a 05/13/2020 Quarterly Minimum Data Set (MDS - an assessment tool) showed the resident admitted to the facility on [DATE], was cognitively impaired, and used an indwelling catheter. Review of a 07/21/2020 hospital Social Worker (SW) report showed, . in the wound care note there's this just really tragic picture of how his catheter's just torn up the part of this man's private parts basically . In an interview on 07/28/2020 at 9:19 AM, the SW stated the resident's penis is split, the large part of his penis and suspecting the catheter pulling caused the ventral (the underside) erosion to the level of the scrotum. In an interview on 08/03/2020 at 8:28 AM, Staff D, Resident Care Manager/Licensed Practical Nurse (RCM/LPN) confirmed he completed the resident's skin assessment on admission and identified, It looked like the middle of the penis the catheter was coming out. It was fissured when we got him, it was mid shaft. When asked how much skin was intact below the opening of the mid-shaft, Staff D stated, . maybe two to three cm from the scrotum to the mid shaft, about an inch or inch and a half. The remainder of the skin was intact, not opened up towards the top of penis and below the fissure it was intact. When asked how large was the fissure opening, Staff D stated, The fissure itself was open I would say maybe almost 1.5 centimeters approximate. When asked if there was any drainage or opened and moist soft tissue, Staff D stated, Nothing. When asked if it was unusual to see the catheter coming out of the mid shaft of the penis and if a urology referral was considered for further evaluation, Staff D stated, He had just come from the hospital and they are the ones who put the foley catheter in so we were thinking he must have been seen by the urologist if he came with it. Review of a 03/03/2020 Care Plan (CP) showed, Use of a urinary catheter due to [MEDICAL CONDITION]. This CP also showed, Foley cath (catheter) care Q (every) shift and PRN (as needed) and Leg strap to keep catheter anchored. This CP showed no indication of the identified [MEDICATION NAME] open mid shaft of penis. A 04/23/2020 nurse practitioner (NP) progress note showed, Patient is seen lying in bed . has a chronic Foley catheter in place . catheter exit at the base of the penis shaft . Unclear if he is being seen by an (sic) urologist. Urologist referral given the tip of his catheter ends at the base of penis. Needs strap and Foley catheter care twice daily. In an interview on 08/04/2020 at 9:32 AM, when asked to describe where the catheter was coming out from the penis, the NP stated, In the middle of his penis, not really at the end, it was at the middle of the penis. When asked if the remaining skin integrity was intact below or above where the catheter was coming out of, the NP stated, Skin was intact yes . just the opening of the middle of the penis and I wanted that evaluated. When asked if he recalled seeing an erosion all the way down the penile shaft, the NP stated, I don't think so. It (the catheter) exited mid (middle) of the shaft, not at the base. When asked how much skin was intact between the mid-shaft and the scrotum, the NP stated, I guess probably about an inch but not sure. I do not remember any erosion not that I remember. When asked why he recommended the use of a catheter strap, the NP stated, So it doesn't pull on it. When asked if he recalled seeing a catheter strap in use during this examination, the NP stated, If I wrote that it's probably he didn't have it on. In an interview on 08/03/2020 at 8:28 AM, when asked why the CP instructed the staff to use a leg catheter strap, Staff D stated, So that the catheter doesn't get pulled out and prevents trauma. The strap holds it in place. When asked how the facility ensured the leg strap was in place, Staff D stated, Check for placement every evening shift, and stated the documentation for this would be found, I would say on the treatment sheet. Review of Treatment Administration Records (TARS) between January and July 2020 showed no documentation staff applied a leg strap to keep catheter anchored to prevent catheter-associated injury. Staff D stated, It doesn't say there, when asked if the TARs showed that staff ensured the catheter tubing was securely anchored with a leg catheter strap. Staff D then stated, The CNAs (Certified Nursing Assistants) check for placement every shift. In an interview on 08/24/2020 at 11:24 AM, when asked what kind of catheter care she provided Resident #13, Staff G, CNA, stated, We just cleaned his private parts and we dumped the urine every shift. When asked if she recalled seeing a catheter strap, Staff G stated, No, the nurses did that. Review of a 01/28/2020 Individual Plan Report (IPR) showed, Bladder - Foley catheter to wear catheter strap provide Foley catheter care q (every) shift and as needed. Notify LN (Licensed Nurse) if noted with new skin breakdown. Review of a Catheter Detail Report associated with the IPR showed the absence of Catheter Care/Management between 08/26/2019 and 07/19/2020, with periods ranging from three days to two months. The IPR showed no documentation Catheter Care/Management was provided for a period of nine weeks and 3 days between 04/07/2020 to 06/12/2020, and again from 06/14/2020 to 07/19/2020 (day of discharge), a five week period. In addition, review of Bowel and Bladder Detailed Entry Reports between 05/06/2020 to 07/17/2020 showed no documentation staff ensured Resident #13's Foley catheter tubing was anchored securely with a catheter strap as instructed by the NP, the CP, and the IPR. Review of a 07/18/2020 progress note timed at 1:19 PM showed the resident stated, I feel like I have not been peeing. Upon assessment his catheter bag was empty and abdomen felt distended . new IFC (indwelling foley catheter) inserted and currently patent and draining. Approximately 900cc (cubic centimeters) output of urine was noted upon re-insertion. Placed on alert. Review of the progress notes showed no documentation staff notified the physician of the identified change in urinary status and the need for catheter reinsertion. Review of the progress notes between 07/18/2020 at 1:19 PM and 07/19/2020 at 6:30 AM showed no documentation staff monitored the resident's response to the re-inserted catheter. A transfer form showed the resident was transferred to the hospital approximately 17 hours later on 07/19/2020 for respiratory symptoms and a fever. The transfer form also showed the resident to have abdominal distention and blood in urine. The above findings were shared with Staff D on 08/03/2020 at 8:55 AM, who acknowledged the lack of monitoring after reinsertion of the catheter. Review of a 07/20/2020 hospital wound consult note timed at 3:05 PM showed, . he has a chronic foley (catheter) in place . Penile shaft - ventral (underside). Foley placement is located in an orifice (opening) at the base of the penile shaft, a fissure thin extends superiorly to the glans penis (top of the penis), Full thickness depth, wound base is 100% moist mucosa, no bruising, or [DIAGNOSES REDACTED] (redness) is noted . Review of Care Everywhere notes Urology visit note in May of 2020 with no mention of any abnormalities. NO prior surgical intervention is noted in medical history. Etiology (origin) of wound is unknown - it may be associated with pressure from his catheter, though with no a/az (sic) of ecchymosis or other trauma present - seems unlikely . Plan: urology consult. Penis - . pressure relief - place non-adhesive foam between penis and catheter tubing to prevent pressure trauma. Review of a 07/20/20 hospital urologist note timed at 6:31 PM showed, Assessment - urethral erosion . The patient has had long standing catheter drainage which is pulling downward and causing the ventral erosion to the level of the penile scrotal junction. Nursing facility needs education on how to prevent this downward pressure. In an interview on 08/21/2020 at 3:31 PM, when asked if he recalled if Resident #13 had any skin issues, Staff GG, LPN, stated, Skin issues . not that I remember. When asked if he recalled Resident #13 using a catheter, Staff GG stated, Yes, he was. When asked if he performed any catheter care and what that entailed, Staff GG stated, We just gonna' clean it up the foley catheter. When asked if he recalled where the catheter was coming out from, Staff GG stated, So, actually, he was a little bit weird. It's kind of like a little bit of split like the tip of the penis was split. He had it when he was admitted . When asked if it was split all the way to the scrotum, Staff GG stated, I never measured it but it's just a little bit of a split, superficial, like a tear, it doesn't go all the way down, just open, hard to describe. When asked how long the split from the tip of the penis was, Staff G stated, Between 1 cm. When asked how much skin was intact from the scrotum upwards, Staff GG stated, I can't tell maybe two centimeters to two and a half centimeters. When asked when was the last time he had been assigned to Resident #13, Staff GG stated, Long time ago, two or three months ago, can't recall. In an interview on 08/03/2020 at 11:30 AM, when asked about Resident #13's skin integrity, Staff E, LPN, stated, Umm, I know from working with him he had a rash on his buttocks, and then the tip of his penis where his catheter was at, it was just like split. The catheter wasn't at the tip, it's not inserted in the tip because the tip is split. When asked how long had the tip of his penis been split, Staff E stated, since two or three months ago which Staff E stated was also the time she was first assigned to the resident's care and, The first time I saw it they said he came with it