Every finding on record at Avamere Rehabilitation of Cascade Park

Based on interview and record review, the facility failed to provide a safe and orderly discharge for 1 of 1 residents (Resident 1) reviewed for admission, transfer, and discharge. This failure placed residents at risk of lack of stable housing and disruption of continuity of care.Findings included. Record review of facility policy Discharge Planning, dated 01/09/2002, stated that once discharge was anticipated, Social Services shall arrange or assist in arranging necessary services and shall identify discharge location, supports, and equipment arranged. The policy further stated that for residents without an identified discharge location, the facility will enlist the support of the assigned Medicaid case manager and other public agencies to secure appropriate housing. Resident 1 was admitted to the facility on [DATE] with diagnoses including atherosclerosis of coronary artery bypass graft(s) (plaque buildup and narrowing in blood vessels that were surgically placed to improve blood flow to the heart).Record review of Resident 1's Nursing Home Transfer or Discharge Notice, dated 01/29/2026, showed the facility issued an emergency discharge effective 01/29/2026 under the reason that the safety of other individuals in the facility was endangered. The discharge location was documented as Car (Personal), with the address listed as NA. The record did not identify an established discharge address or confirmed housing placement where Resident 1 could access shelter or hygiene facilities. On 02/12/2026 at 1:10 PM, Staff A, Administrator, stated the discharge was processed as an emergency discharge and that law enforcement was present when the discharge notice was delivered. Staff A stated Resident 1 packed his belongings and left the facility that same day. On 02/12/2026 at 1:25 PM, Staff C, Social Worker, stated the discharge was processed as an immediate discharge. Staff C stated the discharge location was documented as Car on the discharge notice. Staff C stated no confirmed housing placement was secured prior to discharge.On 03/02/2026 at 1:45 PM, Resident 1 stated he was escorted from the facility by police on 01/29/2026. Resident 1 stated his POA (Power of Attorney) secured motel lodging for several days following discharge and stated he was currently staying with a friend. On 03/04/2026 at 2:45 PM, Staff A acknowledged that discharge to a hotel would have been preferable to discharge to Resident 1's vehicle. Reference WAC 388-97 -0120(1)(2)(a)-(d)(3)(a)(4)(b)(5); 388-97-0080; 388-97-0140(1)(a)-(c)(i)-(iii)

Based on record review and interview, the facility failed to ensure a safe and appropriate discharge for 1 of 3 former residents (Resident 1) reviewed for discharge. As a result of this failure, Resident 1 experienced harm when she was discharged without necessary supports, which led to complications from an existing stage 4 sacral wound requiring hospitalization for symptom management.Findings included.Resident 1 was admitted to the facility 07/09/2025 with multiple diagnoses including sepsis (a systemic infection), acute cystitis (bladder infection), encephalopathy (disease or damage of the brain) , Parkinson's (progressive movement disorder), stage 4 sacral pressure wound (deep wound exposing muscle, tendon or bone) and adult failure to thrive (gradual decline in physical and mental health leading to significant weight loss and function). The Minimum Data Set (MDS), a comprehensive assessment tool, dated 07/15/2025, documented the resident required partial to moderate assistance with upper-body dressing and oral hygiene, substantial to maximal assistance with bathing, and was dependent for toileting and lower-body dressing. On September 23, 2025, at 11:25 a.m., Collateral Contact 1 (CC1), the Home and Community Services (HCS) case manager, stated that she had concerns regarding the facility's discharge of Resident 1. CC1 stated the resident was discharged home even though hospital records from prior to Resident 1's admission reportedly indicated the resident lacked capacity to make independent decisions. CC1 reported the discharge paperwork was signed by Resident 1's daughter, who did not have legal authority to act on her behalf, and that Resident 1 was returned to a home environment that was unable to meet her care needs. Record review of Resident 1's progress notes, showed the following:On 07/11/2025 at 15:04 (3:04 p.m.), a social services note documented Resident 1 was non-verbal but able to communicate effectively by reading lips and responding to questions with a thumbs-up or thumbs-down gesture to indicate yes or no. On 08/11/2025 at 10:23 a.m., a social services note documented Resident 1's primary care provider advised the resident should not be discharged home and required a higher level of care. On 08/20/2025 at 12:17 p.m., a social services note documented ongoing barriers to discharge, including wound-care needs, cognitive decline, 24-hour care requirements, and lack of available family supports. On 08/22/2025 at 14:09 (2:09 p.m.), a nursing note documented the family planned to discharge Resident 1 home the following day against medical advice. The nurse listed risks of wound deterioration, sepsis, neglect, and the need for 24-hour care with frequent repositioning. On 08/23/2025 at 10:30 a.m., a nursing late entry documented Resident 1 was discharged home, wound-care teaching was provided to the daughter, and AMA (Against Medical Advice) paperwork was signed by the daughter. There was no documentation that Resident 1 participated in or consented to the discharge decision. Record review of Department Records, dated 09/25/2025, documented that on 08/27/2025, Resident 1 was observed lying in bed, non-verbal, and responding by raising her thumb. When asked if she was in pain and wanted medical help, Resident 1 indicated yes. Emergency medical services were contacted, and the resident was transported to the hospital. Resident 1 had been discharged from the skilled nursing facility against medical advice on 08/23/2025, and that no home health or wound-care services were in place at the time of the home visit. Record review of Resident 1's emergency department admission notes, dated 08/27/2025, showed Resident 1 was admitted from home with an infected Stage IV sacral decubitus ulcer (deep wound exposing muscle, tendon or bone) with cellulitis (skin infection causing redness swelling and pain) and symptoms of buttock pain. The documentation noted Resident 1 had recently left the skilled nursing facility against medical advice and that family members were unable to provide care at home. On 10/03/25 at 10:40 a.m., Collateral Contact 2 (CC2, Resident 1's daughter) stated she received a call from the facility social worker on 08/20/2025, who advised that insurance would no longer cover Resident 1's stay and that discharge would need to occur in three days. CC2 stated she had no suitable location prepared to receive her mother and that the social worker did not offer information regarding Medicaid or the option to remain in the facility pending coverage approval. CC2 stated Resident 1 required two-person assistance and that she told the social worker the resident's partner was not capable of providing that level of care. CC2 stated no home-health services were arranged and a low-pressure mattress promised prior to discharge was not delivered. CC2 later discovered the facility had documented the discharge as against medical advice (AMA), which she denied initiating, stating she believed the discharge was premature and unsafe. CC2 stated she obtained power of attorney following Resident 1's hospitalization, allowing her to complete the Medicaid application. On 10/03/2025 at 2:16 p.m., Collateral Contact 3 (CC3, Resident 1's significant other) stated he was provided little to no instruction regarding Resident 1's needs. He stated he did not receive any training from the facility related to wound care. CC3 stated no home-health or nursing services were arranged while Resident 1 was at home and that he did not recall receiving any equipment or supplies from the facility. CC3 stated staff had informed them Resident 1 required two-person assistance for transfers. CC3 stated Resident 1's daughter managed transfers for a few days, though he had no plan for providing care after the daughter returned to [NAME]. On 10/08/2205 at 12:15 p.m., Resident 1 was observed in the hospital. Resident 1 was alert and able to respond to simple questions using nonverbal gestures (thumbs up) but was unable to verbalize intelligibly. She was unable to provide additional information regarding her discharge or recent hospitalization On 10/08/2025 at 1:15 p.m., Staff 2 ,facility social worker, stated Resident 1's daughter requested discharge against medical advice. Staff 2 stated the daughter declined to assume power of attorney due to distance and inability to commit, leaving the Medicaid application incomplete and preventing insurance coverage from progressing. Staff 2 stated guardianship should have been pursued to ensure appropriate discharge planning but was not initiated. Resident 1's significant other was identified as the primary caregiver, though staff expressed doubt about his ability to provide the level of care required. Staff 2 stated facility staff, including nursing and the physician, believed the discharge was unsafe. Staff 2 stated no home-health referral was made. Staff 2 stated Resident 1 required one staff for transfers, repositioning, and bathing, and two staff for toileting, and that he did not know how those needs would be met at home, as Resident 1 was being discharged to live only with her significant other. On 10/08/2025 at 1:38 p.m., Staff 3, Registered Nurse (RN)/ Resident Care Manager, stated Resident 1 was nonverbal and unable to make her needs known. Staff 3 stated discharge home was unsafe due to the risk of wound deterioration and sepsis and that the resident required 24-hour care. On 10/08/2025 at 1:49 p.m., Staff 4, Certified Nursing Assistant, stated Resident 1 was unable to make her needs known and required two-person assistance for transfers and most activities of daily living. On 10/08/2025 at 2:00 p.m., Staff 1, Director of Nursing, confirmed Resident 1's daughter signed AMA paperwork for Resident 1. Staff 1 stated that an against medical advice discharge did not remove the facility's responsibility to ensure a safe and coordinated discharge, including appropriate assessments, instructions, medications, supplies, and follow-up arrangements.Reference WAC 388-97-0120 (1)(b)-(f)(2)-(4)

Based on observation, interview, and record review, the facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for 2 of 4 sampled residents (Resident 75 & 112) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.Findings included. Record review of the facility's policy titled, Restraint and Device Guideline, undated, documented, When a safety device is determined to be needed to provide a safe environment for the resident the RCM [Resident Care Manager] or designee will:A. Complete or update the Safety Device Assessment.B. Notify the Physician of evaluation and obtain needed order.C. Notify the resident and/or Responsible Party.I. The Responsible Party may give consent over the phone.E. Initiate Care Plan and update Kardex. 1) Resident 75 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool), dated 09/30/2025, showed resident 75 was severely cognitively impaired. In an observation on 11/17/2025 at 2:26 PM, Resident 75's bed was observed low to the ground, about three to four inches off the floor. In an observation on 11/20/2025 at 9:08 AM, Resident 75 was observed lying in bed with the bed low to the ground, about three to four inches off the floor. In an observation on 11/20/2025 at 11:13 AM, Resident 75 was observed lying in bed with the bed low to the ground, about three to four inches off the floor. Review of Resident 75's Electronic Health Record (EHR) showed no Safety Device Evaluation and Consent, and/or physician's order, related to the bed in low position to the ground was completed. Record Review of Resident 75's Comprehensive Care Plans, initiation dated 06/24/2025, did not show a Focus, Goal, or Intervention related to the bed placed in a low position. In an interview on 11/20/2025 at 11:20 AM, Staff E, Resident Care Manger/Registered Nurse (RN) said when a resident had their bed placed in the low position or against the wall, they needed to have physician orders, evaluations and consent, and a care plan in place. In a joint observation and interview at 11/20/2025 at 11:26 AM, Staff E went to Resident 75's room and observed the bed in low position stating, Yes, I would consider that to be bed in low position. After looking at Resident 75's EHR, Staff E said there was not a physician's order, evaluation, consent, or care plan for the bed to be in low position and there should have been. 2) Resident 112 was admitted to the facility on [DATE]. Record review of Resident 112's BIMS (Brief Interview for Mental Status, a screening tool used to evaluate a resident's cognitive function and identify the presence and severity of cognitive impairment), dated 11/18/2025, showed Resident 112 was moderately cognitively impaired. In an observation on 11/17/2025 at 12:00 PM, Resident 112's left side of the bed was observed against the wall. In an observation on 11/20/2025 at 8:38 AM, Resident 112 was observed lying in bed with the left side of the bed against the wall. Review of Resident 112's Electronic Health Record (EHR) showed no Safety Device Evaluation and Consent and/or physician's order related to the bed against the wall was completed. Record Review of Resident 112's Care Plans, initiation dated, 11/12/2025, did not show a Focus, Goal, or Intervention related to the bed placed against the wall. In a joint observation and interview on 11/20/2025 at 11:44 AM, Staff E, Resident Care Manger/Registered Nurse (RN) went to Resident 112's room and observed the left side of the bed against the wall. Staff E said she did not realize the bed was against the wall. After looking at Resident 112's EHR, Staff E said there was not a physician's order, evaluation, consent, or care plan for the bed against the wall. In an interview on 11/20/2025 at 1:15 PM, Resident 112 said he felt his bed against the wall helped him from rolling out of bed on the left side. In an interview on 11/21/2025 at 10:03 AM, Resident 112 said it was a staff member that moved it against the wall when he told them he felt like he may roll out of bed on that side. In an interview on 11/21/2025 at 10:21 AM, Staff B, Director of Nursing/RN said it was her expectation an evaluation, consent, and physician's order was in place for a resident's bed against the wall and/or in low position. Reference WAC 388-97-0620 (4)(a)(b)

