Every finding on record at Avamere Rehabilitation of Shoreline

Based on observation, interview, and record review, the facility failed to maintain a clean, safe, and homelike environment for 5 of 6 residents (Residents 52, 26, 43, 42 & 3), reviewed for environment. These failures placed the residents at risk for injury, a less than homelike environment, and a diminished quality of life.Findings included.Review of the facility's policy titled, Homelike Environment, revised in February 2021, showed that the facility maximizes to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting and that Residents are provided with a safe, clean, comfortable and homelike environment.Review of the facility's policy titled, Maintenance Service, revised in December 2009, showed that the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Additionally, it showed, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.Observation on 08/16/2026 at 9:17 AM, showed the shared sink in Resident 52's and Resident 26's room had cracks (small openings) in the wall around the edge of the sink and did not feel secure when applying pressure.Observation on 08/16/2026 at 12:02 PM showed broken blinds in Resident 43's room.Observation on 08/16/2026 at 2:15 PM, showed the heater in Resident 42's room was coming away from the wall and was in disrepair.Observation on 08/17/2026 at 12:27 PM, showed broken and missing blinds in Resident 3's room.In an interview and joint observation on 08/21/2026 at 8:45 AM, Staff T, Certified Nursing Assistant, stated that they notified maintenance if they noticed anything in resident rooms that were in disrepair. A joint observation of Resident 42's room showed the heater coming away from the wall and in disrepair. Staff T stated, we need to report this to maintenance. A joint observation of Resident 52's and Resident 26's room showed the wall cracking around the sink. Staff T stated, it's [it is] cracked, I think maintenance knows. A joint observation of Resident 3's room showed broken and missing blinds. Staff T stated that the blinds were broken and it's an old building. A joint observation of Resident 43's room showed broken blinds and Staff T stated that they are broken.In an interview and joint observation on 08/21/2026 at 9:15 AM, Staff S, Facility Operations Manager, stated that we rely on aides to let us know if anything is broken or needs to be fixed. Staff S stated that they did not do routine checks of resident rooms. A joint observation of Resident 42's room showed the heater coming away from the wall. Staff S stated, there's [there is] a loose screw or something, I wish someone had told me. A joint observation of Resident 3's room showed missing and broken blinds. Staff S stated that the blinds were torn and I would expect them [aides] to tell me. A joint observation of Resident 52 and Resident 26's room showed cracking around the sink. Staff S stated that they would expect someone to tell me about that. A joint observation of Resident 43's room showed broken blinds. Staff S stated, those are broken.In an interview on 08/21/2026 at 1:30 PM, Staff A, Administrator, stated that maintenance was responsible for maintaining resident rooms and that all [staff] are responsible for finding broken things and should report it. Staff A stated that maintenance should be routinely checking resident rooms. Staff A further stated that they absolutely expected a homelike environment for residents.Reference: (WAC) 388-97-0880 (1).

Based on interview and record review, the facility failed to provide bed hold and transfer notices to the residents and/or their representatives in writing for 4 of 6 residents (Residents 1,13, 31 & 64), reviewed for hospitalization. In addition, the facility failed to ensure a copy of the transfer notice was sent timely to the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) office. These failures placed the residents at risk of not having an opportunity to make an informed decision about their transfers.Findings included . Review of the facility's policy titled, Transfer and Discharge Policy, revised in April 2026, showed, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing, and in a language and manner they understand. A copy of the notice is sent to the office of the State Long-Term Care Ombudsman. The policy further showed that the written notice must include the notice of the facility's bed hold and return policy. RESIDENT 1Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute bronchitis (a temporary inflammation and swelling of the main air passages that carry air to the lungs) and pneumonia (a lung infection). Review of the progress notes dated 07/11/2026 showed Resident 1 was transferred to the hospital for increased shortness of breath. Review of the progress notes dated 07/22/2026 showed Resident 1 was transferred to the hospital for acute hypoxic respiratory failure (a sudden, life-threatening condition where the lungs can no longer transfer enough oxygen into the bloodstream, depriving vital organs of the oxygen they need to function). Review of Resident 1's Electronic Health Records (EHR- progress notes, Miscellaneous and assessment notes) showed no transfer and discharge notice was sent to the Ombudsman. Further review of the EHR showed no bed hold policy was given to the resident and/or the resident representative. During a joint record review and interview on 08/18/2026 at 11:44 AM with Staff L, Registered Nurse, showed that there was no transfer/discharge notice sent to the Ombudsman, and there was no bed hold policy signed by the resident or the resident representative in the EHR. Staff L stated that they were not sure whether the bed hold, and transfer and/or discharged notice was sent to the Ombudsman. During an interview on 08/18/2026 at 11:52 AM, Staff E, Resident Care Manager, stated that staff were supposed to offer the bed hold notice to residents and send the transfer/discharge notice to the Ombudsman. Staff E further stated that the transfer/discharge notice normally is completed by the social worker. A joint record review and interview on 08/18/2026 at 12:07 PM with Staff B, Director of Nursing, showed that no transfer/discharge notice was sent to the Ombudsman, and no bed hold notice was given to the resident/resident representative. Staff B stated that the transfer/discharge notice was supposed to be completed by the social worker, and the bed hold notice by the nurses. Staff B further stated that it was their expectation that these tasks should have been completed by staff. RESIDENT 13Review of a nursing progress note dated 08/08/2026 showed Resident 13 had a change in condition and had been transferred to the hospital. Further review of the progress note did not show a bed hold and written transfer/discharge notice were provided to Resident 13 or their representative. Review of Resident 13's EHR did not show a bed hold and/or written transfer/discharge notices were provided to them or their representative. In an interview on 08/19/2026 at 9:16 AM, Staff E stated that Resident 13 had been transferred to the hospital due to their change in condition and that a transfer form was completed that Resident 13's representative had been informed. Staff E stated that they did not offer a bed hold notice and a written notice of transfer/discharge to Resident 13 or their representative. Staff E further stated that they were working on the issues regarding bed hold and written transfer/discharge notices. In an interview on 08/20/2026 at 2:09 PM, Staff G, Social Services Director, stated, I was only sending the notice of transfer/discharge for those residents that were being discharged to their homes [or Community] and a copy of that is sent to the Ombudsman. Staff G stated that they did not provide the notice of transfer/discharge or bed hold to the residents being transferred to the hospital setting. In an interview on 08/20/2026 at 3:04 PM, Staff B stated, Nothing has been done and we were able to identify that the notice of transfer has not been provided to the resident or their family [representative]. Staff B further stated that they expected staff to present the notice of transfer/bed hold to the resident or family immediately. RESIDENT 31Review of the progress notes dated 06/14/2025 and 07/11/2026, showed that Resident 31 was transferred to the hospital for a change in condition. Review of the discharge Minimum Dat Set (an assessment tool) dated 06/14/2026 and 07/11/2026, showed that Resident 31 had an unplanned discharges to a Short-term General Hospital. Review of Resident 31's EHR showed no documentation that transfer/discharge or bed hold notices were provided to Resident 31 or their representative. In an interview and joint record review on 08/20/2026 at 11:13 AM, Staff F, RCM, stated that they did not know about transfer/discharge and bed hold notices. A joint record review of Resident 31's EHR showed no documentation that a transfer/discharge or bed hold notices were provided to Resident 31 or their representative. Staff F stated that they did not see a notice of transfer/discharge or bed hold in Resident 31's EHR. In an interview on 08/21/2026 at 7:51 AM, Staff B stated that they expected the transfer/discharge and bed hold notices would be provided to the resident or their representative upon transfer/discharge to the hospital. RESIDENT 64Review of Resident 64's EHR showed that Resident 64 transferred to the hospital on [DATE]. Further review showed no documentation that written transfer/discharge and bed hold notices were provided to Resident 64 and/or their representative. In an interview on 08/20/2026 at 11:43 AM, Staff G stated that nurses were responsible for providing a written transfer/discharge notice to residents and/or their representatives when they transferred to the hospital. In an interview and joint record review on 08/20/2026 at 2:00 PM, Staff E stated that staff would provide verbal notification to residents and/or their representatives when a resident discharged to the hospital. Staff E stated that providing a bed hold notice to residents and/or their representatives was a work in progress. A joint record review of Resident 64's EHR showed that Resident 64 transferred to the hospital on [DATE]. Further review showed no documentation that written transfer/discharge and bed hold notices were provided to Resident 64 and/or their representative. Staff E stated that no, nothing [written transfer/discharge notice] was provided and that a bed hold should be offered to Resident 64. In an interview on 08/21/2026 at 1:12 PM, Staff B stated that they expected the written transfer/discharge notice and bed hold notice to be done immediately upon going to the hospital and that the nurses were responsible to start the process. Reference WAC 388-97-0120 (2)(a-c)(4) .

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 2 walked into Resident 1's room and placed their hands around Resident 1's neck and pushed inward with both hands. This failure placed residents at increased risk of injury, emotional instability, and a diminished quality of life.Findings included .RESIDENT 1Review of the admission Minimum Data Set (MDS - a required assessment tool) dated 04/28/2026, showed Resident 1 was admitted to the facility on [DATE], had severely impaired thinking/memory and was dependent for all mobility, transfers and care needs. The diagnosis list included severe intellectual (characterized by delays in speech, mental and physical development) disabilities. RESIDENT 2Review of the admission MDS dated [DATE], showed Resident 2 was admitted to the facility on [DATE], had severely impaired thinking/memory and required minimal to moderate assistance with mobility, transfers and care. The diagnosis list included Vascular Dementia (decline in thinking/memory); Psychotic Disorder with Delusions (causes fixed, false beliefs) and anxiety disorder (intense ongoing fear, worry and panic that interferes with daily life). Review of an incident investigation report dated 07/11/2026 showed a Certified Nursing Assistant [Staff C] heard screaming sounds coming from a room and went to check where the sounds came from, walked into Resident 1's room and found Resident 2 with their hands around Resident 1's neck. The incident investigation report further showed Staff C, immediately directed Resident 2 out of Resident 1's room, stayed with Resident 2 and called out for assistance from the nurse. In an interview on 08/04/2026 at 5:11 PM, Staff C stated, I went to go get a snack for Resident 2 when I heard screaming coming from one of the resident rooms, when I went to check, I found Resident 2 in Resident 1's room with their hands around Resident 1's neck. Resident 2 had both their hands around Resident 1's neck and was choking them. I immediately told Resident 2 to leave the room, and they did. I stayed with Resident 2 when they left Resident 1's room and I called out for help from the nurse. In an interview on 08/04/2026 at 5:16 PM, Staff D, Registered Nurse, stated Resident 2 often wandered into other resident's rooms, especially during the evening hours. We have Resident 2 on close staff supervision starting at 5:00 PM, but this incident occurred around 2:00 PM [in the afternoon]. Staff D stated Resident 1 and Resident 2 had an adjoining bathroom and Resident 2 went through the door of the bathroom to Resident 1's room. Staff D stated they were called into Resident 1's room by Staff C when they found Resident 2's hands around Resident 1's neck. Staff D stated they went to check Resident 1 for pain or injuries and did see some redness around Resident 1's neck where Resident 2's hands had been placed. Staff D stated Resident 2 was transported and admitted to the local hospital for assessment and evaluation of their behavior. Staff D further stated it was physical abuse when Resident 2 placed both their hands around Resident 1's neck, choking them.In an interview on 08/13/2026 at 12:59 PM, Staff E, CNA, stated if a resident went over to another resident and put their hands around their neck and tried to choke them, that would be physical abuse. In an interview on 08/13/2026 at 1:26 PM, Staff F, Licensed Practical Nurse/Resident Care Manager, stated that one of the types of abuse was physical abuse and if a resident went over to another resident and tried to choke them, that would be physical abuse. In an interview on 08/13/2026 at 2:30 PM, Staff B, Director of Nursing Services, stated that it was willful when Resident 2 went over to Resident 1 and placed their hands around Resident 1's neck and started to press down, that it was physical abuse.In an interview on 08/13/2026 at 2:52 PM, Staff A, Administrator, stated when Resident 2 placed their hands around Resident 1's neck [choking them] that was physical abuse. Reference: (WAC) 388-97-0640(1).

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for 1 of 3 residents (Resident 1), reviewed for significant medication errors. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of life. Findings included . A review of the admission record dated 07/14/2026 showed Resident 1 was readmitted to the facility from the hospital on [DATE]. A review of the Skilled Nursing Facility Transfer Form dated 07/14/2026 showed Resident 1 was diagnosed with a possible transient ischemic attack (TIA - similar to a stroke/heart attack but lasts only a few minutes to an hour. A TIA occurs when the blood supply to the brain is briefly blocked and then reopens). The skilled nursing facility transfer form showed the risk factors for stroke/heart attack or TIA were high cholesterol (too much fat in the blood), high blood pressure, and atherosclerosis (sticky deposits build up and slow blood flow). The Skilled Nursing Facility Transfer Form further showed the following:- Medications orders for carvedilol (medication used to treat high blood pressure) 25 milligrams (mg-a unit of measurement) take 0.5 tablet by mouth two times a day, wait to take this until 07/18/2026; lisinopril (medication used to treat high blood pressure) 20 mg tablet take one tablet by mouth daily, wait to take this until 07/25/2026. - Orders for new medications levetiracetam (medication used to treat seizures [sudden, uncontrolled burst of electrical activity in the brain]) 500 mg tablet take one tablet by mouth two times a day. - Dosage changed for atorvastatin (medication used to reduce risk of heart attack/stroke [from 40 mg] to 80 mg tablet take one tablet by mouth daily at bedtime. A review of the July 2026 Electronic Medication Administration Record (EMAR) showed the carvedilol 25 mg, 0.5 mg tablet had been administered to Resident 1 on 07/15/2026 at 8:00 AM, three days earlier than the ordered start date of 07/18/2026. Lisinopril 20 mg had been administered to Resident 1 on 07/15/2026 between the hours of 7:00 AM and 10:00 AM, ten days earlier than the ordered date of 07/25/2026. A review of July 2026 EMAR did not show the order for levetiracetam 500 mg tablet take one tablet by mouth two times a day or an order for atorvastatin 80 mg tablet take one tablet by mouth daily at bedtime as ordered on the Skilled Nursing Transfer order dated 07/14/2026. Resident 1 did not receive levetiracetam 500 mg on the evening of 07/14/2026 or the morning of 07/15/2026 or atorvastatin 80 mg one tablet by mouth at bedtime on 07/14/2026, as ordered on the Skilled Nursing Transfer form dated 07/14/2026. In an interview on 07/16/2026 at 1:11 PM with Staff C, Licensed Practical Nurse, stated that the Resident Care Managers (RCM) completed the admission or the readmission physician orders when a resident admitted /readmitted to the facility. An interview and joint record review on 07/16/2026 at 2:22 PM with Staff D, Registered Nurse/RCM, stated they completed the readmission physician orders for Resident 1. Staff D stated they did not use the Skilled Nursing Transfer form dated 07/14/2026 to complete the readmission for Resident 1, that they used a nursing checklist form because Resident 1 readmitted to the facility and was not considered a new admission. A joint record review of the July 2026 Medication Administration Record (MAR) and the Skilled Nursing Transfer form dated 07/14/2026 showed the physician orders were not completed as ordered. A joint record review and interview on 07/16/2026 at 2:46 PM with Staff B, Director of Nursing Services, showed the July 2026 MAR did not have the physician orders from the Skilled Nursing Transfer form dated 07/14/2026. Staff B stated two nurses were required to verify that orders were correct when residents admitted or readmitted from the hospital. Staff B further stated, this was a significant medication error. In an interview on 07/16/2026 at 3:20 PM, Staff A, Administrator, stated their expectation was for the nurses to give medications as ordered by the physician and follow the facilities policies and procedures. Reference: (WAC) 388-97-1060(3)(k)(iii) .

Based on interview and record review, the facility failed to report a missing resident within the required reporting timeframe for 1 of 4 residents (Resident 2), reviewed for abuse reporting. The failure to notify law enforcement, the state agency and the failure to follow its policy requirement of immediate notification of the Administrator, Director of Nursing Services, the resident's legal representative, and the attending physician when a resident is missing placed the resident at risk for unidentified abuse and/or neglect.Findings included .Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, .are reported to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).Review of the facility's policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, approved on 05/2026, showed Mandated reporters are to immediately report all alleged violations to the Administrator, state agency, and all other required agencies (e.g.[example] law enforcement when applicable) within specified timeframes when they have reasonable suspicion of abuse, neglect, exploitation and misappropriation of resident property has occurred or reasonable suspicion that a crime has occurred. It showed, The Administrator and Director of Nursing Services shall be immediately notified of all allegations of abuse and neglect. The policy further showed, Any incidents of abuse or injuries of unknown origin will be reported to State officials and or/ law enforcements per the State regulations/requirements.Review of the facility's policy titled Wandering and Elopements, showed that if a resident is missing, staff are to initiate the elopement/missing resident emergency procedure and if the resident is not located, the policy directs staff to notify the Administrator, Director of Nursing Services, the resident's legal representative, and the attending physician.Review of the admission record printed on 06/15/2026 showed that Resident 2 was admitted to the facility on [DATE].Review of the October 2025 incident log showed that Resident 2 had a concern documented on 10/30/2025, with the nature of the occurrence logged as AMA [Against Medical Advice]. The review further showed that an incident for Resident 2 occurred on 10/25/2026 and had not been reported to the state agency and law enforcement until 10/27/2025.Review of the Electronic Health Record (EHR) showed that Resident 2 left the faciity on [DATE] to visit family and did not return to the facility. The review further showed that Resident 2 did not knowingly leave the facility AMA.Review of the investigation report dated 10/28/2025, showed Resident [Resident 2] was noted to be gone from the facility on 10/25[10/25/2025] in the afternoon hours. Her assigned nurse attempted to reach out to the resident consistently over the weekend but were not able to get a hold of her. On 10/27 [10/27/2026] transcribing nurse attempted to get a hold of Resident 2 by the cellphone but was unable to get a hold of her. Calls were made to her brother.with no success as well. Per char review, resident [Resident 2] had listed grandparent whose contact was called as well with no success. Transcriber then met with IDT [Inter Disciplinary Team] and it was agreed to contact the police department and social services director submitted an APS [Adult Protective Services] report.Review of the facility provided Sign Out/Sign In Sheet documentation for October 2025 did not show whether Resident 2 signed out or signed in on 10/25/2025.Review of Resident 2's EHR did not show documentation that the facility Administrator, Director of Nursing Services and / or the attending physician were notified about the incident immediately.In an interview on 06/16/2026 at 1:12 PM, Staff C, Resident Care Manager, stated that when a resident leaves the facility, We have to notify the provider, and assess the resident's mental and physical status to make sure the resident is safe to go out. Staff C stated they did not know whether Resident 2 was safe or unsafe to leave the facility on that specific date. Staff C stated the incident occurred over the weekend, and law enforcement and state agencies were notified two days after the incident, on 10/27/2025.In an interview on 06/16/2026 at 12:03 PM, Staff E, Social Services Director, stated that when a resident leaves the facility, they would check the sign out log, attempt to contact the resident, and notify the family if the resident cannot be reached. Staff E added that they would report the situation to APS and law enforcement as soon as they realized a resident was missing and would not wait two days to report it.In an interview on 06/16/2026 at 2:22 PM, Staff B, Director of Nursing, stated that it was their expectation that staff report Resident 2's incident to all required parties immediately once it was determined the resident was missing.In an interview on 06/16/2026 at 2:48 PM, Staff A, Administrator, stated, My expectation is to be informed of the incident immediately. I will speak with the appropriate individuals and then report it to law enforcement within few hours.Reference: (WAC) 388-97-0640 (5)(a).

