Every finding on record at Bellevue Post Acute

Based on observation, interview, and record review, the facility failed to ensure dietary needs and preferences were provided for 4 of 5 residents (Residents 3, 4, 5 & 6), reviewed for food preferences. This failure placed residents at risk for dissatisfaction with food, weight loss, and a diminished quality of life.Findings included .Review of the facility's policy titled, Food and Nutrition Services, revised in October 2017, showed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Reasonable efforts will be made to accommodate resident choices and preferences.Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.RESIDENT 3In an interview on 07/23/2026 at 9:27 AM, Resident 3 expressed their concerns regarding meal accuracy. Resident 3 stated their breakfast menu ticket for that day showed scrambled eggs, bacon, a cinnamon roll, and fruit. However, they were served pancakes and sausages instead. Resident 3 further stated they did not believe the kitchen staff reviewed the menu tickets when preparing food.Observation on 07/23/2026 at 12:00 PM, revealed that the lunch menu posted in the first-floor main dining room listed baked cheese lasagna, capri vegetable blend, garlic bread, frosted gelatin pork cake, milk, and beverages.Observation on 07/23/2026 at 12:01 PM, showed that the first-floor tray carts were delivered to the floor, and staff were observed distributing the trays to residents' rooms. At 12:57 PM, Resident 3 had not yet received their lunch.During a joint observation and interview on 07/23/2026 at 1:07 PM, Staff G, Certified Nursing Assistant (CNA), was observed delivering a lunch tray to Resident 3's room. Observation showed that Resident 3 was served grilled cheese sandwiches and zucchini, and there was no meal ticket on the tray. Staff G stated that Resident 3's lunch had not been sent from the kitchen, requiring them to return to the kitchen to get it. When asked how they verified that this was the correct meal for the resident, Staff G stated, I do not know. Resident 3 was asked if they had requested the lunch menu that was served to them, Resident 3 stated, I did not request or order this.RESIDENT 4A review of Resident 4's breakfast meal ticket titled, Breakfast - day 12 7/24/2026 [07/24/2026] - Fri [Friday] showed that scrambled egg and sausage patty were crossed out on the resident's menu ticket. Further review of the ticket indicated that egg was listed under Resident 4's dislikes.During a joint observation and interview at the facility's kitchen breakfast tray line on 07/24/2026 at 7:44 AM, Staff K, Dietary Aid, was observed placing Resident 4's meal ticket onto a tray containing scrambled eggs. Staff K then placed the tray into a tray cart that was ready for delivery to the unit. When Staff D, Dietary Manager, was asked about Resident 4's meal ticket and the breakfast tray with scrambled eggs, Staff D stated that the scrambled eggs were crossed out on the ticket. Staff D further stated that the resident frequently changes their preference, and stated, I can't keep up with [Resident 4] likes and dislikes.A review of Resident 4's lunch meal ticket titled, Lunch - day 19 7/30/2026 [07/30/2026] - Thu [Thursday] showed that Orange Glazed Chicken Breast was crossed out on the resident's menu ticket. Further review of the ticket menu indicated that chicken was listed under Resident 4's dislikes.In an interview on 07/30/2026 at 12:20 PM, Resident 4 stated that the facility was not following their food preferences. Resident 4 stated that staff frequently delivered food items they disliked. When asked about the most recent occurrence of this issue, Resident 4 stated, Today they sent me chicken for lunch.A joint observation and interview on 07/30/2026 at 12:24 PM, showed Staff J, CNA, removing a lunch tray from Resident 4's room. Observation showed an untouched chicken breast remaining on the resident's tray. Staff J stated that the chicken breast was crossed out on the meal ticket and listed as dislikes and that Resident 4 should not have received it.RESIDENT 5A review of Resident 5's breakfast meal ticket titled, Breakfast - day 12 7/24/2026 [07/24/2026] - Fri [Friday] showed that Chef's Choice Fruit was listed under the resident's breakfast menu.During a joint observation and interview at the facility's kitchen breakfast tray line on 07/24/2026 at 7:48 AM, Staff K placed Resident 5's tray into a tray cart that was ready for delivery to the unit without adding fruit to the breakfast tray. When asked why Resident 5 was not served fruit, Staff K stated, I do not have fruit for everybody.RESIDENT 6A review of Resident 6's breakfast meal ticket titled, Breakfast - day 12 7/24/2026 [07/24/2026] - Fri [Friday] showed that scrambled egg and bacon were crossed out on the resident's menu ticket. Further review of the ticket indicated that bacon and eggs were clearly listed under Resident 6's dislikes.During a joint observation and interview at the facility's kitchen breakfast tray line on 07/24/2026 at 7:52 AM, Staff L, Dietary Aid, was observed placing Resident 6's meal ticket onto a tray containing scrambled eggs and bacon. Staff L then placed the tray into a tray cart that was ready for delivery to the unit. When the staff was asked regarding Resident 6's meal ticket, Staff L stated that the bacon and scrambled eggs were crossed out on the ticket.In an interview on 07/30/2026 at 11:07 AM, Resident 6 stated that the facility was not following their dietary preferences. Resident 6 stated that they could not eat scrambled eggs and bacon due to their medical condition, but the facility continued to serve them for breakfast. Resident 6 further stated that this had occurred several times.In an interview on 07/23/2026 at 1:26 PM, Staff E, Lead Cook, stated that dietary staff did not follow the meal tickets during the tray line. Staff E further stated that there were multiple concerns within the dietary department and that multiple staff members have expressed these issues to Staff D, who was aware of the concerns.In an interview on 07/24/2026 at 9:02 AM, Staff H, CNA, stated that residents occasionally reported that the meals they received did not match with the items listed on their meal tickets.In an interview on 07/24/2026 at 9:12 AM, Staff I, CNA, stated that there have been several incidents where residents reported they did not receive their meals according to their meal tickets. Staff I further stated that this had occurred multiple times.In an interview on 07/30/2026 at 11:48 AM, Staff D stated that they would expect dietary staff to read the meal tickets, follow the documented preferences, and serve food appropriate for the resident's prescribed diet, texture, and preferences. Staff D stated that if a food item was crossed out on the meal ticket, it meant that the item should not be sent to the residents. Staff D further stated that certain dietary staff required additional training, and that the facility was conducting further education to improve their accuracy.In an interview on 07/30/2026 at 1:55 PM, Staff A, Administrator, stated that they would expect dietary staff to do their best to honor resident preferences and to serve food according to the meal ticket.Reference: (WAC) 388-97-1120 (3)(a).

Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 4 residents (Resident 1), reviewed for incident investigations. This failure placed residents at risk for repeated incidents, inappropriate corrective actions, and unrecognized abuse/neglect.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. 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. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect.Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2024, showed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Review of the admission record printed on 07/23/2026 showed Resident 1 was admitted to the facility on [DATE].Review of the admission Minimum Dat Set (an assessment tool) dated 06/25/2026 showed Resident 1 had intact cognition.Review of the investigation report dated 06/26/2026 showed that Resident 1 and their collateral contact reported an unwitnessed fall.Review of the progress note dated 07/17/2026 showed that Resident 1 left the facility with their collateral contact. Upon return, the collateral contact reported that Resident 1 experienced a fall at their home.Review of the June 2026 and July 2026 incident report log showed no incident was logged for Resident 1's fall incident dated 06/26/2026 or 07/17/2026.In an interview on 07/24/2026 at 10:16 AM, Staff F, Registered Nurse, stated that if a resident self-report a fall incident, a facility investigation would be completed.In an interview on 07/30/2026 at 11:01 AM, Staff C, Charge Nurse, stated that if a resident self-report a fall incident, the resident and any witnesses were interviewed, the attending physician would be notified, the resident would be assessed for injury, and an investigation would be completed.In an interview and joint record review on 07/30/2026 at 11:08 AM, Staff B, Director of Nursing, stated that the purpose of an incident investigation was to determine if the event must be reported to the state, identify the root cause, maintain resident safety, and rule out any abuse or neglect related to the incident. A joint record review of the progress note dated 07/17/2026 showed that Resident 1's collateral contact reported that Resident 1 experienced a fall at their home. Staff B stated that they were unaware of the fall reported on 07/17/2026, noting that this incident should have been investigated. A joint record review of the June 2026 and July 2026 incident log showed no entries for the fall incidents on 06/26/2026 or 07/17/2026. Staff B stated, I do not see these falls on the incident log, and that they should have been recorded. When asked if abuse/neglect was ruled out with Resident 1's fall incident on 07/17/2026, Staff B stated, We do not know because we did not investigate the incident.In an interview on 07/30/2026 at 1:55 PM, Staff A, Administrator, stated that all falls should be investigated.Reference: (WAC) 388-97-0640 (6)(a)(c).

Based on interview and record review, the facility failed to notify the physician of abnormal vital signs (measurements of the body's most basic functions [temperature, blood pressure]) for 1 of 3 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk for unrecognized medical complications, unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Acute Condition Changes - Clinical Protocol, revised in March 2018 showed, The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example.someone with unstable vital signs. The policy further showed, Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident.and how to communicate these changes to the Nurse.Review of Resident 1's May 2026 temperature log showed the following temperatures, which indicated hypothermia (a condition that occurs when the body temperature drops below 95.0 Fahrenheit [ F -temperature scale]):-On 05/02/2026, temperature was 94.7 F and 94.9 F.-On 05/5/2026, temperature was 86.8 F.-On 05/06/2026, temperature was 86.5 F.-On 05/10/2026, temperature was 86.4 F.-On 05/17/2026, temperature was 94.6 F.-On 05/21/2026, temperature was 86.8 F.-On 5/22/2026, temperature was 86.9 F.-On 05/23/2026, temperature was 86.4 F.-On 05/24/2026, temperature was 85.7 F.-On 05/25/2026, temperature was 94.6 F.-On 05/26/2026, temperature was 94.5 F.-On 05/27/2026, temperature was 86.6 F.Review of Resident 1's May 2026 blood pressure (BP) log showed the following, which indicated hypotension (low BP with a reading that is less than 90/60 millimeters of mercury [mmHg-a unit of pressure]):-On 05/03/2026, BP was 85/48 mmHg.-On 05/04/2026, BP was 88/54 mmHg.-On 05/08/2026, BP was 87/53 mmHg.-On 05/13/2026, BP was 87/63 mmHg.-On 05/17/2026, BP was 84/52 mmHg.-On 05/24/2026, BP was 88/65 mmHg and 86/57 mmHg.-On 05/25/2026, BP was 79/51 mmHg and 75/48 mmHg.-On 05/26/2026, BP was 86/55 mmHg.-On 05/27/2026, BP was 73/47 mmHg.Review of a physician progress note dated 05/21/2026, showed Staff D, Medical Director, documented that Resident 1's temperature was 86.8 F on 05/21/2026 at 9:25 AM.Review of a nursing progress note dated 05/27/2026 showed that Resident 1 was sent to the hospital from the emergency room from their appointment due to altered mental status and low BP.Review of Resident 1's hospital note dated 05/27/2026 showed that they were at the clinic where they were noted to be altered from their baseline and sent to the emergency department for further evaluation. The hospital notes further showed that Resident 1 was found to be hypothermic to 82.4 F by EMS [Emergency Medical Services] and that they were admitted to the MICU [Medical Intensive Care Unit- a specialized unit for patients with severe, life threatening medical conditions that require continuous monitoring and non surgical critical care] for further evaluation and management.Review of Resident 1's physician orders printed on 06/01/2026 showed no interventions to manage their low temperature and low BP.In an interview and joint record review on 06/03/2026 at 11:06 AM, Staff A, Certified Nursing Assistant (CNA), stated that they received training on how to take vital signs and that they took residents' vital signs in the morning and as needed. Staff A stated that the normal range for vital signs were a temperature of 98.6 F, BP of 120/80 mmHg, pulse (heart rate) of 60 to 100 beats per minute, and a respiratory rate of 16 to 20 breaths per minute. Staff A stated that if the resident's vital signs were abnormal, they would retake their vital signs and that if their vital signs continued to be abnormal, they would notify the nurse. Staff A stated that the nurse would then retake the resident's vital signs. A joint record review of Resident 1's vital signs on 05/27/2026 showed a temperature of 86.6 F and a BP of 73/47 mmHg. Staff A stated that they had notified Staff B, Registered Nurse, of Resident 1's vital signs and that Resident 1 always runs a lower blood pressure and lower body temperature and that they were not alarmed because Resident 1 always had low temperatures and BPs.In an interview on 06/03/2026 at 12:52 PM, Staff B stated that if a resident's vital signs were abnormal, they would have expected the CNAs to notify them. Staff B stated that they would recheck the vital signs and if it remained out of parameter, they would notify the physician. Staff B stated that they were Resident 1's nurse on 05/27/2026 and that they were not aware that Resident 1 had a temperature of 86.6 F and a BP of 73/47 mmHg. Staff B stated that Staff A did not notify them and that Resident 1's temperature and BP were out of parameter and that if they knew, they would have rechecked Resident 1's vital signs. Staff B stated that they did not notify the physician because they were not notified of Resident 1's abnormal vital signs. Staff B stated that if they were notified, Resident 1 would not have gone to their appointment and that they would have spoken to the physician about it. When asked if they were aware that Resident 1 was having low temperatures and low BP, Staff B stated that Resident 1's baseline temperature was around 96.0 F and a BP of 95/58 mmHg. Staff B stated that they were not aware that their temperatures were in the 80's [ F] and that their BPs were in the 70's to 80's mmHg. Staff B stated that a temperature below 95.0 F was serious and that Staff A should have notified them. When asked if Resident 1 had interventions in place to address temperatures below 95.0 F, Staff B stated that they would provide the resident with warm blankets and if the room was cold, they would notify maintenance. When asked if Resident 1 had physician orders for these interventions, Staff B stated that it was for any residents and that it was general care.In an interview and joint record review on 06/03/2026 at 1:44 PM, Staff C, Assistant Director of Nursing, stated that they were not aware that Resident 1 had abnormal temperatures and BPs. In a joint record review of Resident 1's May 2026 temperatures and BPs showed temperatures below 95.0 F and BPs below 90/60 mmHg. Staff C stated that they were not aware. When asked if there were any monitoring or interventions in place to manage their abnormal temperatures and BPs, Staff C stated that they did not know. Staff C stated that the primary nurse should have been alerted on Point Click Care (PCC-charting system) that Resident 1's vital signs were out of range and to notify the provider. In a follow-up interview at 3:30 PM, Staff C stated that they considered a temperature of 86.6 F and BP of 73/47 mmHg a change in condition that required provider notification if after staff reassessed the resident's vital signs and continued to be out of range. Staff C stated that they considered it an urgent matter that would require staff to call the provider and notify them. Staff C stated that on 05/27/2026, they would have expected the CNA to notify the nurse, the nurse to reassess and check Resident 1's vital signs manually and that if it continued to be out of range, they would have expected the nurse to notify the physician. Staff C further stated that they would have canceled Resident 1's appointment, notified the provider, and if the provider wanted to send them out, they would have sent Resident 1 out [to the hospital].In an interview and joint record review on 06/04/2026 at 10:16 AM, Staff D stated that if residents' had abnormal vital signs, they would expect staff to report it to them. When asked if they were aware that Resident 1 had temperatures as low as in the 80's F and BPs as low as 73/47 mmHg, Staff D stated that they were not aware. Staff D stated that they were aware that Resident 1 had low BPs and that it was stable. When asked what interventions were in place, Staff D stated that they were monitoring and increasing Resident 1's oral intake. When asked if there was a physician order, Staff D stated that they remembered giving a verbal order, but not in PCC. A joint record review of Staff D's progress note dated 05/21/2026 showed that Resident 1's temperature was 86.8 F on 05/21/2026 at 9:25 AM. Staff D stated that interventions were not in place for Resident 1's low temperature because if a resident had abnormal vital signs, they would have expected staff to notify them and that they did not pay attention to Resident 1's temperature because nobody alerted them. Staff D stated, If there's [there is] low vitals [signs], [the] patient would not be stable at all. In a joint record review of Resident 1's vital signs on 05/27/2026 showed a temperature of 86.6 F and BP of 73/47 mmHg. Staff D stated that they were not notified. Staff D stated that Resident 1's temperature definitely is abnormal and that staff should have notified them. Staff D stated that it's [it is] hypothermia by definition and that if they were notified, they would have sent Resident 1 out [to the hospital]. Staff D further stated that Resident 1 had a change in condition and that staff should have notified them about it.In an interview and joint record review on 06/04/2026 at 11:52 AM, Staff E, Director of Nursing, stated that if a resident had an abnormal vital sign, they would expect the CNA to notify their nurse on the floor and the nurse would recheck to verify the vital signs were accurate, and if they were accurate, the nurse should notify the provider ASAP [as soon as possible]. In a joint record review of Resident 1's May 2026 temperature and BP log showed temperatures below 95.0 F and BPs below 90/60 mmHg. Staff E stated that Resident 1's abnormal vital signs should have been reported immediately. When asked if they were aware that Resident 1 had temperatures as low as in the 80's and BPs as low as 73/47 mmHg, Staff E stated that they did know until they got the word that Resident 1 had been sent out to the hospital from their appointment. When asked if there were any interventions to address their low temperatures and BP, Staff E stated that the provider was aware of Resident 1's low BP and that Resident 1 had been hypotensive. Staff E stated that they were not aware of Resident 1's vital signs on 05/27/2026 and how low it was. Staff E stated that there were no interventions in place to manage it and that there should have been. Staff E stated that they expected the CNA to recheck Resident 1's vital signs and notify the nurse. Staff E stated that they expected the nurse to recheck Resident 1's vital signs manually and if they were out of parameters, they would have expected the nurse to notify the physician and follow their orders. Staff E further stated that they were sure that Staff D would have sent her out 911 [emergency number]. Reference: (WAC) 388-97-1060 (1).