so I didn't think anything was new. The top part was intact, the split was at the bottom below the top of the penis towards the scrotum, split all the way down to the scrotum. The split ended near the scrotum so that's where the catheter insertion was at. Staff E stated she did not recall seeing any moist open tissue of a fresh wound or trauma. When asked if the resident used a leg strap, Staff E stated, Yes, when I did catheter care I see that it's on and stays on. Review of June and July 2020 TARs showed Staff E assessed Resident #13 to have non-intact skin on 06/01/2020, 06/08/2020, 06/15/2020, 06/22/2020, 06/29/2020, 07/06/2020 and 07/13/2020. Review of the medical record showed no documentation Staff E identified the non-intact skin. In a follow up interview on 8/24/2020 at 11:48 AM, when asked about the non-intact skin, Staff E stated, I was referencing to the penis because it was not intact. When asked what the nurse was supposed to do when non-intact skin was identified, Staff E stated, What I would do is find out if it's something new or not, and ask the RCM, and do a skin incident report. And then alert the nurse practitioner and put them on alert charting for three days. He wasn't bleeding or anything, that's why it didn't alarm me. They said he was admitted with that. That wasn't something new. I just checked it as non-intact skin because the penis is split. I don't consider that intact skin. That's why I went to ask when I first saw it, and was told he came in with it. It was the supervisor for sure who told me, yes, since he's the RCM. I wish I would have done some measurements for it. Review of the resident's medical record showed no documentation staff monitored a [MEDICATION NAME] open mid shaft identified on admission, or prevented its progression to a ventral erosion to the level of the penile scrotal junction. The above findings were shared with Staff B, Director of Nursing Services on 08/13/2020 at 3:30 PM. Staff B stated she expected staff to check the catheter strap at least every 8 hours to make sure it is securely anchored, and acknowledged that catheter-related trauma can be prevented by, that's why we always have a leg strap to the catheter or the weight will pull it down from the bag, can have a split when it pulls down, can also damage the urethra. We make sure the leg strap is secured right and is always on. When you move you don't want pulling. When asked if the medical record showed staff securely anchored Resident #13's catheter tubing with a leg strap, since admission through discharge to the hospital (a period of 11 months), Staff B stated, No. I see a gap here. SIMILAR FINDINGS Review of IPRs for Residents #14, #15 and #16 showed, Foley cath leg strap in place and change as needed. Review of Catheter Detail Reports showed an absence of Catheter Care/Management (Resident # 15 with periods of two days to two months of no documentation between 12/21/2019 and 08/12/2020; Resident #14 with periods of two days to two and a half months with no documentation between 10/15/2019 to 08/12/2020; for Resident #16 with periods of three days to one month of no documentation between 03/23/2020 to 08/12/2020). The above findings were also shared with Staff B. No further information was provided. REFERENCE: WAC 388-97-1060 (3)(c).

Based on observation, interview, and record review, the facility failed to ensure a safe environment for one (#54) of one residents reviewed with an air mattress on a bariatric bed. Failure of the facility to ensure the air mattress of the resident, who was significantly cognitively and physically impaired, fully covered the underlying mattress, created an immediate jeopardy (IJ) due to the resultant increased risk for entrapment, falls, and related injuries. On 05/29/19, the facility was notified of an IJ related to Accident Hazards. On 05/31/19, validation of the IJ removal occurred based on revision of the resident's bed and assistive devices, staff training, and administrative interviews. Findings included . Review of Resident #54's Quarterly MDS (Minimum Data Set-an assessment tool) dated 03/14/19 showed the resident re-admitted on [DATE] with multiple medical and cognitive conditions, which included dementia, muscle weakness, [MEDICAL CONDITION], and visual impairment. According to this MDS the resident was assessed with [REDACTED]. Additionally, the resident was totally dependent on two or more staff for bed mobility and transfers, and unable to walk. Review of Device Assessments dated 04/23/19 showed; use of a bariatric (larger sized) bed was assessed to decrease rolling out of bed and was marked the resident had a history of [REDACTED].½ siderails for positioning, with facility identified risks of Getting limbs caught in rails and Entrapment. Review of Resident #54's Care Plan, last revised 05/07/19, showed the resident had a history of [REDACTED]. An entry dated 04/20/19 stated, Swings legs over edge of bed. The care plan showed the resident wore sage boots (a protective padded covering) and had wounds to both his feet. The care plan showed the resident was bedfast and a Bariatric Bed (symbol for with) air overlay mattress. On 05/23/19 at 8:33 AM, Resident #54 was observed with sage boots on lying in bed. Review of an Occurrence Report dated 05/25/19 showed that on that day at approximately 6:10 AM, an aide heard the resident yelling and found the resident, .knelling (sic) on floor on his both knee and upper body lying (sic) on bed, bilateral sag (sic) boot was on . The report stated the resident said, I was trying to get out of this bed. The call light was noted to be off, and both knees were noted as .slightly reddish . The report said the resident had weakness to his left upper and lower extremities related to a [DIAGNOSES REDACTED].his inability to make significant changes in his positioning. The follow-up plan included, Move bed against the fall (sic) to reduce the potential for his feet to fall off the bed and sliding off the bed. A physician telephone order dated 05/28/19 and timed 11:00 AM stated, (MONTH) have bed against the wall (symbol for due to) falls. Review of a Device assessment dated [DATE] showed the facility assessed the resident to require the Bed Against Wall to Decrease rolling out of bed, Decrease risk of injury, Decrease unassisted ambulation and Decrease risk of falls. The facility identified risks to the resident included entrapment and strangulation. Review of an Occurrence Report dated 05/29/19 showed that day at approximately 8:30 AM, the resident was heard to yell for help, and staff found him .knelling (sic) on floor on his both knee on his left side of bed and upper body lying in bed . The report stated the resident said, I was trying to get out of this bed and to walk around. The report said the call light was in reach and not on. The report also said both the resident's knees were reddish and had abrasions, and a bruise was present on the resident's left shin. On 05/29/19 at 10:39 AM, Resident #54 was observed in his wheelchair in his room. The resident's bariatric bed, was observed to be up against the window wall of the resident's room. Both of the resident's upper side rails were elevated. A gap was noted between the wall and the bed on the lower portion of the bed where there were no side rails. At 10:48 AM, further observation showed the inflatable overlay air mattress, on top of the bariatric bed, was smaller than bariatric bed. It was observed there was space on both sides of the air mattress where the air mattress did not meet the bariatric bed perimeters. The same day, at 11:54 AM, the resident was observed to not be in bed, and the measured gap between the edge end of bariatric mattress and wall was 3.5 inches. During an interview on 05/29/19 at 2:29 PM, Staff Q, Certified Nursing Assistant (CNA) stated that when the resident was awake, usually in the mornings, Resident #54 tried to stand and get up independently, from both sides of the bed, and did not use the call light purposely. On 05/29/19 at 2:35 PM, Staff D, a Licensed Practical Nurse-Resident Care Manager (LPN-RCM) was asked why the order for the bed against the wall had been instituted. Staff D said the resident had been trying to get out of bed on the right side and had been kicking his feet on the right side. Staff D said the order was to keep the resident from kicking the wall and from falling out. On 05/29/19 at 3:25 PM, Staff A, the Administrator, Staff B, the Director of Nursing Services (DNS) and Staff C, corporate consultant were informed of the risk related to the gap between Resident #54's bed and wall, and the air mattress which did not fit his bed, which created risk of entrapment and injury. On 05/29/19 at 4:33 PM, observation showed the resident's bariatric bed and the side rails had been removed, the resident's bed was now a low bed, which was not against the wall, and fall mats on both sides of the bed were present. On 05/30/19 at 12:09 PM, Staff C, a corporate consultant, said the air mattress was about an inch and a half high, and there was 6.5 inches between the air mattress and the wall. Staff C also confirmed there was a 3.5 inch gap from the bariatric mattress to the wall, as noted above. On 06/03/19 at 2:08 PM, a representative for Resident #54 stated, He kept trying to get out of bed. When asked if the resident was successful in getting out of bed, the representative said, he was, and would end up on his knees. During the same interview, another resident representative was asked if staff had discussed the risks of having the bed against the wall. The representative replied staff had told her, He might go between the bed and the wall. The resident representative said, He's been trying to get out lately due to his dementia. He slides his leg off the bed. He can't stand. This representative said the resident's sage boots, tend to slide off, they're slippery. The facility identified and analyzed the risks and hazards of entrapment for the known behaviors of wanting to get up alone. The facility moved the resident's bed against the wall, as to not reduce the risks as much as possible for entrapment, injury or even strangulation. Reference: WAC 388-97-1060(3)(g)