Based on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 1 of 3 residents (Resident 1) reviewed for Activities of Daily Living (ADLs). The failure to provide bathing care for a resident who was dependent on staff for assistance placed the resident at risk for poor hygiene, unmet care needs, and a diminished quality of life.Findings included .Review of the facility's policy titled Activities of Daily Living, reviewed in June 2026, showed, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The policy further stated, Appropriate care and services are provided for residents who are unable to carry out ADLs independently.in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, and oral care).Review of the admission record printed on 06/15/2026 showed that Resident 1 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness.Review of the admission minimum data set (a required assessment tool) dated 03/11/2026 showed that Resident 1 required two person assistance for bathing.Review of the shower schedule showed that Resident 1's bathing was scheduled twice weekly, on Tuesdays and Thursdays.Review of the ADL care plan revised on 06/09/2025 showed that Resident 1 had a self care performance deficit related to impaired mobility and blindness. The care plan further showed that Resident 1 was dependent on care and required two staff to assist with bathing.In an interview on 06/15/2026 at 10:37 AM, Resident 1 stated they had not been receiving their bathing care consistently for the past six months. Resident 1 stated that staff did not come to their room to offer a bed bath and hair washing. Resident 1 stated, Staff only document that I refused the bath, without including my explanations, and although there were a few days I postponed due to pain and the small Hoyer sling causing discomfort, this does not accurately reflect what actually occurred. When informed that the facility had multiple entries indicating refusals, Resident 1 stated, They must be marking me as refusing, even when the bath was never offered.In an interview on 06/16/2026 at 10:13 AM, Staff D, Certified Nursing Assistant, stated that Resident 1 required two female caregivers for bathing and that they were previously one of the shower aides assigned to the resident. Staff D reported that in April 2026, Resident 1 fired them and no longer wanted them to provide care. Staff D stated they had not provided bathing care to Resident 1 since that time. Staff C stated the facility currently had only two shower aides (one male and one female) and that they did not know who had been providing bathing care for Resident 1.A joint record review of Resident 1's January 2026 Kardex (care guide) and interview on 06/16/2026 at 1:12 PM with Staff C, Resident Care Manager, showed that Resident 1 was scheduled for eight showers, received two (on 01/06/2026 and 01/23/2026), and had three refusals on 01/09/2026, 01/13/2026, and 01/2026. The review of February 2026 Kardex showed that Resident 1 received a bath on 02/27/2026 and had refusals on 02/04/2026, 02/06/2026, 02/13/2026, 02/16/2026, 02/18/2026, 02/20/2026, 02/24/2026, 02/25/2026, and 02/26/2026. The review of March 2026 Kardex showed Resident 1 received no bath and had refusals on 03/03/2026, 03/06/2026, 03/16/2026, 03/20/2026, and 03/27/2026. The review of April 2026 Kardex showed Resident 1 received no bath and had refusals on 04/07/2026, 04/10/2026, 04/16/2026, 04/17/2026, 04/21/2026, and 04/24/2026.The review of May 2026 Kardex showed Resident 1 received no bath and had refusals on 05/05/2026, 05/08/2026, 05/12/2026, 05/19/2026, and 05/26/2026. The review of June 2026 Kardex showed that Resident 1 had not received bath and no documentation for refusal. The record further showed that Resident 1 received no bathing care in April, May, or June 2026. When asked whether an assessment had been completed to identify the root cause of Resident 1's consistent refusals of bathing care, Staff C stated that no assessment had been completed and that they did not know the reason for the resident's ongoing refusal behavior. A joint record review of Resident 1's Electronic Health Record (EHR) did not show that the facility consistently discussed the risks and benefits of bathing care with Resident 1. Staff C stated they would expect the facility to offer and re-offer all scheduled bathing care, to have consistent discussions with Resident 1 regarding the risks and benefits of bathing, to update the care plan and to complete an assessment to identify the root causes of the resident's refusals.In an interview on 06/16/2026 at 2:22 PM, Staff B, Director of Nursing, stated that the facility became aware of the shower issues the previous week and was working on addressing the concerns. Staff B stated they would expect Resident 1 to be offered all scheduled baths, for staff to re-offer the care if a refusal occurred, for the care plan to be updated, and for the risks and benefits to be discussed with Resident 1 and/or their representative. Staff B further stated they would expect Resident 1's assessment to be completed to identify the root cause of their refusals.Reference: (WAC) 388-97-1060 (2)(c).

Based on interview and record review, the facility failed to monitor a resident taking a diuretic (used to help remove extra fluid from the body) medication and failed to notify the provider of weight gain for 1 of 4 residents (Resident 1), reviewed for quality of care. These failures placed residents at risk for unrecognized weight gain, medical complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated July 2025, showed that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 02/2026, showed, Our facility promptly notifies.their attending physician.of changes in the resident's medical/mental condition and/or status.Review of the face sheet printed on 04/20/2026, showed that Resident 1 had Chronic Right Heart Failure [a long-term condition in which the right side of the heart cannot effectively pump blood to the lungs].Review of the comprehensive care plan, printed on 04/20/2026, showed that Resident 1 had heart failure with an intervention to monitor/document/report to MD [Medical Doctor].changes in weight.Review of the March 2026 Medication Administration Record showed an order for Torsemide (a diuretic medication).Review of Resident 1's weights from 02/26/2026 through 03/18/2026, showed that on 02/26/2026 Resident 1 weighed 365 pounds (lbs-a unit of measurement) and on 03/18/2026 they weighed 397.75 lbs (a 32.75 lb weight gain).In an interview on 05/14/2026 at 12:55 PM, Resident 1 stated that they were on a diuretic medication. When asked how the facility monitored Resident 1's diuretic use, Resident 1 stated that pretty much I tell them, if I notice swelling I tell them. Resident 1 further stated that they were supposed to have daily weights, sometimes doesn't [does not] happen.In an interview and joint record review on 05/15/2026 at 10:07 AM, Staff B, Medical Doctor, stated that they expected staff to notify them if a resident was on a diuretic and had a weight gain. A joint record review of Resident 1's weights from 02/26/2026 through 03/18/2026, showed that on 02/26/2026 Resident 1 weighed 365 pounds lbs and on 03/18/2026 they weighed 397.75 lbs. When asked if they had been notified of the weight gain, Staff B stated that they were not coming here at the time, another provider might have mentioned something [in their notes]. A joint record review of the physician notes from 03/06/2026, 03/24/2026, and 03/30/2026 showed no documentation that the physician had been notified of Resident 1's weight gain. Staff B stated that the other physician did not mention anything. Staff B further stated that if they had known about the weight gain they would have sent her to the hospital and they could treat here with more things at the hospital.In an interview on 05/15/2026 at 10:50 AM, Staff C, Registered Dietician, stated that they were responsible for monitoring resident weights along with, the doctor and nursing. Staff C stated that they do monthly weight reports for all residents and if there was a significant weight change, they would notify the physician. A joint record review of Resident 1's weights from 02/26/2026 through 03/18/2026, showed that on 02/26/2026 Resident 1 weighed 365 pounds lbs and on 03/18/2026 they weighed 397.75 lbs. Staff C stated that yes, it was a significant change. Staff C further stated that they were not aware of Resident 1's weight gain and didn't [did not] tell the provider.In an interview on 05/15/2026 at 11:29 AM, Staff D, Licensed Practical Nurse, stated that they monitored residents on diuretics by taking their weight and we should have orders to check the weight. Staff D stated that they would let the doctor know if there was a change in a resident's weight. Staff D stated that they followed care plans and physician orders. Staff D stated that Resident 1 was on a diuretic for heart failure and was monitored by taking weights. A joint record review of Resident 1's weights from 02/26/2026 through 03/18/2026, showed that on 02/26/2026 Resident 1 weighed 365 pounds lbs and on 03/18/2026 they weighed 397.75 lbs. Staff D stated that that was pretty much a 30 pound weight increase. Staff D further stated that they would let the doctor know if a resident's weight increased that much.In an interview and joint record review on 05/15/2026 at 12:03 PM, Staff E, Resident Care Manager, stated that if a resident had a significant change in their weight they expected staff to come to me and talk to the doctor. Staff E stated that they expected staff to follow care plans. Staff E stated that Resident 1 was on Torsemide for heart failure and stated that she should still be on daily weights. A joint record review of Resident 1's weights from 02/26/2026 through 03/18/2026, showed that on 02/26/2026 Resident 1 weighed 365 pounds lbs and on 03/18/2026 they weighed 397.75 lbs. Staff E stated that it was like a 30 pound weight gain and that it was way more than [a] significant change in weight. A joint record review of Resident 1's progress notes showed no documentation that the physician was notified. Staff E stated that they [nursing] should have notified the doctor and written a progress note. A joint record review of Resident 1's comprehensive care plan, showed that Resident 1 had heart failure and an intervention to monitor/document/report to MD [Medical Doctor].changes in weight. Staff E stated that they expected staff to follow the care plan.In an interview on 05/15/2026 at 12:49 PM, Staff A, Interim Director of Nursing, stated that they absolutely expected staff to follow care plans. Staff A stated that they expected staff to talk to the physician if a resident was on a diuretic and had a significant weight gain. A joint record review of Resident 1's weights from 02/26/2026 through 03/18/2026, showed that on 02/26/2026 Resident 1 weighed 365 pounds lbs and on 03/18/2026 they weighed 397.75 lbs. Staff A stated that expected staff to follow the care plan and notify the physician of Resident 1's weight gain.Reference: (WAC) 388-97-1060 (1).

Based on interview and record review, the facility failed to obtain and implement physician orders for Continuous Positive Airway Pressure (CPAP - a machine that helps a person breathe more easily while they sleep) treatment in a timely manner for 1 of 4 residents (Resident 1), reviewed for respiratory care. This failure placed the resident at risk for poor sleep quality, related medical complications, and a decreased quality of life.Findings included.Review of the facility's policy titled, Physician Services, revised in February 2021, showed Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician.Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnosis that included obstructive sleep apnea (a condition when a person stops breathing over and over while they sleep because their airway keeps getting blocked) and a need for assistance with personal care.Review of Resident 1's hospital Discharge summary, dated [DATE], showed that Resident 1's diagnosis of sleep apnea was managed per home regimens, with CPAP use facilitated by nursing due to cognitive impairment [a person's thinking and memory do not work as well as they used to] and that Resident 1 may use own CPAP machine.Review of a document titled, Inventory of Personal Effects, dated 04/13/2026, showed Resident 1's personal CPAP machine was listed among the items brought with him upon admission to the facility. Review of a nursing progress note dated 04/14/2026, showed [Resident 1] uses CPAP at night r/t [related to] OSA [obstructive sleep apnea].Review of Resident 1's April 2026 physician orders showed orders for CPAP treatment were obtained on 04/16/2026 (three days after Resident 1's admission to the facility).Review of Resident 1's April 2026 Medication Administration Record showed physician orders for CPAP treatment were implemented on 04/16/2026.In an interview on 04/30/2026 at 2:02 PM, Staff B, Licensed Practical Nurse, stated that residents admitted to the facility with physician orders to ensure medical treatments were implemented and that we follow treatment orders from the hospital or from home. Staff B stated that when a resident was admitted with a CPAP machine, a physician's order would be obtained immediately and that The order should be in place as soon as they admit to the facility, the CPAP order should be available for them, that's critical. Staff B further stated, some patients like to use it [CPAP machine] when they nap or use it at night.In an interview and joint record review on 04/30/2026 at 2:08 PM, Staff C, Resident Care Manger, stated that the facility managed residents who used a CPAP and that when a resident admitted to the facility, we make sure we have the [physician] orders, the CPAP machine, and other supplies. Staff C stated that CPAP-use would be implemented within the same day [of admission to the facility], if they come in at noon, they need it by bedtime. A joint record review of Resident 1's April 2026 physician orders showed orders for CPAP treatment were obtained on 04/16/2026. Staff C stated that they expected physician orders for CPAP therapy would have been obtained and implemented when Resident 1 was admitted to the facility.In an interview on 04/30/2026 at 2:24 PM, Staff A, Director of Nursing, stated that they expected Resident 1's CPAP therapy would have been implemented in a timely manner and that It [CPAP therapy] should have been continued on the date of admit, if they [staff] didn't [did not] see [physician] orders, they should have contacted the provider.Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within the required timeframe for 3 of 7 residents (Residents 1, 2 & 3), reviewed for abuse reporting. This failure placed the residents at risk for potential unidentified mistreatment and lack of protection due to unrecognized abuse.Findings included.Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2025, showed Nursing Home responsibilities included:-Report all suspected incidents of abuse, neglect, financial exploitation, or misappropriation of property. -Notify the State Hotline of allegations immediately or as soon as resident is protected.-Log in state reporting log abuse and neglect.RESIDENT 1Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnoses that included need for assistance with personal care and unspecified dementia (a condition that affects the brain and makes it harder for a person to remember things, think clearly, make decisions, or take care of daily tasks).In an interview on 03/05/2026 at 2:19 PM, Resident 1 stated, [Resident 2] comes in and takes my nice clothes from here, that's [that is] why I brought a suitcase to put my nice clothes. I told them [Facility staff] she [Resident 2] comes in, I told them if I slap [Resident 2] it's their [Facility staff] fault because they [Facility staff] don't [do not] watch [Resident 2]. Resident 1 further stated, She came in here just today again. When asked about Resident 1's missing clothes, Resident 1 stated, Some clothes go to the laundry and never come back.RESIDENT 2Review of a face sheet showed Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance (acting in ways that are unusual for them and that may be hard for others to manage) and psychosis (a person's brain has trouble telling what is real from what is not).Review of Resident 2's care plan, revised on 12/02/2025, showed, Problematic behavior in which [Resident 2] acts characterized by ineffective coping: verbally or physical aggression.wandering to other residents' rooms, self-propelling around the facility, being agitated when [Resident 2] knows that she is being monitored related to diagnosis of dementia.Review of the facility's incident logs for December 2025, January 2026, and February 2026 did not show documentation of incidents involving Resident 1 and/or Resident 2. Further review of the incident log through 03/05/2026, did not show entries related to Resident 1 and/or Resident 2.In an interview on 03/05/2026 at 2:40 PM, Staff A, Administrator, was informed of Resident 1's allegation that Resident 2 entered her room and that some of her property was missing.In a follow-up interview on 03/13/2026 at 1:28 PM, Resident 1 stated that [Resident 2] came into the room when I was asleep, around four AM, she came and took the pillow from the other bed. I called the nurse to let them know and they came and took [Resident 2]. When asked when the incident occurred, Resident 1 stated, It was the night before last night, I think.In an interview and joint record review on 03/13/2026 at 1:38 PM with Staff B, Interim Director of Nursing, and Staff C, Interim Administrator, stated that they followed the Purple Book guidelines for reporting allegations of abuse. A joint record review of the facility's March 2026 incident log through 03/13/2026 did not show documentation of incidents involving Resident 1 and/or Resident 2. Staff C stated, We followed up with both residents [Resident 1 & 2] on 03/12/2026 and on 03/13/2026, and that the allegation was not reported to the State Agency when the allegation was reported to Staff A on 03/05/2026. Staff B and Staff C stated that they expected reported allegations would be reported timely.RESIDENT 3Review of a face sheet showed Resident 3 admitted to the facility on [DATE] with diagnoses that included need for assistance with personal care, abnormalities of gait (the way a person walks) and mobility, and dementia.Review of a document titled, Resident Interviews, dated 02/12/2026, showed documentation that Resident 3 reported that Care is a little rough from the men [male staff]. It further showed that the interview was completed by Staff D, Social Services Coordinator/Assistant.In an interview and joint record review on 03/13/2026 at 1:32 PM, Staff D stated that she was trained on abuse and neglect by the facility. A joint record review of a document titled, Resident Interviews, dated 02/12/2026, showed, Resident 3 was documented to report Care is a little rough from the men. Staff D stated that they interviewed Resident 3 and that [Resident 3] mentioned that men are a little rough getting him out of bed. When asked what follow-up actions were taken after Resident 3 reported rough care from men, Staff D stated that an investigation of the allegation was not completed and that I did the interviews and sent them [completed resident interview forms] to the Social Services Director. Staff D further stated that she should have reported Resident 3's allegation to the nurse and that would start the investigation into the allegation.A joint record review and interview on 03/13/2026 at 1:38 PM with Staff B and Staff C, showed the facility's incident log for February 2026 did not show documentation of Resident 3's reported allegation on 02/12/2026. Staff B stated, I do not see [Resident 3's] name on here, I don't [do not] see an investigation completed for that resident. I would expect staff to have followed up on that. Staff B further stated, The interview form should have been reviewed, and [Resident 3] should have been re-interviewed. Staff C stated that they expected reported allegations would be reported timely to the State Agency.Reference: (WAC) 388-97-0640 (2)(b).

Based on interview and record review, the facility failed to ensure allegations of abuse were thoroughly investigated for 3 of 7 residents (Residents 1, 2 & 3), reviewed for abuse investigation. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life.Findings included.Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2025, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences .All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations.RESIDENT 1Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnoses that included need for assistance with personal care and unspecified dementia (a condition that affects the brain and makes it harder for a person to remember things, think clearly, make decisions, or take care of daily tasks).In an interview on 03/05/2026 at 2:19 PM, Resident 1 stated, [Resident 2] comes in and takes my nice clothes from here, that's [that is] why I brought a suitcase to put my nice clothes. I told them [Facility staff] she [Resident 2] comes in, I told them if I slap [Resident 2] it's their [Facility staff] fault because they [Facility staff] don't [do not] watch [Resident 2]. Resident 1 further stated, She came in here just today again. When asked about Resident 1's missing clothes, Resident 1 stated, Some clothes go to the laundry and never come back.RESIDENT 2Review of a face sheet showed Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance (acting in ways that are unusual for them and that may be hard for others to manage) and psychosis (a person's brain has trouble telling what is real from what is not).Review of Resident 2's care plan, revised on 12/02/2025, showed, Problematic behavior in which [Resident 2] acts characterized by ineffective coping: verbally or physical aggression.wandering to other residents' rooms, self-propelling around the facility, being agitated when [Resident 2] knows that she is being monitored related to diagnosis of dementia.Review of the facility's incident logs for December 2025, January 2026, and February 2026 did not show documentation of incidents involving Resident 1 and/or Resident 2. Further review of the incident log through 03/05/2026, did not show entries related to Resident 1 and/or Resident 2.In an interview on 03/05/2026 at 2:40 PM, Staff A, Administrator, was informed of Resident 1's allegation that Resident 2 entered her room and that some of her property was missing.In a follow-up interview on 03/13/2026 at 1:28 PM, Resident 1 stated that [Resident 2] came into the room when I was asleep, around four AM, she came and took the pillow from the other bed. I called the nurse to let them know and they came and took [Resident 2]. When asked when the incident occurred, Resident 1 stated, It was the night before last night, I think.In an interview and joint record review on 03/13/2026 at 1:38 PM with Staff B, Interim Director of Nursing, and Staff C, Interim Administrator, stated that they followed the Purple Book guidelines for reporting allegations of abuse. A joint record review of the facility's March 2026 incident log through 03/13/2026 did not show documentation of incidents involving Resident 1 and/or Resident 2. Staff C stated, We followed up with both residents [Resident 1 & 2] on 03/12/2026 and on 03/13/2026, and that the allegation was not reported to the State Agency when the allegation was reported to Staff A on 03/05/2026. Staff B and Staff C stated that they expected reported allegations would be investigated timely.RESIDENT 3Review of a face sheet showed Resident 3 admitted to the facility on [DATE] with diagnoses that included need for assistance with personal care, abnormalities of gait (the way a person walks) and mobility, and dementia.Review of a document titled, Resident Interviews, dated 02/12/2026, showed documentation that Resident 3 reported that Care is a little rough from the men [male staff]. It further showed that the interview was completed by Staff D, Social Services Coordinator/Assistant.In an interview and joint record review on 03/13/2026 at 1:32 PM, Staff D stated that she was trained on abuse and neglect by the facility. A joint record review of a document titled, Resident Interviews, dated 02/12/2026, showed, Resident 3 was documented to report Care is a little rough from the men. Staff D stated that they interviewed Resident 3 and that [Resident 3] mentioned that men are a little rough getting him out of bed. When asked what follow-up actions were taken after Resident 3 reported rough care from men, Staff D stated that an investigation of the allegation was not completed and that I did the interviews and sent them [completed resident interview forms] to the Social Services Director. Staff D further stated that she should have reported Resident 3's allegation to the nurse and that would start the investigation into the allegation.A joint record review and interview on 03/13/2026 at 1:38 PM with Staff B and Staff C, showed the facility's incident log for February 2026 did not show documentation of Resident 3's reported allegation on 02/12/2026. Staff B stated, I do not see [Resident 3's] name on here, I don't [do not] see an investigation completed for that resident. I would expect staff to have followed up on that. Staff B further stated, The interview form should have been reviewed, and [Resident 3] should have been re-interviewed. Staff C stated that they expected reported allegations would be investigated timely.Reference: (WAC) 388-97-0640 (6)(a).