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 3 of 14 sampled residents (Resident 75, 19, & 71) reviewed for physical restraints, behavior-emotional, dementia care, and unnecessary medications. This failure placed residents at risk for risk of injury, unmet care needs, and a diminished quality of life. Findings included. 1) Resident 75 was admitted to the facility on [DATE] with multiple diagnoses to include Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after a person experiences or witnesses a traumatic event.) The Quarterly Minimum Data Set (MDS, an assessment tool), dated 09/30/2025, showed resident 75 was severely cognitively impaired and had a diagnosis of PTSD. Physical Restraints In an observation on 11/17/2025 at 2:26 PM, Resident 75's bed was observed low to the ground, about three to four inches off the floor. In an observation on 11/20/2025 at 9:08 AM, Resident 75 was observed lying in bed with the bed low to the ground, about three to four inches off the floor. In an observation on 11/20/2025 at 11:13 AM, Resident 75 was observed lying in bed with the bed low to the ground, about three to four inches off the floor. Record Review of Resident 75's Comprehensive Care Plans, initiation dated 06/24/2025, did not show a Focus, Goal, or Intervention related to the bed placed in a low position. In an interview on 11/20/2025 at 11:20 AM, Staff E, Resident Care Manger/Registered Nurse (RN) said when a resident had their bed placed in the low position or against the wall, they needed to have a care plan in place. In a joint observation and interview at 11/20/2025 at 11:26 AM, Staff E went to Resident 75's room and observed the bed in low position stating, Yes, I would consider that to be bed in low position. After looking at Resident 75's Electronic Health Record (EHR), Staff E said there was not a care plan for the bed to be in low position and there should have been. In an interview on 11/21/2025 at 10:21 AM, Staff B, Director of Nursing/RN said it was her expectation a care plan was in place for a resident's bed placed in the low position. Behavioral-Emotional Record review of Resident 75's Comprehensive Care plan showed a Focus area, dated 11/15/2025, Mood/Behavior/Psychosocial Issues Cognitive impairment - Brining up past potential trauma., was initiated four months and 22 days after admission. Record review of Resident 75's Comprehensive Care Plan showed a Focus area, dated 11/17/2025, Trauma: Physical, Emotional, Social Post Traumatic Stress Disorder (PTSD)., was initiated four months and 24 days after admission. Record Review of Resident 75's Comprehensive Care Plan did not show a Focus, Goal, or Intervention related to PTSD prior to 11/15/2025. In an interview on 11/21/2025 at 11:54 AM, Staff I, Social Services Director, said a resident with a diagnosis of PTSD should have a PTSD and/or trauma care plan in place upon admission. After looking at Resident 75's EHR, Staff I said Resident 75 was admitted with a diagnosis of PTSD, and stated, .No, there was no PTSD care plan in place prior to the one in there right now, earlier this week, and there should have been. In an interview on 11/21/2025 at 12:25 PM, Staff B said Resident 75 should have had a PTSD care plan in place prior to November. 2) Resident 19 was admitted to the facility on [DATE], with multiple diagnoses to include dementia (loss of brain function that includes memory and thinking abilities that are severe enough to interfere with daily life). The Significant Change MDS dated [DATE], showed Resident 19 was severely cognitively impaired and was on an antianxiety medication. Antianxiety Medication Record review of Resident 19's physician order, dated 10/18/2025, showed Resident 19 was prescribed Lorazepam (fast-acting prescription anti-anxiety medication used primarily for its calming and sedative effects) 0.5 MG (milligram) as needed for anxiety. The October and November 2025 Electronic Medication Administration Record (EMAR) showed Resident 19 was receiving lorazepam 0.5mg. Record review of Resident 19's care plan did not show a focus addressing Resident 19 having been on an antianxiety medication. In an interview on 11/20/2025 at 10:08 AM, Staff D, Resident Care Manager/Registered Nurse, said Resident 19's care plan should have included the use of antianxiety medication as of the date it was ordered on 10/18/2025. Staff D reviewed Resident 19's care plan and stated, it was initiated on the 11/19/2025, thirty-two days after the medication was ordered. In an interview on 11/20/2025 at 2:05 PM, Staff B said it was her expectation that the use of antianxiety medication care plan was in place when Resident 19 started taking antianxiety medication. Dementia Record review of Resident 19's care plan did not show a focus addressing Resident 19's diagnosis of dementia. In an interview on 11/20/2025 at 10:11 AM, Staff D, said Resident 19's care plan should have included a focus on dementia. Staff D reviewed Resident 19's care plan and stated, it's not in the care plan, referring to dementia diagnosis. In an interview on 11/20/2025 at 2:06 PM, Staff B, said it was her expectation that Resident 19 should have had a dementia care plan. Anticoagulant Medication Resident 71 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 71 was moderately cognitively impaired with multiple diagnosis to include chronic atrial fibrillation (irregular heartbeat) and was on an anticoagulant (blood thinner) medication. Record review of Resident 71's physician order, dated 07/16/2025, showed Resident 71 was prescribed Dabigatran Etexilate Mesylate (anticoagulant) Oral Capsule 110 MG (Milligram) for chronic atrial fibrillation. Resident 71's EMAR from July 2025 to November 2025 showed Resident 71 was receiving Dabigatran Etexilate Mesylate Oral Capsule 110 MG. Record review of Resident 71's care plan did not show a focus addressing Resident 71 having been on an anticoagulant medication. In an interview on 11/20/2025 at 10:41 AM, Staff D said Resident 71's care plan should have included the use of an anticoagulant. Staff D reviewed Resident 71's care plan and stated, it should be included in the care plan but i don't see one, referring to the anticoagulant care plan. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on interview and record review, the facility failed to ensure residents received restorative aid (RA) services for 1 of 3 residents (Resident 8) reviewed for activities of daily living. These failures placed residents at risk for further decline and a diminished quality of life.Findings included.Review of the facility's policy titled, Restorative Services, dated 01/11/2005, showed; It is the policy of this facility to provide its residents the restorative services in an effort to maintain the residents highest level of self-care and independence. 2.Each resident in the program shall receive, including but not limited to, muscular exercises, mental stimulation and improvement in independent living activities of daily living.Resident 8 admitted to the facility on [DATE] with multiple diagnoses. Resident 8's quarterly Minimum Data Set (an assessment tool), dated 09/12/2025, indicated Resident 8 was severely cognitively impaired and showed Resident 8 had one day of Restorative Nursing Program services for range of motion during the review period. Review of Resident 8's physical therapy PT (physical therapy) Discharge Summary, service date 03/07/2025 - 04/23/2025, indicated Resident 8 required a Restorative Program Established/Trained = Other Restorative Program (RA program for sit<>stand transfers and omni cycle [a specialized, motorized therapeutic exercise system designed for medical rehabilitation] x 15 min [minutes] L1-2 [level]to maintain CLOF [current level of function]).Review of Resident 8's Therapy RA Referral Form, dated 04/23/2025, documented Restorative Nursing Plan for Rehabilitation or Restorative Techniques/Practices Active ROM [range of motion]. Transfers. 1. Repeated sit to stands in II (parallel) bars or T/F [transfer] pole 3x10 reps. 3x/week. 2. Omni cycle x15mins L1-2 3x/week.Review of Resident 8's Physical Therapy PT Discharge Summary, service date 09/15/2025-10/13/2025, documented D/C [discharge] Recs Discharge Recommendations: 24 hour care. RA program for [NAME] (lower extremity - [the legs from the hip down to the feet]) strength. Record review of Resident 8's EHR did not show documentation of Resident 8 having RA services. In an interview on 11/20/2025 at 2:39 PM, Staff G, Resident Care Manager/Restorative Therapy Manager/Registered Nurse (RN), said Resident 8 was on a feeding program but did not meet the requirements for a restorative program.In an interview on 11/21/2025 at 9:53 AM, Staff H, Director of Rehabilitation, said Resident 8 was discharged from PT on 04/23/2025 with a recommendation for a restorative program to include sit to stand, transfer pole and the Omni Cycle. Staff H said Resident 8 was picked up for PT in September 2025 related to weakness from Covid. In an interview on 11/21/2025 at 11:54 AM, Staff G said the restorative program assisted with maintaining residents' range of motion and their current strength levels. In an interview on 11/21/2025 at 1:14 PM, Staff B, Director of Nursing/RN, said the restorative program was for residents to maintain or strengthen themselves. Staff B said they were not aware of how Resident 8 was not on a restorative program. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to implement physician orders and/or care plans for 1 of 5 residents (Resident 71) reviewed for weights and 1 of 4 residents (Resident 112) reviewed for physical restraints. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.Findings included . 1) Physical Restraints Resident 112 was admitted to the facility on [DATE]. Record review of Resident 112's BIMS (Brief Interview for Mental Status, a screening tool used to evaluate a resident's cognitive function and identify the presence and severity of cognitive impairment), dated 11/18/2025, showed Resident 112 was moderately cognitively impaired. Record review of Resident 112's Assistive Device care plan, dated 11/12/2025, documented, .Mobility bar/ 1/4 size side rail to right side only to assist w/ [with] stability during transfers and mobility. Resident requires assistive device d/t [due to] Gait unsteady, intermittent dizziness/vertigo w/mobility bradycardia [slow heart rate] . The Assistive Device care plan further documented interventions, dated 11/12/2025, 1/4 SIDERAILS per MD [medical doctor] order for (safety, during cares, to assist with bed mobility) Observe for entrapment/injury.Resident uses a mobility bar on bed to improve/assist with bed mobility. Record review of Resident 112's ADL (Activities of Daily Living) care plan, dated 11/12/2025, documented interventions, .BED MOBILITY: The resident uses an assistive device right side only Mobility bar/bed rail to reposition and turn in bed.POSITIONING: Side Rails Type : Mobility bar: 1/4 size side rail to right side only when transferring out of bed, into bed, repositioning in bed, turning side to side in bed.TRANSFER: The resident uses right sided only mobility bar/bed rail and FWW for assistive device to transfer. Record review of Resident 112's physician orders, dated 11/14/2025, documented, 1/4 side rail to the right side-consent signed. In an observation on 11/17/2025 at 12:00 PM, Resident 112's left side of the bed was observed against the wall with no side rails or mobility bars on the bed. In an observation on 11/20/2025 at 8:38 AM, Resident 112 was observed lying in bed with the left side of the bed against the wall with no side rails or mobility bars on the bed. In a joint observation and interview on 11/20/2025 at 11:44 AM, Staff E, Resident Care Manger/Registered Nurse (RN) went to Resident 112's room and observed the bed with no side rails, and the left side of the bed against the wall. After looking at Resident 112's Electronic Health Record (EHR), Staff E said there was a physician's order, care plan, and consent for a side rail to be on Resident 112's bed and there was not one. Staff E said Resident 112 should have had a side rail on his bed, stating, They never put one on. In an interview on 11/20/2025 at 1:15 PM, Resident 112 said he did not have a rail on his bed since he was admitted . In an interview on 11/21/2025 at 10:21 AM, Staff B, Director of Nursing/RN, said it was her expectation if there was a physician order and care plan for a bed rail, it was on the bed. 2) Weights Resident 71 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool), dated 11/10/2025, showed Resident 71 was moderately cognitively impaired with multiple diagnosis to include congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Record review of Resident 71's physician order, dated 07/16/2025, showed Daily Weights: Notify MD (medical doctor) weight gain of 2 pounds per day for two consecutive Days or 5 pounds in a week. every day shift. Record review of Resident 71's daily weights for November 2025 showed weights increased on the following dates with no MD notification documented: 11/04/2025 430.6 Lbs (Pounds) and 11/05/2025 440.6 Lbs = 10 Lbs weight gain. 11/10/2025 439.1 Lbs and 11/11/2025 442.8 Lbs = 3.7 Lbs weight gain and 11/12/2025 445.4 Lbs = 2.6 Lbs weight gain. 11/15/2025 435.0 Lbs and 11/16/2025 447.4 Lbs = 12.4 Lbs weight gain and 11/17/2025 452.4 Lbs = 5 Lbs weight gain. Record review of Resident 71's weight in October 2025, showed the facility failed to obtain weights on 10/05/2025, 10/06/2025, and from 10/11/2025 to 10/16/2025, for a total of eight days. Record review of Resident 71's weight in September 2025, showed the facility failed to obtain weights from 09/01/2025 to 09/03/2025, 09/11/2025 to 09/17/2025, and 09/22/2025 to 09/26/2025 for a total of 15 days. Record review of Resident 71's weight in August 2025, showed the facility failed to obtain weights from 08/22/2025 to 08/28/2025 and 08/30/2025 for a total of eight days. In an interview on 11/20/2025 at 10:37 AM, Staff D, Resident Care Manager/Registered Nurse, reviewed Resident 71's EHR but was unable to show documentation of MD notifications of Resident 71's weight increase. In an interview on 11/20/2025 at 2:17 PM, Staff B said it was her expectation that Resident 71's weights were obtained as ordered and any increase in weight reported to the provider per physician's orders. Staff B reviewed Resident 71's EHR but was unable to show documentation of MD notification of Resident 71's weight increase. Reference WAC 388-97-1060 (1)(3)(m)