Based on interview and record review, the facility failed to designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the facility's infection prevention and control program. This failure placed the residents, staff, and visitors at risk for unmet infection control issues and lack of oversite of infection control practices.Findings included.Review of the facility's policy titled, Infection Prevention and Control Program, revised in October 2018, showed that The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist), or designee.In an interview on 01/05/2026 at 9:03 AM, Staff A, Administrator, stated that the facility did not currently have an IP and that Staff B, Director of Nursing, was responsible and was not certified.In an interview on 01/09/2026 at 1:48 PM, Staff B stated that they were responsible for the facility's infection prevention and control program. Staff B stated that they did not have specialized training in infection prevention and control and were not certified. Staff B further stated that absolutely, the facility should have a qualified IP.In an interview on 01/10/2026 at 1:54 PM, Staff A stated that there should have been a certified IP responsible for the facility's infection prevention and control program.Reference: (WAC) 388-97-1620 (2)(b)(i)(ii).

Based on observation, interview, and record review the facility failed to provide appropriate infection surveillance for 5 of 6 months (July 2025, August 2025, September 2025, October 2025 & November 2025), reviewed for infection control. Additionally, the facility failed to ensure proper sanitization of vital sign (measurements of the body's essential functions) equipment were conducted by 1 of 2 staff (Staff Y), reviewed for medical equipment use, and failed to clean insulin (a medication that helps regulate blood sugar levels) pens (device used to inject insulin) prior to administration for 1 of 1 resident (Resident 4), reviewed for insulin administration. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.CLEANING OF INSULIN PENSRESIDENT 4Review of the manufacturer's recommendations titled, Insulin Aspart (rapid-acting insulin) Injection, revised in February 2023, showed, Pull of the pen cap. Wipe the rubber stopper with an alcohol swab. Remove the protective tab from a disposable needle. Screw the needle tightly onto your FlexPen [brand of pre-filled insulin pen]. Review of the manufacturer's recommendations titled, How to Use Your Lantus (or Glargine - long-acting insulin) Solostar Pen [brand of pre-filled insulin pen], dated August 2022, showed, Remove the pen cap with clean hands.Wipe the pen tip (rubber seal) with an alcohol swab. Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on. Observation on 01/09/2026 at 8:04 AM showed Staff I, Registered Nurse, was preparing Resident 4's insulin pens. Staff I removed the cap from Resident 4's insulin aspart pen and placed a new pen needle in. Staff I, then removed the cap from Resident 4's insulin glargine pen and placed a new pen needle in. Staff I did not clean Resident 4's insulin aspart and insulin glargine pen rubber seal with alcohol pads before placing the new needles onto the insulin pens. Staff I administered both aspart and glargine insulins to Resident 4. In an interview on 01/09/2026 at 9:33 AM, Staff I stated they would clean the insulin pen rubber seal before placing the new needles in. Staff I stated they should have cleaned [wiped] Resident 4's insulin pens' rubber seals with alcohol swabs before connecting the pen needles. A joint record review and interview on 01/10/2026 at 1:43 PM with Staff C, Charge Nurse, showed the manufacturer's recommendations for both, insulin aspart and insulin glargine pen, showed an instruction to wipe the [insulin pen] rubber stopper/seal with alcohol swab before placing/screwing a new needle onto the insulin pens. Staff C stated that the facility would follow the manufacturer's recommendations. Staff C further stated that staff [Staff I] should have wiped Resident 4's insulin pens' rubber seals with alcohol swab before connecting the pen needles. In an interview on 01/10/2026 at 2:08 PM, Staff B stated they expected insulin pens' rubber seals to be wiped with alcohol swab before placing new needles in. Staff B further stated that staff [Staff I] should have wiped Resident 4's insulin pens' rubber seals with alcohol swabs before connecting new pen needles. Reference: (WAC) 388-97- 1320 (1)(a)(5)(c). Findings included. INFECTION SURVEILLANCEReview of the facility's policy titled, Infection Prevention and Control Program, revised in October 2018, showed that Surveillance tools are used for recognizing the occurrence of infections, recording their number, and frequency, detecting outbreaks and epidemics [the rapid, unexpected spread of a disease].and detecting unusual pathogens [an agent that can cause disease] with infection control implications. It further showed that Data gathered during surveillance is used to oversee infections and spot trends. Review of July 2025 through December 2025 infection line listing (a template for data collection and tracking of infections) showed no documentation of infections from July 2025 through November 2025. Review of a nursing progress note, dated 07/03/2025, showed Resident 78's chest x-ray (a type of medical imaging that takes pictures inside the body) results were given to the physician, and antibiotic orders were ordered for pneumonia (lung infection). Review of Resident 64's laboratory results report, dated 07/30/2025, showed Resident 64 was positive for Klebsiella pneumoniae (a bacteria that can cause serious infections). In an interview on 01/09/2026 at 1:48 PM, Staff B, Director of Nursing, stated that they did not have a surveillance plan for identifying, tracking, or monitoring infections prior to December 2025, but we do now. When asked if there had been any infections in the facility from July 2025 through November 2025, Staff B stated, of course. When asked if those infections should have been on the infection line listing, Staff B stated, yes, absolutely. SANITIZATION OF MEDICAL EQUIPMENTSTAFF YObservation on 01/08/2026 at 8:55 AM showed Staff Y, Certified Nursing Assistant, took the vital signs for Resident 11. Then, Staff Y took the vital sign equipment into Resident 67's room and took their vital signs. Staff Y then took the vital sign equipment into the lounge and took Resident 57 and Resident 21's vital signs. Staff Y took the vital sign equipment into the hallway and took Resident 32's vital signs. Staff Y did not sanitize/disinfect the vital sign equipment between resident use. In an interview on 01/08/2026 at 9:12 AM, Staff Y stated that they were supposed to be [sanitizing the vital sign equipment] between residents. Staff Y further stated that they had not sanitized the vital sign equipment between residents and stated, it was my mistake. In an interview on 01/09/2026 at 1:48 PM, Staff B stated they expected staff to sanitize vital sign equipment before and after use on residents.