Based on observation, interview, and record review, the facility failed to develop and/or implement care plans for 1 of 2 residents (Resident 1), reviewed for comprehensive care plans. The failure to develop/implement care plans for Activities of Daily Living (ADL) and prosthesis (an artificial device that replaces a missing body part) care placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, reviewed in June 2025, showed that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.ADLSReview of Resident 1's discharge Minimum Data Set (an assessment tool) dated 02/03/2026, showed Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. It further showed that Resident 1 had diabetes (a group of diseases that result in too much sugar in the blood) diagnosis.Review of Resident 1's comprehensive care plan printed on 02/12/2026, showed no care plan for providing fingernail care for diabetes.Review of Resident 1's ADL care plan, revised on 01/16/2026, showed that Resident 1 required a minimum of one staff assistance with personal hygiene.Observation on 02/09/2026 at 12:28 PM showed Resident 1 with long fingernails and brown material underneath the fingernails on both hands. Resident 1 stated, It's [it is] hit or miss if I get them [fingernails] trimmed.Observation on 02/11/2026 at 9:30 AM, showed Resident 1 with long fingernails and brown material underneath the fingernails on both hands. Resident 1 stated that they had a shower yesterday [02/10/2026].In an interview and joint observation on 02/11/2026 at 10:03 AM, Staff D, Certified Nursing Assistant (CNA), stated that nail care was included in ADLs for dependent residents. Staff D stated that if a resident had diabetes, the nurses provided the nail care but we [CNAs] would let them [nurses] know if [the resident's nails] were getting long or dirty. Staff D stated that Resident 1 needed total care for personal hygiene. Staff D stated that they knew what ADL care that a resident needed by checking the Kardex (care plan used by CNAs). A joint observation of Resident 1's fingernails showed they were long and had brown material underneath the fingernails on both hands. Staff D stated that Resident 1's fingernails were long, dirty and had brown/black material underneath their fingernails.In an interview and joint record review on 02/11/2026 at 11:05 AM, Staff C, Licensed Practical Nurse, stated that nurses would provide nail care to resident with diabetes and that anyone [CNAs or nurses] can clean under the nails. Staff C stated that they expected CNAs to look at the care plan to know what ADLs to provide for residents and to follow that [care plan]. A joint record review of Resident 1's ADL care plan showed that Resident 1 needed minimum of one staff assistance with ADLs. Further joint record review of Resident 1's comprehensive care plan showed no care plan for providing fingernail care for Resident 1. Staff C stated there was no care plan for providing fingernail care for Resident 1.A joint observation on 02/11/2026 at 11:24 PM with Staff C, showed Resident 1's fingernails were long and had brown material underneath the fingernails on both hands. Staff C stated that Resident 1's nails were long, needing some cleaning, not smooth.PROSTHESIS CAREReview of Resident 1's comprehensive care plan printed on 02/12/2026, showed that Resident 1 had bilateral [both sides] BK [below knee] amputation [surgical removal of extremity]. It further showed the intervention for Resident 1 to have prosthesis on daily AM [morning] till [until] bedtime. Shrinker sock [a specialized compression garment designed to reduce post-surgical swelling and shape the limb for proper prosthetic fit] on when prosthesis off.Observation on 02/11/2026 at 9:30 AM, showed Resident 1 was in their bed, their prosthesis was off and they did not have the shrinker socks on. Resident 1 stated, they're [they are] supposed to change [shrinker socks] every day.In an interview and joint observation on 02/11/2026 at 10:03 AM, Staff D stated that they knew what ADL care that a resident needed by checking the Kardex. A joint record review of the Kardex showed that Resident 1 had a care plan for prosthesis on daily AM till bedtime. Shrinker socks on when prosthesis off. A joint observation showed that Resident 1 was in bed, their prosthesis was off and they did not have the shrinker socks on. Staff D stated that the shrinker socks were not on Resident 1 and stated, who took them? Staff D looked in Resident 1's nightstand, found the shrinker socks and then put them on Resident 1. Staff D stated that the shrinker socks should have been on Resident 1.In an interview and joint record review on 02/11/2026 at 11:05 AM, Staff C stated that they expected care plans to be followed. A joint record review of Resident 1's comprehensive care plan showed that Resident 1 had a care plan for prosthesis on daily AM till bedtime. Shrinker socks on when prosthesis off. Staff C stated that Resident 1 should have had the shrinker socks when the prosthesis was off.In an interview and joint record review on 02/11/2026 at 12:00 PM, Staff B, Resident Care Manager (RCM), stated that they expected that staff to follow care plans for residents and if they needed to be updated then the RCMs would update them. A joint record review of Resident 1's comprehensive care plan showed Resident 1 needed substantial/maximal assistance for personal hygiene and showed no care plan for trimming the fingernails of a resident with diabetes. Staff B further stated that they would expect a care plan that stated a licensed nurse should be doing the trimming for Resident 1. Further joint record review showed Resident 1 should have prosthesis on daily AM till bedtime. Staff B stated that they expected that care plan to be followed and that Resident 1 should have the shrinker socks on when their prosthesis was off.In an interview on 02/11/2026 at 2:37 PM, Staff A, Director of Nursing, stated that they expected the care plan for residents to be followed. Staff A stated that they expected staff to provide ADLs for dependent residents and that included fingernail care. Staff A stated that they would not expect a resident's fingernails to be long and dirty after a shower. Staff A further stated that they expected staff to put shrinker socks on as the care plan says for Resident 1.Reference: (WAC) 388-97-1020 (1)(2)(a)(b).

Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 1 of 3 residents (Resident 1), reviewed for ADLs. The failure to provide assistance with personal hygiene placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facilities policy titled, Activities of Daily Living (ADLS), Supporting, reviewed in June 2025, showed Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with.hygiene (bathing, dressing, grooming, and oral care).Review of Resident 1's discharge Minimum Data Set (an assessment tool) dated 02/03/2026, showed Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for personal hygiene. It further showed that Resident 1 had diabetes (a group of diseases that result in too much sugar in the blood) diagnosis.Review of Resident 1's ADL care plan, revised on 01/16/2026, showed that Resident 1 required a minimum of one staff assistance with personal hygiene.Observation on 02/09/2026 at 12:28 PM showed Resident 1 with long fingernails and brown material underneath the fingernails on both hands. Resident 1 stated, It's [it is] hit or miss if I get them [fingernails] trimmed.Observation on 02/11/2026 at 9:30 AM, showed Resident 1 with long fingernails and brown material underneath the fingernails on both hands. Resident 1 stated that they had a shower yesterday [02/10/2026].In an interview and joint observation on 02/11/2026 at 10:03 AM, Staff D, Certified Nursing Assistant (CNA), stated that nail care was included in ADLs. Staff D stated that if a resident had diabetes, the nurses provided the nail care but we [CNAs] would let them [nurses] know if [the resident's nails] were getting long or dirty. Staff D stated that Resident 1 needed total care for personal hygiene. A joint observation of Resident 1's fingernails showed they were long and had brown material underneath the fingernails on both hands. Staff D stated that Resident 1's fingernails were long, dirty and had brown/black material underneath their fingernails.In an interview and joint record review on 02/11/2026 at 11:05 AM, Staff C, Licensed Practical Nurse, stated that nurses would provide nail care to resident with diabetes and that anyone can clean under the nails. Staff C stated that there should be a physician order for nail care for residents with diabetes. A joint record review of Resident 1's physician orders showed no order for nail care. Staff C stated, there's [there is] no order for nail care and that they would talk to the doctor to put an order in.A joint observation and interview on 02/11/2026 at 11:24 PM with Staff C showed Resident 1's fingernails were long and had brown material underneath the fingernails on both hands. Staff C stated that Resident 1's nails were long, needing some cleaning, not smooth.In an interview and joint record review on 02/11/2026 at 12:00 PM, Staff B, Resident Care Manager, stated that aides could clean resident's fingernails and that if they have diabetes trimming is for the nurses to do. Staff C further stated that they would expect there to be a physician order and it would be signed off in the MAR [Medication Administration Record]. A joint record review of Resident 1's physician orders showed no order for providing nail care.In an interview on 02/11/2026 at 2:37 PM, Staff A, Director of Nursing, stated that they expected staff to provide ADLs for dependent residents and that included nail care. Staff A stated that they expected nurses to provide nail care for residents with diabetes and that they expected it to be documented that nail care had been provided. Staff A further stated that they would not expect a resident's fingernails to be long and dirty after a shower.Reference: (WAC) 388-97-1060 (2)(c).

Based on interview and record review the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions (RC) are not inappropriately placed in nursing homes for long-term care) screening form was completed, for an exempted hospital discharge resident who remained in the facility for more than 30 days for 1 of 3 residents (Resident 3) reviewed for PASARR screening. This failure placed the residents at risk of not receiving the appropriate care and services for their needs and/or lacking access to specialized services for individuals with identified mental health diagnoses or disabilities. Findings included .Review of the admission Minimum Data Set assessment (MDS-a required assessment) dated 09/24/2025 documented Resident 3 was admitted to the facility on [DATE]. Review of the Level I PASRR assessment form dated 09/22/2025 showed Resident 3 had Serious Mental Illness Indicators, known or suspected mood disorders, and had evidence that they exhibited functional limitations related to a known or suspected behavioral health disorder. Further review of the Level I PASRR assessment form dated 09/22/2025 showed Resident 3 was admitted to the facility on [DATE] and was discharged from the hospital as an Exempted Hospital Discharge, the form showed Section II.A. Exempted Hospital Discharge, the individual's attending physician certifies that the individual is likely to require fewer than 30 days of nursing facility services. Review of the Level I PASRR assessment form dated 09/22/2025 also showed, no Level 2 evaluation indicated at this time due to exempted hospital discharge: Level 2 must be completed if scheduled discharge does not occur. Review of the discharge MDS assessment dated [DATE] showed Resident 3 was discharged from the facility on 11/28/2025. Review of the Electronic Health Record did not show that a Level 2 PASRR evaluation was completed. In an interview on 12/23/2025 at 2:24 PM Staff C, Social Services Director (SSD) said when a resident admits to the facility with an exempted hospital discharge Level I PASRR, the resident must discharge from the facility within 30 days or a Level 2 PASRR form must be completed and sent out to the PASRR office for evaluation within 30 days if the resident does not discharge. Staff C also said Resident 3 did not have a Level 2 PASRR evaluation completed within 30 days, and was in the facility from 09/22/2025 to 11/28/2025, which was past 30 days. Staff C stated, I did not know that Resident 3 admitted to the facility on [DATE] with an exempted hospital discharge Level I PASRR. In an interview on 12/23/2025 at 2:41 PM Staff A, Administrator stated, the Level 2 PASRR form should have been completed within 30 days for Resident 3. Reference WAC 388-97-1975(5)

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 4 residents (Residents 1 and 2) reviewed for resident-to-resident altercations. Resident 1 sustained skin injuries (a skin tear & bruises) when their arm was grabbed by another resident in the facility (Resident 3). The facility also failed to ensure Resident 2 was free from physical abuse when their hair was pulled by another resident in the facility (Resident 3). These failures had the potential to cause more than minimal physical harm, psychological harm, mental anguish and fear. Findings included. Review of the facility's Freedom from Abuse Policy, dated September 2022, documented that each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including but not limited to other residents. The abuse policy also showed that willful is defined in the definition of abuse and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. <RESIDENT 1> Review of Resident 1's quarterly Minimum Data Set (MDS-a required assessment) assessment dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 1 had intact thinking and memory. Review of the facility incident investigation dated 11/28/2025 showed Resident 1 was talking in the hallway with a resident (Resident 2) when another resident (Resident 3) grabbed their left arm. Resident 1 sustained a skin tear on the left arm when the other resident grabbed their left arm, the skin tear measured 3.5 centimeters (cm-a unit of measurement) by 3.0 cm and had two bruises on the side of the left arm that measured 2.0 cm by 2.5 cm and another bruise on the left side of the arm that measured 4.0 cm by 4.0 cm. In an interview on 12/22/2025 at 2:25 PM Resident 1 stated, I was in my wheelchair in the hallway, talking with a resident [Resident 2] that lives nearby, when another resident [Resident 3] came up to me and grabbed my left arm. I don't know why they did this; I was not talking to them and had not noticed them until I felt them grab my left arm. It all happened so fast. They pulled really hard on my left arm and tore my skin open; it bled a lot at first. My arm bruised up right away, I had bruising all around my arm. It is all healed now.Review of the December 2025 Treatment Administration Record (TAR) with an order dated 11/29/2025 showed, left arm skin tear, cleanse with normal saline, pat dry. Apply dry dressing daily [every evening shift] for wound healing. The treatment stopped being applied on 12/21/2025. Further review of the December 2025 TAR with an order dated 12/01/2025 showed, monitor bruises to left arm until resolved, every evening shift [every Wednesday]. Discontinue date 12/21/2025.Review of the facility's incident investigation dated 11/28/2025 showed that physical abuse was substantiated when Resident 3 grabbed Resident 1's left arm which caused a skin tear that measured 3.5 cm by 3.0 cm and two bruises on the side of the left arm that measured 2.0 cm by 2.5 cm and another bruise on the left side of the arm that measured 4.0 cm by 4.0 cm.<RESIDENT 2> Review of Resident 2's admission MDS dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 2 had severely impaired thinking and memory. Review of the facility incident investigation dated 11/28/2025 showed a resident [Resident 3] used both of their hands and grabbed Resident 2 by the hair shaking hardly. Further review of the facility incident investigation showed the Resident Care Manager (RCM) was present at the time of the incident, separated the residents and then asked Resident 3 why they grabbed Resident 2 by the hair, Resident 3 responded they [Resident 2] stole my phone. The investigation determined this was not true, when Resident 3 dropped their phone during an activity in the dining room, staff picked up the phone and returned the phone to Resident 3 shortly after it was dropped. Further review of the incident investigation dated 11/28/2025 showed Resident 2 was assessed for injuries from their hair being pulled and none were found. The investigation also showed Resident 2 had no recollection of the incident. Review of the facility's incident investigation dated 11/28/2025 showed that physical abuse was substantiated when Resident 3 grabbed Resident 2 by the hair shaking hardly.<RESIDENT 3> Review of Resident 3's admission MDS dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 3 had severely impaired thinking and memory. Review of the care plan dated 09/25/2025 showed, the resident was on antipsychotic (used to manage disorganized thinking) medication related to behavior management, delirium (sudden, severe and rapid change in brain function).Review of the November 2025 Medication Administration Record (MAR) showed Venlafaxine (medication used to treat depression) Extended Release 150 milligrams (mg-a unit of measurement) give one tablet one time a day for depression with a start date of 09/23/2025. The MAR also showed Resident 3 refused to take the medication on 11/25/2025, 11/26/2025 and 11/27/2025.Further review of the November 2025 MAR showed Aripiprazole (medication used to treat mental and mood disorders) 10 mg one time a day for AMS (altered mental status) related to delirium, with a start date of 09/23/2025, and discontinue date of 11/19/2025. Aripiprazole 10 mg one time a day for delusions/delirium was restarted on 11/20/2025. The MAR also showed Resident 3 refused to take the medication on 11/25/2025, 11/26/2025 and 11/27/2025. In an interview on 12/23/2025 at 3:11 PM Staff D, Licensed Practical Nurse said the first incident occurred at 3:20 PM on 11/28/2025 when Resident 3 pulled Resident 2's hair, and the second incident occurred at 4:00 PM, 40 minutes after the first incident on 11/28/2025 when Resident 3 reached out and grabbed Resident 1's left arm which caused a skin tear and bruising. Staff D stated that the RCM was present and witnessed Resident 3 grab Resident 1's left arm before Resident 3 could be stopped. Staff D also said Resident 3 was transferred to the hospital after the incidents that occurred on 11/28/2025 for evaluation of their behavior. In an interview on 12/23/2025 at 3:58 PM Staff E, RCM said Resident 3 had a prior history of agitated behaviors but had been very quiet since they were readmitted to the facility.In an interview on 12/23/2025 at 4:05 PM Staff F, Certified Nursing Assistant said, Resident 3 had a temper and could get angry very easily. Staff F also said Resident 3 had mood swings from happy to angry, but if they wanted something they would get angry very quickly.In an interview on 12/23/2025 at 4:28 PM Staff E said they were present when Resident 3 pulled Resident 2's hair, separated the two residents, remained with Resident 3 and monitored their behavior when Resident 3 reached out and grabbed Resident 1's left arm which caused a skin tear and bruising. Staff E also said it was possible that the refusals of the medications on 11/25/2025, 11/26/2027 and 11/27/2025 could have caused Resident 3's aggressive behavior on 11/28/2025.In an interview on 12/23/2025 at 4:55 PM Staff A, Administrator said the incidents on 11/28/2025 when Resident 3 grabbed Resident 1's left arm and caused a skin tear was substantiated as physical abuse and when Resident 3 pulled Resident 2's hair was also substantiated as physical abuse. Reference WAC 388-97-0640 (1)(2)(a) .

Based on interview and record review, the facility failed to ensure adequate supervision and interventions were implemented to manage aggressive behaviors for 1 of 3 residents (Resident 3) reviewed for resident-to-resident altercations. This failure had the potential to cause substantial injuries to residents, fear and a diminished quality of life. Findings included .<RESIDENT 3>Review of Resident 3's admission Minimum Data Set (MDS-a required assessment) assessment dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 3 had severely impaired thinking and memory. Review of the facility incident investigation dated 11/28/2025 showed Resident 3 grabbed a residents [Resident 1] left arm who was talking in the hallway with another resident [Resident 2] in the facility. The resident [Resident 1] sustained a skin tear when Resident 3 grabbed their left arm. The skin tear measured 3.5 centimeters (cm-a unit of measurement) by 3.0 cm and had two bruises on the side of the left arm that measured 2.0 cm by 2.5 cm and another bruise on the left side of the arm that measured 4.0 cm by 4.0 cm. Basic First Aid was initiated to assist in healing of the skin tear.Further Review of the facility incident investigation dated 11/28/2025 showed Resident 3 used both of their hands and grabbed Resident 2 by the hair shaking hardly. The facility incident investigation showed the Resident Care Manager (RCM) was present at the time of the incident, separated the residents and then asked Resident 3 why they grabbed Resident 2 by the hair, Resident 3 responded they [Resident 2] stole my phone. The investigation determined this was not true, when Resident 3 dropped their phone during an activity in the dining room, staff picked up the phone and returned the phone to Resident 3 shortly after it was dropped. <RESIDENT 1>Review of Resident 1's quarterly MDS dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 1 had intact thinking and memory. In an interview on 12/22/2025 at 2:25 PM Resident 1 stated, I was in my wheelchair in the hallway, talking with a resident [Resident 2] that lives nearby, when another resident [Resident 3] came up to me and grabbed my left arm. I don't know why they did this; I was not talking to them and had not noticed them until I felt them grab my left arm. It all happened so fast. They pulled really hard on my left arm and tore my skin open; it bled a lot at first. My arm bruised up right away, I had bruising all around my arm. It is all healed now.<RESIDENT 2>Review of Resident 2's admission MDS dated [DATE] showed the resident was admitted to the facility on [DATE]. The MDS assessment also showed Resident 2 had severely impaired thinking and memory.Review of the incident investigation dated 11/28/2025 showed Resident 2 was assessed for injuries from their hair being pulled and none were found. The investigation also showed Resident 2 had no recollection of the incident.In an interview on 12/23/2025 at 3:11 PM Staff D, Licensed Practical Nurse stated the first incident occurred at 3:20 PM on 11/28/2025 when Resident 3 pulled Resident 2's hair, and the second incident occurred at 4:00 PM, 40 minutes after the first incident on 11/28/2025 when Resident 3 reached out and grabbed Resident 1's left arm which caused a skin tear and bruising. Staff D stated that the RCM was present and witnessed Resident 3 grab Resident 1's left arm before Resident 3 could be stopped. Staff D also stated Resident 3 was transferred to the hospital after the incidents that occurred on 11/28/2025 for evaluation of their behavior.In an interview on 12/23/2025 at 3:58 PM Staff E, RCM stated Resident 3 had been a resident of the facility previously, had shown agitated/aggressive behaviors during that time, had been discharged from the facility for a few months and since they readmitted to the facility on [DATE] they had been very quiet and had not shown any agitated/aggressive behaviors.In an interview on 12/23/2025 at 4:05 PM Staff F, Certified Nursing Assistant stated, Resident 3 had a temper and could get angry very easily. Staff F also stated Resident 3 had mood swings from happy to angry, but if they wanted something they would get angry very quickly if they did not get whatever they wanted.In an interview on 12/23/2025 at 4:28 PM Staff E stated they were present when Resident 3 pulled Resident 2's hair, separated the two residents, remained with Resident 3, monitoring their behavior when Resident 3 reached out and grabbed Resident 1's left arm which caused a skin tear and bruising. Staff E also stated they could not stop Resident 3. Staff E stated Resident 3 had not shown any agitated/aggressive behaviors since they readmitted to the facility on [DATE] but did have a history of agitated/aggressive behaviors previously. Staff E stated the staff intervention that was implemented to prevent additional resident to resident altercations after Resident 3 pulled Resident 1s hair was close staff supervision of Resident 3. Staff E also stated staff closely supervised Resident 3 after they readmitted to the facility on [DATE] in case they had any aggressive behaviors.In an interview on 12/23/2025 at 4:55 PM Staff A, Administrator stated staff were present and provided supervision after Resident 3 grabbed Resident 2's hair, but Resident 3 acted quickly and staff could not stop Resident 3 from grabbing Resident 1's left arm. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure notification about medication changes was provided to 1 of 3 residents (Resident 1), reviewed for changes in medication. The failure to notify Resident 1 that the medication Potassium Chloride (medication used to prevent and treat low potassium levels in the blood) would not be administered for thirteen days placed Resident 1 at risk for lack of knowledge about their medical condition and a diminished quality of life.Findings included . A review of the admission Minimum Data Set (MDS-an assessment tool) dated 09/23/2025, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis that included heart failure and insufficient kidney (filters that clean the blood by removing waste and extra fluid) function. The MDS further showed the resident had intact thinking and memory. In an interview on 11/25/2025 at 1:01 PM, Resident 1 stated, I did not know that the medication I took for Potassium was turned off [stopped], I know I did not receive it for a while, but I did not know why. I do not know who turned it off. Then just like it was turned off, it was turned back on again [restarted]. Nobody here ever told me anything about this. A review of the November 2025 Medication Administration Record (MAR) showed an order dated 09/21/2025 for Potassium Chloride 20 milliequivalent (MEQ-a unit of measurement) give one packet in the morning for supplement, dissolve in 4-6 (four to six) ounces of water. The MAR showed the Potassium Chloride order dated 09/21/2025 had the capital letter H [the medication was put on hold] on the MAR where initials were routinely placed after the medication was administered from 11/01/2025 to 11/13/2025, a total thirteen days. An interview and joint record review on 12/09/2025 at 1:41 PM with Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated the documentation on the November 2025 MAR in the Electronic Health Record (EHR) for Potassium Chloride 20 MEQ give one packet dated 11/01/2025 through 11/13/2025, with the capital letter H meant the medication was placed on hold by the physician probably due to some abnormal blood values that was returned from the laboratory after Resident 1 had laboratory work completed. Joint observation of the November 2025 MAR with Staff C from 11/01/2025 to 11/13/2025, showed Hs were documented where initials were routinely placed after the medication was administered from 11/01/2025 to 11/13/2025. On 12/09/2025 at 3:13 PM, Staff D, Primary Care Physician, stated that they put the Potassium Chloride on hold because of Resident 1's abnormal laboratory results and impaired kidney function. On 12/09/2025 at 3:24 PM, Staff E, Registered Nurse, stated that the residents should be notified every time there was a change in their medications. Another interview on 12/09/2025 at 3:26 PM with Staff C stated that the residents were supposed to be notified when their medications were changed or placed on hold. Staff C further stated they could not identify in Resident 1's EHR that they had been notified that their Potassium was held from 11/01/2025 to 11/13/2025. On 12/09/2025 at 4:23 PM Staff B, Director of Nursing Services, stated residents and/or resident representatives should be notified of all changes to the residents' medications. Staff B further stated Resident 1 should have been notified of the change to the Potassium Chloride in November 2025. Reference: (WAC) 388-97-0320 .