Based on interview and record review, the facility failed to monitor for adverse side effects for antianxiety medication (fast-acting prescription medication used primarily for its calming and sedative effects) for 1 of 5 residents (Resident 19) reviewed for unnecessary medication. This failure placed residents at risk for experiencing side effects and a diminished quality of life.Findings included .Resident 19 was admitted to the facility on [DATE], with multiple diagnoses to include Dementia (loss of brain function that includes memory and thinking abilities that are severe enough to interfere with daily life). The Significant Change Minimum Data Set (an assessment tool) dated 10/21/2025, showed Resident 19 was severely cognitively impaired and was on an antianxiety medication.Record review of Resident 19's physician order, dated 10/18/2025, showed Resident 19 was prescribed Lorazepam 0.5mg (milligram) as needed for anxiety. The October and November 2025 electronic medication administration record showed Resident 19 was receiving lorazepam 0.5mg but there was no documentation of monitoring for adverse side effects.In an interview on 11/20/2025 at 10:05 AM, Staff D, Resident Care Manager/Registered Nurse, said it was the expectation that Resident 19 was monitored for adverse side effects while receiving Lorazepam. Staff D reviewed Resident 19's electronic health record and stated, the order was placed on 11/19/2025, 32 days after the medication was ordered.In an interview on 11/20/2025 at 2:05 PM, Staff B, Director of Nursing/Registered Nurse, said it was her expectation that while receiving antianxiety medication, Resident 19 was monitored for adverse side effects.Reference WAC 388-97-1060(4)

Based on observation, interview and record review, the facility failed to use personal protective equipment (PPE, gloves, gown and/or mask) on 1 of 1 resident (Resident 11) reviewed for transmission-based precautions (infection control measures). This failure placed residents at risk of infection transmission and a diminished quality of life.Findings included .Resident 11 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (an assessment tool) dated 8/30/2025, showed Resident 11 was alert and oriented and was dependent on staff for transfers using a Hoyer (mechanical) lift.Record review of Resident 11's physician order, dated 11/18/2028, showed Resident 11 was on contact precautions (measures that are intended to prevent transmission of infectious agents).In an observation on 11/21/2025 at 8:58 AM, Staff J, Certified Nurse Assistant (CNA) was observed transferring Resident 11 from her bed to a stretcher without wearing an isolation gown. Staff K, CNA, was observed assisting Staff J to transfer Resident 11 but did not wear an isolation gown.In an interview on 11/21/2025 at 1:46 PM, Staff B, Director of Nursing/Registered Nurse, said it would be the expectation that staff wear PPE when transferring residents on contact precautions.Reference WAC 388-97-1320

Based on interview and record review, the facility failed to ensure nursing hours were accurately posted and/or updated daily for 31 of 31 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.Findings Included.Record review of the Daily Staffing Hours postings, prior to being edited, from 10/18/2025 to 11/17/2025 were not provided for review. Review of the Daily Staffing Hours postings provided by the facility, from 10/18/2025 to 11/17/2025, showed changes for every day to columns titled Actual Number of staff, and/or Actual Total Hours daily.In an interview on 11/20/2025 at 8:44 AM with Staff F, Staffing Coordinator, and Staff B, Director of Nursing/Registered Nurse, Staff F said she did not update the staffing number and hours for each shift on the posted Daily Staffing Hours throughout the day when there were changes. Staff F said she took down the postings and updated them the next morning with staffing changes from the previous day. Staff F said she did not know they had to be updated with changes and did not update them until the next day after she took them down. Staff B said they were not doing the daily postings correctly and indicated they should be updated throughout the day to reflect current staffing. In an interview and record review on 11/21/2025 9:47 AM, Staff F looked at the Daily Staffing Hours postings provided, dated 10/18/2025 to 11/17/2025, and said the copies she provided were the ones that had already been corrected the next day after taken down. Staff F said they were not updated throughout the day. No WAC Reference

Based on interview and record review, the facility failed to ensure adequate blood sugar monitoring was provided for the administration of oral diabetic medications for 1 of 4 sampled residents [1] reviewed for unnecessary medications. This failure placed residents at risk for not receiving needed medication adjustments and a decline in health status. Findings included . A facility policy and procedure for blood glucose monitoring, revised November 2020, documented Follow the provider orders for glucose monitoring. Examples for various situations may include: 1. For the resident on oral medication(s) who is well controlled, monitor blood glucose levels at least twice weekly. 2. For the resident receiving oral medication(s) who is poorly controlled, monitor blood glucose levels twice to four times daily as needed. Resident 1 was admitted to the facility on [DATE] with diagnoses including Hypoglycemia, Unspecified and Type 2 Diabetes Mellitus Without Complications. The Minimum Data Set assessment, dated 09/20/2024, documented the resident was cognitively intact. Review of physician orders, dated 09/16/2024, showed Resident 1 was prescribed two medications used to maintain blood glucose levels for Diabetes Mellitus Type 2 [DM2] non-insulin dependent residents. --Metformin Oral Tablet Extended Release 500 mg [milligrams], give 3 tablets by mouth one time a day for DM2 with breakfast. --Glipizide Oral Tablet Extended Release 10 MG, give 1 tablet by mouth one time a day for DM2 before breakfast. Resident 1's admission orders, dated 09/16/2024, did not include blood glucose (sugar) monitoring. A progress note, dated 09/22/2024 at 9:40 AM, documented a certified nursing assistant (CNA) reported to nursing staff that Resident 1 had left sided weakness. The physician was notified, and an order was given to send Resident 1 to the hospital. Resident declined. A progress note, dated 09/22/2024 at 9:54 AM, documented Resident 1 was still declining to go to the hospital. A progress note, dated 09/22/2024 at 10:47 AM, documented Resident 1 agreed to go to the hospital and 911 was called. A hospital progress note, dated 09/23/2024 at 7:58 AM, showed a Hospitalist Physician's Assistant (PA) documented Resident 1 was brought to the Emergency Department (ED) on 09/22/2024 by Emergency Medical Services with severe hypoglycemia with a blood glucose of 30 and associated left arm and left leg paralysis. Low suspicion of [left upper and left lower extremities] paralysis in ED was due to stroke - more likely the symptoms were related to hypoglycemia. Symptoms resolved completely with normalization of blood sugars. On 10/02/2024, at 2:46 PM, Staff D, Registered Nurse [RN}, said blood sugars were completed 30 minutes before meals for insulin dependent diabetics. When asked if non-insulin dependent diabetic residents receive blood glucose checks, Staff D said only if the physician orders it. Staff D said usually with oral medications the physicians rely on a Hemoglobin A1C, [a blood test that shows what average blood sugar is over past two to three months] instead of daily glucose checks. The physician may order blood glucose checks if the resident was new to Metformin or Glipizide or just taken off insulin. Staff D said so basically, if the resident had a diagnosis for uncomplicated DM2 non-insulin dependent, the physician probably would not have an order for blood glucose checks. At 2:56 PM, Staff E, RN, said residents who received oral medications for DM2 did not necessarily receive blood glucose checks. Staff E said it depended on the resident and the provider, and what the resident was doing prior to admission. At 3:47 PM, Staff F, RN, said the morning Resident 1 was sent out to the hospital she was having left sided weakness, and the staff responded as though it were a stroke as she had a history of strokes. Staff F said routine blood glucose checks were not completed for DM2 no- insulin dependent residents. More often the Hemoglobin A1C was referred to. Staff F said when Resident 1 returned from the hospital the order for Glipizide was discontinued and an order was received for blood glucose checks twice daily. On 10/07/2024 at 3:49 PM, when asked about the facility policy and procedure for blood glucose monitoring, Staff B, RN and Director of Nursing Services, said she and the Administrator would consult with the provider about admission orders for DM2 non- insulin dependent residents. On 10/08/2024 at 12:25 PM, Staff C, Physician, said she had checked Resident 1's blood glucose and Hemoglobin A1C from the hospital prior to the first admission and they were stable. Staff C said she usually relied on Hemoglobin A1C's every three to six months for stable residents. When asked if she would expect staff to check blood glucose for a resident who had a change of conditions, Staff C said yes, she would. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to ensure pressure ulcers were thoroughly assessed, consistently monitored, and skin care and treatment were provided timely to promote healing of an existing pressure ulcer and prevent development of a new pressure ulcer for 1 of 6 sample residents (51) reviewed for pressure ulcers. Resident 51 experienced harm when an existing pressure ulcer on the coccyx worsened and a new pressure ulcer developed to the right buttock and upper thigh area that became infected and required hospital treatment. This failure placed residents at risk for deterioration in skin conditions, discomfort and a diminished quality of life. Finding included . The (corporation) Wound Management Guidelines, dated 08/25/2020, noted the following: --Skin checks are completed by Licensed nurse weekly. CAN/NAC/Shower aides (nursing assistants) will report any alterations in skin identified during routine care. --If a Resident is identified to have a new skin alteration the Licensed Nurse will: Initiate Risk Management and investigate the potential cause, development, and implement interventions. --If a Resident is identified to have a new skin alteration the Licensed Nurse will: Initiate a referral to the Registered Dietitian [RD] if indicated. Follow up on any RD recommendations. --Residents/and or representatives are informed/educated regarding risk factors for skin breakdown and the importance of following the interventions on the care plan. --Braden Risk Assessment is completed on admission, weekly x 3 weeks and then quarterly, annually, and with a significant change of condition. Resident 51 was admitted to the facility on [DATE] with diagnoses including healing Stage 2 pressure ulcer to the coccyx. The 5-day admission Minimum Data Set (MDS) assessment, dated 11/29/2023, showed Resident 51 was alert and oriented, and required one person assist with bed mobility. The MDS showed the resident was assessed to be at risk of developing pressure ulcers and had a healing Stage 2 pressure ulcer on the coccyx. The Admission Nursing skin assessment, dated 11/23/2023, noted healing pressure wound to coccyx. Nearly healed upon admission, protective Mepilex (foam absorbent dressing for treatment of chronic and acute wounds) in place. No weekly skin audits were documented from the initial assessment date of 11/23/2023 until 12/14/2023 (three weeks without documented weekly skin audits). Record review of Resident 51's medical record showed the admission Braden assessment, dated 11/23/2023; the weekly (x 3 weeks) Braden assessments on 11/30/2023, 12/07/2024 and 12/14/2024; and then no Braden assessments from 12/14/2023 until 06/20/2024. The skin audit, dated 12/21/2023, noted open area to pt [resident's] coccyx [same wound the resident was admitted with] treatment applied. New open area to pt skin fold between R (right) buttock and upper thigh pictures taken. The audit showed the wound measurements were 2.67 cm (centimeter) x 0.76 cm. Depth was not documented. The photo image of the wound showed red/pink open wound to the area described. Review of the care plan showed the skin at risk care plan and/or a skin impairment care plan were not initiated on admission. The alteration in skin integrity care plan and the nutrition care plan were initiated on 12/21/2023 when the pressure ulcers were documented on the skin audit. A wound assessment, dated 01/22/2024, showed the right buttock/upper thigh wound measured 3.43 cm x 2.03 cm. No depth measurement was documented. The photo image showed the wound with a yellow base and a faint pink color in the outer wound areas. Resident 51's December 2023 and January 2024 Treatment Administration Record showed treatment was not initiated, for the new right buttock/upper thigh wound, until 01/24/2024 (34 days after the wounds were documented on the skin audit, dated 12/21/2023). Interventions included cleaning right ischial with normal saline/wound cleanser, apply skin prep to peri-wound and allow to dry, apply santyl (wound debrider) and cover it with a sheet of inter-dry twice daily and PRN (as needed). The quarterly MDS assessment, dated 02/29/2024, did not show a Braden Risk Assessment was completed. Record review of Resident 51's medical record showed the resident was admitted to the hospital for suspected osteomyelitis (bone infection) on 03/12/2024 and surgical debridement of the right ischial wound (right buttock/upper thigh). The medical record showed when Resident 51 was readmitted to the facility on [DATE], a Braden Risk Assessment was not completed until 06/20/2024. On 08/06/2024 at 9:29 AM, Resident 51 said they developed multiple pressure ulcers in the facility since being admitted . Resident 51 said they even had to have one surgically treated. Resident 51 stated they did not have a special wheelchair cushion or pressure relieving mattress for quite some time after being admitted . On 08/08/24 at 9:46 AM, Staff H, RD stated, We will find out about admission pressure ulcers by chart audit, review of nursing admission assessment, or find physician orders. When asked how she would be notified if a resident developed a pressure ulcer in house, Staff H stated, The Resident Care Manager [RCM] will email me or tell me. If a pressure ulcer is identified in house, then the resident will be placed on a weekly monitoring under nutrition at risk and documented interventions. After reviewing Resident 51's medical record, Staff H stated, Resident 51 was placed on nutrition at risk on [03/22/2024]. Staff H stated, Resident 51 was not placed on nutrition at risk on admission despite having an identified pressure ulcer, as the wound was nearly healed. At 10:36 AM, Staff D, RCM and Licensed Practical Nurse, was observed performing a dressing change for Resident 51's right ischial (buttock/upper thigh) pressure ulcer. The wound had moderate drainage and had an unpleasant odor. The wound base was pink. At 11:58 AM, Staff D said Resident 51 was originally on a regular mattress until the facility got a foam mattress. Staff D stated, We got the specialty air mattress sometime toward the end of December [2023]. Staff D stated, We got a waffle seat cushion about the same time. Staff D said no interventions were added to the care plan. At 11:58 AM, Staff B, Director of Nursing Services and Registered Nurse, said any in-house Stage 2 pressure ulcer or higher would be investigated as an incident. After reviewing the incident report log, Staff B said she was unable to provide an investigation for the right buttock/thigh pressure ulcer documented on 12/21/2023. Staff B stated, [Resident 51] was admitted with that wound, but Staff B was unable to find supporting documentation in the medical record. Staff B said she would expect a baseline care plan to be completed by day five after admission. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to ensure an assessment, consent and/or physician order was obtained for beds being against the wall and bed rails for 4 of 5 sampled residents (5, 31, 61, & 189) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . Record review of the facility's policy entitled, Use of Restraints, revised April 2017, documented, 1. Physical Restraints' are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative . 1) Resident 5 was admitted to the facility on [DATE] with diagnoses including right leg below knee amputation. The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 06/09/2024, documented Resident 5 was alert and oriented. Record review of Resident 5's Electronic Health Record (EHR) did not show physician orders for the bed being against the wall or half-length bed rails on the bed. Record review of Resident 5's EHR did not show an assessment and consent for Resident 5's bed being against the wall. On 08/05/2024 at 4:02 PM, Resident 5 was observed lying in bed sleeping. Resident 5's bed was observed with the left side of bed against the wall and half-length bed rails raised on both sides of the bed. On 08/06/2024 at 9:31 AM, Resident 5 was observed lying in bed awake with the left side of bed against the wall and half-length bed rails raised on both sides of the bed. At 1:57 PM, Resident 5's bed was observed with the left side of bed against the wall and half-length bed rails raised on both sides of the bed. On 08/07/2024 at 10:01 AM, Resident 5 was observed sleeping in bed on her right side, with the left side of bed against the wall and half-length bed rails raised on both sides of the bed. On 08/08/2024 at 3:40 PM, Resident 5's bed was observed with the left side of bed against the wall and half-length bed rails raised on both sides of the bed. 2) Resident 31 was admitted to the facility on [DATE]. The Medicare/5-day MDS assessment, dated 07/23/2024, documented Resident 31 was moderately cognitively impaired. Record review of Resident 31's EHR did not show an assessment, consent, and physician orders for the bed being against the wall. On 08/05/2024 at 2:56 PM, Resident 31's bed was observed with the left side of bed against the wall. On 08/07/2024 at 9:58 AM, Resident 31's bed was observed with the left side of bed against the wall. On 08/08/2024 at 2:56 PM, Resident 31 was observed lying in bed on his right side with his wheelchair beside the bed. Resident 31's bed was observed with the left side of bed against the wall. 3) Resident 61 was admitted to the facility on [DATE]. The Modification of Admission MDS assessment, dated 06/30/2024, documented Resident 61 was alert and oriented. Record review of Resident 61's EHR did not show an assessment, consent, and physician orders for the bed being against the wall. On 08/05/2024 at 4:23 PM, Resident 61's bed was observed with the left side of bed against the wall. On 08/06/2024 at 9:12 AM, Resident 61's bed was observed with the left side of bed against the wall. When asked about her bed being against the wall, Resident 61 said she did not know why it was against the wall. At 1:52 PM, Resident 61 was observed lying in bed watching TV with the left side of bed against the wall. On 08/07/2024 at 9:56 AM, Resident 61 was observed sleeping in bed with the left side of bed against the wall. On 08/08/2024 at 2:51 PM, Resident 61 was observed lying in bed looking at her phone with the left side of bed against the wall. 4) Resident 189 was admitted to the facility on [DATE]. The Admission/Medicare-5 day MDS assessment, dated 07/27/2024, documented Resident 189 was alert and oriented. Record review of Resident 189's EHR did not show an assessment, consent, and physician orders for the bed being against the wall. On 08/05/2024 at 4:20 PM, Resident 189 was observed lying in bed asleep with the left side of the bed against the wall. On 08/06/2024 at 10:00 AM, Resident 189's bed was observed with the left side of bed against the wall. When asked about the bed being against the wall, Resident 189 stated, It's always been like that. On 08/07/2024 at 8:38 AM, Resident 189 was observed lying in bed on her right side with the left side of bed against the wall. On 08/08/2024 at 2:59 PM, Resident 189 was observed lying in bed on her right side with the left side of bed against the wall. On 08/09/2024, at 8:40 AM, Staff C, Resident Care Manager and Registered Nurse (RN), said a safety device assessment and consent, and physician orders were needed for residents that had their bed against the wall and/or had side rails on the bed. When asked about Resident 5's bed being against the wall and with half side rails, Staff C said he could not find an assessment, consent, and orders for Resident 5's bed being against the wall. Staff C said he could not find physician orders for half side rails on Resident 5's bed, and stated, That needs to be done for sure . Why is her bed against the wall. When asked about the beds being against the wall for Resident 31, Resident 61, and Resident 189, Staff C said he could not find an assessment, consent, and physician orders for Resident 31's, Resident 61's, or Resident 189's bed being against the wall. At 8:48 AM, Staff B, Director of Nursing Service and RN, said it was her expectation assessments, consents, and physician orders were completed for residents with bed rails and/or beds against the wall. Reference WAC 388-97-0620 (1)(a)(b), (4)(a)(b)