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required 12 hours of training, and/or include abuse/neglect, and dementia (memory loss) management training annually for 3 of 6 staff (Staff M, S & T), reviewed for sufficient and competent nurse staffing. This failure placed the residents at risk for unmet care needs and potential negative outcomes.Findings included.Review of the facility's assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents), updated on 10/14/2025, showed, Required in-service training for nurse aides. In service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training.STAFF MReview of the undated facility's employee record for Staff M, CNA, showed they were hired on 06/19/2023. It further showed no documentation that Staff M received the required 12 hours of annual training.STAFF SReview of the undated facility's employee record for Staff S, CNA, showed they were hired on 11/20/2024. It further showed no documentation that Staff S received the required 12 hours of annual training, including abuse and neglect, and dementia management training.STAFF TReview of the undated facility's employee record for Staff T, CNA, showed they were hired on 07/20/2023. It further showed no documentation that Staff T received the required 12 hours of annual training, including abuse and neglect, and dementia management training.In an interview and joint record review on 01/09/2026 at 3:48 PM, Staff E, Staffing Coordinator, stated that CNAs needed 12 hours of training annually that included abuse/neglect and dementia training. A joint record review of Staff M's employee record showed they received 6.25 hours of training. A joint record review of Staff S's employee record showed they received 5.15 hours of training and did not include abuse/neglect and dementia training. A joint record review of Staff T's employee record showed they received 7.35 hours of training and did not include abuse/neglect and dementia training. Staff E stated Staff M, Staff S, and Staff T did not have 12 hours of annual training as required and that Staff S and Staff T did not have abuse/neglect and dementia training and that they should have.On 01/10/2026 at 9:56 AM, Staff B, Director of Nursing, stated they would expect CNAs to have 12 hours of training annually and would expect to include abuse/neglect and dementia training upon hire. Staff B further stated that Staff M, Staff S, and Staff T should have had 12 hours of training and may have received it prior to their administration and would say it would be doubtful to provide those things.Reference: (WAC) 388-97-1680(2)(a)-(c).

Based on interview and record review, the facility failed to consistently follow an established Antibiotic (antimicrobial substance/medication to treat/prevent infections) Stewardship Program (to promote the appropriate use of antibiotics) and complete monthly surveillance for 5 of 6 months (July 2025, August 2025, September 2025, October 2025 & November 2025), reviewed for antibiotic stewardship program. In addition, the facility failed to ensure appropriate antibiotic use were followed for 1 of 4 residents (Resident 3), reviewed for unnecessary medication. These failures placed residents at risk for potential adverse outcomes associated with inappropriate/unnecessary use of antibiotics and an increased risk for multi-drug-resistant organisms (microscopic organisms that are resistant to many antibiotics).Findings included. MONTHLY SURVEILLANCEReview of the facility's policy titled, Antibiotic Stewardship, revised in December 2016, showed, The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Review of the facility's policy titled, Infection Prevention and Control Program, revised in October 2018, showed that Antibiotic usage is evaluated and practitioners are provided feedback on [antibiotic usage] reviews. Review of July 2025 through December 2025 infection line listing (a template for data collection and tracking of infections) showed no documentation of infections or antibiotic use from July 2025 through November 2025. Review of a nursing progress note dated 07/03/2025, showed that Resident 78 was started on Augmentin (antibiotic) and Doxycycline (antibiotic) for Klebsiella pneumoniae (a bacteria that can cause serious infections). Review of a nursing progress note dated 07/29/2025, showed that Resident 64 was started on Macrobid [antibiotic] for UTI [Urinary Tract Infection-infection of the bladder]. Review of a nursing progress note dated 11/17/2025, showed that Resident 68's urine analysis or lab [laboratory-a facility where tests are conducted on specimens to obtain information about a resident's health, aiding diagnosis, treatment and prevention of a disease] result came back and Augmentin was ordered. In an interview on 01/09/2026 at 1:48 PM, Staff B, Director of Nursing, stated that the facility had not been formally tracking antibiotic use before December [2025]. When asked if there had been any residents on antibiotics from July 2025 through December 2025, Staff B stated, absolutely. When asked if those antibiotics had been tracked, Staff B stated, from July [2025] to December [2025], I can't [cannot] speak to that, now it will be on the [infection] line listing. Staff B further stated that antibiotic use had not been reviewed/discussed at the facility's QAPI (Quality Assurance Performance Improvement) meetings, it wasn't [was not] one of our focuses. RESIDENT 3Review of the facility's policy titled, Antibiotic Stewardship – Orders for Antibiotics, revised in December 2016, showed, When a culture and sensitivity (C&S [a lab procedure used to identify specific microorganisms, such as bacteria or fungi, that cause an infection and determine which medications will be most effective for treatment]) is ordered, it will be completed, and: Lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of Resident 3's physician orders printed on 01/09/2025 showed the following orders:-Urinalysis (urine test), C&S if indicated. STAT [immediately] for hematuria [blood in the urine], possible for UTI with an order date of 12/31/2025.-Bactrim DS (antibiotic) oral tablet. Give 1 tablet by mouth two times a day for UTI for seven days with an order date of 01/05/2026. Review of Resident 3's urinalysis lab results report dated 01/01/2026 did not show C&S results or documentation that the results were pending. In an interview and joint record review on 01/09/2026 at 8:12 AM, Staff K, Registered Nurse, stated that Resident 3 was started on an antibiotic due to confusion and hematuria. A joint record review of Resident 3's urinalysis lab results dated 01/01/2026 did not show the C&S results or documentation that the results were pending. Staff K stated that they did not see it and that the results may be pending. Staff K further stated that sometimes the physician would start an antibiotic and would review it when they received the C&S results. In a joint record review and interview on 01/09/2026 at 8:39 AM with Staff C, Charge Nurse, showed a physician order for urinalysis with C&S if indicated on 12/31/2025. A joint record review of Resident 3's urinalysis lab results dated 01/01/2026 did not show C&S results or documentation that the results were pending. Staff C stated they did not know what happened and would call the lab and clarify. When asked if residents were started on antibiotics prior to getting the C&S results, Staff C stated, Sometimes, yes and that it depended on the resident's condition. Staff C further stated that when they received the C&S results, the physician would review it and would make changes to the residents' antibiotics as needed. In an interview on 01/09/2026 at 11:24 AM, Staff P, Medical Director, stated that if a resident had symptoms of UTI, they would start with a urinalysis C&S if indicated and that they would not start treatment without it. Staff P stated that C&S took 48 to 72 hours to complete. They would start a broad-spectrum antibiotic and then based on the C&S results, they would review it and see if the resident needed to start a new treatment or if the treatment needed to be changed. Staff P stated that if the urinalysis was positive for infection, they would have expected C&S to have been completed. Staff P further stated that they were waiting for Resident 3's C&S result, stating, It didn't [did not] show up and that it should have been completed. In an interview on 01/09/2026 at 1:35 PM, Staff B stated that they expected urinalysis C&S to be completed if it was indicated. Staff B stated that they should get the C&S result back within 72 hours and that if they did not get the results back within 72 hours, staff should call the lab. Staff B further stated that Resident 3's urinalysis C&S should have been completed. Reference: (WAC) 388-97-1620 (2)(b)(i)(ii)