Based on interview and record review, the facility failed to ensure a Licensed Practical Nurse (LPN) had the appropriate competencies, skills set and proficiencies to assess/evaluate wound care for 1 of 1 nursing staff (Staff E), reviewed for competent nurse staffing. This failure placed the residents at risk for unmet care needs, inaccurate wound assessments, and adverse outcomes.Findings included .Review of facility's policy titled, Skin and Wound Monitoring and Management, dated August 2024, showed A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g./ pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alteration6) Describing the progress with healing, and any barriers to healing which may exist7) Identifying any possible complications or signs/symptoms consistent with the possibility of infection. The policy further showed, Assessment of the pressure injury for tunneling [a passageway that forms beneath the skin and extends from the surface of a wound into deeper tissues] and undermining [condition where tissue destruction occurs beneath the intact skin at the edges of the wound, creating a pocket like space] is an important part of the complete pressure injury [damage to the skin and underlying tissue that occurs from prolonged or intense pressure and/or shear] assessment.Resident 2 was admitted to the facility on [DATE].Review of Resident 2's wound care notes provided by the facility showed the following:-Resident 2 was seen by a Nurse Practitioner Wound Care Specialist on 06/19/2025, 07/03/2025, and 07/10/2025. -The initial wound care note dated 06/19/2025, showed an Assessment/Wound description w/[with] size/undermining, for a Stage 4 pressure wound (most severe type of pressure sore, characterized by a deep, open wound exposing muscle, tendons, or bone) to Resident 1's right ischial (the lower and back part of the right hip bone) area. The assessment included staging, measurement, debridement (medical procedure that removes dead, damaged, or infected tissue from wound to promote wound healing), tissue type, exudate (fluid that leaks from a wound as part of the normal healing process), odor/infected/pain, peri-wound (skin surrounding the wound), and plan.-Resident 2 was seen by Staff E, LPN, on 07/14/2025, 07/18/2025, 07/25/2025, 08/04/2025, 08/07/2025, 08/28/2025, 09/02/2025, 09/11/2025, and 09/18/2025. An AvaWound Evaluation [the facility's wound assessment/evaluation] #1-V 2, was completed for these visits. The AvaWound Evaluation #1-V 2, showed an assessment/evaluation for Resident 2's wound location, date it was first observed, type of wound, pressure stage, whether non-pressure, acquisition (whether wound was facility acquired, upon admission, or recurring) , measurement, tunneling, undermining, exudate amount/type/color, wound odor, debridement type, wound bed description, wound edges, surrounding skin/periwound, pain, and treatment plan/recommendations. Further review of the wound care AvaWound Evaluation #1-V 2, for Resident 2 dated 07/14/2025, 07/18/2025, 07/25/2025, 08/04/2025, 08/07/2025, 08/28/2025, 09/02/2025, 09/11/2025, and 09/18/2025 did not show a co-signature of a Registered Nurse (RN) or Wound Care Specialist.In a phone interview on 11/14/2025 at 4:14 PM, Staff E stated that they helped out with wounds and no longer did as of last week as the facility got a third party wound staff. Staff E stated they were with the wound provider for a few weeks, and then they kept doing what the wound care provider did when they were no longer there. Staff E stated they cleaned the wounds, completed measurements, and put dressings on. Staff E stated the wound provider assessed the wounds. When asked if Staff E assessed the wounds, Staff E stated, I wouldn't [would not] call it assessment, and that they did not stage any wounds. Staff E stated that they put their documentation into the wound evaluations. When asked about the evaluations completed for Resident 2, Staff E stated that they did not stage the wounds, that they followed the previous wound care provider's assessment, and if it basically looked the same then that is what they would document. Staff E stated they were not wound care certified. When asked if assessing/evaluating was under an LPN's scope of practice, Staff E stated, I never really thought of that, I am not sure. I will have to get back to you.On 11/14/2025 at 5:00 PM, Staff B, Director of Nursing, stated Staff E had been the facility's wound nurse and that they were not wound care certified. When asked if Staff E could complete wound assessments, Staff B stated, the company calls them evaluations. When asked what an evaluation meant, Staff B stated, I don't [do not] know if I have an answer to that, and stated they were aware their software system classified the evaluation as a full assessment. Staff B stated that an assessment was more specific. When asked if the Wound Care Specialist's assessment from 06/19/2025, 07/03/2025, and 07/10/2025 contained the same assessment as their AvaWound Evaluation #1-V 2, Staff B stated, they look alike. Staff B stated that assessing was not under the scope of practice of an LPN and that they could not provide supporting documentation to show that another Wound Care Specialist or RN was with Staff E during the completion of wound care evaluations. When asked if it was appropriate for Staff E to use the Wound Care Specialist's assessment under their own documentation when they were not present, Staff B stated, no, and that it was not best practice. When asked what stage Resident 2's wound was at upon discharge, Staff B stated according to their evaluations a Stage 4 and on another note, it stated a superficial wound. Staff B further stated maybe the documentation was not accurate and that they would expect nursing staff to document accurately.On 11/14/2025 at 6:45 PM, Staff A, Administrator, stated they would expect there to be a competency skills checklist completed for Staff E. Staff A stated it would be important to complete a competency skills checklist to see if they needed to update their skills set, or if any corrections were needed they could identify and train their staff. On 11/14/2025 at 6:54 PM, Staff F, Human Resources/Payroll, stated they could not find a competency skills checklist completed for Staff E. Staff F stated Staff E was hired on 07/28/2023, and that they would expect there to be a checklist completed for them. Staff F stated that they had reached out to their corporate payroll and had not found anything either.Reference: (WAC) 388-97-1680 (2)(a)(b)(i).

Based on observation, interview, and record review, the facility failed to follow physician's orders and failed to ensure staff documented treatments in accordance with professional standards for 1 of 1 resident (Resident 1), reviewed for treatment administration. These failures placed the residents at risk for unmet care needs, negative outcomes, and a diminished quality of life.Findings included .Review of the facility's policy titled, Administering Medications, dated April 2019, showed that Medications are administered in a safe and timely manner, and as prescribed. The policy showed, The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. The policy further showed, Topical medications used in treatments are recorded on the resident's treatment record (TAR [Treatment Administration Record]).On 11/13/2025 at 1:17 PM, Staff D, Registered Nurse, stated nursing staff were responsible for following medication/treatment orders. Staff D stated if a resident refused, they would document it and report it to the provider.In a joint observation and interview on 11/13/2025 at 2:34 PM, with Staff D showed Resident 1 had two unlabeled dressings covered with kerlix (a brand name for a type of wound dressing made from 100% cotton gauze) on each lower leg. Staff D stated that Resident 1 had venous ulcers (slow healing sores caused by poor blood flow in the veins) on both lower legs and that their order was to have dressing changes every other day. When asked if Staff D had changed Resident 1's dressings on 11/13/2025, Staff D stated no. Staff D stated that Resident 1 had pitting edema (swelling) in their lower legs and did not wear compression stockings/ted hose. Staff D stated that when a dressing was changed, they expected it to be labeled with the initials of the nurse and the date it was completed.In another joint record review and interview on 11/13/2025 at 2:40 PM, with Staff D, showed Resident 1's TAR had the following orders that were administered on 11/13/2025 by Staff D:-An order dated 07/17/2025 for After applying Aquaphor [a healing ointment] in morning, apply compression stockings [used to improve circulation] or TED hose [used to prevent blood clots]. Remove at bedtime. In the morning for lymphedema [chronic condition that causes swelling in the arms or legs due to a blockage or damage that prevents fluid from draining properly] place stockings.-An order dated 10/31/2025 for left lower leg to, Cleanse with Dakins solution [used for wound cleansing and management] and pat dry. Apply A&D [skin protectant] ointment, Calcium alginate [wound dressing that absorbs fluids and promotes healing] to the wound bed ONLY, cover with SUPER ABSORBANT PAD or ABD [abdominal pad], and wrap with kerlix DAILY. every day shift for wound healing.-An order dated 10/31/2025 for right lower leg to, Cleanse with Dakins solution and pat dry. Apply A&D ointment, Calcium alginate to the wound bed ONLY, cover with SUPER ABORBANT PAD OR ABD, and wrap with kerlix DAILY. every day shift for wound healing. Staff D stated they documented the treatment orders were done on 11/13/2025 at 8:52 AM and that they had not done the treatment orders for Resident 1. Staff D stated that they had never seen Resident 1 wear compression stockings/ted hose. Staff D further stated they should have completed Resident 1's treatment first and then documented it in the TAR.On 11/13/2025 at 4:02 PM, Staff C, Resident Care Manager, stated nursing staff should check the physician's orders and have correct documentation after administration of medications. Staff C stated a treatment dressing should be labeled with the nurse's initials and date and time it was done. Staff C stated Staff D was not supposed to document Resident 1's treatment administration until it was done.On 11/13/2025 at 4:24 PM, Staff B, Director of Nursing Services, stated they expected nursing staff to follow physician orders, and if something did not seem right to get clarification. Staff B further stated they expected staff to document after treatment was completed.In a follow-up interview on 11/14/2025 at 11:50 AM, Staff B stated that Staff D should have followed the physician's orders for Resident 1 and checked it off after completing the tasks.Reference: (WAC) 388-97-1620(2)(b)(i)(ii).

Based on interview and record review, the facility failed to meet professional standards of practice to ensure a clinical assessment was completed timely for a change of condition (a sign that something might be wrong and needs attention) for 1 of 3 residents (Resident 3), reviewed for assessment of care services. This failure placed the resident at risk of receiving delayed care and for potential negative outcomes.Review of the facility's policy titled, admission Assessment and Follow Up: Role of the Nurse, revised in September 2012, showed that The following information should be recorded in the resident's medical record: 1. The date and time of the assessment was performed and showed that reporting included report other information in accordance with facility policy and professional standards of practice.Review of a electronic health record showed Resident 3 admitted to the facility on [DATE]. Review of the facility's document titled, Online Incident Report Facility/Agency Information, dated 07/08/2025, showed that Staff B, Director of Nursing, received a verbal report via phone call from Resident 3's Collateral Contact 1 (CC1) regarding an incident on 07/07/2025. It showed that CC1 alleged that Resident 3 was not assessed for a change of condition and that CC1 reported, I don't think [Staff F, Registered Nurse] assessed [Resident 3]. She said [Resident 3's] oxygen was 92% [pulse oximetry - measurement of oxygen carried in the blood] but yet the EMTs [Emergency Medical Technician - trained professional who show up in ambulances when someone calls 911 for a medical emergency] said [Resident 3's] oxygen was 74%. Review of the facility's document titled Exhibit 359 Follow-Up Investigation Report, submitted on 07/08/2025, showed that the 07/07/2025 incident occurred in the evening hours shortly after dinner. It further showed that at the time of the incident Staff F was called to tend to another resident and that Staff F left a NAC [Nursing Assistant Certified] with [Resident 3].Review of the facility document titled, SBAR [Situation/Background/Appearance/Review] Communication Form, dated 07/07/2025, showed Resident 3's recorded vital signs (basic body measurements that help providers quickly check how healthy someone is) for blood pressure and pulse rate were assessed on 07/07/2025 at 8:38 AM. It further showed that Resident 3's recorded pulse oximetry was assessed on 07/07/2025 at 11:22 PM. It did not show that Resident 3 was assessed for their vital signs at the time of the incident. In an interview on 07/15/2025 at 2:00 PM, Staff C, NAC, stated that on 07/07/2025 after dinner, after 8:00 PM and before 8:30 PM, they were called by Staff F to help interpret for Resident 3 who was non-English speaking. Staff C stated that at the time of the incident, Resident 3 was not able to be understood and that [Resident 3] wasn't [was not] talking, it was so slow, [Resident 3] tried to talk but [Resident 3] could not speak the words. Staff C then stated that they told Staff F that Resident 3 was not responding good at the time and that Staff F should call CC1. Staff C further stated that CC1 arrived at the facility around 8:30 PM or 9 PM. When asked if prior to the incident, Resident 3 could be understood verbally, Staff C stated, Yes, we speak the same language.In an interview on 07/15/2025 at 2:06 PM, Staff D, Licensed Practical Nurse, stated that if a resident had a change of condition, they would assess the resident and then check vital signs to see what's going on. Staff D then stated that they would document an assessment performed using the facility's SBAR Communication Form. Staff D further stated that all licensed nurses could assess a resident having a change of condition.In an interview on 07/15/2025 at 2:11 PM, Staff E, Resident Care Manager, stated that they expected an assessment, including checking the vital signs, would be performed in the event a resident had a change of condition. Staff E stated that they expected a resident would be assessed immediately for a change in condition and that their vital signs will be changed [differ from usual vital signs]. When asked if license nurses could delegate assessment of a resident to another staff member, Staff E stated, Yes, if a nurse is busy with another resident, and anytime there's [there is] a change of condition. Staff E stated that, It's the duty of all nurses to do something and that nurses should not walk away until another nurse takes over. In an interview and joint record review on 07/18/2025 at 1:43 PM, Staff B, Director of Nursing, stated that they expected nursing staff would assess a resident for a change of condition, including checking the vital signs. Staff B stated that they considered a change in level of alertness and in the ability to communicate as a change of condition. Staff B then stated that they expected documentation of an assessment performed would be recorded in the facility's SBAR Communication Form and that nurses had the ability to manually enter data onto the form. When asked when the 07/07/2025 incident occur, Staff B stated, It happened in the evening shift between 8:00 PM and 9:00 PM and that they suspected Resident 3 was transferred to the hospital from the facility on 07/07/2025 between 8:00 PM and 9:00 PM. Joint record review of the 07/07/2025 SBAR Communication Form, showed Resident 3's recorded Vital signs for blood pressure and pulse rate were assessed on 07/07/2025 at 8:38 AM and Resident 3's recorded pulse oximetry was assessed on 07/07/2025 at 11:22 PM. Staff B stated that according to the documentation presented Staff F did not perform a clinical assessment to include updated vital signs of Resident 3 at the time of the incident. Staff B stated that Staff F had left Resident 3 with a NAC at the time of the incident. When asked if nurses could delegate observation or care of a resident who had a change of condition to a NAC, Staff B stated No. Staff B further stated that upon identification of a change of condition, I expect them to stay with the resident and ask for additional assistance as needed. Reference: (WAC) 388-97-1620 (2)(b)(i)(ii).

Based on interview and record review, the facility failed to conduct a thorough investigation and to take appropriate corrective action for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included .Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events .Federal law requires the nursing home to do a thorough investigation of the incident. In order for a facility to provide evidence of the thoroughness of the investigation the information must be recorded. It showed that a thorough investigation may require two phases of fact gathering which included phase one, initial investigation (within the first 24 hours) and phase two, extended investigation (after the first 24 hours). It further showed that interview of witnesses, including caregivers in the immediate area and from work shifts prior to the incident discovery was included in phase one and that interviews of expanded sample of witnesses were included in phase two. Review of the facility's policy titled Abuse and Neglect - Clinical Protocol, revised in March 2018, showed that neglect meant, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. It further showed that the staff will investigate alleged abuse and neglect to clarify what happened and identify possible causes and that the facility management and that staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of electronic health record showed Resident 3 admitted to the facility on [DATE]. Review of the facility's document titled, Online Incident Report Facility/Agency Information, dated 07/08/2025, showed that Staff B, Director of Nursing, received a verbal report via phone call from Resident 3's Collateral Contact 1 regarding an incident on 07/07/2025. The document further showed action taken to prevent a recurrence of the incident was that Staff F, Registered Nurse, was suspended pending investigation.Review of the 07/07/2025 incident investigation summary report provided by Staff B showed that the involved caregivers present during the incident were interviewed. The incident investigation report did not show other potential caregiver witnesses were interviewed. Review of staff time cards showed that Staff F worked in the facility on the following dates:-On 07/09/2025, Staff F worked 1.25 hours.-On 07/10/2025, Staff F worked 10.0 hours.-On 07/11/2025, Staff F worked 9.0 hours. In an interview and joint record review on 07/18/2025 at 1:43 PM, Staff B stated that their process for interviewing witnesses while conducting an incident investigation included interviewing people who are assigned to the resident and if there are any witnesses. Joint record review of the 07/07/2025 incident investigation summary report did not show documentation that caregiver witnesses interviews were conducted. Staff B stated that they interviewed other residents and involved staff only. When asked if they would expect to interview potential witnesses of the incident, Staff B stated that they would check the purple book. Staff B further stated that they completed the investigation on 07/12/2025. Staff B stated that during an investigation, staff suspended for allegations of abuse and neglect would remain suspended until the investigation was completed. Joint record review of Staff F's clock-in/out records on 07/09/2025, on 07/10/2025 and on 07/11/2025 showed that Staff F worked in the facility prior to the completion of the investigation. Staff B stated that Staff F worked at the facility during the data collection phase and prior to the investigation conclusion. Reference: (WAC) 388-97-0640 (6)(a)(b).