Based on observation, interview and record review, the facility failed to ensure care and services were provided in a manner that promoted residents' dignity related to urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) care for 2 of 2 sampled residents (Residents 11 & 39) reviewed for urinary catheter. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life. Findings included . 1) Resident 11 was admitted to the facility on [DATE]. The modification of admission Minimum Data Set (MDS) assessment, dated 06/27/2024, documented Resident 11 was moderately cognitively impaired and had an indwelling catheter. Resident 11's Alteration in Elimination Care Plan, dated 06/26/2024, documented .Keep drainage bag covered for dignity. Resident 11's Indwelling Catheter Care Plan, dated 07/26/2024, revised 08/07/2024, documented .drainage bag to remain covered . On 08/05/2024 at 3:59 PM, Resident 11 was observed sleeping in bed with the foley catheter drainage bag hanging off the right side of the bed uncovered. On 08/06/2024 at 10:06 AM, Resident 11's foley catheter drainage bag was observed hanging off the right side of the bed uncovered. At 2:01 PM, Resident 11 was observed lying in bed awake on his back with the foley catheter drainage bag hanging on the right side of the bed uncovered, with urine visible in the drainage bag. On 08/07/2024, at 8:42 AM, Resident 11's foley catheter drainage bag was observed folded in thirds, lying on the floor to the right side of the bed without a hook present on the bag to hang off the bed and without a privacy bag present. At 8:44 AM, Staff G, Certified Nursing Assistant, said foley catheter drainage bags were supposed to hang off the side of the bed and were not supposed to be on floor. Staff G said foley catheter drainage bags were supposed to have a privacy bag over the drainage bag so you cannot see the urine. At 8:47 AM, Staff C, Resident Care Manager and Registered Nurse (RN), said foley catheter drainage bags should be covered and placed in a black bag secured to the bed frame and not on the floor. Staff C said the cover was over the bag, so you didn't see the urine, and stated, It's a dignity issue. After observing the placement of the foley catheter drainage bag folded into thirds on the floor, Staff C said the foley catheter drainage bag should not be on the floor and stated, That should definitely not be like that. It should be covered. It should have a bag. It doesn't even have a hook to hang it. 2) Resident 39 was admitted to the facility on [DATE]. The admission MDS assessment, dated 07/23/2024, documented Resident 39 was moderately cognitively impaired and had an indwelling catheter. Resident 39's Foley Catheter Care Plan, dated 08/06/2024, documented, .Drainage bag to remain covered . On 08/05/2024 at 3:58 PM, Resident 39 was observed sleeping in bed with the foley catheter drainage bag hanging off the right side of the bed uncovered with urine visible in the bag. On 08/06/2024 at 10:40 AM, Resident 39 was observed in the rehabilitation gym working with staff. Resident 39's foley catheter drainage bag was uncovered with urine visible in the bag. At 2:00 PM, Resident 39 was observed lying in bed with the foley catheter drainage bag hanging off the left side of bed uncovered with urine visible in the bag. On 08/07/2024 at 10:02 AM, Resident 39 was observed lying in bed with the foley catheter drainage bag hanging off the right side of the bed uncovered and visible from the hallway. On 08/08/2024 at 11:45 AM, Staff B, Director of Nursing Services and RN, said it was her expectation foley catheter drainage bags were covered and not placed on the floor. Refer F-880 Reference WAC 388-97-0180 (1)(2)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 6 sampled residents (53) reviewed for right to participate in planning care. This failure placed residents at risk of a diminished quality of life when not allowed to be involved in their long-term care needs. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 06/18/2024, showed the resident was alert and oriented. The electronic health records (EHR) showed a care conference was conducted on 03/25/2024, and no other care conferences were documented. The EHR showed Resident 53 had a quarterly MDS assessment, dated 06/18/2024. On 08/08/2024 at 10:27 AM, Staff K, Social Services Coordinator, said care conferences were done at the residents' request, significant change or quarterly. At 10:49 AM, Staff M, Social Services Director, said she expected care conferences to occur quarterly, as needed or for a significant change. Staff M said the MDS and care conference should be in coordination with one another. Staff M said she expected care conferences to be documented in the EHR under assessment or in a progress note. On 08/09/2024 at 8:37 AM, Staff B, Director of Nursing Services and Registered Nurse, said care conferences should be done quarterly. Reference WAC 388-97-1020 (2)(e)(f)

Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 1 of 6 sampled residents (53) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 06/18/2024, showed the resident was alert and oriented. Resident 53's electronic health record did not show an ADs or documentation that ADs were reviewed since March 2024, almost five months since the last review. Resident 53's care plan interventions, dated 03/19/2024, documented: Patient does not want to execute an Advance Directive at this time. On 08/08/2024 at 10:27 AM, Staff K, Social Services Coordinator, said Resident 53 did not want to generate an AD, but an AD should have been reviewed in June 2024. On 08/09/2024 at 8:37 AM, Staff B, Director of Nursing Services and Registered Nurse, said advanced directives should have been reviewed during the care conference in June for Resident 53. Reference WAC 388-97-0280 (3)(c)(i)

Based on observation, interview and record review, the facility failed to ensure a timely response and/or resolution to resident concerns about lost items was completed for 2 of 7 sampled residents (50 & 286) reviewed for grievances. This failure placed residents at risk for not having their concerns addressed, increased frustration and a decreased quality of life. Findings included . Record review of the facility's Lost Item Policy documented, if an item was missing, the resident or responsible party was expected to inform a staff member and/or fill out a Lost, Misplaced, Damaged Item form, which was then forwarded to Social Services. Social Services would initiate a search for the item and if the item was not recovered in the initial search (within three business days), Social Services staff would note the action taken on the Lost Item form and forward this form to the Administrator to determine further action needed. The administrator would notify the resident within five business days once a determination was made. 1) Resident 50 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 06/05/2024, documented Resident 50 was alert and oriented, and required minimal assistance with activities of daily living. An Admission Note, dated 11/30/2023 at 9:42 PM, noted, [Resident's first name in all caps]arrived to facility in wheelchair from an acute hospital for post-acute care to 103-1 . On 08/08/2024 at 9:51 AM, Resident 50 said he was admitted to the facility with a manual wheelchair. The resident said he was later transferred to the hospital; but when he returned, he did not find his wheelchair. Resident 50 said he reported his missing wheelchair to Staff J, Certified Nursing Assistant. Resident 50 stated Staff J gave him a paper to fill out. Resident 50 stated, I spoke to some lady who takes care of that kind of stuff. She brought me the paper I had filled out because she could not read my writing, and I told her about the wheelchair. On 08/07/2024 at 9:16 AM, Staff K, Social Services Coordinator, said Resident 50 had a wheelchair when he came to the facility. Staff K said she had maintenance look for the wheelchair, but it was never found. Staff K said the matter was then forwarded to the Administrator. On 08/08/2024 at 8:29 AM, when asked about Resident 50's missing wheelchair, Staff A, Administrator, stated, I heard of it this morning for the first time. Staff A said if a resident reported a missing item, the facility staff would try to find it and replace it if they were unable to find the item. At 2:43 PM, Staff J said he had conversations with Resident 50 about his wheelchair late last year. Staff J said Resident 50 said the wheelchair had been missing and people had been looking for it. At 3:29 PM, Staff A said Resident 50 did have a wheelchair on admission that was given to him at the hospital prior to coming to the facility. Staff A stated, We are going to replace it. 2) Resident 258 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented Resident 258 was alert and oriented and required minimal assistance with activities of daily living. On 08/05/2024 at 12:23 PM, Resident 286 said she lost personal laundry items which were yet to be returned. On 08/07/2024 at 9:14 AM, Resident 286 said her laundry was picked up a week and a half after her admission and she had missing items that were yet to be returned despite her asking staff members. Resident 286 said on the weekend of 08/03/2024, she wheeled herself to the laundry room and insisted to go through the pile of clothes on the table. Resident 286 was able to retrieve nine items from a pile of clean laundry. Resident 286 said as of 08/07/2024, she was still missing eight or nine of her personal items. On 08/08/2024 at 2:12 PM, Staff L, Resident Care Manager and Registered Nurse, said she was not aware of Resident 286's missing laundry. Staff L said she found out about it when she found a green slip in her mailbox that morning. Reference WAC 388-97-0460 (2)