Based on interview, and record review, the facility failed to ensure one (#1) of five residents reviewed for abuse, were free from sexual abuse when an unsupervised resident (#2) wandered into another resident's room. The facility failed practice resulted in non-consensual inappropriate touching and psychological harm. Findings include: ABUSE, NEGLECT AND EXPLOITATION POLICY Record review found the facility had an abuse and neglect prohibition policy dated (YEAR) which prohibited and prevented resident to resident abuse. RESIDENT #1 Resident #1 admitted to the facility on [DATE] and according to the 11/22/18 Quarterly Minimum Data Set (MDS - an assessment tool), the resident was assessed to be dependent on staff for Activities of Daily Living (ADLs) including mobility and transfers. This MDS documented Resident #1 was able to understand and be understood in conversation, and had a BIMs score of 15, reflective of intact cognition. The resident was admitted with multiple [DIAGNOSES REDACTED]. According to the 11/25/18 Care Plan (CP) Resident #1 was At risk for psychological or emotional harm r/t (related to) patient (pt) being physically touched by another person (pt) without her permission. Observation on 12/07/18 at 2:00 p.m., found Resident #1 using a wheelchair for mobility, responded to a greeting and was able to state date and time. Resident #1 recalled an incident when Resident #2 wandered in her room and inappropriately touched her private area and left the room. When asked, Resident #1 stated, I was frightened in case he resisted to leave the room. Resident #1 was able to identify Resident #2 and stated the actual room number where Resident #2 resided at the time of incident. RESIDENT #2 Resident #2 was discharged from the facility and not available for observation or interview. Medical record review revealed, Resident #2 admitted to the facility 07/03/18 following a fall at home. According to the 10/08/18 Quarterly MDS the resident had severely impaired cognition. The resident's medical history included dementia with new onset behavioral disturbance. According to nurse's progress notes dated 11/27/18, Resident #2 used a wheelchair for mobility. Although the resident had unsteady gait, he sometimes got up from the wheelchair and attempted to self ambulate in the hallway and in his room. According to the 11/23/18 Care Plan (CP), Resident may become unpredictable: yells out, swings at staff - currently on 1:1 (one on one) watch 24/7. Review of progress notes dated 11/23/18, revealed Resident #2 had an altercation with another resident in the dining room, when staff immediately intervened and separated the residents. Resident #2 was assessed to be impulsive, kicking and throwing things at staff. Review of Incident Investigation Report (IIR) revealed, all nursing staff alerted in bldg (building) that assistance to be provided to keep a five foot diameter of clear space around resident as he maneuvers through the building to prevent physical contact with any other residents or visitors. Further Review of progress notes dated 11/24/18 at 11:20 p.m., revealed Resident #2 exhibited angry outbursts, continued to hit staff, refused evening medications and was not cooperative with care. According to progress notes, Resident #2 was assessed to require 1:1 supervision due to increased behavioral disturbance. On 11/24/18 the intervention of Provide 1:1 Supervision until asleep was added to the resident's behavior Care Plan. Record review could not find documentation to show Resident #2 was reassessed and did not require closer supervision to ensure resident safety and prevent resident abuse. Review of Incident Investigation Report (IIR) revealed that on 11/25/18 at approximately 4:00 a.m., Resident #2, undressed and with only a brief on, wandered into an adjacent room, occupied by Resident #1. Resident #2 then sat on the foot of Resident #1's bed, and inappropriately touched Resident #1's private area. Further review of the IIR revealed, Resident #1 then pushed Resident #2 away from the bed and yelled for help. Staff D (Certified Nursing Assistant - CNA) immediately responded to Resident #1's call light. In an interview on 12/18/18 at 7:30 a.m., Staff B (Director of Nursing) said the facility concluded that sexual abuse occurred based on Resident #1's reported statement, the resident's cognition and (Resident #1's) history. In an interview on 12/18/18 at 06:00 a.m., Staff D said on her way to answer Resident #1's light, she noticed (Resident #2) was awake in his room and undressed. Staff D further said that, when she approached Resident #1's room, Resident #1 was red in the face and was crying. When Staff D asked why the resident was crying, Resident #1 said that Resident #2 wandered in her room and inappropriately touched her in the private area. Resident #1 denied sexual intercourse. Staff D then comforted Resident #1 and reported the allegation of sexual abuse to (Staff C -Licensed Practical Nurse - LPN). Staff C immediately assessed the resident and placed the resident on frequent and psychological monitoring, and assigned a staff member to supervise Resident #2 (1:1 care). On 12/18/18 at 6:20 a.m., when asked where the 1:1 companion was when the incident of sexual abuse occurred, staff C said, the 1:1 companion clocked out and went home at approximately 11:00 p.m. on the night of 11/24/18. When Staff C was asked how it was determined Resident #2 did not require further close supervision 1:1, Staff C did not respond. Staff C indicated the 1:1 supervision was discontinued by Staff B. In an interview on 12/18/18 at 7:30 a.m., when asked why the 1:1 supervision was discontinued, Staff B (Director of Nursing) indicated after the resident went to bed and fell asleep, she didn't believe Resident #2 required one on one supervision. When asked what was put in place to protect residents from sexual abuse, Staff B said Staff C and Staff D where assigned to ensure abuse did not occur. When Staff B was asked why assigned staff were unable to prevent resident abuse, Staff B did not provide an answer. Reference WAC 388-76-0640(1)

Based on observation, interview and record review the facility failed to recognize, assess and treat two residents (#71 & 40) who experienced untreated pain. Failure to implement identified effective interventions to reduce pain, including administration of pain medication and/or non-medication interventions, prior to care and services that were identified to cause pain, resulted in Resident #71 experiencing trendable, recurrent episodes of untreated pain and placed Resident #40 at risk for untreated pain with dressing changes. Findings include: RESIDENT #71 Resident #71 admitted to the facility on [DATE], and according to the 10/31/17 Quarterly Minimum Data Set (MDS-an assessment tool) the resident was able to understand and be understood in conversation and was cognitively intact. Staff assessed Resident #71 as requiring one person extensive assist for bed mobility and transfers. He was able to walk in his room and in the corridor and move around the unit with supervision and cueing only. This MDS reflected the resident used no regularly scheduled pain medication and no prn (as needed) pain medication but did receive non-medication interventions for pain. Staff documented the resident experienced pain occasionally, which did not affect his ability to sleep at night, and was characterized as mild. According to the Significant Change MDS dated [DATE], staff assessed Resident #71's abilities had declined and he now required extensive two person assistance for bed mobility and transfers, and was determined to no longer walk in his room or corridor. While the resident did not receive any regularly scheduled or as needed (prn) pain medication, the resident did receive non-medication interventions for pain and occasionally had moderate pain. Observations on 02/23, 2/26, 2/27, 2/28/18 and 03/01 and 03/02/18 revealed, Resident #71 lying in bed, resting and comfortable. The resident was noted on the morning of 03/02/18 in a shower chair being transported for a shower. In an interview on 03/01/18 at 10:22 a.m., when asked if he experienced pain while participating in therapy, Resident #71 stated, yes. When asked if facility staff provided pain medication as a way to decrease pain prior to therapy the resident stated, I don't remember. In an interview on 03/01/18 at 9:15 a.m., Staff G (Therapy Director) indicated it was the expectation for therapists that if a resident reports or experiences pain, We (therapy staff) immediately talk to the nurse and ask if there is anything on board . Staff G elaborated that therapy staff .would pre-medicate and if the pain limits the task (therapy) we ask for something regularly scheduled. We have a list of people who would benefit from medications (prior to therapy). Staff G said that if therapy was seeing the resident at 1:00 p.m., they would request nursing give pain medication at noon because, .we are trained that pain is a medical emergency. Staff G indicated therapy staff could ask for pain medication for a resident if pain symptoms were present, during therapy, during the course of the treatment. Staff G acknowledged Resident #71 