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the Infection Preventionist (IP), to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities. This failure minimized the effectiveness of the interdisciplinary QAA team's ability to identify processes and outcomes related to infection control practices and disease management.Findings included .Review of the document provided by the facility on 01/05/2026 titled, QAA Committee Information, showed the committee met on a weekly basis in the facility conference room and consisted of the Administrator, Director of Nursing (DON), Medical Director, Social Services Director, Case Manager, Therapy Consultant, Charge Nurse, MDS (Minimum Data Set-an assessment tool) Director, Registered Dietitian, and Dietary Director. The document did not show that an IP was included in the QAA committee. Review of the facility's QAPI agenda/minutes dated 11/19/2025, showed a QAPI meeting was held. The minutes did not show that an IP attended the meeting. On 01/10/2026 at 10:05 AM, Staff B, DON, stated that there had not been an IP at their facility and had recently just hired one within the last three days. Staff B stated that they would have expected an IP to be a part of their QAA committee. On 01/10/2026 at 11:26 AM, Staff A, Administrator, stated that an IP was a required QAA committee member and that they did not have one prior and would have expected to have one.Reference: (WAC) 388-97-1620(2)(b)(i).

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 6 Staff (Staff D), 1 of 1 Dry Storage Room, and 2 of 4 Refrigerators (Kitchen Walk-in Refrigerator & First Floor Food Refrigerator), reviewed for food services. The failure to perform hand hygiene, label and discard food items past the use by/best by date, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included. Review of the facility's policy titled, Preventing Foodborne Illness – Food Handling, revised in July 2014, showed, Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Review of the facility's policy titled, Food Receiving and Storage, revised in November 2022, showed, Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). The policy showed, All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). The policy further showed, Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in August 2019, showed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy showed to use an alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap and water for the following situations: before donning (put on) sterile gloves, after removing gloves, before and after eating or handling food. The policy further showed, The use of gloves does not replace hand washing/hand hygiene. HAND HYGIENE Observation on 01/08/2026 at 12:28 PM, showed Staff D, Director of Food Services, entered the kitchen from the dining room and went to their office to answer the phone. When they were done, Staff D went inside the walk-in refrigerator. At 12:30 PM, Staff D came out of the walk-in refrigerator with a bowl, then walked over to the preparation station with the bowl and applied gloves. When Staff D was done in the preparation station, they removed their gloves and gave the bowl to an unknown person that was by the exit door to the dining room. Staff D did not perform hand hygiene when they entered the kitchen, before applying their gloves and after removing their used gloves. In an interview on 01/08/2026 at 12:47 PM, Staff D stated that staff were to perform hand hygiene before/after glove use, after they took the trash out, and before/after entering the kitchen. Staff D stated they were making pureed bread for a resident. Staff D further that they should have performed hand hygiene before they entered the kitchen and before/after glove use. In an interview on 01/09/2026 at 1:25 PM, Staff B, Director of Nursing, stated that they expected dietary staff to perform hand hygiene before/after entering the kitchen, and before/after glove use. DRY STORAGE ROOMObservation of the Dry Storage Room on 01/05/2026 at 8:15 AM, showed the following:-One opened container of vanilla extract with no opened date or used by/expiration date. -One unlabeled plastic bag of croutons with no open or use by date. -One opened container of Kikkoman (brand) Sweet and Sour Sauce with a best by date of 09/26/2025. In an interview and joint observation on 01/05/2026 at 8:35 AM, Staff L, Cook, stated that food items that were past the use by or best by date would be thrown away. Staff L stated that everything that had been opened needed to have an open date and that they would ask Staff D how long it would be good for. A joint observation of the Dry Storage Room showed one opened container of vanilla extract with no opened date and used by/expiration date. Staff L stated that the container did not have an open date and that they could not find an expiration date. Staff L further stated that it should have had an open date. A joint observation showed one unlabeled plastic bag of croutons with no open or use by date. Staff L stated that after a food item was taken out of the original packaging it had to be labeled with the name of the ingredient, the open and use by date. Staff L stated that it should have been labeled and dated once it was opened. A joint observation showed one opened container of Kikkoman Sweet and Sour Sauce with a best by date of 09/26/2025. Staff L stated that it should have been discarded. WALK-IN REFRIGERATORIn a joint observation and interview on 01/05/2026 at 8:39 AM with Staff L, showed the Walk-in Refrigerator had a container of Sweet Baby Rays [brand] Korean Barbeque and Wing Sauce with a best by date of 11/27/2025 and one plastic bag labeled Peperoni [Pepperoni] with a use by date of 12/31/2025. Staff L stated that they should have been discarded. In a follow-up observation on 01/08/2026 at 9:05 AM, the Walk-in Refrigerator had the following:-One plastic container labeled cranberry sauce with a preparation date of 12/13 [12/13/2025] and without use by date. -One container of dill pickles dated 07/01 [07/01/2025] and without a use by/expiration date.-Three unlabeled and uncovered round pizza doughs on a sheet pan.-One unlabeled and uncovered raw chicken on a sheet pan. In an interview and joint observation on 01/08/2026 at 9:15 AM, Staff D stated that large containers were good for 30 days once they were opened. A joint observation showed an opened container of pickles dated 07/01 [07/01/2025]. Staff D stated that it should have been discarded. A joint observation showed one plastic container labeled cranberry sauce with a preparation date of 12/13 [12/13/2025] and without a use by date. Staff D stated it was good for seven days and that it should have been discarded. A joint observation showed three unlabeled and uncovered round pizza dough and one unlabeled and uncovered raw chicken on a sheet pan. Staff D stated that the pizza dough and raw chicken should have been covered and labeled when it was pulled [out of the freezer]. In an interview on 01/10/2026 at 9:04 AM, Staff A, Administrator, stated that if food items were past the use by/expiration date, they expected staff to throw it away. Staff A stated that food items should be labeled and dated. Staff A further stated that they expected staff to perform hand hygiene as required and to follow their hand hygiene protocol. FIRST FLOOR FOOD REFRIGERATORA joint observation and interview on 01/08/2026 at 3:41 PM with Staff C, Charge Nurse, showed the First-Floor Food Refrigerator had six unopened half pints of 2% (percent) milk cartons with best by date of 01/06 [01/06/2026]. Staff C stated that they needed to clarify with the kitchen staff to see if the milk could be given to residents after 01/06/2026. In an interview on 01/08/2026 at 3:45 PM, Staff D stated that the six milk cartons with best by date of 01/06/2026 should have been used by 01/06/2026 or should have been discarded on 01/07/2026. In an interview on 01/10/2026 at 1:05 PM, Staff A stated they expected foods to be stored as regulation requires. Staff A further stated that the milk cartons with best by date of 01/06/2026 in the refrigerator should not be used past 01/06/2026 and that they should have been removed. Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to ensure the menu/meal tickets were followed for 3 of 8 residents (Residents 35, 27 & 32), reviewed for food services. This failure placed the residents at risk for unmet nutritional needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility's policy titled, Food and Nutrition Services, revised in October 2017, showed, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. The policy further showed, If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. RESIDENT 35On 01/06/2026 at 9:33 AM, Resident 35 stated that the dietary staff did not follow their menu/meal ticket. Resident 35 stated that they were supposed to get fruit but didn't [did not] get any. On 01/08/2026 at 8:31 AM, Resident 35 stated that they did not get what was on their menu/meal ticket. Resident 35 stated, I didn't get a fruit cup. Review of Resident 35's menu/meal ticket showed a mixed fruit cup. Observation of their breakfast tray did not have a mixed fruit cup and that they had a plate of half of a banana. In a joint observation and interview on 01/08/2026 at 8:43 AM with Staff M, Certified Nursing Assistant (CNA), showed a mixed fruit cup on Resident 35's menu/meal ticket. A joint observation of Resident 35's breakfast tray did not show a mixed fruit cup and that they had a plate of half of a banana. Staff M stated that the plate of half of a banana was not a fruit cup. Staff M stated they have been having a lot of issues where residents were not receiving food items listed in their menu/meal ticket and that they had notified management about it. In an interview on 01/08/2026 at 9:26 AM, Staff D, Director of Food Services, stated that they had a few incidents where they had to change the menu. Staff D stated that if they were to change the menu, they would notify nursing staff of the change and that nursing staff would notify the residents of the change. When Staff D was informed that residents did not receive a mixed fruit cup for breakfast as stated in their menu/meal ticket and that they received a plate of half of a banana, Staff D stated that they did not notify nursing staff about the change and that they should have. In an interview on 01/10/2026 at 8:59 AM, Staff A, Administrator, stated that they expected dietary staff to follow the menu and expected the residents to receive the food items listed on their menu/meal ticket. RESIDENT 27On 01/06/2026 at 11:19 AM, Resident 27 stated that what is served isn't [is not] always what is on the menu. Observation on 01/08/2026 at 8:24 AM, showed Resident 27 was served half of a banana with their breakfast meal. The menu/meal ticket that came with the meal tray showed that the resident would receive a mixed fruit cup. It further showed that there was no mixed fruit cup on the tray. Resident 27 stated, they're [they are] giving subs [substitutes]. RESIDENT 32In a joint observation and interview on 01/08/2026 at 8:39 AM with Staff W, CNA, showed Resident 32 had half of a banana on their tray. It further showed that the menu/meal ticket showed mixed fruit cup and not a banana. Staff W stated that it's [it is] not a mixed fruit cup, it's a banana and it's probably a miscommunication with the kitchen. In an interview on 01/09/2026 at 11:27 AM, Staff X, CNA, stated that the menu and what the residents received matched 80% [percent] of the time and we don't know [if the menu changed] until it [the meal tray] shows up. In an interview on 01/09/2026 at 1:25 PM, Staff D stated that if there was a change in the menu, they let nursing know, so they will tell them [residents], they spread the word. Staff D stated that the menu/meal ticket should match what a resident received. When asked about yesterday's (01/08/2026) menu that showed mixed fruit cup and a banana was served instead, Staff D stated we went with the banana, since they were going bad. I forgot to let nursing know. In an interview on 01/10/2026 at 1:54 PM, Staff A stated they expected the menu/meal ticket to be followed. Staff A further stated that they expected that the menu/meal ticket would match what the residents received on their meal trays. Reference: (WAC) 388-97-1180 (1)(3) .