Based on interview and record review, the facility failed to provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 2 of 6 sampled residents (36 & 31) reviewed for notices of bed holds. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 36 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment, dated 06/13/2024, showed the resident was severely cognitively impaired. The electronic health records (EHR) documented Resident 36 transferred to an acute hospital on 05/04/2024. No documentation was noted showing contact was made to the resident or resident's family regarding a Bed-Hold. On 08/07/2024 at 2:18 PM, Staff F, Admissions Coordinator, said when a resident was admitted to the hospital, admissions contacted the resident or the resident representative and covered the bed-hold agreement with them. Staff F said the documentation would be put into the EHR. At 2:42 PM, Staff F said she was not able to find a bed-hold for Resident 36. 47518 2) Resident 31 was admitted to the facility on [DATE]. The Medicare/5-day MDS assessment, dated 07/23/2024, documented Resident 31 was moderately cognitively impaired. Resident 31 was hospitalized on [DATE] and returned on 07/17/2024. The Electronic Health Record did not show documentation of a written bed hold notice. On 08/08/2024 at 11:20 AM, Staff F, Admissions Coordinator, said the admissions department completes the bed hold form for residents that transfer to the hospital. Staff F said if they could not reach the resident or resident representative, they would make a progress note and try again. Staff F said she did not have a copy of the bed hold notice for Resident 31. At 11:45 AM, Staff B, Director of Nursing Services and Registered Nurse, said they should have followed up again with Resident 31's representative and offered a bed hold notice. Staff B stated, We are not in compliance. Reference WAC 388-97-0120 (4)

Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for focused areas of care for 1 of 2 sampled residents (61) reviewed for care plans related to skin conditions. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 61 was admitted to the facility on [DATE]. The Modification of Admission Minimum Data Set assessment, dated 06/30/2024, documented Resident 61 was alert and oriented and had an open lesion(s) on the foot. Record review of Resident 61's physician orders, dated 07/12/2024, documented: 1) Left lateral ankle abrasion: Cleanse with wound cleanser, skin prep periwound [tissue surrounding a wound], apply foam dressing. Change 3 times per week and as needed. every evening shift every other day for Wound care. 2) Right great toe abrasion: Cleanse with wound cleanser, skin prep periwound, apply hydrofera blue [an antibacterial wound dressing] and cover with border foam dressing, change 3 times per week and as needed. every evening shift every other day for Wound care. 3) Right medial ankle abrasion: Cleanse with wound cleanser, skin prep periwound, apply hydrofera blue and cover with border foam dressing, change 3 times per week and as needed. every evening shift every other day for Wound care. 4) Right plantar foot abrasion: Cleanse with wound cleanser, skin prep periwound, apply foam dressing. Change 3 times per week and as needed. every evening shift every other day for Wound care. Record review of Resident 61's physician orders, dated 07/18/2024, documented: 1) blister to top of R [right] foot: clean with NS [normal saline]. cover with foam every evening shift. Record review of Resident 61's comprehensive care plan did not document a focus area, goal, and/or interventions related to abrasions and/or blisters to the right or left foot. On 08/08/2024 at 12:24 PM, Resident 61 was observed with a foam dressings on her right foot covering the great toe and bottom middle inner area of foot. At 12:31 PM, Staff C, Resident Care Manager and Registered Nurse (RN), said the Admission Nurses would develop resident care plans upon admission and the Resident Care Managers would review the care plan and update them throughout the resident's stay. Staff C said if a resident had a skin condition, there would be a care plan to reflect it. Staff C was unable to locate a skin condition care plan for Resident 61. Staff C stated, She doesn't have one. Why would she not have one. We will have to create one for her . At 3:12 PM, Staff B, Director of Nursing Services and RN, said it was her expectation skin care plans were in place for residents with skin conditions. Reference WAC 388-97-1020 (1)(2)(a)(b)(c)

Based on observations, interviews and record review, the facility failed to ensure necessary care and services were provided for positioning in a wheelchair for 1 of 1 sampled resident (#21) reviewed for quality of care related to positioning. This failure placed residents at risk for unmet care needs, discomfort, a diminished quality of life and being unable to attain or maintain their highest practicable level of well-being. Findings included . Resident 21 was admitted to the facility on [DATE] with diagnoses including Inclusion Body Myositis (IBM). The quarterly Minimum Data Set assessment, dated 07/18/2024, showed Resident 21 was alert and oriented, had functional impairment on both sides, and required a motorized wheelchair for mobility once he is out of bed. The care plan, dated 12/16/2022, showed the resident has impaired physical mobility due to weakness requiring two person assist with a hoyer lift. The use of adaptive equipment to include power wheelchair for mobility. On 08/05/2024 at 11:28 AM, Resident 21 was observed sitting in a tall back motorized wheelchair, leaning to his left side, with the head rest to right of his neck and a self-releasing seatbelt across his upper abdomen. The left arm rest was tilted down toward the ground appearing not in alignment with his right arm rest. On 08/06/2024 at 11:03 AM, Resident 21 was observed leaning to his left in his motorized wheelchair with the left armrest hanging below his abdomen and the wheelchair appeared tilted to the left side. Resident 21 said his specialty wheelchair was new as of the first of this year (2024). Resident 21 said he was fitted for the wheelchair but the wheelchair did not fit him correctly. Resident 21 said no one ever checked to see if the new wheelchair was appropriately fitted. Resident 21 stated the chair caused him extreme discomfort and I am unable to get help to fix the wheelchair. Resident 21 said he was so upset about the wheelchair, and stated, I went to therapy and threatened a lawsuit. Resident 21 said the vendor for the wheelchair came out about a month or so ago and told him the [NAME] was broken and he would have to find out if there was a warranty. Resident 21 said the wheelchair vendor had not been back nor had he heard anything about the status. On 08/07/2024 at 10:29 AM, Staff C, Resident Care Manager (RCM) and Registered Nurse (RN), said someone was supposed to come look at the wheelchair for a wobbly wheel. When asked about the incidents of Resident 21 running into the bed and the wall, Staff C stated at first we just took it out of auto mode, so it became a manual wheelchair and staff had to maneuver it. We then turned it back on so [Resident 21] could operate it, but [the resident] was supposed to keep the chair in off status when not moving. At 10:55 AM, Staff E, Speech Language Pathologist and Therapy Director, said an assessment was done for the wheelchair on 11/02/2023 to have a new custom motorized wheelchair ordered. Staff E said she would look for the documentation related to; vendor notes about the wheelchair as no in house assessment appears to have been done. At 1:05 PM, Resident 21 stated, Sitting in this wheelchair is like being a cork inside a bottle, referencing the wheelchair fit for his body habitus (shape and size of a person's body or body parts). Resident 21 stated, I have run into my bed and the wall several times. Resident 21 said because the controller was positioned under his stomach. The resident said his stomach leaned into the controller propelling the wheelchair into the wall and bed. Resident 21 said he had to yell for help to get staffs' attention for assistance to stop the wheelchair. On 08/08/24 at 11:58 AM, when asked about injuries to Resident 21 caused by accidental controller activation due to the wheelchair's fit, Staff D, RCM and Licensed Practical Nurse, stated, We padded the bed frame. Staff D said she removed back support pieces from the specialty wheelchair because they were not placed right and causing pressure to [the resident's] skin. Staff D stated, the seatbelt helps to hold his stomach up from touching the lever. At 11:58 AM, Staff B, Director of Nursing Services and RN, said the motorized wheelchair was newer. Staff B was not aware of the plan for the wheelchair repair. When asked if Resident 21's positioning in the wheelchair had ever been assessed for proper fit, Staff B stated PT [physical therapy] should have. They know about the incidents because they attend the morning meetings. On 08/09/2024 at 9:45 AM, Staff E said she was not aware of the chair pieces being removed from the back rest of the wheelchair. Staff E said the records reflected the wheelchair [NAME] was documented in June 2024, when the wheelchair vendor assessed the wheelchair. Staff E said the broken armrest was new to her as of this week. Staff E stated she thinks PT was present for the wheelchair delivery. Staff E said she was unable to find an assessment for the wheelchair fit upon receipt of new motorized wheelchair. Staff E stated, Usually, we would do an assessment, but he was outside of his skilled window, (meaning he was not on services). Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure infection control and prevention practices were implemented for hand hygiene during a clean technique dressing change and during care of catheter bags for 2 of 8 sampled residents (Residents 51 & 11) reviewed for infection prevention and control. This failure placed residents at risk for wound infection, health complications and a diminished quality of life. Findings included . 1) Resident 51 was admitted on [DATE]. The 5-day admission Minimum Data Set (MDS) assessment, dated 11/29/2023, showed Resident 51 was alert and oriented, required one person assist with bed mobility, was assessed to be at risk of developing pressure ulcers, and had a healing Stage 2 pressure ulcer to the coccyx. The quarterly MDS, dated [DATE], indicated Resident 51 had one Stage 4 pressure ulcer to the right ischium (buttock and upper thigh). Resident 51's medical record showed the wound was first documented on 12/21/2023 measuring 2.67 cm (centimeter) x 0.76 cm. Most recent measurements on 07/29/2024 documented the Stage 4 wound measured 2.12 cm x 1.66 cm with deepest depth 7.2 cm. On 08/08/2024 at 10:36 AM, Staff D, Licensed Practical Nurse (LPN), was observed during Resident 51's wound care for the right ischial pressure ulcer. After Staff D removed and discarded the old dressing and dirty gloves, Staff D did not wash her hands before putting on clean gloves and continuing with wound care. On 08/08/2024 at 11:19 AM, Staff I, Infection Control Nurse and LPN, stated, I would expect a nurse to gather supplies for wound care, enter the room, undress wound with clean gloves, sanitize hands, allow to dry, then place on a new pair of clean gloves to apply new dressing to wound. On 08/09/2024 9:45 AM, Staff B, Director of Nursing Services and Registered Nurse (RN), stated, I would expect a nurse to change gloves and wash hands, between removal of a dirty dressing, and placement of a clean wound dressing. 47518 2) Record review of the facility's policy entitled, Catheter Care, Urinary, revised August 2022, documented Infection Control . 2. Be sure the catheter tubing and drainage bag are kept off the floor. Resident 11 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection. The Modification of Admission MDS assessment, dated 06/27/2024, documented Resident 11 was moderately cognitively impaired and had an indwelling catheter (a tube inserted into the bladder that drains urine into a bag outside of the body). Resident 11's Indwelling Catheter Care Plan, dated 07/26/2024, revised 08/07/2024, documented .drainage bag to remain covered, off the ground . On 08/07/2024 at 8:42 AM, Resident 11's foley catheter drainage bag was observed folded in thirds, lying on the floor to the right side of the bed with no hook present on bag to hang off the bed, and no privacy bag present. At 8:44 AM, Staff G, Certified Nursing Assistant, said foley catheter drainage bags were supposed to hang off the side of the bed and were not supposed to be on floor. At 8:47 AM, Staff C, Resident Care Manager (RCM) and RN, said foley catheter drainage bags should be in a black bag secured to the bed frame and not placed on the floor. After observing Resident 11's foley catheter drainage bag folded into thirds on the floor, Staff C said the foley catheter drainage bag should not be on the floor and stated, That should definitely not be like that. It should be covered. It should have a bag. It doesn't even have a hook to hang it. On 08/08/2024, at 11:45 AM, Staff B, Director of Nursing Services and RN, said it was her expectation foley catheter drainage bags were covered and not placed on the floor. Refer to F-550 Reference WAC 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to ensure Local Health Jurisdiction (LHJ) cohorting (the practice of grouping together residents who are infected with the same organism to confine their care to one area and prevent contact with other residents) recommendations were implemented to help prevent the development and transmission of communicable diseases and infections for eight of 14 sampled residents (# 5, 7, 8, 9, 10, 11, 12 & 13) reviewed for infection control. This placed residents at risk for infection from a highly contagious respiratory infection, diminished quality of life and death. This failure increased the likelihood for exposure and possibility of contracting [MEDICAL CONDITION] causing [MEDICAL CONDITION] Disease 2019 (COVID-19), a new disease caused by a novel [MEDICAL CONDITION] that has not been previously seen in humans, and placed all residents in immediate jeopardy for infection and death. An Immediate Jeopardy was called on 08/07/2020 at 10:45 AM when the facility was cohorting COVID-19 negative residents with COVID-19 positive residents. Findings included . On 07/24/2020 at 4:57 PM, the facility reported to the State Agency one staff member had tested positive for COVID-19. On 07/27/2020 at 10:32 AM, the facility reported to the State Agency one resident had tested positive for COVID-19. Infection control program documentation showed six additional residents and four staff tested positive for COVID-19 on 07/29/2020. Infection control program documentation showed three additional residents tested positive for COVID-19 on 08/01/2020. Infection control program documentation showed three additional residents tested positive for COVID-19 on 08/03/2020. Infection control program documentation showed five additional residents and nine staff tested positive for COVID-19 on 08/06/2020. Infection control program documentation showed two additional residents and two staff tested positive for COVID-19 on 08/12/2020. Infection control program documentation showed, between 07/27/2020 and 08/12/2020, 20 residents and 16 staff members were infected with and tested positive for COVID-19. The facility's policy entitled, Infection Prevention and Control Manual Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated 05/14/2020, included procedures for managing a COVID-19 outbreak including the following: Immediate reporting/notification and consultation with the local/state public health department for specific directions to include: place residents in private room if able and cohort residents identified with same symptoms/COVID-19 confirmation. On 08/05/2020 at 10:45 AM, the following observations were made: *Resident #7 and Resident #8 were observed in room [ROOM NUMBER] together. Resident #8 tested positive for COVID-19 on 08/04/2020. The facility's daily census showed the residents were in the shared room on 08/04/2020, 08/05/2020 and 08/06/2020. Resident #7 tested positive for COVID-19 on 08/06/2020. *Resident #10 and Resident #11 were observed in room [ROOM NUMBER] together. Resident #10 tested positive for COVID-19 on 08/03/2020. The facility's daily census showed the residents were in the shared room on 08/03/2020, 08/04/2020, 08/05/2020 and 08/06/2020. Resident #11 tested positive for COVID-19 on 08/06/2020. *Resident #5 and Resident #9 were observed in room [ROOM NUMBER] together. Resident #9 tested positive for COVID-19 on 07/31/2020. The facility's daily census showed the residents were in the shared room on 07/31/2020, 08/01/2020, 08/02/2020, 08/03/2020, 08/04/2020 and 08/05/2020. The census report on 08/06/2020 shows Resident #5 was moved to room [ROOM NUMBER], a private room. Resident #5 tested positive for COVID-19 on 08/12/2020. *Resident #12 and Resident #13 were in room [ROOM NUMBER] together. Resident #13 tested positive for COVID-19 on 07/30/2020. The facility's daily census showed the residents were in the shared room on 07/30/2020, 07/31/2020, 08/01/2020, 08/02/2020, 08/03/2020, 08/04/2020, 08/05/2020 and 08/06/2020. The census report on 08/07/2020 showed Resident #13 was moved to room [ROOM NUMBER]-1 to cohort with a resident that had also tested positive for COVID-19. On 08/05/2020 at 12:05 PM, Staff A, Administrator, and Staff B, Registered Nurse (RN) and Director of Nursing Services, said the LHJ did not recommend residents be moved off the 200 hall due to the residents' potential exposure. When asked if room changes had been discussed with the LHJ, Staff A and Staff B did not indicate if cohorting had been discussed with the local health jurisdiction or what the recommendations were. On 08/06/2020 at 2:12 PM, Staff B said residents that tested positive for COVID-19 should never be left in a room with a resident that had tested negative. When asked why on 08/05/2020 Room(s) 203, 204, 207 and 211 had positive and negative residents cohorted, Staff B said she would have to check into it. At 5:18 PM, Collateral Contact (CC) A, RN with the local health jurisdiction, said the department was working with the facility regarding the COVID-19 outbreak and had made recommendations. The recommendations were to make 200 hall the COVID unit, and residents that tested positive needed to be in a private room. CC A said she had discussed cohorting residents previously and she made it clear today to never have a positive and negative COVID-19 resident in the same room. CC A said the facility told her they would make the room changes to separate positive and negative residents. On 08/18/2020 at 12:00 PM, Staff A said the outbreak of COVID-19 happened so fast the facility did not have the room to make the necessary changes to follow the local health jurisdictions recommendations regarding cohorting residents. Reference WAC 388-97-1320 (2)(a)