Based on observation, interview, and record review, the facility failed to prevent abuse (physical and verbal) for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This failure caused harm to Resident 1 who sustained physical injuries including significant bruising and scratches on his left arm, was punched in the head, and psychosocial harm in the form of anger, frustrations, which affected his sleep patterns and mood. Findings included . The Code of Federal Regulations (CFR) define abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident 1 had intact cognition and needed supervision to one person staff assistance with locomotion on/off unit (moving in between locations in room and/or to/from distant areas on the floor). A review of the facility's incident reporting log for September 2022 showed that on 09/10/2022, Resident 1 was involved in an altercation with another resident (Resident 2) that resulted in physical injuries. On 09/13/2022 at 8:30 AM, Staff B, the Director of Nursing stated and confirmed that Resident 1 had a physical altercation with Resident 2 [they were roommates] on 09/10/2022 at around 9:30 PM. According to Staff B, Resident 2 threw several punches to Resident 1 that resulted in physical injuries to Resident 1 including being hit in the head at least twice, significant bruising and several scratches on the left arm. On 09/13/2022 at 8:45 AM, Staff C, Registered Nurse, stated that prior to the 09/10/2022 physical altercation between Resident 1 and resident 2, there was a previous verbal altercation between them on 09/09/2022 and that she was the 6 AM to 2 PM day shift nurse that day. Staff C stated that Resident 1 and Resident 2 had a verbal altercation incident during her shift at approximately from 1:00 PM to 2:00 PM, and both residents were loud and yelling at each other and that there were name calling exchanges that occurred between them such as Resident 2 calling Resident 1 a jack*** and Resident 1 calling Resident 2 a mother******. According to Staff C, she immediately asked both residents to stop and offered room moves. However, Staff C stated that both residents refused the room change and both remained in the same room. Staff C also stated that she did not document the incident and she failed to report the 09/09/2022 verbal altercation between Resident 1 and Resident 2 to appropriate authorities including the resident's physician, Staff A, Administrator and/or Staff B. Staff C further stated that she did not initiate any other interventions after the incident other than offering the residents for a room change. On 09/13/2022 at 9:05 AM, Resident 2 stated that Resident 1 was his previous roommate, and that Resident 1 was trouble and a pain in the a**. Resident 2 stated that prior to the incident [altercations on 09/09/2022 and 09/10/2022], Resident 1 would always yell and scream at him on a regular basis for little things such as turning off the lights, turning on/off the air conditioning and even about closing their bathroom door. According to Resident 2, he had several exchanges of words that weren't nice prior to the incident on 09/10/2022 including the day before on 09/09/2022 [unable to recall specific time] when he called Resident 1 a jack***, a drug addict, and a racist. Resident 2 stated that Resident 1 was clearly a racist and had anger problem because his normal conversation with him and staff were always out of anger, and he was always loud. Resident 2 stated that he finally had enough when Resident 1 decided to shut and slammed the bathroom door on him on 09/10/2022 [unable to recall the specific time]. Resident 2 also stated that Resident 1 yelled at him to shut the f****** door and slammed it very hard. This was when he decided to take matters into his own hands and started punching Resident 1. According to Resident 2, he probably threw at least 5-6 punches that landed a hit but he was not sure because he was blind but felt that he hit him pretty hard. Resident 2 stated that his right hand/knuckle was sore and was still painful from the incident. A light purple bruise that measured 6 centimeter (cm) in length and 6 cm wide was observed on Resident 2's right hand. A review of Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's quarterly MDS assessment dated [DATE] showed Resident 2 had an intact cognition. On 09/13/2022 at 9:30 AM, Resident 1 stated he was assaulted by Resident 2 and was punched several times on 09/10/2022. Resident 1 also stated that Resident 2 came out of the bathroom door swinging really hard, and he was hit two or three times in the head and he took more punches and scratches on his left arm when he tried to cover and protect his face and head. According to Resident 1, the argument between him and Resident 2 started the day before on 09/09/2022 around noon when Resident 2 called him names including a jack***, a drug addict, a Heroin (illegal drug) user, and a racist. Resident 1 stated that he responded to Resident 2 by telling him to F*** off and by calling him a mother******. Resident 1 further stated that they always had issues as roommates that included basic preferences with the lighting in the room, the air conditioning but most commonly, an issue with Resident 2 for always leaving the bathroom door open when using it. Resident 1 stated, I told him maybe a hundred times to close the bathroom door because it stinks but he never listens. Resident 1 stated that on the night of 09/10/2022 [he could not recall the specific time], Resident 2 was in the bathroom and had asked Staff D (Nursing Assistant Certified) to turn on the air conditioning in the room, then Resident 2 had left the bathroom door open again, even though I just asked him nicely to please close the door [of the bathroom]. According to Resident 1, as soon as Staff D left the room, Resident 2 stood up, got into his wheelchair and slammed the bathroom door close. Resident 1 stated that was when Resident 2 came out of the bathroom door swinging and throwing punches at him. Resident 1 also stated that he did not punch back or hurt Resident 2, but Resident 2 called him all sorts of names again. Resident 1 stated, I am not a racist, I am not a drug addict and that those words really bothered me and keeps me up all night. Resident 1 further stated that he was angry and upset about what happened and that his head hurts from being punched hard twice and his left arm was still sore/hurting and was severely bruised from the incident. A purple bruise was observed on the left forearm of Resident 1 that measured 13.5 cm in length and 10 cm wide including multiple scratches (at least 6 scratches were visible) that each measured approximately 1 cm in length and 1 cm wide. On 09/13/2022 at 10:00 AM, Staff B stated the facility had substantiated the physical abuse between Resident 1 and Resident 2 and that the incident [on 09/10/2022] had resulted in physical injuries to both residents. See also F607 - Develop/Implement Abuse/Neglect policies and F609 - Reporting of Alleged Violations. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure that policies and procedures for elopement were effectively implemented by providing necessary supervision, and implementing resident directed care plans for 6 of 6 residents (Residents 1, 2, 3, 4, 5 and 6) reviewed for elopement and/or avoidable incidents. The facility did not implement its policy and procedure for Resident 1 who was at risk for elopement and was found wandering alone on a busy street by a concerned citizen which required intervention by law enforcement officers. Although the concerns around the lack of an effective system for prevention of elopements and lack of supervision for Resident 1 was shared with the facility, there was a continued lack of adequate supervision and failure to implement safety plans for Resident 1. The facility's failure to implement its own written elopement policies and procedures placed Residents 1, 2, 3, 4, 5 and 6 at risk for incidents that could result in serious injuries, serious harm, and death. On 06/17/2022 at 1:30 PM, an Immediate Jeopardy (IJ) situation was identified related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. The facility removed the IJ immediacy on 06/24/2022, verified by an onsite inspection. The facility removed the immediacy by reassessing residents for elopement risks, developing and updating elopement care plans and by reeducating staff on how to provide needed supervision for residents at risk for elopement. Findings included . A review of the facility policy titled, Elopement dated 01/14/2021 showed that the purpose of the policy was to provide a safe environment for all residents particularly those who were assessed as at risk for elopement and those with exit seeking and/or unsafe wandering behaviors. The policy stated: 1. Residents are identified as at risk for elopement/exit seeking/unsafe wandering immediately at the time of admission. Preventive measures included: Resident direct visual observation was determined by actions and behavior of the resident and facility assessment of need. In some situations, it may be necessary to visually check the resident every 15 minutes, every 30 minutes, once per shift or provide one to one supervision. The amount and type of supervision is documented in the resident record. 2. A complete assessment of risk factors for unsafe wandering/elopement was completed using the elopement/wandering review and updated quarterly or with any significant change in the resident's behavior. 3. The resident's care plan identified the risks and contained specific interventions. 4. Residents experiencing an increase in behavior and continually attempting to exit will be placed on every 15-minute checks or one to one until an effective safety plan can be implemented. 5. When a resident was found outside the facility in an unsecured area without supervision, the resident would be placed on every 15-minute checks or one to one monitoring until an effective safety plan can be implemented. RESIDENT 1 Resident 1 was a long-term care resident of the facility. The resident's diagnosis list included Alzheimer's disease (memory problem) and [CONDITION(S)] (weak and fragile bones). A review of Resident 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had impaired cognition and needed the supervision of one staff with ambulation on and off the unit. The MDS also showed that the resident had exhibited wandering behavior daily. Resident 1's Self Care deficit care plan dated 04/05/2021 showed the resident required and needed one-person staff assistance in ambulation and locomotion (movement or ability to move from one place to another). A review of Resident 1's care plan dated 02/01/2022 showed the resident was a high risk for elopement due to impaired cognition and for not understanding why she could not go home. A review of the resident's Elopement Risk assessment dated [DATE] showed that Resident 1's elopement score was 10, indicating an increased risk for elopement. However, the assessment documented that the resident was not at risk for elopement because the resident was compliant with care most of the time, and was not exit seeking/did not express any desire to leave at the time of the assessment. A review of the facility's incident investigation report dated 05/20/2022 showed that on 05/20/2022 at approximately 8:26 PM, the facility received a call from Resident 1's son (FM1) that the police just called to inform him that Resident 1 was found on the street across from the facility. The incident investigation also showed that the Licensed Nurse on duty last saw the resident at approximately 8:00 PM that night when the resident refused to take her medications. The incident investigation report documented that the resident was found by good Samaritan woman who put her inside of her vehicle and called 911. The incident report also documented that the police had to assist in controlling the traffic to keep Resident 1 safe and to allow Resident 1 to cross the road safely. The resident was confused and was unable to clearly state how she got out of the facility. A review of the Social Services notes dated 05/17/2022 showed that on 05/16/2022, Resident 1 was more agitated than usual and she was exit seeking, going to the front and back door of the facility trying to leave. The note documented, She wanted to go and that she did nothing wrong. A nursing progress notes dated 05/17/2022 at 11:50 PM, showed that the resident was restless and had tried to get to the back door but was unsuccessful and turned back to her room twice. A review of Resident 1's clinical records including the resident assessments, care plans and Kardex (care directives) showed no evidence that the facility had reassessed Resident 1's risks for unsafe wandering and elopement, no care plan changes were made, and no increase in supervision was provided to Resident 1 after she was found to have increased wandering and exit seeking behaviors (as directed by the facility policy). The facility had knowledge of Resident 1's increased unsafe wandering and exit seeking behavior but failed to act and initiate timely interventions to prevent and minimize the risk of an avoidable elopement incident. On 06/17/2022 at 10:00 AM, Staff B, Director of Nursing (DNS), stated that Resident 1 had documented increased in behaviors including unsafe wandering and exit seeking patterns of behaviors. However, Staff B stated she was not able to find new interventions that were put in place to keep Resident 1 safe prior to the 05/20/2022 elopement incident and that the facility failed to follow and implement their own elopement policies and procedures related to elopement prevention. Staff B stated that Resident 1 continued to exhibit increased in unsafe wandering and exit seeking behaviors and the resident was observed by staff to be exit seeking throughout the day but mostly in the afternoon/late hours especially after the visit from FM1. According to Staff B, Resident 1 now had a wander guard (alert system to notify staff) when she tried to exit the front and back doors. Staff B also stated that staff were supposed to monitor Resident 1's location every 15 minutes (in addition to the wander guard) due to the resident's previous attempts to enter the door code and cancel the wander guard alarm and that even with the wander guard system in place, the exit doors would still open if Resident 1 (or any other resident) held or pushed the door by at least 5-15 seconds. On 06/17/2022 at 10:10 AM, Resident 1 was observed wandering throughout the facility (front desk area/front doors then back to unit 400/500 hall/back doors). The resident attempted to push the back exit doors and tried to enter the door code to cancel the door alarm several times, then walked back to the hallway including other resident rooms, dining area then back to the front door. There was no staff member to supervise Resident 1 for at least 30-45 minutes during this observation to visually check the resident's location and provide redirection as needed as directed by the resident's care plan. It was not until 11:00 AM when a staff member [Staff I, Nursing Assistant Certified (NAC)] looked for Resident 1 and found her at the main dining room area with the surveyor. On 06/17/2022 at 11:00 AM, Resident 1 stated she had active plans to leave the facility and that she wanted to go far away. Resident 1 stated she does not know what she did wrong and why the facility would not let her walk outside to get fresh air. Resident 1 was tearful and visibly upset during the interview. Resident 1 further stated that she knew how to enter the door codes and she would try to leave the facility when and after her son arrives, and stated, I want to leave. I want to get out of here. On 06/17/2022 at 11:05 AM, Staff E, NAC, stated that Resident 1 was a high risk for elopement and was actively exit seeking. Staff E also stated that Resident 1 was capable and had attempted to put in the door codes in the past and that Resident 1 was on every 15-minute safety checks but sometimes it was not possible to keep track of Resident 1's location specially when they were busy attending other residents and/or when providing incontinent care to other residents that would sometimes take more than 15 minutes of their time. On 06/17/2022 at 11:10 AM, Staff F, Licensed Practical Nurse (LPN), stated that Resident 1 was a high risk for elopement and was actively exit seeking. Staff F stated that Resident 1's behavior had worsened recently specially during the afternoon/evening hours after FM1's visits. Resident 1 was very mobile and could get to point A to point B in no time. Staff F also stated that Resident 1 would try to exit the front or the back doors and would require constant staff supervision and redirection to keep her safe. On 06/17/2022 at 11:15 AM, Staff G, LPN, stated Resident 1 no longer required every 15-minute safety/visual checks. Staff G stated that sometimes it was hard to supervise Resident 1, but staff tried to keep her safe the best they could. Staff G also stated that some staff could not even do the 15-minute safety check because they were busy but other staff would try to cover if they could. Staff G further stated that the 15-minute safety check logs have blanks and holes to it because staff were not able to supervise the resident as required. On 06/17/2022 at 11:30 AM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM) and Staff D, LPN/RCM, both stated that Resident 1 was no longer on every 15-minute safety checks. Staff C stated the facility was thinking that having a wander guard should be sufficient to keep Resident 1 safe. However, Staff C stated she was not aware that Resident 1 had attempted to put in the door codes to cancel the alarm and exit the facility in the past, and that Resident 1 continued to attempt to exit seek and verbalize plans to leave the facility. On 06/17/2022 at 11:40 AM, during a meeting with Staff B, Staff C, and Staff D, Staff B reiterated the need for both the wander guard alert system and every 15-minute visual/safety checks for Resident 1. According to Staff B, there was a miscommunication between the staff and the unit managers because Resident 1's current behaviors and care plan still required for Resident 1 to have the safety checks, and staff should continue to monitor and complete the log every 15-minutes to monitor the resident's location. On 06/17/2022 at 11:50 AM, Staff B stated that staff were not providing the needed and required supervision for Resident 1 to keep her safe and to minimize the risk of avoidable accidents of elopement. Staff B reviewed the 15-minute safety checks from 05/20/2022 to 06/17/2022, and it showed that staff were not consistently providing the needed supervision to Resident 1 and that the log showed Resident 1 was left unsupervised for at least 8 to 16 hours a day on 05/29/2022, 05/30/2022 and 05/31/2022. On 06/17/2022 from 12:15 PM to 12:45 PM, Resident 1 was once again left unsupervised by staff while attempting to push the exit doors and exit using the back door of the facility. There was no staff member around to supervise and redirect the resident as required, and as directed by Resident 1's care plan. RESIDENT 2 Resident 2 was a long-term care resident of the facility. The resident's diagnoses list included dementia (memory problem), history of falls, and anxiety disorder. A review of the resident's quarterly MDS assessment dated [DATE] showed the resident had impaired cognition and needed supervision of one staff for locomotion on and off the unit. The MDS also showed that the resident had exhibited wandering behavior daily. Review of the resident's Elopement Risk assessment dated [DATE] (nine days overdue) showed that Resident 2's elopement assessment score was 10, indicating an increased risk for elopement that required frequent monitoring from staff. The assessment also showed that the resident had a wander guard alert system placed in Resident 2's purse as part of the elopement risk intervention. A review of Resident 2's elopement and behavior care plans, both dated 03/31/2020 showed the resident was a high risk of elopement due to her current medical and mental condition. The care plan also showed that the resident had wandering and exit seeking behaviors. The care plan directed the facility staff to monitor and document the resident's location with visual checks. On 06/17/2022 at 10:30 AM, Resident 2 was observed wandering in the hallway passing the nursing station, Unit 400 and up to the back door of the facility. The resident also got lost entering other residents' room and near the facility exit doors without any staff around to provide supervision or redirection. Additionally, the resident did not have her purse [with the wander guard] with her so when the resident tried pushing the back door exit, the wander guard alarm did not sound or trigger. On 06/17/2022 at 11:05 AM, Staff E stated Resident 2 was a high risk for elopement and had exhibited exit seeking behaviors recently and in the past. Staff E stated that Resident 2 required frequent visual checks at least every 2 hours. Staff E was not aware of Resident 2's location and stated that she had not seen the resident recently and was not able to provide a time of when she last saw Resident 2. On 06/17/2022 at 11:10 AM, Staff F stated Resident 2 was a high elopement risk resident and had exhibited exit seeking behaviors recently and in the past. Staff F stated that Resident 2 would wander around the facility and would sometimes attempt to exit the facility. Staff F stated that Resident 2 was on a frequent visual checks and should be checked every time staff passed by the resident's room and/or every time care was being provided. Staff F also stated that the care plan was not clear on what the frequency of the visual check should be and could be interpreted differently by staff. On 06/17/2022 at 11:15 AM, Staff G stated that Resident 2 should be monitored and supervised at least every 15 minutes. Staff G stated that Resident 2 was a high risk of elopement, exit seeking and would wander around the facility and sometimes end up in other resident rooms. However, Staff G was not aware of Resident 2's location and stated he did not have any documentation or log to record the resident's location as directed by the care plan. Staff G was not able to provide a time of when she last saw Resident 2. Review of the clinical records including Resident 2's assessments, care plans, nursing progress notes, tasks, and the Kardex, showed the facility did not monitor the resident's location with visual checks as directed by the resident's care plan. Additionally, Resident 2's elopement risk assessment was 9 days overdue, and the elopement care plan interventions were not specific for staff to properly interpret/implement and evaluate its effectiveness as directed by the facility policy. RESIDENT 3 Resident 3 was a long-term care resident of the facility. The resident's diagnoses list included dementia and history of repeated falls. A review of Resident 3's annual MDS assessment dated [DATE] showed the resident had impaired cognition and needed one-person limited assistance with locomotion on and off the unit. Review of Resident 3's Elopement Risk assessment dated [DATE] (47 days overdue) showed that Resident 3's elopement score was 9, indicating an increased risk for elopement. Review of Resident 3's care plan showed the resident was at risk for elopement due to impaired cognition and current ambulatory status. The care plan directed the facility staff to monitor the resident's location with visual checks. A review of Resident 3's clinical records including the resident assessments, care plans, nursing progress notes, tasks, and the Kardex showed that the facility had not monitored the resident location with visual checks as directed by the resident's care plan. Additionally, Resident 3's elopement risk assessment was 47 days overdue, and the elopement care plan interventions were not specific for staff to properly interpret/implement and evaluate its effectiveness as directed by the facility policy. RESIDENT 4 Resident 4 was a long-term care resident at the facility. The resident's diagnoses list included history of stoke with left sided weakness and history of falls. A review of Resident 4's annual MDS assessment dated [DATE] showed the resident had impaired cognition and needed one-person staff supervision for locomotion on and off the unit. A review of Resident 4's Elopement Risk assessment dated [DATE] showed that Resident 4's elopement score was 9, indicating an increased risk for elopement. A review of Resident 4's clinical records including the resident assessments, care plans, and the Kardex showed the facility failed to develop a person-centered care plan to address the resident's increase risk for elopement. RESIDENT 5 and RESIDENT 6 Resident 5 was a long-term care resident of the facility. The resident's diagnoses list included dementia and history of repeated falls. A review of Resident 5's elopement care plan dated 11/01/2021 showed the resident was a high risk for elopement due to his previous history of elopement attempts. The care plan directed the facility staff to monitor the resident's location with visual checks. Resident 6 was a long-term care resident of the facility. The resident's diagnoses list included dementia and history of repeated falls. A review of Resident 6's elopement care plan dated 06/15/2022 showed the resident was at high risk for elopement due to his dementia and current condition. The care plan directed the facility staff to monitor the resident's location with visual checks. Review of Resident 5 and Resident 6's clinical records including the residents' assessments, care plans, nursing progress notes, tasks, and the Kardex showed that the facility had not monitored the resident location with visual checks as directed by the residents' care plan. Additionally, Resident 5 and Resident 6 elopement care plan interventions were not specific for staff to properly implement and/or evaluate its effectiveness as directed by the facility policy. On 06/17/2022 at 1:00 PM, Staff A, Administrator and Staff B, stated they both reviewed the elopement incident of Resident 1. Staff B stated that she was not sure what went wrong and why the staff had failed to implement the safety plan and care plan interventions, including the required every 15-minute safety/visual checks to keep Resident 1 safe and to minimize the risk of another elopement incident. Both Staff A and Staff B stated they had not reviewed the facility's elopement risk plan to validate whether the incident involving Resident 1 was an isolated incident and/or for other residents that had the increased likelihood of elopement. Both Staff A and Staff B also stated that they were not aware of the lack of current assessments for Resident 2 and Resident 3, lack of elopement care plan for Resident 4, and the need to individualize/need for specific elopement interventions for Resident 2, Resident 3, Resident 5, and Resident 6. On 06/17/2022 at 1:30 PM, Staff A and Staff B were notified of the IJ situation related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. Both Staff A and Staff B stated that they would immediately reeducate and re-train the staff about the facility's elopement risk policies and procedures, improve the resident safety checks monitoring and documentations, including each resident specific elopement risks and care plans to keep residents safe and minimize the risk of another elopement incident at the facility. FAILURE TO IMPLEMENT THE FIRST IJ REMOVAL PLAN On 06/21/2022 at 12:55 PM, Staff B stated that both Resident 1 and Resident 2 were both on every 15-minute safety/visual checks due to their continued unsafe wandering and exit seeking behaviors. On 06/21/2022 at 1:15 PM, Resident 1 was observed sitting at the unit 400 hallway alone and unsupervised by any staff member. The resident was confused and stated she would like to go and leave the facility. The resident was restless and was observed to be walking back and forth the hallway, the front exit doors, and the back exit doors. A review of Resident 1's safety check log dated 06/21/2022 showed that the last time a staff member monitored Resident 1's location was at 12:30 PM (45 minutes ago). Additionally, the safety check log for Resident 1 showed the resident was not supervised and/or monitored as required on 06/18/2022 from 6:30 AM to 1:45 PM. Review of Resident 1's behavior monitoring sheet showed that Resident 1 had at least three episodes of exit seeking behavior on 06/18/2022 and two exit seeking behavior/attempts on 06/19/2022. On 06/21/2022 at 1:30 PM, Resident 2 was observed wandering in the unit hallway alone and unsupervised by any staff member. The resident was confused and refused to speak to the surveyor. The resident was restless and was observed to be going back and forth the hallway, the nurses' station, and the main dining area. Review of Resident 2's safety check log dated 06/21/2022 showed that the last time a staff member monitored Resident 2's location was at 12:15 PM (1 hour and 15 minutes ago) that day. Additionally, the safety check log for Resident 2 showed the resident was not supervised and/or monitored as required on 06/18/2022 (all shift) and 06/19/2022 (all shift). On 06/21/2022 at 1:55 PM, Staff J, LPN, stated he was aware that staff were not completing Resident 2's safety check log as required during the weekend of 06/18/2022 and 06/19/2022. Staff J stated he re-educated the staff about the importance of providing the required supervision to keep both Resident 1 and Resident 2 safe. According to Staff J, he was not sure as to why staff could not provide the required supervision and complete the residents' safety check log as required. On 06/21/2022 at 2:15 PM, during a joint record review and interview with Staff B, Staff B stated and confirmed that the facility staff were not following the required every 15-minute safety checks for both Resident 1 and Resident 2. Staff B stated she was not aware that staff were not following the safety check plan for both residents and that she just recently re-educated and re-trained the licensed nurses, including the unit managers to make sure that each staff member complete the safety check documentation as required. Staff B stated that she would personally conduct another round of training with return demonstrations to ensure that staff really understand the importance of providing adequate supervision to Resident 1 and Resident 2. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to provide adequate supervision and implement the care plan for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and falls. These failures caused harm to Resident 1 and placed other residents at risk for harm and injury. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses list included stroke and muscle weakness. A review of Resident 1's admission Minimum Data Set (MDS) assessment, dated [DATE], showed the resident had intact cognition and needed two-person physical assistance from staff with bed mobility and transfers. A review of Resident 1's care plan, dated [DATE], showed the resident was at risk for falls and required two-person assist for all care in bed, including turning, repositioning and transfers. A review of the facility's incident investigation report, dated [DATE], showed that on [DATE] at 9:34 PM, Resident 1 had a fall in her room. The incident investigation report also showed that the facility had established the cause of the incident and concluded that Staff C, Nursing Assistant Certified (NAC) did not follow Resident 1's care plan and had provided one-person care to Resident 1 when turning and repositioning Resident 1 in bed. The incident investigation documented that the facility had substantiated neglect of care against Staff C. A review of Resident 1's hospital records, dated [DATE], showed that Resident 1 was transferred to the emergency room for further evaluation related to the fall on [DATE]. Resident 1 was discharged from the hospital on [DATE] with a diagnosis of fall with head injury. On [DATE] at 4:00 PM, Resident 1 tearfully stated she could recall exactly what happened to her when she fell on [DATE]. Resident 1 stated a male staff member (the resident could not recall the name of the staff) turned her in bed and she fell off the bed face down hitting her head and nose. According to Resident 1, she thought she broke her nose because of the incident, and she hit her head hard. The resident stated that this incident had caused her physical pain and [now] had a fear of falling every time a staff person turned or repositioned her in bed. Joint observation on [DATE] at 4:05 PM with Staff F, Licensed Practical Nurse (LPN) showed Resident 1 had a bruise on the head (right) that measured approximately 4-centimeter (cm) in length by 4 cm wide with a small-closed/dry cut at approximately 1 cm in length and 1cm wide at the center of the hematoma. There was also a light purple discoloration measured at approximately 2 cm in length and 2cm wide observed around the resident's cheek area close to the left ear. Resident 1 complained of pain in these areas and stated she has had a headache for a while which since affected her ability to sleep and rest. On [DATE] at 4:15 PM, Resident 1's family member 1 (FM1) stated he visited Resident 1 on [DATE] at approximately 11:00 AM. FM1 stated he saw Resident 1 with a cut on her head, bloodied nose and swelling on the left cheek. FM1 also stated that Resident 1 kept on saying that she thought her nose was broken because she fell on her face hitting her nose. According to FM1, he was very concerned about Resident 1's fall because she was on a blood thinner. FM1 stated he was not sure as to why the staff was not aware of what happened and why Resident 1 was not seen or evaluated as soon as possible by a physician. A review of Resident 1's clinical record showed the resident was on [MEDICATION(S)] (anticoagulant/blood thinner) twice a day, which increased the risk of bleeding. The clinical records also showed that there was a delay in notifying the physician and a delay in sending the resident to the hospital for evaluation [after the fall]. Additionally, the clinical records showed no documented evidence that the facility consistently monitored the resident for injuries, including the hematoma on the resident's head. On [DATE] at 4:45 PM, Staff B Director of Nursing (DNS) stated Resident 1's fall was due to Staff C's failure to read and follow the resident's care plan for bed mobility. Staff B also stated Staff C's initial statement about the incident was that he witnessed and assisted Resident 1 to the floor. However, Staff C later changed his story and admitted that Resident 1 fell on the floor during care when he attempted to turn the resident by himself. According to Staff C, the facility did not have this information until the following day of the incident ([DATE]). Staff B further stated that after the facility investigation, the facility had substantiated neglect of care and had terminated Staff C's employment with the facility. On [DATE] at 5:05 PM during a telephone interview, Staff C (NAC) stated that he did not know what was on Resident 1's care plan at the time of the incident. Staff C stated the resident fell out of bed, face down, when he tried to provide care and turn Resident 1 in bed by himself. On [DATE] at 5:30 PM, Staff B (DNS) stated she was not aware of any other injury to Resident 1 including the hematoma on the forehead. Staff B stated that the injuries could have been latent injuries, but she would follow-up to make sure it was being monitored by staff. On [DATE] at 1:45 PM, Resident 1 verbalized fear while being turned and repositioned in bed by Staff D Registered Nurse (RN) and Staff E NAC. Both Staff D and Staff E stated that the resident verbalized fear and worry of falling out of bed every time they turned or repositioned her in bed. On [DATE] at 2:00 PM, Resident 1 stated she was afraid of falling out of bed again every time a facility staff offered to turn and reposition her in bed. Resident 1 also stated that she was traumatized by the previous incident, and she could not easily forget what happened. Resident 1 further stated she had lost her ability to trust caregivers because of the incident, had lost some sleep and had to see her family to get reassurance about her safety at the facility. On [DATE] at 12:09 PM, the Physician Assistant (PA) stated and confirmed that there was a delay in the notification on Resident 1's fall that happened on [DATE]. The PA stated they were not notified of the incident until the following day ([DATE]). Reference: (WAC) [DATE] (1)