experienced pain during therapy stating, Everybody knows he is in pain; he would tell you; that's what triggered the x-ray (on 01/04/18) he still had pain. In an interview on 03/01/18 at 9:40 a.m., Staff I (Physical Therapy Assistant-PTA) stated the treatment for [REDACTED]. I will specifically work around it if the resident is in pain. Staff I indicated he would inquire with nursing staff if the resident received a routine pain medication and schedule therapy based on the anticipated effectiveness of the pain medication. When asked if a resident who experienced pain but had no regularly scheduled pain medication, only as needed, Staff I indicated therapy staff maintained a list of residents who were assessed to benefit from pain medication prior to receiving therapy. Staff I stated therapy staff communicated with nursing, .so the nurse knows when to give it, it's not me saying when to give it. Review of this Pain Management Schedule form, last updated on 01/11/18, revealed Resident #71 was not listed. When asked what therapy staff were to do if a resident experienced pain during the therapy session, Staff I replied, The nurse will be notified. We will mention it in the daily treatment note; probably the initials of the nurse (to whom it was reported). A lot of time I haven't had anything happen that needed nursing to be notified. In an interview on 02/28/17 at 9:05 a.m., when asked if a resident, who was assessed by therapy to experience pain with weight bearing and movement, should receive pain medication, Staff D (Resident Care Manager-RCM) stated, If therapy noted pain, they should notify nursing staff, they (nursing) would assess the resident and yes, administer pain medication. Staff D elaborated, If we knew about the pain we should pre-medicate prior to therapy. A progress noted dated 12/13/17 indicated resident #71 was, independent with ambulation via walker . Nursing progress notes dated 12/15/17 at 9:04 a.m. indicated, Also on alert for fall yesterday (12/14/17) with right knee pain .Right knee with mild swelling and res(ident) states knee aches. Able to bear weight and ROM (Range of Motion) per baseline. Tender to touch. Per evening nurse report, MD (Medical Doctor) deferred X-Ray until further evaluation today. A 12/15/17 progress note at 10:35 a.m. indicated the resident, c/o (complained of) right knee pain 8/10 medicated with [MEDICATION NAME] 10 mg with relief. Awaiting MD visit. On 12/16/17, nursing staff administered 10 mg of [MEDICATION NAME] for knee pain 5/10 and right knee with mild swelling. A Telephone Order (TO) dated 12/15/18 directed nursing staff to apply ice pack x 20 minutes (every) one hour (as needed) for (right) knee swelling and pain. A telephone order dated 12/18/17 directed, PT (physical therapy) to eval(uate) and treat as indicated. According to PT notes dated 12/20/17, Patient referred to PT due to new onset of R(ight) knee pain, reduced dynamic balance, reduced static balance limited and painful movement, R knee joint instability, falls/fall risk, decreased postural alignment, decrease in strength, decrease in range of motion (ROM) and functional limitation with ambulation. The therapist assessed that prior to the fall of 12/14/17 the resident was walking with (single point cane) within facility with supervision. The therapist identified the resident sustained [REDACTED].R knee pain and swelling. Therapy staff identified prescribed medications, remaining still relieved the pain and that standing, bending exacerbated the pain. The listed clinical impression was, Res(ident's) main limiting factor is R knee pain and swelling. The 12/20/17 assessment indicated the resident was unable to demonstrate standing due to c/o severe R knee pain. Occupational Therapy (OT) intake notes dated 12/21/17 revealed, Pt unable to ambulate to toilet (secondary to) pain. Pt currently using urinal for voiding and that the resident reported, My knee feels swollen. In an interview on 3/01/18 9:15 a.m. Staff G (Therapy Director) indicated that staff could anticipate Resident #71 would have pain with movement. Review of Medication Administration Records (MARs) revealed the resident received no pain medication on 12/20/17. In an interview on 3/01/18 9:15 a.m., Staff G stated, There should be notes we talked to the nurse . when the resident experienced pain. Staff G specified that she spoke with nursing staff on 12/20/17 about Resident #71's pain. Review of 12/20/17 progress notes revealed no indication therapy notified nursing staff. Review of December 2017 MARs revealed the resident received no Tylenol or [MEDICATION NAME] on 12/20/17. PT notes dated 12/27/17 indicated Resident #71 experienced right knee pain that was 8/10 was sharp. While therapy staff documented that ice, prescribed medications relieved pain, there was no indication the resident received ice application and according to the MAR, the resident received no pain medication on 12/27/17. PT notes dated 12/28/17 indicated that precautions/contraindications were R knee pain and swelling. Staff documented the resident reported his pain was, A lot, I don't know about those #'s. PT staff's objective assessment of the resident's pain at that time was a 3/10. When asked to describe the type of pain the resident stated, It just hurts. While PT staff documented that ice relieved pain, there was no indication ice was applied. Despite resident reports of pain, no pain medication (Tylenol or [MEDICATION NAME]) was administered on 12/28/17. According to the MARs, nursing staff administered [MEDICATION NAME] 10 mg at 7:00 a.m. for reports of 8/10 knee pain on 12/29/17. PT notes on the same day at 3:56 p.m. indicated the resident received icing (of the) right knee and indicated the resident reported pain of 4/10 that was aching and sharp with WB (weight bearing). Staff documented, Pt states difficulty with PT (because of) pain and lack of function. There was no indication therapy staff considered or implemented pre-medication prior to therapy despite their assessed anticipation the resident would experience pain with movement and weight bearing. Similar findings of therapy staff identifying Resident #71 having anticipated pain with movement with Occupational Therapy (OT) with no pain medication administration were found for 12/21/17 and 12/26/17 when the resident reported pain of 5/10 and 8/10 respectively. PT notes dated 01/02/18 measured the resident's mid patellar girth of 48 cm, documented the resident had pain of 5/10 stating, It just hurts. While PT staff documented the resident had pain, that was relieved with ice, remaining still there was no indication the resident received ice application and according to the MAR, no pain medication was administered on 01/02/18. PT notes on 01/03/18 revealed, pt's static and dynamic standing and transfer balance affected by his painful R knee. Pt is having difficulty with his balance because he is unable to wt (weight) bear on his R LE (Lower Extremity). Pt is now a fall risk. Staff identified, pain and swelling in his R knee. Regarding response to therapy, PT staff documented, Pt is willing to participate but he is limited by pain and swelling in his R knee. There was no indication of ice application and according to the MARs, Resident # 71 received no pain medication, prior to, during, or after therapy, despite the anticipation of, and reports of pain, on 01/03/18. PT notes on 01/04/18 indicated the resident self limit(ed) R LE WB (weight bearing) and reported ache and sharp (pain) with stand and pivot pain levels of 5/10 to the right knee. Therapy staff again documented Ice, Remaining still relieved the resident's pain. There was no indication therapy staff considered pre-medication despite repeated, clear identification that the resident experienced pain with movement (therapy) and record review revealed the resident received no ice application during or after therapy and no pain medication on 01/04/18. Record review revealed no indication facility staff assessed the resident required, or made a referral to the facility Physiatrist (a physician specializing in physical medicine and the treatment of [REDACTED]. Nursing progress notes dated 01/04/18 at 6:24 p.m. indicated, Right knee 2 views x-ray done to rule out fracture and noted an acute patella fracture per x-ray report and MD notified and new orders pending. X-ray results dated 01/04/18 indicated There is an acute [MEDICAL CONDITION] (knee cap) with mild displacement .There is a joint effusion (escape of fluid from its natural vessels into a body cavity). Following identification of the fracture, the primary physician ordered, right knee immobilizer at all times . non-weight bearing on (right) knee. A pain assessment dated [DATE] indicated the resident had an origin of pain of (right) knee swelling/pain . that was acute and indicated at it's worse, his pain was an 8 on a scale of 0-10 which improved to a 2-3 three hours after medication. Staff assessed the resident indicated pain was relieved by medication, cold and remaining still. Pain was assessed to increase with movement and repositioning. Staff determined the resident's pain prevented him from ambulation, transfer, positioning. Staff indicated on this assessment the resident had current medications that included: as needed Tylenol every 6 hours for pain of 1-4 and [MEDICATION NAME] 10 mg every four hours for pain of 5-10. Physical Therapy notes dated 01/10/18 indicated the resident had R patella pain .6/10 (with movement) and that pain was relieved with prescribed medications, remaining still. Review of MARs revealed the resident received no pain medication or ice application on 01/10/18. According to consultant pain specialist notes dated 