Based on observation, interview and record review, the facility failed to ensure infection control procedures, including hand hygiene, use of designated equipment and surveillance of infections, were being followed to prevent the spread of infectious diseases within the facility for six of 10 sampled residents (#9, 40, 10, 43, 76 & 78) and four of four observed staff (Staff EE, BB, DD & CC) reviewed for infection prevention and control. These failures placed residents at risk for an influenza outbreak and spread within the facility and a diminished quality of life. This failure resulted in an Immediate Jeopardy on 03/03/2020. The immediacy was removed on 03/05/2020 when the facility educated staff on hand hygiene and validated competencies in infection control practices. Findings included . The facility's policy and procedure entitled, Infection Prevention and Control Program, revised August 2016, showed the following steps to be taken for prevention of infection and outbreak management including: *Preventing the spread to other residents *Educating the staff and the public *Educating staff and ensuring they adhere to proper techniques and procedures The facility's policy and procedure entitled, Influenza, Prevention and Control of Seasonal (sic) policy and procedure, revised April 2013, showed the following hygiene practices staff were to follow: *Droplet precautions will be initiated for suspected or confirmed influenza. *Staff will wear a face mask when entering a room of a resident with suspected or confirmed influenza. *Face mask will be removed and staff will perform hand hygiene when leaving the room. The facility's policy and procedure entitled, Handwashing/Hand Hygiene, revised April 2012, showed when hand washing/hand hygiene should be performed including: *Before and after direct resident contact *Before and after entering isolation precaution settings *Before and after assisting a resident with a meal <HAND HYGIENE> On 03/02/2020 at 10:31 AM, Staff B, Registered Nurse (RN) and Director of Nursing Services, said the facility had one confirmed resident with Influenza A and one resident pending the results from a flu swab (used to test for Influenza). At 12:16 PM, Staff EE, Activities Director, was observed bringing a beverage into room [ROOM NUMBER] for two residents. Staff EE did not perform hand hygiene after leaving the room. At 12:23 PM, Staff EE was observed stirring Resident #359's coffee in the 100 Hall dining room. Staff EE coughed into her right sleeve and left the dining room without performing hand hygiene. Staff EE returned to the dining room, put sugar into Resident #30's coffee, picked up Resident #30's spoon and stirred the coffee. On 03/03/2020 at 7:58 AM, Staff EE was observed to scratch her face and reach into a cupboard for brown sugar and syrup for Resident #17. Staff EE did not perform hand hygiene after touching her face. At 8:02 AM, Staff EE was observed wheeling Resident #22 into the dining room, adjusted the leg rest on the wheel chair, handed a creamer to Resident #292, rubbed Resident #22's back and then left the dining room. No hand hygiene was performed. Between 8:29 AM and 8:32 AM, Staff EE was observed entering three rooms on 100 Hall (room [ROOM NUMBER], 106 and 113) to deliver newspapers. Staff EE was observed opening blinds, moving bedside tables and touching bed linens in the resident's rooms. Staff EE was not observed to perform hand hygiene before entering or after exiting the rooms. At 9:17 AM, Staff EE said it was a good idea to wash hands anytime before entering and exiting a resident room. On 03/03/2020 at 3:28 PM, a Droplet Precautions sign was observed on the wall outside of room [ROOM NUMBER] included the following directions: *Steps before care: mask for staff and visitors upon entry into the room *Steps after care: Perform hand hygiene using proper handwashing techniques. At 3:28 PM, Staff BB, Social Services, was observed standing approximately three feet inside the doorway of room [ROOM NUMBER] (with the Droplet Precaution sign), talking to Resident #9 (positive for Flu) and Resident #76. Staff BB was holding a clipboard and was not wearing personal protective equipment (PPE). Resident #9 was sitting in her wheel chair interacting with Staff BB. The privacy curtain was not completely pulled between Resident #9 and Resident #76's sides of the room. At 3:33 PM, Staff BB was observed asking Resident #76 if her coffee was OK, told the residents she would visit with them later and left the room. Staff BB did not perform hand hygiene before leaving the room. Staff BB left room [ROOM NUMBER] and pushed through the closed fire door between 100 and 200 Hallways. Staff BB walked down 100 Hallway to the front of the facility, passing two wall mounted hand sanitizers along the way. Staff BB did not perform hand hygiene. At 4:50 PM, Staff BB said she had been trained on isolation precautions and the signs outside the room told staff what they were to do. When asked about performing hand hygiene when leaving room [ROOM NUMBER], Staff BB stated, I just really didn't think that I needed to wash. At 3:34 PM, Staff M, RN and Infection Preventionist, said staff should wash their hands before serving a meal and between assisting residents especially if touching the chair, table or other residents. Staff M said the expectation was all staff would use hand sanitizer going in and out of rooms and wash their hands with soap and water if they came into contact with body fluids. At 5:25 PM, Staff M said the expectation was for staff to perform some sort of hand hygiene every time entering and leaving a room with isolation precautions, even if not interacting with the affected resident. On 03/03/2020 at 4:22 PM, Staff DD, Certified Nursing Assistant (CNA), was observed entering Resident #343's room. No hand hygiene was observed. Staff DD adjusted the resident's bed linens. Staff CC, CNA, was in the room at the time and left to go to the nurse station. No hand hygiene was performed. Staff CC returned to the room without performing hand and transferred Resident #343 to bed. At 4:55 PM, Staff DD said hand hygiene should be done before entering and before leaving a resident's room. Staff DD said she had not worked the three days prior and had not received any education regarding the influenza outbreak. At 5:00 PM, Staff CC said hand hygiene should be done before and after entering and exiting resident rooms. On 03/03/2020 at 5:03 PM, Staff M said three residents were now positive for Influenza A: *Resident #40, room [ROOM NUMBER]-2, was the first resident with confirmed Influenza A. The resident was diagnosed at the hospital on [DATE]. Resident #40 was admitted to the hospital and was not currently in the facility. *Resident #9, room [ROOM NUMBER]-2, was the second resident with confirmed Influenza A. The resident was diagnosed at the hospital and sent back to the facility on Droplet Precautions. *Resident #10, room [ROOM NUMBER]-1, was confirmed positive for Influenza A on 03/02/2020. At 5:10 PM, Staff M said staff were trained on 03/02/2020 on flu personal PPE and hand hygiene. Staff M said the education was facility wide for all staff. Staff M said the education did not include return demonstration or a post-test to validate understanding of flu PPE and hand hygiene. Review of the In-service Attendance Record, dated 03/02/2020 at 10:45 AM, 2:00 PM and 3:35 PM, showed Staff BB and Staff DD were not educated on flu PPE. There was no documentation night shift staff had received education regarding the flu outbreak or hand hygiene until 03/04/2020. On 03/03/2020 at 5:20 PM, Staff M said the roommate (Resident #76) of a resident on droplet precautions (Resident #9) should wash their hands before coming out of their room. On 03/05/2020 at 3:48 PM, Resident #76 was observed coming out of her room without performing hand hygiene first. Resident #76's roommate was positive for influenza A (Resident #9). Staff did not encourage Resident #76 to perform hand hygiene when she was observed to be outside of her room. On 03/06/2020 at 12:20 PM, Staff M said the facility tried to keep the roommate of a resident on droplet precautions in their room. Staff M said staff tried to encourage Resident #76 to perform hand hygiene before coming out of her room. At 12:30 PM, Staff M said the facility had five confirmed residents with influenza A. Staff M said all five residents lived on the 200 hall with rooms in close proximity: *Resident #9 in room [ROOM NUMBER]-2 *Resident #78 in room [ROOM NUMBER]-2 *Resident #10 in room [ROOM NUMBER]-1 *Resident #40 in room [ROOM NUMBER]-2 *Resident #43 in room [ROOM NUMBER]-1 <Designated Equipment> On 03/03/2020 at 5:30 PM, an isolation cart was observed outside of room [ROOM NUMBER]. A Droplet Precautions sign was on the wall outside the room. A stethoscope was sitting on top of the isolation cart. At 5:50 PM, an isolation cart was observed outside of room [ROOM NUMBER]. A Droplet Precautions sign was on the wall outside the room. A blood pressure cuff and stethoscope were sitting on top of the isolation cart. At 5:52 PM, Staff GG, RN, said the equipment (on the isolation carts) was for use on residents who had the flu or were being tested for the flu. Staff GG said the equipment should be cleaned and stored inside the isolation cart, not on top of it. At 6:00 PM, an isolation cart was observed outside of room [ROOM NUMBER]. A Droplet Precautions sign was on the wall outside the room. A stethoscope was sitting on top of the isolation cart. At 6:05 PM, Staff M said the dedicated vital sign equipment should be cleaned between use and stored inside the isolation cart, not on top of it. <Surveillance> Review of the facility's infection surveillance documentation showed the monthly line listing did not include the residents affected by the Influenza outbreaks in the facility in January 2020 and March 2020. On 03/06/2020 at 1:00 PM, Staff M said it was her understanding that only infections requiring antibiotics needed to be on the line list. Reference WAC 388-97-1320(1)(a), (1)(c), (2)(a)