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and treat a resident's skin condition, and develop and implement timely interventions to minimize the risk and the development of pressure injuries for 1 of 3 residents (Resident 1) reviewed for pressure injury/ulcers. These failures caused harm to Resident 1 who developed an in-house acquired pressure injury and placed other residents of the facility at risk for harm and unmet care needs. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (yellow/white dead tissue) and eschar (necrotic/dead tissues) are not present. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Moisture Associate Skin Damage or MASD is defined as an inflammation and erosion of skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate (discharge), [MEDICATION(S)] or saliva. Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's admission Minimum Data Set (MDS) assessment, dated 12/08/2021, showed the resident had intact cognition and needed two-person physical assistance from staff with bed mobility and transfers. The MDS also showed that the resident was at risk for developing pressure injuries. A review of Resident 1's admission assessment, dated 12/02/2021, showed that the resident admitted to the facility with no pressure ulcers. The admission Braden Scale (assessment for predicting pressure ulcer risk), dated 12/02/2021, showed Resident 1 was at high risk for developing a pressure ulcer. A review of Resident 1's care plan, dated 12/02/2021, showed Resident 1 was at risk for developing a pressure injury due to her current medical conditions. The care plan directed facility staff to: a. Encourage and assist resident to reposition and turn at least every 2 hours, and b. Monitor for skin changes every shift and notify the physician and family of any changes. On 02/08/2022 at 4:00 PM, Resident 1 stated that she had sores on her buttocks area that bothers her a lot. Resident 1 stated that she has bedsores because she's always in bed and stayed on her back for a long period of time without being turned. Resident 1 also stated she had trouble with bowel movements (BM), and it would sometimes take a long time, at least 30 to 60 minutes or sometimes longer, for staff to change her, so she would be sitting on her own BM at times, especially at night. On 02/08/2022 at 4:15 PM, Resident 1's family member 1 (FM1) stated he visited Resident 1 on a regular basis. FM1 stated Resident 1 had two pressure injuries on her buttock area that developed while at the facility. FM1 stated the facility was aware of Resident 1's care needs, including the need for turning and repositioning at least every 2 hours to prevent skin breakdown. FM1 stated that during most of his visits, he did not witness staff turning Resident 1 on a consistent basis. A review of Resident 1's clinical records from 12/02/2021 to 01/26/2022 showed the following: On 12/14/2021, Resident 1 was found to have excoriation to her left buttock area. The wound was described as very pink/red moist but not bleeding. The documentation lacked a comprehensive assessment and was not clear about the extent of the wound including the size and the possible cause of the newly identified wound. Additionally, the December 2021 Treatment Administration Record (TAR) showed no actual treatment was started until 12/17/2021 (3 days after the wound was found). On 01/08/2022, Resident 1's buttocks wound was described as having some slough on the wound bed. The documentation lacked a comprehensive assessment and was not clear about the specific type, location and the extent of the wound, including the size and the condition of the surrounding skin. Additionally, there was no documented evidence that the facility had evaluated the condition of the left buttock excoriation identified on 12/14/2021, and whether the current treatment and plan of care was effective or not. On 01/13/2022, Resident 1's left buttock wound was described as 100 % pink, moist, no s/sx [signs and symptoms] of infection, no drainage, no odor, and surrounding area in good condition. The documentation lacked a comprehensive assessment and was not clear about the specific type and the extent/size of the wound. On 01/14/2022, the Physician Assistant (PA) documented that Resident 1 had two Stage 2 pressure injuries in the sacral region (portion of spine between lower back and the tailbone). However, the documentation lacked a comprehensive assessment and was the extent of the wounds, including the size and the condition of the surrounding skin/area. On 01/21/2022, the PA documented that Resident 1 had the two Stage II pressure injuries in the sacral region that were healing. However, the PA also documented that Resident 1 had MASD to the perineal area complicated by incontinence, loose stool and reduced mobility. The documentation lacked a comprehensive assessment as to the extent of the wounds, including the size and the condition of the surrounding skin/area. The clinical records showed lack of comprehensive assessment, adequate monitoring and recording of Resident 1's wound(s) condition, location and measurement. Additionally, the clinical records showed no documented evidence that the facility had evaluated Resident 1's risk factors, including the effectiveness of the current treatment plan from 12/14/2021 to 01/13/2022. The clinical records showed no documented evidence that the facility had monitored the resident's skin condition every shift and notified the physician and family of any changes. In addition, there was no documented evidence that staff consistently assisted Resident 1 with repositioning and turning at least every 2 hours as directed by the resident's care plan. On 01/26/2022, Resident 1 was transferred to a local hospital for a change in condition (heart-related). The emergency room notes, dated 01/26/2022, showed Resident 1 arrived at the hospital with second (Stage 2) and third degree (Stage 3) pressure injuries to the sacral and the left buttock area. Resident 1 was discharged and transferred back to the facility on [DATE] with discharge diagnoses, including Stage 3 pressure injuries to the sacrum and left buttocks area. On 02/08/2022 at 4:45 PM, Staff B, Director of Nursing (DNS) stated that Resident 1's pressure injuries on her sacrum and left buttock area had developed while residing in the facility. Staff B stated that both were documented as Stage 2 pressure injuries, and that the resident was being followed by a wound specialist since she returned from the hospital. When asked why the facility staged Resident 1's wounds as Stage 2, rather than Stage 3 as documented and described by the hospital notes and discharge summary, Staff B stated the facility did not receive the hospital documentation on time and only staged the wounds as is and how it had presented on the time of admission. A joint observation on 02/09/2022 at 1:45 PM with Staff D Registered Nurse (RN) and Staff E (NAC) showed Resident 1 had two pressure ulcers, one in the sacrum area and one on the left buttock area. Staff D measured the sacral pressure injury at 1.5 centimeter (cm) in length, 0.5 cm wide with a depth of 0.1 cm. Staff D described the wound bed with 100% epithelialization. Staff D measured the left buttock pressure injury at 2.5 cm in length and 1.5 cm wide with a depth of 0.1 cm. Staff D described the wound bed with the beefy red appearance, granulation tissue with at least 50% and the rest of the wound covered with epithelial tissues (50 % epithelialization). Resident 1 complained of pain the in the sacrum and the left buttock area during wound care. On 02/09/2022 at 2:30 PM, Staff B (DNS) stated that the wound photographs that the facility had taken and reviewed (undated without proper resident identification) showed that Resident 1's pressure injury had some slough in them. However, when asked if a Stage 2 pressure injury could have slough in the wound bed, Staff B stated, No because a pressure injury with slough would involve a deeper layer of the skin [Stage 3 pressure injury or deeper]. On 02/11/2022 at 1:30 PM, Staff B (DNS) stated that Resident 1's clinical record did not have evidence of a comprehensive wound assessment and wound evaluation since identification of the initial wound on 12/14/2021. Staff B stated the facility did not have documented evidence that Resident 1's wound had been monitored on a regular basis that showed the progression of the wound(s). Staff B also said that the facility did not have documented evidence that showed whether the initial interventions were effective or not to minimize the risk of the development of the pressure injuries and preventing them from deterioration from 12/14/2021 to 01/26/2022. Staff B did not provide an answer as to why there was a delay (at least 4 weeks) to have a medical practitioner to assess and document Resident 1's pressure injuries, and in obtaining a referral for a wound specialist. Staff B stated there should have been a comprehensive wound assessment from 12/14/2021 that clearly described Resident 1's wound(s), daily monitoring and/or documentation of the wound condition, and at least a weekly wound evaluation to monitor and evaluate the condition of the wounds. On 02/11/2022 at 3:00 PM, the facility's Wound Consultant (WC) stated she had assessed Resident 1's wounds initially as Stage 2 pressure injuries on 01/26/2022. However, the WC stated she had no previous information regarding the condition of the wounds and did not have any information related to the previous stages of each pressure injury, including a nursing assessment on 01/08/2022 that showed Resident 1's wound had slough on the wound bed. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to implement written infection control policies and procedures, follow standards of practice related to hand hygiene/washing, donning (put-on) and doffing (removal) of Personal Protective Equipment (PPE), and the required isolation/transmission-based precautions when providing housekeeping and maintenance services to fourteen of fourteen residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) reviewed for quarantine and isolation precautions. Additionally, the facility failed to develop and implement an effective infection control program and failed to implement infection control care plan for 1 of 1 resident (Resident 1) who tested positive for COVID-19 and was not able to follow safety precautions to minimize the risk of COVID-19 transmission. These failures placed residents and staff of the facility in the likelihood of serious harm and for acquiring communicable diseases and serious infections including COVID-19 and constituted a situation of an Immediate Jeopardy (IJ). On 01/21/2022 at 5:30 PM, the facility was notified of the IJ related to CFR 483.80 F880, Infection Prevention and Control. The facility removed the immediacy on 01/24/22 by developing a policy and procedure and by providing a one on one supervision to Resident 1. Additionally, the facility removed the immediacy by re-educating staff about infection control practices related to hand hygiene/washing, donning (put-on) and doffing (take-off) of Personal Protective Equipment (PPE), and the required isolation/transmission-based precautions when caring and providing services for residents with known or suspected COVID-19. Findings included . According to the Centers for Disease Control (CDC), COVID-19 is an illness caused by a virus (coronavirus) that can spread from person to person and through contact with contaminated surfaces. The CDC also stated that a person can become infected from respiratory droplets when an infected person coughs, sneezes or talks. Resident 1 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated 10/03/2021, showed the resident was cognitively impaired and had exhibited wandering behaviors daily. A review of Resident 1's clinical records and infection control care plan, dated 01/20/2022, showed the resident tested positive for COVID-19 on 01/19/2022. The care plan also showed that Resident 1 ambulated in the hallway independently and was non-compliant with wearing a mask. The care plan directed facility staff to: A. Redirect away from other residents when ambulating in the hallway. B. Redirect away from other residents' rooms when approaching doorways. C. Staff to redirect from leaving the COVID-19 unit and engage in 1:1 (one on one staff engagement/care). Observation on 01/17/2022 at 3:45 PM showed Resident 1 wandering in the unit 400 hallway without wearing a mask. The resident walked past several resident rooms, sat at a chair in the hallway, walked up to the nurses station and then went back to her room (room [ROOM NUMBER]) without a mask. The resident would sometimes enter other resident rooms, including rooms [ROOM NUMBERS]. There were no observed staff member(s) around, while Resident 1 was wandering, to engage or encourage the resident to wear a mask and/or to redirect the resident away from other resident rooms. On 01/17/2022 at 3:55 PM, Resident 1 stated that she was lost and she was looking for her room. Resident 1 also stated she was looking for a hair comb and that there was no staff member around to help her. Observation on 01/21/2022 at 3:30 PM showed Resident 1 was again wandering in the COVID-19 positive unit without a mask. The resident was also observed touching contaminated gowns that were in garbage bins placed in the hallways and wandering in covid-19 positive residents' hallway(s). There were no staff members present to redirect the resident. On 01/21/2022 at 3:35 PM, Resident 1 stated that she was looking for her personal belongings and that she was not able to find anybody to help her. Resident 1 continued to search in between the garbage bins filled with used and contaminated disposable gowns. Observation on 01/21/2022 at 3:45 PM showed Resident 1 wandering [walking in the hallways, opening other residents' doors, and entering other resident rooms] on the non-COVID-19 unit without wearing a mask. The resident entered rooms 403, 404, 406, 408, 410, and 412. The residents inside these rooms had been identified as COVID-19 negative and those residents were not wearing a mask. There were no staff members present to redirect the resident. On 01/21/2022 at approximately 4:00 PM, Resident 1 stated she was lost and was also missing a lot of personal belongings. Resident 1 stated that she was checking all the rooms nearby to find anybody to help her. The resident continued to wander in unit 400 hallway up to the nurses station, then back outside room [ROOM NUMBER]. On 01/21/2022 at 4:35 PM, both Staff C, Licensed Practical Nurse (LPN) and Staff D, Nursing Assistant Certified (NAC) stated that Resident 1 was confused and would wander/walk in and out of the COVID-19 unit without a mask. Both Staff C and Staff D stated it was difficult, and most of the time, impossible for them to supervise Resident 1 because they spent a lot of time providing care to other residents with COVID-19. Both Staff C and Staff D stated they were not aware that Resident 1 was touching the trash bins with contaminated gowns or that the resident had left and wandered outside the COVID-19 unit. On 01/21/2022 at 4:50 PM, Staff B, Director of Nursing (DNS) stated Resident 1 had recently tested positive for COVID-19. Staff B also stated Resident 1 was cognitively impaired and was not able to follow safety and COVID-19 isolation precautions. However, according to Staff B, Resident 1 was care planned to be redirected by staff if she started to exit the COVID-19 unit and wander in the facility. Staff B was not able to provide an answer as to why there were no staff present to redirect Resident 1 when she exited the COVID-19 unit and entered multiple non-COVID-19 resident-occupied rooms. Staff B also stated that garbage bins used to discard contaminated PPE and gowns should have been kept inside residents' rooms and not in the hallway to help contain and minimize exposure and possible cross contamination. On 01/24/2022 at 10:30 AM, Staff B DNS stated that the facility tested the residents that were potentially exposed to COVID-19 from Resident 1 on 01/21/2022 and at least one resident (Resident 2) had tested positive for COVID-19 on 01/22/2022 after the reported exposure from Resident 1. On 01/27/2022 at 9:30 AM, Staff B DNS stated the facility did not have a policy or procedure on how to manage a COVID-19 positive resident, including Resident 1, who wandered around the facility unable to follow health and safety protocols. According to Staff B, the facility just recently developed a policy titled, MANAGEMENT OF COVID-19 POSITIVE RESIDENTS WHO WANDER on 01/23/2022. TRANSMISSION BASED PRECAUTIONS, PPE USE AND HAND HYGIENE A review of the facility policy titled, TRANSMISSION BASED PRECAUTION, dated 01/2022, showed that for both Aerosol and Quarantine Precautions, all facility staff, including visitors, doctors, and staff, were expected to: a) Clean hands when entering and leaving the resident/isolation room; and b) Gown and gloves at the door. The policy showed these precautions would be used for respiratory viruses, including COVID-19. Observation on 01/21/2022 at 3:35 PM showed Staff E, Maintenance and Plant Director (MPD) doing maintenance work in room [ROOM NUMBER] (Resident 3), a COVID-19 positive room with an Aerosol Precaution sign posted at the door. After the visit, Staff E exited the room without removing his gown and gloves, and without performing any form of hand hygiene. Staff E removed and discarded both his gloves and gown after walking down the hallway, which was 4-6 rooms away from room [ROOM NUMBER]. Observation on 01/21/2022 at 4:10pm showed Staff F, Housekeeping Aide (HA) providing housekeeping services to rooms 302 (Resident 5 and 6), 303 (Resident 7 and 8), 304 (Resident 9 and 10), 305 (Resident 11 and 12), 306 (Resident 13 and 14), 307 (Resident 15), and 309 (Resident 4 and 16). All 7 rooms were on quarantine precautions for suspected/COVID-19 precautions. Staff F used the same contaminated gloves and gown when cleaning each room and did not perform any form of hand hygiene in between resident rooms. On 01/21/2022 at 4:40 PM, Staff F (HA) stated that she was aware of the COVID-19 quarantine precautions and she should have removed her gown, gloves, and should have performed hand hygiene in between resident rooms. On 01/21/2022 at 4:50 PM, Staff B (DNS) stated that both Staff E (MPD) and Staff F (HA) should have followed the facility's infection control procedures including the transmission-based precautions posted at each room to prevent and minimize the risk of cross contamination and COVID-19 transmission and infection. Staff B stated that Staff E should have doffed and performed hand hygiene before exiting room [ROOM NUMBER], and Staff F should have doffed and performed had hygiene in-between resident rooms. On 01/24/2022 at 10:30 AM, Staff B (DNS) stated that the facility had tested the residents that were potentially exposed to COVID-19 and/or identified to be in rooms that had a break in infection control on 01/21/2022. Staff B stated that at least one resident in room [ROOM NUMBER] (Resident 4) had tested positive for COVID-19 on 01/22/2022. The facility had a COVID-19 outbreak beginning 01/02/2022. As of 01/28/2022, the facility had a total of at least 33 residents and 29 staff members who tested positive for COVID-19. There were at least 2 resident hospitalization s and 1 death that were associated with COVID-19. Reference: (WAC) 388-97-1320 (1)(a)(c)(2)(a)(4)