Based on observation, interview, and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 1 of 1 dining room (First Floor Dining Room), reviewed for dining observations. This failure placed the residents at risk for 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, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The policy further showed, The facility staff and management minimizes, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting.Observation of the First Floor Dining Room on 01/05/2026 at 11:50 AM, showed Staff V, Certified Nursing Assistant (CNA), took a tray from a metal cart and served it to Resident 78. Staff V removed the cover from the plate and left the tray on the table. Staff U, CNA, took a tray from a metal cart, served it to Resident 11 and left the tray on the table. Staff U took another tray from a metal cart, served it to Resident 64 and left the tray on the table. Staff V and Staff U did not offer the residents if they would like their tray removed from the table. Staff V and Staff U went on to serve other residents their tray in the dining room, and they did not remove their tray or offer the residents if they would like their tray removed from the table. In another observation of the First Floor Dining Room on 01/05/2026 at 12:05 PM, showed Residents 36, 57, 64, 78, 21, 43, 80, 39, 11, 67, 30, 44, 41, and 59 were eating their meal on a tray. Observation of the First Floor Dining Room on 01/07/2026 at 12:15 PM, showed that Residents 13, 8, 57, 64, 18, 10, 21, 43, 80, 39, 11, 68, 67, 30, 41, 32, 44, and 59 were eating their meal on a tray. On 01/07/2026 at 12:40 PM, Resident 13 was asked if they liked having the tray with their meal, Resident 13 stated it bothered them, that it's [it is] in the way and that it was a disturbance. Resident 13 further stated that staff did not offer to remove the tray and that staff served their meal on a tray for every meal and that everyone on the table has one. In an interview and joint observation on 01/07/2026 at 12:42 PM, Staff U stated that they would serve residents' their meals in the tray in the dining room. Staff U stated that some residents would request it to be removed and that if residents did not like their meals on the tray, they would remove it. Joint observation showed that the residents that were remaining in the dining room were eating their lunch from the tray. Staff U stated that they did not offer to remove their meal from the tray.In an interview on 01/09/2026 at 11:56 AM, Staff C, Charge Nurse, stated that staff would leave the tray when the residents were served their meals in the dining room. In a follow-up interview at 1:45 PM, Staff C stated that they expected staff to remove the tray when serving residents their meals in the dining room. In an interview on 01/10/2026 at 9:11 AM, Staff A, Administrator, stated that they expected the residents to be able to eat safely in the dining room and to make it as homelike as reasonable. Reference: (WAC) 388-97-0880 (1).