01/11/18, (Resident #71) is a gentleman with a history of mechanical fall with right-sided knee pain. He has increased right knee pain and swelling. This pain overall has been improving. Prior to discovery of the fracture he was ambulating with physical therapy . According to TOs dated 01/11/18, staff were directed to apply ice to the resident's right knee, .for 20 minutes 2-3 (times) daily, elevate the knee above the level of heart. Nursing staff transcribed the icing order, which was identified as an intervention which helped alleviate pain, as an as needed order. Rather than being implemented 2-3 times daily as intended by the physician, nursing staff implemented the icing order only once in January, on 01/15/18. PT notes on 01/15/18 indicated the resident reported pain of 5/10 to the right knee. According to the MAR, at 10:00 a.m. the resident received an ice bag to R knee (for) (complaint of) pain/burning however, no pain medication was administered on this day nor was there consideration by therapy staff that pre-medication prior to therapy might benefit the resident. PT notes dated 01/19/18 indicated that during therapy the resident reported pain of 4/10 to the right knee. Review of MARs revealed the resident received no pain medication on 01/19/18. Similar findings were identified for 01/25/18, 01/26/18 and 01/30/18 when therapy staff documented the resident had pain of 5/10 with no pain medication administered. Additionally, there was no consideration of pre-medication prior to therapy or assessment the resident might benefit from pain medication. Similar findings of OT staff identifying Resident #71 reported pain with no pain medication administration, was found for 01/04/18 and 01/10/18. PT notes on 02/01/18 and 02/04/18 indicated the resident reported pain of 5/10. Specifically on 02/04/18 the resident states pain in R knee during transfers at 5/10. Review of MARs revealed no consideration of, or administration of pain medication despite documented awareness the resident experienced pain with movement. Therapy notes on 02/07/18 reflected, Pt does have c/o pain when he completes AROM (Active Range of Motion) or I put too much weight on (RLE). On 01/19/18 OT staff documented, Pt reports decreased motivation to participate in therapy sessions specifically while ambulating (secondary two) (Right Lower Extremity) pain. No pain medication was administered this day. Despite staff awareness of resident reports of pain impacting the resident, no further interventions were considered or implemented. Similar findings were identified of untreated pain, per OT notes and MAR indicated [REDACTED] Record review revealed no regularly scheduled medication was provided until a TO dated 02/01/18 for, Tylenol 650 mg (orally) (three times a day) routine x 1 week . A second TO dated 02/08/18 extended this order for three more weeks. There was no indication if this order was for pain, swelling, or both. RESIDENT #40 Resident #40 admitted to the facility 12/22/17. According to the 12/29/17 Comprehensive MDS the resident was assessed as cognitively intact with a BIMS of 15. According to this MDS the resident did not receive scheduled pain medications, or non-medication interventions for pain, did receive as needed pain medications, opioids on six of seven days and reported occasional, moderate pain in the five days of the assessment period, and mouth or facial pain, discomfort or difficulty with chewing. Review of the 01/04/18 Care Area Assessments (CAAs) indicated prior to admission, the resident went to urgent care with pain on right side of face (had had for years) .testing done showed invasive squamous [MEDICAL CONDITION] of the right axilla. According to this document, the resident had surgery to remove the right eye and bone surrounding the eye and jaw. The dental care CAA indicated the resident reports pain/discomfort with chewing . According to a 12/22/17 Pain Assessment the resident had [MEDICAL CONDITION], post surgical wounds and pain that was increased by facial movements. The 12/22/17 Pain Care Plan, listed a goal of Will have decreased pain level 0-3 daily. Interventions listed included Administer medications per MD order timely. In an interview on 02/22/18 at 10:19 a.m. Resident #40 said I don't get my pain medication quick enough sometimes. Review of current Physician order [REDACTED]. Review of the MAR indicated [REDACTED]. In an interview on 03/01/18 at 08:25 a.m., Resident #40 said I wait until its almost 10 and then I go get the nurse to get it, the doctor said to wait until 8 or 9, because by the time they give it to you it will be a 10. Further review of POs revealed orders for dressing (dsg) changes twice a day. A 02/05/18 PO instructed staff to Cleanse right eye wound with NS (Normal Saline). Apply wet to dry dsg using Kerlix, soaked with NS. Apply dry gauze on top. Secure dressing with blue eye patch to secure dressing twice a day as needed. Review of progress notes revealed on 02/05/18 at 9:51 p.m. .dressing to Rt (right) eye was done .PRN [MEDICATION NAME] 15 mg was given for rt facial pain 8/10 w/relief ., on 02/06/18 at 10:30 p.m. .dressing to Rt eye was done .PRN [MEDICATION NAME] 15 mg was given for rt facial pain 8/10 w/relief ., similar findings were noted on 02/07/18 at 11:52 p.m., 02/11/18 at 12:19 a.m., 02/12/18 at 11:40 p.m., 02/20/18 at 11:29 p.m. A 02/26/18 10:17 p.m. note revealed, .Dressing change per order to right facial wound .Complained pain r/t (related to) right facial wound 10/10 pain scale; gave PRN [MEDICATION NAME] 15 mg PO; effective 0/10 pain . In an interview on 03/01/18 at 8:25 a.m. Resident #40 said the the dressing was changed, anytime in the morning and once in the afternoon or towards evening. Resident #40 said the pain jumps from 0 to 10, especially right after they change the dressing. The air comes in and hits it. Review of the February 2018 TAR (Treatment Administration Record) revealed the dressing change was completed twice a day on day and evening shifts. Review of the February 2018 MAR indicated [REDACTED]. On 03/01/18 at 8:00 a.m., Staff M (Licensed Practical Nurse - LPN) said Staff Q (LPN) would be changing the resident's dressing around 9:00 a.m. or 9:30 a.m. On 03/01/18 at 9:13 a.m., Staff Q was observed to enter the resident's room to perform the dressing change. Staff Q asked Resident #40 if he was in pain and the resident responded yes, at a level of 7/10. Staff Q said she would come back after the resident received pain medication, and if feeling better, do the dressing change. Resident #40 then said, It's a nine, it hurts .I was trying to get medicine before you got here. On 03/01/18 at 9:21 a.m., Staff M was observed to prepare [MEDICATION NAME] 15 mg to administer to Resident #40. When asked, why if she knew his dressing change was scheduled for 9:00 a.m. she did not pre-medicate, Staff M replied, Because he's not asking and it's not written to pre-medicate. On 03/01/18 at 9:56 a.m., Resident #40 reported a pain level of 1/10 and said I hold in my pain, you learn that in the military. Staff Q was observed to perform the dressing change as ordered. Resident #40 denied pain during the procedure. In an interview on 03/01/18 at 9:31 a.m., Staff E (RCM) indicated the expectation was for staff to pre-medicate prior to performing the dressing change stating, yes as it would hurt. Reference WAC 388-97-1060(1).

Based on observation, interviews and record review, the facility failed to consistently monitor residents for change of condition for 3 of 3 sample residents (1,2,3). Failure to assess Resident 1 and 3 in a timely manner and/or document assessments resulted in Resident 1 and 3's rapid medical deterioration resulting in hospitalization and placed Resident 2 at risk for delayed treatment. Findings include: The facility's policy for Change of Condition (C(NAME)) directed all staff were to ensure all condition changes are identified, assessed, documented and have care planned interventions as necessary. The standards read all staff observes and reports changes in condition immediately to Licensed Nurse (LN) including shortness of breath (SOB), changes in food/fluid intake/choking, and changes in level of consciousness (L(NAME)). The policy indicated LNs would evaluate the C(NAME) and determine the course of action based on standard of practice, the physician is notified immediately by phone, and LNs may initiate transport of a resident via 911 to the ER without a physician order [REDACTED]. Another policy provided on 2/24/17 regarding Change in Condition notification revealed immediate notification to the physician was required for any symptom, sign or apparent discomfort that is: acute or sudden in onset, and: a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. The Policy also indicated staff were to immediately report a oxygen saturation less than 90%, acute episode with wheezing, dyspnea or respiratory distress, dyspnea-acute onset of change from usual pattern or new onset or progressive choking or aspiration. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] for rehabilitation following surgery for [REDACTED]. The hospital records from 10/12 to 10/20/16 revealed Resident 1's oxygen saturation level was 100% on room air (RA). The hospital's Speech and Language therapist (SLP) note dated 10/20/16 documented that Resident 1 needed to be alert and awake during meals and be in an upright position for 30 minutes after meals and was to be monitor for signs and symptoms of aspiration. The facility's initial nursing assessment form dated 10/21/16 documented that Resident 1 was alert, had clear speech and exhibited no shortness of breath (SOB). The facility's SLP evaluation dated 10/24/16 documented Resident 1 presents with mild-mod oropharyngeal dysphagia impacting safety and ability to consume meals. The note revealed SLP would assess and evaluate safe swallowing strategies, provide education and diet texture modification. The note also revealed Resident 1 was at risk for weight loss, pneumonia and aspiration. The facility's SLP notes dated 10/28/16 documented Resident 1 had increased difficulty with diet today. In previous SLP sessions, pt (patient) had occasional immed (immediate) cough on thins, able to utilize positioning to improve. Today, pt was coughing consistently on solids and thins (liquids) -improvement given nectar (thick liquids). Downgraded to nectar liquids, small bites/sips, assistance due to increased aspiration. The notes documented she exhibited overt s/sx (signs and symptoms) of aspiration. During an interview and review of the SLP notes on 1/31/17 at 10:53 a.m. with the SLP, she stated Resident 1 was at high risk of aspiration due to the positioning of her head which was tilted up due the cervical (neck) brace. The SLP stated she had evaluated Resident 1 on 10/28/16 during the breakfast meal around 8:00 a.m., and changed her diet to nectar thick liquids due to Resident 1's increased coughing and difficulty chewing. The SLP stated due to Resident 1's overt and acute changes which she had assessed during the breakfast meal (10/28/16), she had informed the Resident Care Manager (RCM F) that Resident 1 required observation for the next 2 hours and if coughing continued she needed to be sent out due to the acute changes. She also stated she had informed nursing staff that Resident 1 required 1:1 supervision with eating. The SLP stated at lunch time on 10/28/16, Resident 1 was observed coughing and required 1:1 assistance with her feeding. She stated a family member was at the bedside. During this interview, the SLP she stated interventions for aspiration precautions would include maintaining a resident in an upright position for 30 minutes after meals and stop feeding a resident if coughing. A nursing note entry for 10/25/16 revealed Resident 1 had a non-productive cough and her oxygen saturation level was 93 % on room air (RA). The note revealed the physician ordered a device for deep breathing (incentive spirometry-IS) every 2 hours while awake related to her cough. The nursing note indicated that nursing would continue to monitor the resident. The facility's physician note dated 10/25/16 documented Resident 1 was on spine precautions and revealed she had a non productive cough which was new and upon assessment had rhonchi in both lungs. The physician ordered scheduled breathing treatments, continued IS, and documented if worsens or fever a chest x-ray would be ordered. The nursing note dated 10/26/16 documented the resident received breathing treatments due to cough and rhonchi. The next day a nursing progress note for the evening of 10/27/16 documented upon assessment, the resident lung sounds were diminished bilaterally and seen by physician (no note), and at 6:07 p.m., an order was received to check the oxygen saturation level every shift to keep above 90% and to place the resident on alert charting. There was no corresponding physican note for the 10/27/16 nursing note. A physical therapist (PT) note dated 10/27/16 documented Resident 1 was experiencing extreme fatigue and pt (patient) short of breath (SOB) with minimal activity, very low activity tolerance. Pt's O2 level was low at 85. Even though Resident 1 was placed on alert, there was no documentation for the evening shift or night shift for 10/27/16 except for a recorded oxygen saturation level on the Administration Record (MAR/TAR). During an interview on 1/30/17 at 12:33 p.m., with LN E, Registered Nurse stated if a resident is placed on alert charting, LNs are to monitor and document every shift for 3 days order to evaluate if the medical condition is getting better or worse. During an interview on 1/30/17 at 12:50 p.m., the Director of Nursing (DNS) stated when a resident is on alert charting, every shift needs to monitor and document the assessment every shift for 72 hours (3 days). Chart review revealed there was no documented evidence nursing had assessed Resident 1's vital signs, oxygen level or lung sounds on 10/28/16 even after the SLP had alerted nursing staff that Resident 1 was at high risk of aspiration due to coughing and the SLP's assessment at breakfast on 10/28/16. LN D, a Licensed Practical Nurse who was Resident 1's nurse on 10/28/16 was interviewed on 1/31/17 at 3:30 p.m. LN D stated the SLP was with the resident during the morning medication pass to evaluate her swallow due to coughing. LN D stated the SLP spoke with the Resident Care Manager (RCM F) about Resident 1's condition. LN D stated he only returned to check on Resident 1 when the family informed him she hit her head (around noon). LN D stated he had attempted to give Resident 1 a spoon of soup but she started to cough, she was sleepy and had a hard time to get breath. LN D stated he recalled checking Resident 1's lung sounds and vital signs on 10/28/16 but had not documented any assessments in the clinical record. During an interview on 2/24/17 at 12:15 p.m., the therapist (PT) who had seen Resident 1 on 10/27/16 stated she had worked with Resident 1 in her room as she was not up to therapy and her oxgen saturation level was below 85%. The PT stated she could not recall if she had informed nursing about the change in condition and/or decreased oxygen saturation level. During an interview on 2/1/17 with a family member who was at the facility on 10/28/16 around breakfast time. She stated Resident 1 was observed slumped over her breakfast tray, slumped to one side, she appeared to be sleepy, was very lethargic and not very alert. The family member stated when nursing staff came into Resident 1's room, she had to inform the staff that she was in no condition to eat. The family member stated she took the resident outside in a wheelchair but noted that she was unable to keep eyes open, was drooling and had commented to staff regarding her condition change was not right. She stated PT (physical therapy) staff had stated this is not right and would address the situation. The family member stated she had informed the RCM earlier that morning that her mother needed 1:1 meal assistance and could not tolerate feeding herself and needed further assessment (i.e blood work). The family member stated Resident 1 sat in her wheelchair the rest of the morning without any assessment by LNs. When her lunch tray was brought in, staff left the tray without assisting her. The family member said I needed to inform the nursing staff that resident needed assistance with feeding/meal. The staff member who brought in the tray told the family member that I don't do meal assistance and left the room. The family member went on to say while Resident 1 was seated in the wc, her head hit the lunch tray (bedside) which awaken her. The family member said she requested staff to put her back in bed as I had to hold her up and said to staff look at her. At this time, RCM F, a Licensed Practical Nurse, came in and Resident 1 was put back to bed. I asked about the blood work and RCM F informed me the order was put in. It was obvious there was a decline, they were not paying attention, it was bothersome. I had informed the RCM F early that morning regarding her drooling and not keeping eyes open. During a family interview on 2/23/17, a family member stated Resident 1 had a steady decline. On 10/28/16, another family member had notified her regarding the resident's condition change, not the facility. The other family member informed her that Resident 1 was incoherent, not responsive and unable to complete sentences. When she arrived on 10/28/16, food was coming out of her mouth as the LN was attempting to feed the resident and did not see any oxygen in use at this time. She was informed the oxygen saturation level ranged 75% and 85%. The ambulance note dated 10/28/16 at 12:58 pm documented the resident's temperature was 100.1 F and her respiratory rate was 28 to 32 breaths per minute (normal respiratory rate-20 per minute). The Fire Department personnel (BLS) treatment summary documented Resident 1 was started at 4 liters of oxygen per nasocanula (NC) and was changed to a non rebreather mask at 10 liters per minute which improved her oxygen saturation levels. The narrative note by ambulance transfer revealed Resident 1 had oxygen in place at 4 liters per NC, her breathing was shallow and rapid, she would drift off into sleep when not being engaged, eyes would shut and head would nod. When pt (patient) would drift off, her oxygen (O2) stats would decrease and lethargic mental status remained constant. The emergency room (ER) note for 10/28/16 indicated Resident 1 reported dyspnea and cough and that she choked this morning. The ER note documented BLS noted her decreased oxygen saturations being in the high 80 until they applied 4 liters of oxygen which increased the saturation to low 90s. The ER's physical exam note documented Resident 1 had diffusely course breath sounds, crackles of lower left lobe, with tachypneic (increased respiratory rate) and somnolent. A chest x-ray revealed pneumonia and laboratory results revealed an elevated white blood cell of the blood and bacteria in the urine. Resident 1 was admitted to the hospital with [REDACTED]. Even though nursing was aware of Resident 1's cough and respiratory changes on 10/25/16, skilled therapy's (PT) note regarding documented low oxygen saturation levels on 10/27/16 and the overt and acute changes the morning of 10/28/16, there was no documented evidence consistent