Based on observation, interview and record review, the facility failed to operationalize all components of the infection prevention and control program to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 15 of 15 residents of 29 residents sampled (Residents #1-#15). This failure increased the likelihood for exposure and possibility of contracting [MEDICAL CONDITION] causing Coronavirus Disease 2019 COVID-19, a new disease caused by a novel coronavirus that has not been previously seen in humans, and placed all residents in immediate jeopardy for infection and death. Findings included . COVID-19 OUTBREAK in the facility According to the facility report to the State agency [DATE]: the facility had an outbreak of the COVID-19 virus disease in the facility between [DATE] and [DATE]: 62 residents were tested COVID-19 positive, 26 staff were COVID-19 positive and there were 16 COVID-19 positive resident deaths. In an interview on [DATE] at 10:15 a.m., the facility Director of Nursing Services (DNS) stated the facility just had their first resident with a positive test for COVID-19 virus who had a fever, went to the hospital and was deceased . In addition, the facility sent another resident out to the hospital who was also tested and was positive for COVID-19 virus. The facility had two staff members at that time with symptoms and COVID-19 tests pending. The DNS stated the facility had Personal Protective Equipment (PPE) for staff. In a subsequent interview the same day at 3:00 p.m., the DNS stated the facility now had six residents total with positive COVID-19 virus tests. On [DATE], three days later, at 10:45 a.m., the facility DNS stated the facility now had 14 residents with positive COVID-19 tests and a total of four staff with COVID-19 positive tests. In an interview on [DATE] at 11:00 a.m., the DNS stated the facility now had 17 residents with positive COVID-19 tests and two resident deaths. On [DATE] at 1:30 p.m., the facility DNS also stated there were seven facility resident deaths related to positive COVID-19 virus disease testing. FAILURE TO PROVIDE CARE WITH REQUIRED Personal Protective Equipment (PPE) for Droplet Precaution Isolation for COVID-19 virus In an interview on [DATE] at 10:15 a.m., the Director of Nursing Services (DNS) stated all residents on the 500 wing of the facility were on Droplet Precautions. The DNS also stated all residents on the wing were presumed to be COVID-19 positive, although not all residents on 500 wing had been tested and not all residents on 500 wing had symptoms of [MEDICAL CONDITION], so for some residents on the 500 wing, their COVID-19 status was actually unknown. The DNS stated some residents may have been previously exposed to roommates with COVID-19 virus on other wings of the facility, so they were moved to the 500 wing. The plan was to test residents on the 500 wing if and when they actually develop symptoms of the COVID-19 virus. In addition, the DNS also stated the staff wear full PPE for Droplet Precautions on the 500 wing and do not change gowns in order to conserve supplies. On [DATE] at 2:57 p.m., in an additional interview, the facility DNS stated the residents on the 500 wing of the facility that were designated as COVID-19 positive (per a resident roster list provided by the facility) had symptoms and were tested and confirmed COVID-19 positive. The residents designated as presumed had no symptoms of [MEDICAL CONDITION], and had not been tested , but had been in another room with a COVID-19 positive resident previously, so the DNS stated the residents with unknown COVID-19 status could be in rooms with a confirmed COVID-19 positive resident on 500 wing now. When asked where the procedure came from to co-hort confirmed tested positive COVID-19 residents in a room with residents who had unknown COVID-19 statues, no symptoms and were not tested , the DNS stated the facility Medical Director gave her that direction. The DNS also stated the Department of Health and a sister facility told the facility about the procedure to place short sleeved cloth gowns over the top of the yellow cloth gowns for staff to work with all residents on the 500 wing of the facility in order to save supplies. On [DATE] at 1:30 p.m., the DNS stated the staff on the 500 wing should be entering all rooms with an isolation gown, mask, eye protection, gloves and should place a cloth gown over the paper isolation gown if the resident in the room is confirmed COVID-19 positive. The DNS also stated all rooms have a Droplet Precaution isolation sign outside the door. The DNS also stated they follow infection control and PPE as well as isolation precautions according to the Centers for Disease Control guidelines (CDC). Review of the facility PPE policy dated [DATE] showed, during times of crisis extended or re-use of certain PPE may be used to conserve supplies: the practice of using the same piece of protective equipment by one healthcare worker for multiple residents with the SAME DIAGNOSIS, or use of the same piece of equipment by the SAME healthcare worker. Review of the Department of Health PPE Conservation Strategies showed, group together residents who are CONFIRMED to have COVID-19, re-use gowns on the SAME healthcare worker was permitted. Review of the CDC PPE Guidelines dated [DATE] showed, for Droplet Precautions for COVID-19, staff should use face shield or goggles, face mask preferably an N95, gloves, and isolation gown. There were no recommendations to use a short sleeve gown over a long sleeve gown in Droplet Precaution isolation rooms. Observation and review of the facility Droplet Precautions sign outside of the facility residents' room doors on [DATE] at 10:00 a.m. showed, everyone must wear a face mask, wear eye protection (face shield or goggles), gown, gloves, and keep the door closed. During observation on [DATE] at 11:15 a.m., Staff A, a licensed nurse, entered the room of Resident #1 who was on Droplet Precaution isolation for a positive COVID-19 test on [DATE] per the facility Infection Control Outbreak Line List. Resident #2 was also positive for COVID-19 per lab report [DATE]. During the observation, Staff A wore a mask, no eye protection, no gloves, and wore a paper long sleeved gown with a short sleeved gown on top. The arms of the yellow gown were exposed outside of the short sleeved gown while in the room. Resident #1 was observed coughing in the room during this time. Staff A, the licensed nurse, then took the short sleeved top cloth gown off and hung it on a hook in the room, left the room with the long sleeved paper gown still on and went out into the hallway. Staff A did not perform any hand hygiene, then went to the medication cart and changed the batteries in the electronic thermometer which is shared equipment used on all residents. In an interview on [DATE] at 1:10 p.m., Staff D, a nurse aide, stated he was trained to wear two gowns for the Droplet Precaution isolation rooms on wing 500: a long sleeved paper gown with a cloth short-sleeved gown on top to go into the Droplet Precaution isolation rooms. In an interview on [DATE] at 1:00 p.m., Staff E, a nurse aide, stated he was told to wear a long sleeved paper gown with a short sleeved cloth gown on top to go into the Droplet Precaution isolation rooms on the 500 wing in the facility and that is what he did. In an interview on [DATE] at 4:10 p.m., Resident #1, who was alert and oriented, and had a cognitive assessment score of ,[DATE] on the facility Minimum Data Set assessment (MDS) assessment dated [DATE], stated the staff wore mask, gloves, goggles and sometimes a gown in her room, but not always. In an interview on [DATE] at around 12:30 p.m., the DNS stated the staff were wearing the same isolation gowns throughout the shift for the residents who are confirmed COVID-19 positive, and during care for the residents who do not have COVID-19 tests results or symptoms. The surveyor discussed with the DNS the exposure of COVID-19 positive residents with residents not confirmed with COVID-19 by wearing the long sleeve gowns with short sleeve gowns over them and the possible droplet contamination that can be carried on the unprotected long sleeves of the paper gowns from room to room and resident to resident. In an interview on [DATE] at 12:10 p.m. the DNS stated expectations of full PPE for staff to wear for Droplet Precaution isolation are mask, eye protection, gown, and gloves before entering resident rooms. When the surveyor informed the DNS there were staff not wearing gloves in a Droplet Precaution room to give medications, the DNS then stated that was okay if the nurse was just setting medications down in the room and not touching the resident. (although this is not what the directions are on the facility Droplet Precaution isolation signage, and not what the DNS said in a previous interview above). Review of the facility Pandemic [MEDICAL CONDITION] Procedure for Infection Control dated [DATE] showed, the facility had a policy that all staff should know what precautions to take to avoid transmission including hand hygiene and proper PPE. During observations on [DATE] at around 11:30 a.m., Staff A, a registered nurse, and Staff B, a nurse aide, were in Resident #4's room, who had a positive COVID-19 tests on [DATE] per lab report, and was on Droplet Precaution isolation, Staff A wore only eyeglasses and no further eye protection as required, wearing long sleeved paper gowns and cloth short sleeved gowns over top of the long sleeved paper gowns. Staff A and Staff B then left their cloth short sleeved hospital gowns on a hook in the room and left the paper long sleeved gowns on when they went into the hallway. Cloth short sleeved gowns were also observed on [DATE] at 11:35 a.m. hanging on walls in rooms for Residents #1, 2, and 3. In an interview on [DATE] at 12:00 p.m., Staff C, a registered nurse, stated on 500 wing for Droplet Precautions the staff were wearing yellow paper isolation gowns in all rooms with the second cloth gown (short sleeved hospital gown) over the paper gown and leaving the cloth gowns hanging in the rooms. Staff C stated the cloth gowns were used just for the COVID-19 positive residents or if a resident had symptoms of [MEDICAL CONDITION]. Staff C also stated the facility staff were wearing their own eyeglasses because they did not have fancy face shields like the surveyor, and the staff wore goggles for eye protection if they did not have their own eyeglasses. In addition, Staff C stated the staff use only the gold top wipes containers for cleaning and disinfecting shared resident equipment as these were verified to be used for the COVID-19 virus. In an interview on [DATE] at 1:00 p.m., the facility DNS stated the facility had 24 staff out with symptoms of the COVID-19 virus. During observation on [DATE] at 12:05 p.m., Staff G entered room of Resident #15 who was on Droplet Precaution isolation which was confirmed with Staff G, a licensed nurse. Staff G entered the room without eye protection except her personal eyeglasses. Staff G stated full PPE was required to enter the isolation room, and Resident #15 had a fever of over 100 degrees F yesterday. In an interview on [DATE] at 9:00 a.m., a Collateral Contact at the local Department of Health (DOH) who worked with the facility infection control COVID-19 outbreak, confirmed that the use of a short sleeve gown over a long sleeve gown in the facility when staff were working with COVID-19 positive residents was not standard of infection control practice as the long sleeved gown under the short sleeved gown was at risk for contamination and was not protected. The DOH contact also stated eyewear must be worn in all rooms with residents who are COVID-19 positive even if just giving medications. In additional multiple staff interviews on [DATE], [DATE], [DATE], [DATE], multiple facility staff who requested anonymity stated: -PPE was not available for staff on [DATE], there were no gowns in the Droplet Precaution isolation carts -some staff were wearing -the facility did not enough masks available or accessible, PPE was nor available on the weekends in late [DATE] and early [DATE] -multiple staff were using the same gowns in the resident rooms and on multiple residents, then leaving the used gowns on hook in the rooms, as they were told by the facility to share gowns -in [DATE] and early [DATE] there was often no eye protection available in the facility to be used for Droplet Precaution isolation -the staff felt confused and received poor communication /training about what PPE to wear -some staff were not trained on proper PPE until [DATE], three weeks after the outbreak started -staff are not using PPE correctly In an interview on [DATE] at 3:30 p.m., the DNS stated she was not aware that multiple staff were using the same cloth gowns in the Droplet Precaution isolation rooms and she was aware the staff were doing some things wrong in regards to protocols. The DNS also stated the facility never had a shortage of masks for the staff. In an interview on [DATE] at 2:00 p.m., the DNS confirmed the facility had a census of 62, with 42 residents with positive COVID-19 tests, 8 COVID-19 positive residents in the hospital and 13 COVID-19 positive resident deaths. DROPLET PRECAUTION ISOLATION SIGNAGE During observation on [DATE] at 12:20 p.m., Resident #5 who was on Droplet Precautions for positive COVID-19 test [DATE] (per facility IC Line List) had no Droplet Precaution signage outside the room door. In an interview on [DATE] at 2:22 p.m., Resident #5, an alert and oriented resident with a cognitive score of ,[DATE] on the MDS dated [DATE], stated he knew he had [MEDICAL CONDITION], and had to stay in his room, and the staff were wearing protection such as a gown over their uniform and a mask over their nose and mouth. Resident #5 stated the staff were not using anything over their eyes like goggles or face shields when they came in his room. This was clarified with Resident #5 twice with additional interview at that time, and he stated the staff were not wearing any eye protection in his room, no goggles, eye shields/face shields. In an interview on [DATE] at 11:15 a.m. Staff C, a registered nurse working on the 500 wing in the facility, did not know what the infection control isolation precautions were for Resident #5 and did not know Resident #5 was positive for COVID-19. During observations on [DATE] at around 10:40 a.m., Droplet Precautions signs were posted outside of rooms [ROOM NUMBERS] that said keep door closed but these rooms had all doors open to the hallway. Observation on [DATE] at 11:20 a.m. showed, Droplet Precaution signs said keep door closed but all 500 wing rooms had all doors open to the hallway. CROSS CONTAMINATION Observation [DATE] at 11:00 a.m. showed, Staff I was passing water pitchers from a cart in the hallway: room [ROOM NUMBER] had signage for Droplet Precaution Isolation. Staff I entered with no PPE except face mask on, no gown, gloves or eye protection. Staff I took a water pitcher in for a resident, but the resident stated no ice, so Staff I went out to the cart in the hallway and placed that water pitcher back on the top of the cart with the other clean water pitchers, and took another pitcher in the room for the resident, then emptied the resident's cup with lid and straw into the sink and refilled it with the water pitcher then placed the used water pitcher from the isolation room [ROOM NUMBER] back on the water pitcher cart where other pitchers were waiting to be taken to other rooms. Observation on [DATE] at 11:05 a.m. showed, outside of room [ROOM NUMBER] on the medication cart was a can of (PDI Sanicloths Plus) wipes with a red top and coronavirus was not listed on the label. At that time Staff H, a licensed nurse stated they use the wiped from the red top can to clean the shared equipment used for residents. At 12:10 p.m, the DNS stated the staff should be in full PPE for passing the water pitchers in rooms on Droplet Precaution isolation and should not place dirty pitchers from the isolation room back on the cart they are passing water pitchers from for other residents. The DNS also stated the staff should be using Clorox wipes on shared equipment not the red top can of wipes (Sanicloth wipes). The DNS then replaced the red top wipes outside room [ROOM NUMBER] with a gold top can of wipes labeled Clorox. The DNS then confirmed with the surveyor the red top wipes cans did not have coronavirus on their label and should not be used to sanitize reusable equipment on residents. On [DATE] at 4:44 p.m. the DNS stated in an email the facility follows recommendations from the Centers for Disease Control (CDC) and the Department of Health for Infection Control. FAILURE TO PROVIDE SAFE INFECTION CONTROL CO-HORTING of POSITIVE COVID-19 RESIDENT with RESIDENTS of UNKNOWN COVID-19 STATUS Review of the Washington State Department of Health PPE Strategies dated [DATE] showed, resident co-horting should be grouping residents who are CONFIRMED positive for COVID-19 virus together. The procedure also noted staff should use re-usable face shields or goggles for eye protection when in the Droplet Precaution isolation rooms. Staff can re-use a gown on the same resident by the same healthcare worker or until visibly soiled, or use the same gown for multiple residents if not soiled when the facility is in an extreme supply situation, however, there was no use noted for the same cloth gown to be used on multiple staff is as an accepted practice). In an interview on [DATE] at 1:30 p.m., the DNS again stated and confirmed the residents on the 500 wing of the facility were either tested and confirmed COVID-19 positive, or were not tested and had no symptoms so they had an unknown COVID-19 status. The DNS stated resident are only tested if they have symptoms of [MEDICAL CONDITION]. The DNS also stated all residents on the 500 wing were on Droplet Precaution isolation regardless of COVID-19 testing. The DNS also stated they did have one resident who they considered presumed positive for COVID-19 virus (may have been exposed in another room) who had no signs or symptoms and who tested negative. Review of the facility Resident Placement Recommendations document dated [DATE] from the DNS showed, separate COVID positive residents from residents who do not or who have unknown COVID-19 status. During observation on [DATE], the following co-horting was observed and presented infection risks for residents with no COVID-19 confirmed and no COVID-19 virus symptoms: Resident #4 was COVID-19 positive on [DATE] per the facility IC Line Listing, but was COVID-19 positive [DATE] per lab report, had an elevated temperature and was on Droplet Precaution isolation. Resident #4 was co-horted in a room on [DATE] with Resident #11 who had not been tested , and had no symptoms of COVID-19 at that time. Resident #4 died [DATE], and had a post-mortem positive COVID-19 test on [DATE] with results [DATE]. Resident #5 was COVID-19 positive on [DATE] per IC Line List and co-horted in a room with Resident #12 who had not been tested at that time and had no symptom of COVID-19 virus. Resident #7 was COVID-19 positive per lab report [DATE] and was co-horted in a room with Resident #8 who had not been tested and had no symptoms of COVID-19 virus at that time. In addition, Resident #13 who was symptomatic for COVID-19 and according to the DNS was presumed positive for COVID-19 virus, was co-horted in a room with Resident #14 who had no symptoms of COVID-19 and tested negative on [DATE] per lab report. Resident #9 who was not confirmed positive for COVID-19 as of the observation on [DATE], was co-horted with Resident #10 who was COVID-19 positive (per IC Line Listing on said [DATE] but the lab report said [DATE]). On [DATE] at 7:00 p.m., the Administrator and Director of Nursing were informed of Immediate Jeopardy related to the failure to operationalize Infection Control practices related to the management of COVID-19 residents, use of appropriate droplet precaution isolation with appropriate PPE use, inadequate isolation signage and staff without knowledge of isolation status for a COVID-19 positive resident, creating the likelihood of COVID-19 infection being transmitted to residents and staff. In an interview on [DATE] at 1:00 p.m., when asked why the facility had residents with COVID-19 positive tests confirmed co-horted in rooms with residents who had no COVID-19 test and were not symptomatic, the facility Medical Director stated, the 500 wing of the facility was meant to be for all COVID-19 positive confirmed residents, so the staff are doing all the same things for the PPE and precautions for everyone. The facility Medical Director further stated the residents who may have been previously exposed to roommates who were COVID-19 positive but who did not have tests or symptoms should be on isolation precautions, however, the Medical Director stated it must have been a misunderstanding on the part of the facility staff in regards to the definitions for the co-horting of residents on the 500 wing of the facility who placed residents who had not been confirmed with COVID-19 positive nor had symptoms, in rooms with residents who had confirmed positive COVID-19 tests. In an interview on [DATE] at 9:00 a.m., a Collateral Contact at the local Department of Health (DOH) who worked with the facility infection control COVID-19 outbreak in [DATE], stated the co-horting of residents with confirmed COVID-19 positive residents with residents in a room who are not confirmed (and asymptomatic) is not standard for infection control. In an interview on [DATE] at 1:00 p.m., the DNS stated the facility now had 37 residents with positive COVID-19 tests, 15 resident deaths, and 24 staff positive for COVID-19. INCOMPLETE SURVEILLANCE/DATA ANALYSIS during the COVID-19 OUTBREAK to prevent spread Review of the facility Pandemic [MEDICAL CONDITION] policy dated [DATE] showed, if there are suspected or actual cases of COVID-19 virus, the facility must increase surveillance and tracking of those cases on a separate floor plan to map infections for residents and staff. The policy also included maintain a chronology of the steps taken during the outbreak to assist with post event follow up. According to the facility Infection Control Line Listing dated [DATE], residents had symptoms of possible COVID-19 as early as [DATE]. In addition, on [DATE], Resident #6 had decreased oxygen and was hospitalized , and had a COVID-19 positive test; Resident #3 had an elevated temperature, and tested positive for COVID-19 [DATE]. Record review of facility Infection Control logs/line listings of infections as of [DATE] showed, the facility did not have completed line listings for surveillance to include all COVID-19 tests with dates, and no documented tracking system correlated with the line listings for COVID-19 exposures and room moves for infection control /co-horting plans for March2020 and [DATE] to track and prevent further outbreak in the facility. Review of the facility Infection Control Report Summary dated [DATE] showed, the ADNS/Infection Preventionist for the facility had no documented plan to further prevent the COVID-19 outbreak in the facility. In an interview on [DATE] at 1:20 p.m., the ADNS stated she tracked room changes for infection control on the daily census sheet. Review of the facility census sheets for [DATE], [DATE], [DATE], [DATE]. [DATE] showed no documented infection control plan in relation to room moves, surveillance of trends in the facility or plans to prevent further outbreak of COVID-19 virus infection. Record review of an email dated [DATE] showed, according to a collateral contact at the local Department of Health, the facility was re-doing their line list surveillance later that week with guidance from the local department of health on how to complete the facility Infection Control line lists correctly. On [DATE] the facility submitted an infection control line listing: Line List for COVID-19 Outbreak in Long Term Care Facilities that did not contain dates of COVID-19 tests or dates of death for the Infection Preventionist to analyze the data and trends for a facility plan for infection control: The COVID-19 test result column asks for test result and date, no date entered; the death column asks for Y or N and date, no dates entered for the Y's; the last column asks for notes such as hospital, ER info, had dates and POS marked however it is unclear if these dates are dates tested , dates of results, or what the dates mean. The report did not have any summary for further surveillance plans to contain the COVID-19 outbreak in the facility and the document was incomplete as described above. In an interview with the facility Infection Preventionist (IP) on [DATE] at 1:20 p.m., the IP stated the dates of death were not on the line listing because she had issues with the computer program. The IP confirmed line listing was done last week [DATE]. Previous to that, the surveillance was done on facility logs, as well as a CDC form that was not completed. The facility had no documentation of infection data analysis, interpretation of the data about the COVID-19 outbreak in the facility, no tracking to check staff were using PPE correctly and no clear outbreak investigation. According to the facility DNS on [DATE] during telephone exit with the surveyors, the facility now had a census of 60, total residents COVID-19 positive to date 62, 37 residents in the facility COVID-19 positive, three residents out to the hospital, 26 staff COVID-19 positive with one sick, and 16 resident deaths with COVID-19 confirmed. Reference (WAC) [DATE] (1)(a)(c)(2)(a)(b)(c)