Based on interview and record review the facility failed to implement an appropriate and safe discharge plan including follow up for caregiver support, and discharge orders being verified prior to discharge from the facility for 1 of 3 sampled residents (#1) reviewed for discharge planning. This failure placed residents at risk for medical complications, hospitalization , failed discharge and a diminished quality of life. This caused harm to Resident #1 when she was sent to emergency room (ER) on 04/10/19, two days after discharge from the facility and was hosptalized on [DATE], three days after discharge from the facility. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 03/22/19, documented the resident was cognitively intact, required assistance with activities of daily living (ADLs) and had an active discharge plan. Resident #1's medical record showed the resident had coronary artery bypass graft surgery (improves blood flow to the heart) on 03/11/19 and had an incision to the chest and right inner leg. Resident #1's discharge care plan, initiated 03/19/19, documented discharge plan was for the resident to discharge home with family. Barriers to discharge included the amount of support at discharge and pain. Interventions included specific needs will be determined prior to discharge to ensure the discharge is safe. Resident #1's After Visit Summary, dated 03/21/19, signed by resident, documented discharge instructions included orders for home health services for RN and Physical Therapy (PT) and a referral be placed to the home health provider. The discharge instructions included medications [MEDICATION NAME] (diuretic) and potassium to be taken every morning through 03/29/19 then stop. The wound care orders were to wash wounds with soap and water daily. Resident #1's PT discharge summary, dated 03/23/19, documented the following; Follow up recs (recommendations): home health services. Supervision/Assist: safety checks every other day. Comments included resident with increased anxiety regarding discharge. The Occupational therapist discharge summary, dated 03/23/19, documented the following; Follow up rec (recommendations): home health services. Recommended Adaptive equipment = shower chair A nurses progress note, dated 03/24/19, documented the resident was supposed to discharge home on 03/24/19, but family felt she was not ready to discharge home. Resident #1's After Visit Summary record, dated 04/05/19, not signed by the resident, contained discharge instructions including medications [MEDICATION NAME] and potassium to be taken daily. Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. The start date was 04/06/19. Resident #1's medical records showed the resident had a medical appointment on 04/08/19 at 10:30 AM. Resident #1's office visit record, dated 04/08/19, documented the resident was worried that she is being discharged from the (nursing home) and has no one to go home to. (Resident #1) needs help with transitioning back into her home and getting care. The record showed the resident had an incision dehiscence (wound separation) between breast with slough (white, yellow or grey tissue on wound bed) and lower leg swelling. The plan for the resident was to restart the daily medications [MEDICATION NAME] and potassium for the lower leg swelling and wound care orders were changed to apply iodosorb (wound gel used to clean infected wounds) every other day just within the incision. Orders included to wear compression socks. Resident #1's medical records showed the resident discharged home alone on 04/08/19 at 1:00 PM. The records did not show home health services and caregivers were in place. Resident #1's Medications discharged with Resident record (part of the facility's record), undated, did not show medications [MEDICATION NAME] and potassium were discharged with the resident. Resident #1's hospital records, dated 04/10/19, documented the resident was evaluated in the ER for post-operative pain, wound dehiscence and anxiety. The record documented, She had not been taking her medications. The record noted arrangements were made for home health services to follow up. A home health note, dated 04/11/19, documented the resident was unable to care for herself related to pain, anxiety and the fact she has no assistance in her home. Home health support had insufficient resources to address the resident needs. The resident reported she was unable to wear compression socks as she was unable (put them on and take them off). The resident reported she had no food in the house. Resident #1's home care visit, dated 04/11/19, documented medication reconciliation completed and patient is missing [MEDICATION NAME] and potassium. Patient reports she is unaware she should be taking. The resident reported she had no family or friends who were able to assist with filling her prescriptions and she had not been cleared to drive. The resident was noted to have a wound measured 1.5 centimeter (cm) by 1.4 cm by 0.3 cm with tunneling noted to superior (upper) aspect of wound measuring 0.5 cm. Resident #1's hospital records dated 04/11/19, showed the resident was admitted to the hospital due to decreased ability to care for herself at home and chest wound wall infection. The record documented, Due to surgical pain/sternal precautions patient is currently needing assistance (with) housekeeping, laundry, washing hair, toileting/wiping, and is not yet cleared to drive by her surgeon. A late entry social services note, created 04/16/19, documented the resident had Medicaid coverage and the collateral contact was able to assess the resident for part-time care assistance at home for higher level of activities of daily living. The resident was to stay in the facility until 04/08/19. On 05/08/19 at 10:30 AM, Staff D, Social Service Director, said Resident #1 discharged home alone. Staff D said the resident's family member was concerned for the resident being able to do housekeeping, meal preparation, and higher level ADLs. Staff D said it was identified that the resident needed care giver assistance at home. Staff D said a collateral contact was working on providing caregiver support, but she was not aware of when they would start. Staff D said she usually does not know when caregivers would start. When asked if she made a follow up (phone call or inquiry) for the caregiver start date, Staff D said she did not. Staff D said she typically did not follow up. Staff D said the facility contracted managed care sets up home health services, and she did not know the start of care for the residents that were admitted under the facility contracted managed care. Staff D said she was not aware home health services were not set up for Resident #1. Staff D said she felt it was a safe discharge without caregivers set up. At 10:58 PM, Staff C, Registered Nurse (RN) and Resident Care Manager, said Resident #1 went to an appointment on 04/08/19, returned to the facility and then discharged home on[DATE]. Staff C said the floor nurses were responsible for reviewing orders upon return from appointments and at the time of discharge. Staff C said Resident #1 returned to the facility without new orders. Staff C said Resident #1's discharge orders were written on 03/21/19 and there were no changes to the orders upon discharge on 04/08/19. Staff C said the resident had no nursing needs post discharge. Staff C said wound care was provided to an open spot to the chest area for the resident. At 2:00 PM, Staff B, RN and Director of Nursing Services, said it was expected if the resident required extensive assistance, the resident was to have a caregiver in place at time of discharge. Staff B said for Resident #1, she felt the discharge without caregivers was safe as the resident was independent in her care needs prior to discharge. Staff B indicated follow up should have been made to ensure caregivers were set up at the time of discharge. Staff B said the resident did not need home health services. At 2.20 PM, Staff B said her expectation was when residents returned from appointments, nurse aides were to obtain the packet and provide it to the licensed staff. Staff B said she expected licensed staff to ask for the packet if it was not provided to them by the nurse aides. Staff B said when Resident #1 returned from the office visit on 04/08/19, there was no packet provided to the licensed nurses. Staff B said the licensed nurse should have asked for the packet. Staff B said orders should have been reviewed by the licensed nurse prior to the resident discharging. At 2:30 PM, Staff E, Physical Therapist, said she made recommendations for the resident to be checked on every other day due to the nature of the surgery the resident had. Staff [NAME] said the resident had anxiety of how she would manage at home. At 2:35 PM, Staff D said she was not aware of the recommendations made by therapy. At 2:40 PM, collateral contact said she went to the facility on [DATE] to have the resident sign paperwork and she was told by facility staff the resident had discharged home. She said she felt the resident should not have discharged until caregivers were in place. On 05/28/19 at 2:05 PM, when interviewed, Resident #1 said she felt she was discharged too soon. The resident said she could not toilet and wipe herself, take a shower or make some food. The resident said anxiety level increased and she was unable to care for herself. Resident #1 said she went to emergency room two days later and then was hospitalized . The resident said Staff D told her she needed to go home as her bed was already booked. Resident #1 said the facility was aware she needed help at home, but they sent her home. The resident said she was not notified if the caregivers were in place or not, and she had no help at home. Resident #1 said she felt the facility pushed her to go home. Reference WAC 388-97-0080

Based on observation, interview and record review, the facility failed to promptly identify and implement interventions to prevent weight loss and failed to ensure residents received adequate oral fluid intake for 2 of 6 sampled residents (#51 & 35) reviewed for weight loss and hydration. This failure placed residents at risk for impaired nutrition, impaired hydration, and a decline in health status. This caused harm to Resident #51 and Resident #35. Findings include . 1) Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 01/09/19, documented the resident was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs). On 01/23/19 at 10:57 AM, the resident stated, I have lost some weight. It just happened. No one has talked to me about it. Review of the Electronic Health Record (EHR) showed the resident weight on admission (12/26/18) was 277 pounds (#). The resident's weight on 01/24/19 was 262.4#, a difference of 14.6#, a 5.2 % weight loss. Review of the admitting [DIAGNOSES REDACTED]. On 01/07/19 a dietician assessment was done and the resident was placed on 120 milliliters (ML) of a health shake (dietary supplement) twice a daily. The (MONTH) 2019 Medication Administration Record [REDACTED] The (MONTH) 2019 Treatment Administration Record (TAR) showed the resident had an order, dated 12/26/18, for daily weights and to notify the physician of weight gain of two (2) pounds per day for two consecutive days or five pounds in a week every day shift. Review of weights recorded on the (MONTH) 2019 TAR were as follows: On 01/12/19 there was no documentation of weight being done. On 01/13/19 there was no documentation of weight being done. On 01/14/19 the weight was documented as 268.4#. On 01/15/19 the weight was documented as 266#. On 01/16/19 the weight was documented as 266#. On 01/17/19 the weight was documented as 255# On 01/18/19 the weight was documented as 255#. On 01/19/19 the weight was documented as 254.6#. On 01/20/19 the weight was documented as 253.9#. On 01/23/19 the weight was documented as 258.3#. On 01/24/19 the weight was documented as 258.3# On 01/25/19 the weight was documented as 262.4#. Review of the resident's weight summary showed no re-weights were obtained on the above dates. Nursing progress notes, dated 01/10/19 to 01/25/19, did not show documentation the physician or the Resident Care Manager (RCM) had been notified of the resident's weight change. On 01/25/19 at 4:04 PM, Staff C, Registered Nurse (RN)/RCM said it was her expectation that nurses who documented daily weights and recorded them on the TAR would notify the physician if a weight loss or gain was noted, placing the resident on alert and notifying the RCM. Staff C said she could not find documentation that any of those things happened. On 01/27/19 at 3:56 PM, Staff B, RN/Director of Nursing Services (DNS), said if a resident was weighed and there was a ten pound weight difference from the day before, I would immediately have them re-weighed and if there was still a difference I would expect them to notify the physician. 2) Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 12/28/18, documented the resident was cognitively intact, did not reject care and was on tube feeding. The Nutrition/Hydration Care Plan, dated 11/1/18, showed, Document and notify MD, S/S dehydration: sunken eyes, poor skin turgor, dry mucous membranes, lethargy, etc. The Skin Integrity Care Plan, dated 11/1/18, documented to offer fluids every shift, if resident is awake. The Registered Dietitian Assessment, dated 11/23/18, documented: - Resident #35's fluid consumption is 500 ml/day or less - Current dietary orders were clear liquids diet, no texture, thin consistency - Fluid need (ml/day) - approximately 2000 ml/day The Dehydration Care Plan, dated 11/29/18, documented, Monitor for signs and symptoms of dehydration: Dry mucous membranes, slow skin turgor, dry lips, sunken look, sunken eyes, decreased urine output, concentrated urine, decreased urine output, change in mentation, weakness, weight loss >3lbs per week. Notify MD if present. Physician orders [REDACTED].@ 8.5ml (milliliters)/hour via [DEVICE] (tube feeding) x 18hours from 1600-1000, to allow for day time appointments without disruption and to provide total volume of 1530ml/day with 60ml flush water every hour from 1600-1000 through [DEVICE] starting 01/08/19. The Nutrition Risk Assessment, dated 01/17/19, documented Resident #35's Intervention Plan included clear liquid diet. On 01/23/19 at 11:18 AM, Resident #35 was observed with dry lips, pale skin color and appeared to be tired. The resident said staff were not bringing him water, and he wanted bottles of water to drink from, not the cups with straws. A red labeled full bottle of water, approximately 16 ounces (oz), was observed on the resident's bedside table, which he said his family member brought him. On 01/24/19 at 2:20 PM, Resident #35 said staff had not brought him any water today. The resident's skin was observed to be pale and dry-looking, and he appeared to be sleepy. The Order Summary Report, reviewed on 01/24/19, documented Resident #35 was on a regular diet, regular texture, thin consistency, PRN (as needed) for snacks. On 01/25/19 at 8:42 AM, Resident #35 was observed asleep in bed, and his skin was dull colored. At 8:46 AM, Staff P, Certified Nursing Assistant (CNA), said water was given to residents from the snack tray. Staff P said she did not think Resident #35 wanted his water in a different way than the cup/straw. At 10:51 AM, the 200 hall nurses station snack tray (containing labeled beverages for specific residents) was observed and did not have beverages labeled for Resident #35. At 2:25 PM, the resident told Staff T, Licensed Practical Nurse, about his itchy eyes. No hydration was provided to the resident. At 3:45 PM, Resident #35 said he was thirsty all the time. The resident stated, What sounds good is an ice cold bottle of water. I like to drink a lot of water. The last couple of weeks, I haven't drank much water. At 3:52 PM, Resident #35 was observed to be tired and sullen, and when the resident spoke, there were saliva strings on the inside corners of his mouth. The printed Kardex (daily care instructions for staff), reviewed on 01/25/18, showed no instructions under hydration. The Fluid Intake Record, dated 12/28/18 to 1/26/19, documented Resident #35's fluid intake was 0 on 14 of 29 days. On 01/26/19 at 6:42 AM, Staff T took the resident's vital signs and left the room. The 16 oz red-labeled plastic bottle of water was on the bedside table. The resident said he took a drink from it. Resident #35's skin and lips appeared dry, and the resident said he was tired. At 10:48 AM, Resident #35 was observed in bed. His skin was dry; and when the resident spoke, there were saliva strings on the inside corners of his mouth. At 10:54 AM, Staff AA, CNA, said there was nothing in writing to say who got snacks and drinks. Staff AA said she looked in the Kardex to know what to do for a resident. At 11:00 AM, Staff R said hydration was everyone's job. Staff R said even the nurses need to give water, if the water container is empty. On 01/27/19 at 8:38 AM, the resident was observed asleep in bed. At 12:22 PM, Resident #35 was observed lying in bed, eyes closed, dry lips, shivering, breathing heavily and did not respond to greetings. At 12:44 PM, Staff R, Registered Nurse (RN)/Resident Care Manager said after an assessment I was a little bit scared. He looked a little distressed. A Nursing Progress Note, dated 01/27/19 at 1:38 PM, documented, Resident seemed slightly off from his normal interaction with LN (licensed nurse), but he did shake his head yes or no when asked questions. At 2:51 PM, Staff R said Resident #35's oxygen (O2) saturation (how much O2 the blood is carrying) levels had dropped to 89 with 4 liters O2, and the resident seemed to be in respiratory distress. Medical records showed on 01/27/19, at 2:59 PM, Resident #35 was transported to the hospital. At 3:30 PM, Staff B, RN/Director of Nursing Services, said her expectation was a resident on tube feeding would receive hydration every shift. Reference WAC 388-97-1060 (3)(h)(i)