assessment and monitoring of Resident 1's condition to identify and evaluate the need for medical interventions. RESIDENT 2 Resident 2 was admitted [DATE] following a spinal fracture and wore a [MEDICATION NAME] support splint (TLSO) when out of bed to stabilize his spine. On 1/30/17 at 11:50 a.m., during meal observations, Resident 2 was observed seated in a chair wearing his [MEDICATION NAME] (chest) splint which covered his entire chest area. He stated due to coughing and swallowing issues his diet had been changed to nectar thick liquids. He stated since his liquid consistency was changed things slid right down. The nursing notes from 1/4/17 to 1/11/17 documented Resident 2 had a productive cough, decreased breath sounds and his oxygen saturation levels remained 95% without oxygen use. The notes indicated he received breathing treatments ([MEDICATION NAME]) and and antibiotics due to his chest x-ray of 1/5/17 that revealed consolidation of his lungs. A nursing note entry for 1/12/17 at 7:02 a.m. (night shift) documented Resident 2 complained of shortness of breath (SOB) and had anxiety and was placed on continuous oxygen at 3 liters per minute with saturations at 94%. The note revealed the physician was notified about resident concerns. Even though Resident 2 required oxygen use and exhibited SOB, there was no further assessment documented regarding lung sounds, vital signs (blood pressure, heart rate, respiratory rate) to evaluate whether further decline or medical interventions would be needed. Another nursing note entry for 1/12/17 at 3:55 p.m., documented Resident 2 was assessed by the physician who ordered stat (immediate) laboratory (blood) work to rule out cardiac abnormalities and/or blood clots in the lungs due to SOB. Review of the laboratory form for the stat blood draw revealed the blood sample was collected on 1/12/17 at 6:15 p.m. and the reported result time was 10:02 p.m. on 1/12/17. Even though Resident 2's physician ordered tests to rule out cardiac issues or blood clots, the LNs did not consistently monitor or thoroughly assess Resident 2's cardiorespiratory status on the evening and night shift of 1/12/17, 1/13/17, 1/14/17 and 1/15/17. A nursing note entry for 1/16/17 revealed after the physician reviewed the laboratory results, orders for a chest scan to rule out [MEDICAL CONDITION] embolism (blood clots) and an injection of anti-clot medication ([MEDICATION NAME]) due to Resident 2's abnormal blood levels. Not until 1/16/17 at noon was a SBAR (situation, background, assessment, request) completed regarding the elevated abnormal blood results. The SBAR revealed when the hospital was notified, radiology stated they would fit Resident 2 in their schedule. There was no consistent and thorough documentation regarding Resident 2's C(NAME) even though he required oxygen for SOB and blood work to rule out a possible blood clot in the lungs. RESIDENT 3 Resident 3 was initially admitted to the facility 01/19/17 with multiple health conditions which included metabolic [MEDICAL CONDITION], elevated cardiac enzymes, Rhabdomyolysis and elevated white blood cell count. Resident 1's Minimum Data Set (MDS), a comprehensive assessment tool dated 1/26/17, indicated the resident was severely impaired in his cognition and required extensive Physical assistance of staff for and activities of daily living (ADLs). The MDS also revealed he required assistance with toileting, was incontinent of urine and had no skin issues. The Care Area Assessment (CAA) revealed nursing staff would provide good peri care after each incontinent episode. According to record review, Resident 3 had swelling and redness of the scrotum on 02/13/17. A test performed and Hydrocele (buildup of watery fluid around the testicles) was found. On the morning of 02/14/17, the physician visited with the resident and noted Resident 3 had symptoms of a swollen and reddened scrotum with excoriation. The physician ordered a urine test. Nursing determined to monitor and notify the physician if swelling or wound became worse. Review of a nurse's progress note that included day and evening shift, dated 02/14/17 at 10:44 p.m., revealed Resident 3 experienced increased sleepiness, weakness and decreased functional ability preventing him from participating with therapy. This progress note also revealed, Resident 3 had increased swelling extending from the scrotum to the gluteal and groin area indicating a change in condition. Further review of the resident's record, indicated there was no documentation the physician was notified of the change in condition. Review of the resident's medical record could not find evidence the LNs monitored the resident closely to ensure tracking of his health / acute condition. On 02/15/17, approximately 08:00 a.m., Resident 3's condition had increasingly worsened. The resident was transferred to the hospital for further evaluation where he was diagnosed with [REDACTED]. The hospital's Emergency (ER) note dated 2/15/17 indicated Resident 3 had a large scrotal mass, diffuse [DIAGNOSES REDACTED] (reddness) extending to peri rectal area with tenderness to palpation and was diagnosed with [REDACTED]. During an phone interview on 2/28/17 with Resident 3's physician (MD), stated when he assessed the resident on the morning of 2/14/17, he noted scrotal swelling and excoriation and drainage. The MD stated when he assessed Resident 3 there was no involvement in the groin and/or gluteal region and the resident was alert. In an interview, on 03/02/17 approximately 4:20 p.m., LN H, a Registered Nurse who documented the 2/14/17 note that included Resident 3's symptoms worsening and a change in condition. She acknowledged the physician was not notified. The failure to identify an acute change in symptoms or to notify the physician timely caused a delay in treatment. See also F 157 for additional information

Based on interview, and record review, the facility failed to provide the necessary supervision and assistance for 1 of 3 sample residents (1) who exhibited a change in condition. Failure to identify the need for increased supervision and implement timely interventions resulted in an avoidable injury to Resident 1's head. Findings include: RESIDENT 1 Resident 1 was admitted to the facility on [DATE] for rehabilitation following surgery for [REDACTED]. The cervical collar placed the resident's head in a tilted upright position. The initial nursing assessment form documented that the resident was alert and speech was clear. A physical therapist (PT) note dated 10/27/16 documented Resident 1 was experiencing extreme fatigue and pt (patient) short of breath (SOB) with minimal activity, very low activity tolerance. Pt's O2 level was low at 85. Review of the facility's investigative report dated 10/28/16 revealed Resident 1 had hit her head and sustained a bruise to forehead. The report revealed she was sent to hospital to rule out stroke. RCM F documented a late entry dated 10/29/16 that he noticed a change in Resident 1's responses after breakfast on 10/28/16 where she appeared sleepy and dosed off during conversation. During an interview with the Speech and Language therapist (SLP) on 1/31/17 at 10:53 a.m. she stated on 10/28/16 she had informed the Resident Care Manager (RCM F) that Resident 1 required observation for the next 2 hours due to the overt and acute changes and required 1:1 supervision with eating due to increased coughing and difficulty chewing. During an interview on 2/1/17 with Resident 1's family member who was at the facility on 10/28/16 around breakfast time. She stated Resident 1 was slumped over her breakfast tray and not very alert. The family member stated she had informed nursing that Resident 1 was in no condition to eat, unable to keep eye open, and was drooling and that the resident's condition changewas not right and was an obvious decline. The family member stated when Resident 1's lunch meal tray was brought in, she again informed staff that she needed assistance with her meal but the staff member had stated I don't do meal assistance and left. The family member stated on 10/28/16 when Resident 1 hit her head on the tray which awaken her. I requested staff to put her back in bed as I had to hold her up and tell nursing staff to look at her condition. At this time, the RCM came in and the resident was put back to bed. In an interview on 1/30/17 at 5:45 p.m., RCM F stated staff charting is done by exception and indicated there was no documented assessment or interventions implemented for safety prior to Resident 1 hitting her head on the bedside table. LN D, a Licensed Practical Nurse who was Resident 1's nurse on 10/28/16 was interviewed on 1/31/17 at 3:30 p.m., LN D stated that after the morning medication pass, he only returned to check on Resident 1 when the family informed him, the resident had hit her head (around noon). LN D stated at that time, he attempted to give the resident a spoonful of soup but she started to cough, she was sleepy and had a hard time to get breath. During an interview with the Director of Nursing on 1/31/17 at 1:15 p.m., regarding Resident 1's change of condition and need for 1:1 supervision, he stated during the noon meal on 10/28/16 the nursing assistant (NAC) brought the tray for Resident 1 but did not provide the 1:1 assistance that she required. Even though staff had identified along with the family member who reported, Resident 1's altered mental status early in the day, and the SLP report of an overt and acute change and recommendation for 1:1 supervision with feeding, there was no documented evidence Licensed Nurses recognized the risks or implemented increased supervision to reduce the risk of an avoidable accident.