Based on interview and record review, the facility failed to ensure Level II (or Level 2) Preadmission Screening and Resident Review (PASARR or PASRR - an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 5 residents (Resident 19), reviewed for PASRR screening. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, admission Criteria, revised in March 2019, showed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I [or Level 1] PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.Review of a Level 1 PASRR form, revised in June 2025, showed, Exempted Hospital discharge: .a person may be admitted to a NF [nursing facility] directly from a hospital after receiving acute inpatient care at the hospital; the NF admission is to treat the condition for which the person was hospitalized ; and the person's attending physician, ARNP [Advanced Registered Nurse Practitioner], or physician's assistant certifies that the person requires fewer than 30 days of nursing facility services.Review of a progress note dated 10/27/2025 showed Resident 19 was admitted to the facility on [DATE].Review of the diagnoses sheet printed on 01/07/2026 showed Resident 19 had diagnoses that included psychosis (loss of contact with reality) and anxiety (having excessive/persistent worry and fear).Review of Resident 19's Level 1 PASRR dated 10/21/2025 showed that Section IA (SMI Indicators) was marked for mood disorders (conditions that significantly impact a person's emotional state, leading to prolonged periods of extreme sadness, hopelessness, or irritability) and anxiety. Further review showed that Section IV (Service Needs and Assessor Data), was marked, No level 2 evaluation indicated at this time due to exempted hospital discharge: Level 2 must be completed if scheduled discharge does not occur [after 30 days from admission].Review of the electronic health records (progress notes and miscellaneous/documents tab from 10/27/2025 through 01/09/2026) showed Resident 19 had no new Level 1 PASRR completed after 30 days of admission and that no Level 1 PASSR was sent to the PASRR Coordinator.In an interview and joint record review on 01/09/2026 at 4:41 PM, Staff F, Director of Social Services, stated that Level 1 PASRR forms marked as exempted hospital discharge were for residents who were expected to be in the facility for less than 30 days. Staff F stated that their process was to send the exempted Level 1 PASRR form to the PASRR Coordinator on day 31 from admission. A joint record review of the Level 1 PASRR form dated 10/21/2025, showed that Resident 19 had SMIs and it was marked that Level 2 evaluation was not indicated due to exempted hospital discharge. Staff F stated that Resident 19's Level 1 PASRR form should have been sent to the PASRR Coordinator after the 30th day, on 11/28/2025 or 11/29/2025.In an interview on 01/10/2026 at 1:05 PM, Staff A, Administrator, stated that residents who admitted with hospital exemption Level 1 PASRR that had not discharged by day 30, would have a new Level 1 PASRR completed and sent to the PASRR Coordinator on day 31. Staff A stated that Resident 19's Level 1 PASRR should have been sent to the PASRR Coordinator after 30 days of admission.Reference: (WAC) 388-97-1915 (1)(2) (a-c).

Based on interview and record review, the facility failed to provide a written transfer/discharge notice as required for 2 of 3 residents (Residents 6 & 64), reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their protection of resident rights during transfers, and a diminished quality of life.Findings included. Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed residents and/or representatives are notified in writing and in a language and format they understand, at least thirty days prior to a transfer or discharge. The policy showed under certain circumstances, the notice would be given as soon as practicable but before the transfer or discharge. The policy further showed the resident and representative would be notified in writing the specific reason, date, location for the transfer/discharge, an explanation of the resident's rights to appeal, and contact information for the Office of 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). RESIDENT 6Review of the nursing progress note dated 11/02/2025, showed Resident 6 was transferred to the hospital for a change in condition. Review of the discharge Minimum Data Set (an assessment tool) dated 11/02/2025, showed Resident 6 had an unplanned discharge to a Short-Term General Hospital. Review of Resident 6's Electronic Health Record (EHR- progress notes, miscellaneous tab) showed no documentation that a written notice of transfer/discharge was provided to Resident 6 and/or their representative. On 01/07/2026 at 1:59 PM, Staff F, Director of Social Services, stated that they recently downloaded the notice of transfer/discharge and caught that they had to provide them to all residents that transferred or discharged from the facility. Staff F stated there was no notice of transfer/discharge provided to Resident 6. On 01/10/2026 at 8:14 AM, Staff A, Administrator, stated they would expect a written notice of transfer/discharge to be given when it was required. RESIDENT 64Review of Resident 64's EHR (progress notes and miscellaneous tab from 01/05/2025 through 01/05/2026) showed Resident 64 was transferred to the hospital on [DATE] and did not show documentation that Resident 64 and/or their representative were provided with a written notice of transfer/discharge. In an interview and joint record review on 01/07/2026 at 1:57 PM, Staff F stated that their process had been to notify resident representatives with a phone call when a resident was transferred to the hospital and had not been providing a written notice of transfer/discharge. A joint record review of Resident 64's EHR showed no documentation that Resident 64 and/or their representative were provided with a written notice of transfer/discharge when they transferred to the hospital on [DATE]. Staff F stated, no, they [Resident 64] were not given that form. In an interview on 01/10/2026 at 1:54 PM, Staff A stated that a written notice of transfer/discharge should have been provided to Resident 64 and/or their representative when they transferred to the hospital on [DATE]. Reference: (WAC) 388-97-0120 (2) (a-c) .

Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 1 resident (Resident 45), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included .Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2024, showed all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are thoroughly investigated. The policy showed any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The policy further showed the individual conducting the investigation at a minimum would interview the resident (as medically appropriate) or the resident's representative, staff members who had contact with the resident during the period of the alleged incident, and other residents to whom the accused employee provided care or services for.Review of Resident 45's admission Minimum Data Set (an assessment tool) dated 11/17/2025, showed they were cognitively intact.On 01/05/2026 at 12:19 PM, Resident 45 stated that they had received neglectful care when Staff N, Certified Nursing Assistant (CNA), had denied them a salad on one occasion and had left them soiled on more than one occasion and it made them feel bad.Review of Resident 45's investigation dated 01/07/2026, showed on 01/05/2026 at approximately 1:30 PM, the facility was informed by a. surveyor that [Resident 45] made an allegation that she was being neglected. She claims that it takes too long for call lights to be answered and that is neglectful. She also claims that she asked for a salad at one point in time and the CNA [Staff N] wouldn't [would not] get it for her. She claims that at night the male CNAs will come to check on her and just stand and her doorway and not come in to help her at all. Further review of the investigation did not include the alleged staff or other residents' interviews.On 01/09/2026 at 1:19 PM, Staff N stated that Resident 45 had requested a turkey burger and not a salad and that the kitchen did not have all the condiments for a turkey burger. Staff N stated that they tried to ask Resident 45 if they still wanted what was available and that Resident 45 and their representative told Staff N, they did not want them to care for Resident 45. Staff N further stated they were not aware of the allegations Resident 45 had made towards them and was not interviewed by facility staff regarding the allegations.On 01/10/2026 at 9:34 AM, Staff E, Staffing Coordinator, stated that denying a resident food or leaving the resident soiled could be potential allegations of abuse or neglect. Staff E stated that the allegations would need to be reported into the state, thoroughly investigated, and suspend the alleged staff until the allegation was investigated. Staff E stated they were not aware of the allegations Resident 45 made towards Staff N and that Staff N had not been suspended.In an interview and joint record review on 01/10/2026 at 10:08 AM, Staff B, Director of Nursing, stated they expected staff to follow their abuse/neglect policies and investigations to be thorough. Staff B stated they would expect the alleged staff to be interviewed and taken off the schedule until a determination was made. Staff B stated they would expect to interview other residents to give them the opportunity to report any issues. A joint record review of Resident 45's investigation dated 01/07/2026 did not show Staff N and/or other residents' interviews were included in the investigation. Staff B stated they should have interviewed Staff N and other residents that Staff N had cared for.On 01/10/2026 at 11:30 AM, Staff A, Administrator, stated they would expect staff to follow their abuse and neglect policies and expected an investigation to be complete and thorough. Staff A stated that they were primarily responsible for completing an investigation. When asked if the alleged staff was interviewed for Resident 45's investigation, Staff A stated that Resident 45 had not named Staff N as the alleged staff. Staff A stated that Resident 45 mentioned another name that started with the letter D and that they were not employed at the facility. When asked if that statement/interview from Resident 45 was included in the investigation to support that, Staff A stated no and that they should have included it. Reference: (WAC)388-97-0640(6)(a)(b).