Based on observation, interview and record review, the facility failed to provide necessary care and services for 2 of 4 residents (#154 & 22) reviewed for pain management, wound care and assessments after an accident. These failures placed residents at risk of receiving delayed treatment, placed them at risk of being unable to reach their highest level of physical, mental and psychosocial well-being and caused harm to Resident #154 when pain was not managed. Findings include: <Resident #154: Pain> According to the resident's Minimum Data Set (MDS), an assessment tool dated 1/18/17, Resident #154 was admitted to the facility 1/11/17. The skin assessment identified three pressure ulcers on admission for which she was receiving pressure ulcer care. One pressure ulcer was identified as a Stage 3, defined as full tissue loss but bone or tendon was not visible. Resident #154 was identified to have occasional pain rated five out of ten and had received routine and as needed (PRN) pain medications during the assessment period. On 2/10/17 at 8:22 a.m., Licensed Nurse (LN) A reported Resident #154 had her wound vac (a machine used to treat advanced pressure ulcers that were difficult to heal on their own) changed every Monday, Wednesday and Friday. Record review on 2/13/17, of the Wound Care Flow Sheet dated 2/8/17, indicated the Stage 3 pressure ulcer to Resident #154's right leg measured 9.5 centimeters (cm) in length, 6 cm in width and 1 cm in depth. A review of the policy and procedure titled, Pressure Ulcer Treatment listed Stage 3 ulcer intervention/care strategies #5: to manage pain. At 10:38 a.m., Resident #154 gave permission for the wound vac dressing change to be observed and apologized in advance for what she stated were her behaviors. When asked if the right leg wound was painful she stated yes and that she appreciated the pain medicine she got before the dressing changes she received when it was changed at the wound clinic. She reported the wound clinic used [MEDICATION NAME] prior to the dressing change which helped a lot with the pain. At 10:40 a.m., the wound vac dressing change was observed to Resident #154's right leg. The resident was positioned on her left side so the right outer calf could be seen. As the nurse began to remove the adhesive tape holding the old dressing in place the resident began gasping. Once the adhesive holding the foam dressing was removed and LN A began applying saline to the foam, the resident was observed with her fist to her mouth groaning and gasping. LN A stated, Removing the foam is the worst part. I go slowly and soak it off and take a break. As LN A began to remove the foam the resident stated, Oh LN A, I'm going to be sick. At that point only about half of the foam had been loosened from the wound and the resident requested a rest. After resting a short time, LN A began to loosen more of the foam. Resident #154 was gasping and shaking her fist stating, Oh that is painful, oh it is so painful, no more. Sobbing, she continued, I'm sorry. It is painful. I can't take it. I just can't take it. Once the foam was completely removed Resident #154 stated, It makes me sick to my stomach. As the wound was cleaned before the new dressing was applied, the resident was moaning and pulling her leg away slightly. The resident was noted to have her eyes clenched and her fist to her mouth as the new foam was applied to the wound. Once the dressing change was completed and the resident was resting quietly, she was observed to be rubbing her right thigh. In interview with LN A during the wound care, she stated the facility did not have orders to use [MEDICATION NAME]. When asked if the facility could request the use of [MEDICATION NAME] she replied, Maybe we could ask. At 11:26 a.m., Resident #154 stated when [MEDICATION NAME] was used at the wound clinic she was able to get through the dressing change without pain. At 11:35 a.m., LN A was standing at the nurse's station and stated sometimes Resident #154 will indicate she is having pain before we even start the dressing change and that today was quite extreme. When LN A was told that Resident #154 said she had no pain with the use of [MEDICATION NAME] at the wound clinic she replied, I'm not sure I believe that. LN A reported she had given Resident #154 her routine Tylenol 650 mg at about 9 a.m., an hour and half before wound care was started. During an interview with Resident #154's roommate at 5:15 p.m., she reported Resident #154 was in just incredible pain from that wound on her leg. It's just got to be terrible for her. She went on to state that she is quiet now but when they work on her leg she is just miserable. On 2/14/17 at 10:08 a.m., Nursing Assistant D reported that Resident #154 had pain whenever her right leg was touched. She went on to say, I saw it (the wound) last week and I see why. A review of nurse progress notes, from admission on 1/11/17 through 2/14/17, showed eight entries documenting pain, at times severe, in the right leg wound with several of those entries reporting pain even with the use of [MEDICATION NAME] (a narcotic pain medication). The entry dated 2/6/17 documented the resident had requested pain medication before wound care and was medicated with [MEDICATION NAME] and the resident still complained of severe pain, with crying, while taking sponge off. Progress notes dated 2/9/17 and 2/14/17, made by the nurse practitioner, indicated dressing changes continued to be quite painful and [MEDICATION NAME] was necessary for resident comfort during wound care. A review of the resident's January and February 2017 Medication Administration Record [REDACTED]. A review of the Physician order [REDACTED]. On 2/14/17 at 9:44 a.m., LN B stated [MEDICATION NAME] had been discontinued because Resident #154's daughter had concerns about the use of pain medications and when the MAR indicated [REDACTED]. When asked if it was possible she didn't use the pain medication during those days due to not having wound care done, LN B stated one of the three days she did have the wound vac changed. When asked about a discussion with the daughter regarding modifying the pain management routine or other options, LN B stated that the daughter's main concern was related to problems in the past. On 2/14/17 at 10:53 a.m., the Director of Nursing Services (DNS) stated she had knowledge of Resident #154's pain and believed it was only with wound care. She also reported that she had been told the pain behaviors would often start before she was even being touched. When asked if this could be her anticipating pain she replied, I suppose. Interventions documented on the resident's Pain Care Plan included: assess/intervene for signs and symptoms of distress or pain unrelieved by ordered [MEDICATION NAME]/treatment and educate resident/family on pain management. The resident's pain assessments were reviewed on 2/13/17. One assessment had been completed on admission on 1/11/17 and the other one was completed after the surveyor observed the wound vac dressing change on 2/13/17. The facility's policy and procedure titled, Pain Assessment and Management stated the pain management program is a commitment to resident comfort and is defined as a process of alleviating the resident's pain to a level that is acceptable to the resident The policy identified possible behavioral signs of pain as groaning, crying, screaming, grimacing, clenching of jaws, rubbing particular body part, etc. Potential cause of pain included pressure, venous or arterial ulcers. Situations where a resident's pain may be anticipated included treatments such as wound care of dressing changes. Monitoring and modifying approaches included if the pain was not adequately controlled, the multidisciplinary team should make adjustments as indicated. The facility's failure to manage Resident #154's pain during wound care and the anticipatory pain she experienced before wound care resulted in harm to the resident. <Resident #154: Wound Care> Wound care to Resident #154's right lateral (outer) calf was observed on 2/13/17 at 10:40 a.m. and completed by LN A. The old dressing was removed. The wound was cleansed with normal saline (NS), black foam was applied to the wound and secured with wound vac clear dressing. During the dressing change LN A pointed out that the mesh covering the wound bed was new and was to be left in place. A review of February 2017 physician orders [REDACTED]. On 2/14/17 at 9:36 a.m., LN A stated the collagen powder was not used because it wasn't a common item and the facility did not have it yet. At 9:44 a.m., LN B, a care manager, stated wound care supplies should be ordered and expedited if not available in the facility. LN B stated if the supplies were not available the prescriber should be notified. Review of the progress notes from 2/13/17 through 2/14/17 indicated neither the physician nor the wound clinic were notified the collagen powder was not available. The facility failed to follow Physician order [REDACTED]. <Resident #22: Accident> Resident #22 was admitted on [DATE] with multiple [DIAGNOSES REDACTED].) The resident's care plan indicated the resident was identified as a high risk for falls. On 1/27/17, Resident #22 fell while alone in the bathroom, transferring himself from the toilet to his wheelchair. The resident incurred skin abrasions to his right knee and mid lower back, and a lump to his parietal lobe area (area of brain towards the back of the head.) On 2/13/17, Neurological Monitoring Guidelines for the facility were reviewed which stated: Neurological assessments, (a neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) should be conducted in a specific interval. Every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for 4 hours, every 4 hours for 16 hours, every 8 hours for 48 hours. Monitoring will be for a minimum of 72 hours, residents being monitored for neurological deficits will be placed on alert. On 2/13/17 at approximately 2 p.m., the neurological assessment for Resident #22 was reviewed and found to be missing one half hour assessment, four hourly assessments, as well as every four hour assessments for 16 hours, and every 8 hours for 48 hours. There was no continuous assessment for 72 hours to ensure that the resident did not have any late effects from his unwitnessed fall. At 2:53 p.m., LN D, a care manager, stated documentation should start at the time of the fall and should include a statement from the resident with the person's recollection of the event. The assessment and the immediate interventions should be written into the progress note. The progress note was reviewed with LN D. The note read, Pt (patient) had a fall in the bathroom, resulting in a few abrasions to body, neuro checks in place. When asked if the progress note written about the fall was informative and sufficient, she stated she would have liked to have had more information in that note. At 3:45 p.m., the Director of Nurses stated neurological assessments should be completed per the policy. On 2/14/17 at 10 a.m., LN B stated that neuro checks should be done on unwitnessed falls and with head injuries. A thorough assessment should be completed, the resident should be placed on alert, an incident report should be completed and family and physician should be notified. When asked how often neurological assessments should be done, LN B stated, I would have to look how often, it slipped my mind right now.