Based on interview and record review, the facility failed to notify the physician for 3 of 3 sample residents (1, 2 and 3) who required medical interventions. Failure to notify a physician regarding Resident 2's abnormal laboratory results and Resident 1's change in swallowing and/or respiratory status and Resident 3's clinical condition resulted in delayed evaluation and treatment for [REDACTED]. Findings include: The facility's policy for Change of Condition (C(NAME)) policy indicated Licensed Nurses (LNs) would evaluate the C(NAME) and determine the course of action based on standard of practice, the physician is notified immediately by phone, and LNs may initiate transport of a resident via 911 to the ER without a physician order [REDACTED]. Another policy provided on [DATE] regarding Change in Condition notification revealed immediate notification to the physician was required for any symptom, sign or apparent discomfort that is: acute or sudden in onset, and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. The policy directed the physician to be immediately notified if abrupt/general weakness with acute symptoms. The Policy also indicated staff were to immediately report a oxygen saturation less than 90%, acute episode with wheezing, dyspnea or respiratory distress, dyspnea-acute onset of change from usual pattern or new onset or progressive choking or aspiration. RESIDENT 1 The facility's Speech and Language Therapist (SLP) notes dated [DATE] documented Resident 1 had increased difficulty with diet today. In previous SLP sessions, pt (patient) had occasional immed (immediate) cough on thins (liquids), able to utilize positioning to improve. Today, pt was coughing consistently on solids and thins-improvement given nectar (thick liquids). Downgraded to nectar liquids, small bites/sips, assistance due to increased aspiration. The notes documented she exhibited overt s/sx (signs and symptoms) of aspiration. During an interview and review of the SLP notes on [DATE] at 10:53 a.m. with the SLP, she stated Resident 1 was at high risk of aspiration due to the positioning of her head which was tilted up due to the cervical (neck) brace. The SLP stated she had evaluated Resident 1 on [DATE] during the breakfast meal around 8:00 a.m., and changed her diet to nectar thick liquids due to Resident 1's increased coughing and difficulty chewing. The SLP stated due to Resident 1's overt and acute changes which she had assessed during the breakfast meal ([DATE]), she had informed the Resident Care Manager (RCM F), Licensed Practical Nurse, that Resident 1 required observation for the next 2 hours and if coughing continued she needed to be sent out due to the acute changes. She also stated she had informed nursing staff that Resident 1 required 1:1 supervision with eating. There was no documented evidence the physician was notified of the overt and acute change. RESIDENT 2 A nursing note entry for [DATE] at 7:02 a.m. (night shift) documented Resident 2 complained of shortness of breath (SOB) and had anxiety and was placed on continuous oxygen at 3 liters per minute with saturations at 94%. The note revealed the physician was notified about resident concerns. Another nursing note entry for [DATE] at 3:55 p.m., documented Resident 2 was assessed by the physician who ordered stat (immediate) laboratory (blood) work to rule out cardiac abnormalities and/or blood clots in the lungs due to SOB. Review of the laboratory form for the stat blood draw revealed the blood sample was collected on [DATE] at 6:15 p.m. and the reported result time was 10:02 p.m. on [DATE]. Not until [DATE] at noon was a SBAR (situation, background, assessment, request) completed regarding the elevated abnormal blood results. The SBAR revealed when the hospital was notified of the chest scan, radiology stated they would fit Resident 2 in their schedule. A nursing note entry for [DATE] revealed after the physician reviewed the laboratory (lab) results, orders were received for a chest scan to rule out [MEDICAL CONDITION] embolism (blood clots) and an injection of anti-clot medication ([MEDICATION NAME]) due to the abnormal blood levels. Even though Resident 2's physician ordered stat lab (blood) tests to rule out cardiac issues or blood clots on [DATE], there was no documented evidence the physician was notified regarding abnormal laboratory levels until four days later on [DATE]. During an interview on [DATE], with LN B, Registered Nurse regarding notification for abnormal laboratory (labs) results, LN B stated lab (blood) results are reviewed by LNs. If the labs are abnormal the physician should be notified. The notification is then documented in the resident's clinical record and the resident is placed on alert charting. RESIDENT 3 Resident 3's Minimum Data Set (MDS) assessment dated [DATE] revealed he required assistance with toileting, was incontinent of urine and had no skin issues. The Care Area Assessment (CAA) revealed nursing staff would provide good peri care after each incontinent episode. A nursing note, SBAR (Situation, Background, Assessment, Request) and investigative report dated [DATE] documented Resident 3's scrotum was swollen, abcess looking like measuring 2.5 centimeters (cm) by 1.1 cm. with opening area with scant drainage. The physician was notified and an ultrasound was ordered and revealed hydrocele of scrotum. The LN documented the physician needed to be notified if scrotal swelling or wound become worse. On [DATE], the physician visited Resident 3 and documented that he had scrotal swelling and excoriation. Another nursing progress note dated [DATE] at 10:44 p.m., documented Resident 3 needed to be orientated, had increased sleepiness, weakness and decrease in functiional ability. The LN's note revealed his scrotum, L (left) inguinal area and L gluteal (buttock) area was swollen. There was no documented evidence that the physician was notified when the swelling had extended to the groin and buttocks. In an interview, on [DATE] approximately 4:20 p.m., LN H, a Registered Nurse who noted Resident 3's symptoms indicating a worsening change in condition, acknowledged the physician was not notified with the resident's worsening change in condition. During an phone interview on [DATE] with Resident 3's physician (MD), he stated when he assessed the resident on the morning of [DATE], he noted scrotal swelling and excoriation and drainage. The MD stated when he assessed Resident 3 there was no involvement in the groin and/or gluteal region and the resident was alert. On [DATE], Resident 3's condition had increasingly worsened. The resident was transferred to the hospital for further evaluation. The hospital's Emergency (ER) note dated [DATE] Resident 3 had a large scrotal mass, diffuse [DIAGNOSES REDACTED] (reddness) extending to peri rectal area with tenderness to palpation and gangrene of the scrotum and died on [DATE].

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 3 sample residents (1) relating to aspiration precautions and neurological deficient related to spinal fracture. Failure to develop a comprehensive care plan resulted in resident not receiving care and services to prevent harm. Findings include: RESIDENT 1 Resident 1 was admitted to the facility on [DATE] for rehabilitation following surgery for [REDACTED]. The hospital records from 10/12/16 to 10/20/16 revealed Resident 1's oxygen saturation level was 100% on room air (RA). The hospital's Speech and Language therapist (SLP) note dated 10/20/16 documented that Resident 1 needed to be alert and awake during meals, be in an upright position for 30 minutes after meals and was to be monitored for signs and symptoms of aspiration. The facility's SLP's evaluation dated 10/24/16 documented Resident 1 presents with mild-mod oropharyngeal dysphasia impacting safety and ability to consume meals. The note revealed the SLP would assess and evaluate safe swallowing strategies, provide education and diet texture modification. The note also revealed she was at risk for weight loss, pneumonia and aspiration. The weekly multidisciplinary medicare review note dated 10/24/16, documented Resident 1 would be monitored for neurological changes associated with spinal fracture. The facility's physician's progress note dated 10/25/16 documented Resident 1 was experiencing persistent pain and pain with swallowing, and plaques (white rash) were noted in her mouth and throat which required medications. Review of the interdisciplinary Care Plan dated 10/21/16, revealed there were no care plan interventions regarding aspiration precautions or monitoring for neurological deficit related to a spinal fracture. Resident 1's Care Directives did not have any safety interventions regarding aspiration precautions such as making sure the resident is alert and awake and in an upright position during meals or reporting any neurological changes. During an interview on 1/30/17 at 1:25 p.m., the Director of Nursing (DNS) stated care plans should be developed and the specific interventions would be formatted on the Care Directives used by the nursing assistants (NACs) to ensure care needs are being met. During an interview on 1/31/17 at 12:55 p.m., NAC G stated the care plan would provide the necessary information regarding a resident's care needs. Refer to 483.24 F 309 Quality of Life

Based on interview and record review, the facility failed to follow accepted standards of clinical practice for 1 of 3 sample residents (Resident 3). Failure to thoroughly assess, evaluate and notify physician per facility policies for condition changes resulted in delayed evaluation and treatment for [REDACTED]. Finding include: RESIDENT 3 A nursing note, SBAR (Situation, Background, Assessment, Request) and investigative report dated [DATE] documented Resident 3 with scrotum swollen, abscess looking like measuring 2.5 centimeters (cm) by 1.1 cm. with opening area with scant drainage. The physician was notified and an ultrasound was ordered and revealed hydrocele of scrotum. The LN documented the physician needed to be notified if the scrotal swelling or wound became worse. The next nursing note documentation was dated [DATE] at 6:02 a.m. The note documented scrotum was elevated with wash cloth related to swelling and redness. The note indicated LNs would continue to monitor. Another nursing progress note dated [DATE] at 10:44 p.m., documented Resident 3 needed to be orientated, had increased sleepiness, weakness and decrease in functional ability. The LN note revealed his scrotum, L (left) inguinal area and L gluteal (buttock) area were swollen. In an interview, on [DATE] approximately 4:20 p.m., LN H, a Registered Nurse who noted Resident 3's symptoms indicating a worsening change in condition, acknowledged the physician was not notified with the resident's worsening change in condition. A SBAR dated [DATE] documented resident was very sleepy this morning with a decreased level of consciousness and was difficult to arise. The note revealed that the scrotal area was very swollen, hard, red and painful. On [DATE], Resident 3's condition had increasingly worsened. The resident was transferred to the hospital for further evaluation. The hospital's Emergency (ER) note dated [DATE], indicated Resident 3 had a large scrotal mass, diffuse [DIAGNOSES REDACTED] (redness) extending to peri rectal area with tenderness to palpation and an ultrasound revealed gangrene of the scrotum. Resident 3 died on [DATE]. Even though Resident 3's scrotal swelling had extended to the groin and buttocks, the LNs failed to recognize acute condition changes and/or the need to notify the physician. Refer to 483.10 (g) (14) Notify of Changes Refer to 483.24 Quality of Life