Based on observation, interview and record review the facility failed to accurately and comprehensively assess smoking safety and/or provide the necessary supervision and monitoring for 2 of 3 residents (55 & 65) who smoked. The facility failed to recognize the danger of smoking materials for Resident 55 who was observed to have burn holes in his clothing and wheel chair cushion and having the appropriat protection in place for Resident 65. In addition, the likelihood of serious injury from burns for 2 residents smoking, constituted a situation of immediate jeopardy. Additionally, oxygen cylinders were found unsecured in the oxygen/biohazard room. This failure to secure the oxygen cylinders placed residents at risk for harm. Findings include: RESIDENT 55 Resident 55 was admitted to the facility October 2014 for rehabilitation therapy following leg surgery. The 04/05/16 Minimum Data Set (MDS) Assessment identified the resident as having intact cognition, and used an electric wheelchair independently inside and outside the facility. He was able to independently transfer himself in and out of a wheelchair. The facility identified this resident as being able to smoke cigarettes independently. Resident 55's Smoking Safety Evaluation was initially conducted on 04/24/14. The resident was identified as able to smoke independently and follow the facility's smoking policy. Subsequent quarterly evaluations were conducted (the most recent evaluation was on 04/18/16). The resident continued to be identified as being able to independently smoke safely. Resident 55's Care Plan, dated 10/28/14, approach included: Observe for unsafe smoking behaviors. Immediately inform center management .Check clothing quarterly and as needed for burn holes. The resident was observed several times at the facility designated smoking area. He was observed smoking cigarettes and wearing a smoking apron. The resident was known to go off the facility property and smoke cigarettes. On 05/23/16 at 2:35 PM, the resident was observed lying in bed. The resident's electric wheelchair was next to the bed. On the wheelchair was a cushion (with a cushion cover) with at least 6 small holes. The holes were located near the front edge of the cushion, between where a person's legs would be. The surveyor asked the resident about the holes. The resident said the holes on the cushion were from embers dropped from his cigarettes and that he had not burned himself. He said the last time an ember dropped was about 6 months ago. He said the facility staff knew about the cigarette holes on the cushion cover. Further observation of the resident found there were several similar size holes on the pants he was wearing. A smoking apron was observed on a box near the bed, with items on top of it. At 2:37 PM, Staff A, Licensed Practical Nurse (LPN), was asked if she knew about Resident 55's wheelchair cushion cover and the cigarette burn holes. She said she was unaware of them but would let the Administrator know. She also said she had seen what looked like cigarette burn holes in his wheelchair cushion about 3 or 4 months ago. The cushion had been in his room, off to the side behind some boxes. She said she took it and gave it to the Therapy Aide. She said she had not told anyone else or documented it anywhere. She went on to say she saw him wear a smoking apron when he smoked in the smoking area. She said the resident had been educated on the risks and benefits of smoking and smoking safety and if he went out of the facility he could use a smoking apron that they gave him. We give smokers their own smoking aprons. At 2:41 PM, Staff A said she spoke with the Therapy Department and therapy gave him 2 new cushions and new cushion covers for his wheelchair within the past month. At 4:00 PM, Resident 55 said he smoked 4 or 5 cigarettes per day, both in the facility smoking area and off the facility property. He said he wore a smoking apron when smoking at the facility but would not wear one when off the property. There were 5 clean pants, on hangers, in his closet. Holes, similar in size to the holes on his wheelchair cushion cover, were observed on the front groin area of each pair of pants. The Director of Nursing Services (DNS) and Administrator were interviewed on 05/23/16 at 4:22 PM. According to the DNS, she had observed the resident's wheelchair cushion on 05/20/16. She stated there were no burn marks observed at that time. On 05/24/16 at 2:30 PM, Staff B, Therapy Aide, said he had been a Therapy Aide at the facility for 7 or 8 months. He has been the only Therapy Aide during this time. Part of his job was to replace damaged wheelchair cushions and cushion covers. He said he had no recollection of seeing any wheelchair cushions or cushion covers with holes. If he saw any with holes he would notify the Rehabilitation Director. On 05/24/16 at 7:57 AM, Staff C, Laundry Supervisor, said personal laundry is washed every day. If burn holes were found in clothing, the Administrator would be notified right away. I have not seen any burn holes in Resident 55's clothes. At 8:10 AM, Staff D, Laundry Assistant, said she delivered laundry to the residents' rooms. I organize his clothes for him. He likes that. I do not look at the clothes for holes. If I saw one, I would give it to the Administrator or tell her. RESIDENT 65 An observation on 05/24/16 starting at 2:27 PM revealed Resident 65 was in the smoking area. The resident was in a tilt and space electric wheelchair and was leaning back in an approximate 65 degree angle. A black cloth was visible at mid chest and covered her lap. It did not have a neck tie or protecting her upper body. Folded wash cloths and towels were noted to be laying in the chair beside her. The DNS was notified of the observation and went out to talk with the resident. The DNS stated the resident should not have had that smoking apron on, as it was an older garment and was no longer used. The resident stated she had kept it in her room and used it periodically. A new smoking apron was brought to the resident. OXYGEN/BIOHAZARD ROOM During the initial tour on 05/22/16 at 9:20 AM there were four small oxygen tanks not secured in the Oxygen/Biohazard room. A sign posted on the wall stated oxygen tanks were not to be stored on the floor and were to be secured. There was oxygen stored on the left hand side of the room in six crates. One small oxygen tank was on the floor, separate from the other tanks and not secured. Three other small tanks were observed lying across the top of other oxygen tanks stored in a crate, not secured. Two of the three tanks lying across the oxygen tanks indicated they were ¼ of the way full. The oxygen tank on the floor was not full. The same observation was observed at 10:00 AM and 11:44 AM. At 11:49 AM, the Director of Nursing Services observed the unsecured oxygen tanks. The DNS was made aware the oxygen tanks were not safely stored. The DNS took care of the hazard immediately. See also F 272 for additional information

Based on observation, interview and record review the facility failed to accurately and comprehensively assess for smoking safety for 1 of 3 sample residents (55) who smoked. The facility failed to recognize without an accurate assessment the risk was so high to the health and safety of the resident who was observed to have burn holes in his clothing and wheel chair cushions. In addition, the likelihood of serious injury [MEDICAL CONDITION] the resident smoking, constituted a situation of immediate jeopardy. Based on observation, interview and record review, the facility failed to accurately and thoroughly assess 1 of 3 sample residents (55) reviewed for independent safe smoking. This failure placed residents at risk for burns. Findings include: Resident 55 was admitted to the facility October 2014 for rehabilitation therapy following leg surgery. The 04/05/16 Minimum Data Set (MDS) Assessment identified the resident as having intact cognition, used an electric wheelchair independently inside and outside the facility. He was able to independently transfer himself in and out of a wheelchair. Resident 55's Smoking Safety Evaluation was initially conducted on 04/24/14. The resident was identified as able to smoke independently and follow the facility's smoking policy. Subsequent quarterly evaluations were conducted (the most recent evaluation was on 04/18/16). The resident continued to be identified as being able to independently smoke safely The 10/28/14 Smoking Plan of Care identified Resident 55 as having Potential for smoking related injury due to disease or [DIAGNOSES REDACTED]. The resident was observed several times at the facility on 05/22, 05/23, 05/24, 05/25, 05/26, and 05/27/16 to be in the designated smoking area. He was observed smoking cigarettes and wearing a smoking apron. The resident was known to go off the facility property and smoke cigarettes. An 03/20/15 Behavior Management Care Plan identified the resident as having disregard to personal safety. On 05/23/16 at 2:35 PM, Resident 55 was observed lying in bed. The shorts he was wearing had several small holes (approximately ½ centimeter in diameter) in the groin area. His electric wheelchair was next to the bed. In the wheelchair was a cushion with a cover. Near the front edge of the cover (near where someone's legs would be) there were at least 6 small holes, the same size as the holes on his pants. The resident was asked about the holes on his pants and cushion cover. He said the holes were due to dropping embers from his cigarettes. He denied he was burned. He said the last time an ember dropped was about 6 months ago, and the facility staff were aware of the holes on the cushion. The resident gave permission to look at his clothing in his closet. There were 5 clean pairs of pants, each with similar size holes as the holes on the wheelchair cushion cover and the pants he was wearing. On 05/23/16 at approximately 3:15 PM, Staff A and G, both LN's, and Staff H, I, J, K, Nursing Assistants Certified (NAC's) were interviewed regarding smoking safety at the facility. Each staff interviewed said residents who smoke were to be observed for safety and to report anything unsafe, including burn holes in clothing, to the nurse or administration. Residents who smoke were to be using smoking aprons. The Director of Nursing Services (DNS) and Administrator were interviewed on 05/23/16 at 4:22 PM. According to the DNS, she had observed the resident's wheelchair cushion on 05/20/16. She stated there were no burn marks observed at that time. Resident 55 had not been thoroughly and accurately assessed for safe smoking. This failure of incomplete assessment placed the resident at risk for burns. See also F 323 for additional information.

Based on observation, interview, and record review, the facility failed to prevent, and to implement preventative measures after risks were identified for pressure ulcers developed for 1 of 3 sample residents (107) reviewed for pressure ulcers. Failure to consistently identify and implement preventative interventions resulted in harm for Resident 107 who had a stage II pressure ulcer upon admission to the facility and developed additional pressure ulcers. This failure also placed other residents at risk for developing pressure ulcers. Findings include: Per the Resident Assessment Instrument (RAI) Manual, a Suspected Deep Tissue Injury (SDTI) is defined as purple or maroon area of discolored intact skin due to damage of underlying soft tissue. A stage 2 pressure ulcer was a partial thickness loss of the dermis presenting as a shallow open ulcer with a re-pink wound bed, without slough. May also present as an intact or open/ruptured blister The facility's Skin and Wound Care policy, dated 09/11/15, included the following: - The Licensed Nurse (LN) performed a thorough skin assessment within 2 hours of admission. Identified wounds were documented utilizing Wound Rounds. - residents who chose not to follow recommendations related to their skin care program were educated regarding risks, benefits and offered alternative options. - Weekly skin assessments were documented on the Treatment Administration Record (TAR). - Bi-weekly assessments of pressure ulcers were documented in Wound Rounds. - Daily documentation in the nursing progress notes included: status of the dressing, status of surrounding tissue, signs of infection, pain and compliance with recommended interventions. Resident 107 was admitted to the facility in February 29, 2016 with [DIAGNOSES REDACTED]. A right knee immobilizer was to be worn at all times. According to the Minimum Data Set (MDS) assessment, dated 03/07/16, the resident required extensive assistance of two people for bed mobility, transfers and dressing. The MDS identified the resident had a stage II pressure ulcer. The admit skin assessment, dated 02/29/16, revealed Resident 107 had a 2 centimeter (cm) by 2 cm fluid filled blister on the right upper calf and the 2 + [MEDICAL CONDITION] to the right lower extremity. A Braden skin risk assessment dated [DATE], indicated the resident at risk for skin breakdown. The LN initiated a turning schedule to protect both heels and to monitor closely for sensory impairment. Review of the skin care plan, dated 02/29/16, revealed the resident was at risk for skin breakdown and was admitted with a right calf blister. The care plan did not identify the resident was at risk for developing pressure ulcers related to the right knee immobilizer. Progress notes showed that on 03/01/16, the day after admit, that the right calf blister ruptured on day shift. The stage II pressure ulcer measured 2 cm x 1.5 cm x 0.1 cm. Review of a History and Physical, dated 03/02/16, revealed the resident had an open blister on the right upper calf. The physician indicated the resident was to use a heel lift when in bed, and was at high risk for pressure ulcers. Review of a physician progress notes [REDACTED]. Nursing progress notes showed that on 03/22/16 a right heel scar was noted. Review of a physician order, dated 03/24/16, revealed staff were to place the right knee immobilizer on during transfers. The immobilizer was to be removed when in bed or up in the wheelchair to relieve pressure to the right calf wound. On 03/24/16, a second open area, below the first pressure ulcer was noted on the right calf. The new open area was not identified as a pressure ulcer nor was it assessed to determine the possible causative factor. The new open area measured 0.2 cm x 0.5 cm x 0.1 cm. On 03/25/16, a new order was received to have the right knee immobilizer on with all transfers and removed when in bed or up in the wheelchair to relieve pressure to the right calf wound. On 03/26/16, a SDTI was found on the resident's right heel. It measured 2 cm x 3 cm. The LN initiated sage (a type of soft boot that covers the resident's foot, heel and up to the middle of the calf) boots and encouraged every two hour repositioning. Review of an Interdisciplinary Pressure Ulcer Review dated 03/29/16, written by the Director of Nursing (DNS) indicated the resident was admitted to the facility with 2 blisters on her right calf area. There was no documentation found that there were two areas. Documentation also showed the resident was at high risk of clinically unavoidable skin breakdown and for delayed or non-healing and complications of existing breakdown. On 03/31/16, the right heel SDTI measurements had not changed. The LN documented the blister was reabsorbing and the skin was intact. The March 2016 TAR revealed the resident was to have a knee immobilizer on the right leg at all times until 03/24/16 and the skin was to be checked and the knee immobilizer reapplied every shift. There was no documentation in the progress notes or the TAR of the condition of the skin every shift. On 04/02/16, the risk and benefits were discussed with the resident due to not wearing the sage boots at all times. The resident agreed to have the right sage boot on when in bed at all times and when up as tolerated. On 04/04/16, the right heel pressure ulcer had resolved. On 04/06/16, the stage II pressure ulcer to the right calf measured 2 cm x 1.5 cm x 0.2 cm. The second open area size had not changed. On 04/12/16, the second open area had resolved. On 04/24/16 the resident refused to wear the sage boots. There was no documentation on the TAR reflecting the resident refused either intervention. Review of the nursing progress notes from 02/29/16 to 05/24/16 revealed the resident refused to be repositioned twice on 03/03/16, refused to wear the right knee immobilizer on 03/25/16 and refused to wear the sage boots on 04/24/16. Review of the March to May 12th TAR revealed the resident was to have a heel lift in place when in bed and sage boot worn at all times. On 05/04/16, the stage II right calf pressure ulcer measured 0.3 cm x 0.4 cm x 0.2 cm. On 05/12/16, an order was received to wear the sage boots only when in bed. There was no documentation on the May TAR indicating the resident had refused to wear the sage boots. In an observation on 05/22/16 at 2:45 PM, the resident was lying in bed. There was no heel lift or sage boots in place. In an observations on 05/23/16 at 7:30 AM, 9:00 AM, 10:03 AM, 10:30 AM and 1:00 PM, the resident was lying in bed. There was no heel lift or sage boots in place. In observations on 05/24/16 and 05/25/16, the resident was observed to not have the heel lift or sage boots in place. In an interview on 05/24/16 at 7:55 AM, the resident stated she had a blister on the back of her right calf that had ruptured and was currently being treated. The resident was not sure how she obtained the blister but thought she developed the blister at the facility. The resident stated she developed another open area beneath the current area on her calf, but it had since healed. The resident further stated she had developed an issue on her right heel that nursing staff had monitored and had taken pictures. The resident stated the area had since been healed. On 05/26/16 at 7:30 AM with Staff R, wound nurse, Resident 107's right calf wound was observed. The pressure ulcer was healed. The center of the healed ulcer was indented. Staff R stated there was no change in prior assessments of the area. Staff R stated the resident was admitted with a right calf blister. Staff R was not able to state how the resident obtained the blister. Staff R stated the blister was monitored weekly and documentation was located on the TAR. Staff R was not able to state how the MDS nurse coded the MDS when an assessment was due, but did communicate with the MDS nurse when needed on the progress of a resident's wounds. Staff R stated that on 03/26/16 the resident had developed a blister to the right heel. The blister was further identified as a suspected deep tissue injury and was monitored bi-weekly in the Wound Round notes. Staff R did not identify the knee immobilizer as a potential cause to the two right calf pressure ulcers. On 05/26/16 at 8:40 AM, Staff S, Nursing Assistant (NA), stated the resident required total assistance for dressing needs which included placing on the right AFO brace. The resident used the sage boots when up in the chair. Staff S stated the resident did not use the heel lift when in bed but preferred pillows to help keep her heels off the bed. Staff S stated the resident was cooperative with care. On 05/26/16 at 8:45 AM, Staff T, Physical Therapist, and Staff U, Physical Therapy Assistant, stated the resident had admitted with a right knee immobilizer. When the resident was admitted the right knee immobilizer was to be worn at all times. The hospital had padded the bottom portion of the knee immobilizer prior to admission. Staff U stated two therapists were always present when the knee immobilizer was adjusted. Staff U stated the immobilizer would turn inward and needed to be repositioned. Both staff were aware Resident 107 had a ruptured blister on the right upper calf. On 05/26/16 at 9:02 AM, Resident 107 stated she used to have to wear a knee immobilizer all the time, but not any longer. Resident 107 stated she had to wear those moon boots at night and eventually I was able to only wear one boot. The resident stated she had not worn the moon boots for about two weeks. The heel lift was observed to be on a chair in the resident's room. Resident 107 stated she had not worn the heel lift for several weeks. On 05/26/16 at 9:32 AM, Staff F, LN, stated the resident was admitted with a blister on the right calf. This was treated by the treatment nurse. Staff F did not change the dressing to the right calf because there was a treatment nurse seven days a week. Staff F stated when a resident refused a treatment she would circle it on the TAR and document on the back of the TAR or in the nursing progress notes the refusal. Staff F stated the NA alerted her of the pressure ulcer on the resident's right heel. Staff F initiated sage boots at that time. Staff F stated the resident did consistently use the boots but there was a time she did not use and was educated on the risk and benefits. The boots were still in place and the resident was encouraged to use. Staff F was made aware the boots were not observed to be in place on all days of the survey. Staff F was not able to provide any further information. On 05/26/16 at 10:15 AM, Staff T and Staff U placed the knee immobilizer on the resident's right leg. The bottom part of the immobilizer was noted to line up with where the resident's right calf wound was located. The resident stated the immobilizer did slide down her leg at times On 05/26/16 at 10:33 AM, the Director of Nursing Services (DNS) stated the LNs performed weekly skin assessments and documented a narrative on the back of the TAR. The LN was expected to document on the TAR or in the nursing progress notes when a resident refused a treatment or intervention. The DNS stated Resident 107 was known to remove the boots or heel lift when staff left the room and then placed them back on when staff was coming back in. When asked how Resident 107 was able to place the boots on and off or removed the heel lift from the bed when she required total assistance for lower body dressing, the DNS stated the resident did do this all the time. The DNS stated the resident was informed of the risk and benefits of not wearing the sage boots on 04/02/16. The DNS stated alternative interventions were not attempted since this was the first time the resident was educated on the risk and benefits. The DNS was made aware the TAR's and progress notes did not reflect the resident refused the sage boots frequently. The DNS was not able to offer any further information. On 05/26/16 at 12:16 PM, Staff V, LN, stated the resident was admitted with a blister to the right calf. The resident had a brace on the right knee and this caused friction, the blister opened up and at one point there were two open areas. The brace was adjusted and repositioned. The second open area heeled quickly. The resident was compliant with wearing the boots through the healing process. If the resident did refuse to wear the boot, the LN would circle this on the TAR and documented the refusal on the back of the TAR. On 05/27/16 at 7:32 AM, Resident 107 stated she needed one person to dress her lower body. Resident 107 stated she was not able to remove the boots or heel lift without assistance.