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) before the Medicare (federal health insurance program) coverage ended for 1 of 3 residents (Resident 90), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk of not being fully informed and losing their right to an appeals process.Findings included.Review of the facility's policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised in September 2022, showed residents would be informed in advance when changes would occur to their bills. The policy further showed that if the director of admissions or benefits coordinator believed that Medicare would not pay for an otherwise covered skilled service, the resident or representative would be notified in writing why the service(s) may not be covered and the resident's potential liability for payment of the non-covered service(s).Review of the SNF Beneficiary Notification Review form received on 01/07/2026 showed Resident 90 received Medicare Part A (Medically necessary skilled nursing, therapy (physical, occupational, speech), and semi-private rooms for up to 100 days per benefit period) Skilled Services from 08/29/2025 to 10/27/2025. Further review of the document did not show that a SNF ABN was provided to Resident 90.Review of Resident 90's Electronic Health Record did not show documentation that a SNF ABN was provided to Resident 90 prior to their last covered day (10/27/2025).Review of Resident 90's progress note dated 11/02/2025, showed they discharged on 11/02/2025 from the facility back into the community.On 01/10/2026 at 10:37 AM, Staff F, Director of Social Services, stated a SNF ABN was given to residents when they were provided with a Medicare non-coverage notice. Staff F stated it was important to give residents a SNF ABN because it would give them information about their last covered date and their right to appeal. Staff F stated Resident 90's last covered date was 10/27/2025 and that they discharged on 11/02/2025. Staff F further stated that they did not provide Resident 90 a SNF ABN and that they should have.On 01/10/2026 at 11:30 AM, Staff A, Administrator, stated they would expect a SNF ABN notice to be given to a resident as required.Reference: (WAC) 388-97-0300(1)(e)(5).

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 1 resident (Resident 9), reviewed for significant change in condition. The failure to complete a SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD - observation period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the ARD) must be within 14 days from the effective date of hospice election. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date [or effective date of hospice election] plus 14 calendar days).Review of the Hospice SNF [Skilled Nursing Facility] Notification Form, dated 11/03/2025, showed Resident 9 started hospice services on 11/03/2025.Review of Resident 9's SCSA MDS dated [DATE] showed it was completed on 11/30/2025, 27 days after hospice election (13 days late).In an interview and joint record review on 01/10/2026 at 11:08 AM, Staff H, Regional MDS Consultant, stated they expected MDS assessment to be completed accurately and timely. A joint record review of the hospice notification form showed Resident 9 was admitted to hospice on 11/03/2025. Staff H stated that hospice admission date of 11/03/2025 was equivalent to the determination date. A joint record review of Resident 9's SCSA MDS dated [DATE] showed it was completed on 11/30/2025. A joint record review of the RAI manual MDS assessment summary showed that SCSA MDS should be completed 14 days after determination that significant change in resident's status occurred. Staff H stated that Resident 9's SCSA should have been completed 14 days after 11/03/2025, by 11/17/2025. Staff H further stated that Resident 9's assessment was completed late.In an interview on 01/10/2026 at 2:46 PM, Staff B, Director of Nursing, stated they expected MDS assessments to be completed timely and accurately. Staff B stated Resident 9's assessment should have been completed timely.Reference: (WAC) 388-97-1000 (3)(b).

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 6 residents (Resident 15), reviewed for unnecessary medications. The failure to administer medication in accordance with professional standards of practice placed the resident at risk for negative outcomes and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed, multi-dose vials that have been opened or accessed (e.g. [example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. The policy further showed, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.Review of the facility's policy titled, Administering Medications, revised in [DATE], showed, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.Review of the online manufacturer's recommendations titled, Insulin [medication that regulates sugar in the blood] Lispro Kwikpen [or Humalog (brand name) - a rapid-acting insulin pen (device used to inject insulin)], revised in [DATE], showed, Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen.Review of the facility's pharmacy document titled, Injectable [substance administered into the body using a needle and syringe] Diabetic [or diabetes - disease that results in too much sugar in the blood] Medications and Supplies - Expiration Date Reference List, revised in [DATE], showed that insulin Lispro (Humalog) expired 28 days after it was first opened.Review of Resident 15's [DATE] Medication Administration Record (MAR), showed an order for Insulin Lispro (Humalog) Solution 100 Unit/milliliter (unit of measurement) - Inject as per sliding scale: if 251 - 300 [Blood Sugar (BS - concentration of sugar in the blood)] = 2 units; 301 - 350 = 3 units; 351 - 400 = 4 units; 401 - 999 = 5 units Notify MD [Medical Doctor] BS > [more than] 401 OR < [less than] 80, [inject] subcutaneously [into the layer of fat just beneath the skin], before meals for diabetes. The MAR further showed Resident 15 received 2 units of insulin Lispro on [DATE] at 4:30 PM for BS of 290, 4 units on [DATE] at 7:30 AM for BS of 378, and 2 units on [DATE] at 11:30 AM for BS of 272.Review of Resident 15's insulin Lispro pharmacy label instructions with an open date of [DATE], showed, Store using directions provided. Throw away any medicine that remains 28 days after first use.A joint observation and interview on [DATE] at 4:09 PM with Staff C, Charge Nurse, showed Resident 15 had an insulin Lispro pen with an open date of [DATE]. A joint record review of Resident 15's insulin Lispro pharmacy label showed, Throw away any medicine that remains 28 days after first use. Staff C stated that Resident 15's insulin should have been discarded 28 days after it was first opened. Staff C further stated that Resident 15's insulin was good through [DATE] and that it should have been discarded after that date.A joint record review and interview on [DATE] at 4:46 PM with Staff C, showed the [DATE] MAR, indicated that Resident 15 received 2 units of insulin Lispro on [DATE] before dinner, 4 units on [DATE] before breakfast, and 2 units on [DATE] before lunch. Staff C stated that Resident 15 should not have been given insulin doses from the insulin Lispro pen opened on [DATE] after [DATE].In an interview on [DATE] at 11:57 AM, Staff O, Pharmacist Consultant, stated that insulin Lispro should be discarded 28 days after it was first opened. Staff O stated that the effectiveness of medications decreases after their recommended time of use or expiration date. Staff O further stated that the insulin Lispro opened on [DATE] should not be provided to a resident after the 28th day.In an interview and joint record review on [DATE] at 2:10 PM, Staff B, Director of Nursing, stated they expected medications to be discarded by their expiration date. A joint record review of the insulin pharmacy label and [DATE] MAR showed Resident 15's insulin Lispro pen pharmacy label had an open date of [DATE] and received insulin from the same insulin pen on [DATE] and [DATE]. Staff B stated that Resident 15 insulin Lispro should have been discarded after [DATE].Reference: (WAC) 388-97-1300 (1)(b)(i)(3)(a).

Based on interview and record review, the facility failed to monitor a resident taking a diuretic (medication used to help remove extra fluid from the body) medication and failed to notify the provider of weight gain for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. This failure placed the resident at risk for unrecognized weight gain, medical complications, and a diminished quality of life.Findings included.Review of a physician note dated 09/30/2025 showed that Resident 5 had diagnoses that included Chronic Heart Failure (CHF-a condition where the heart muscle cannot pump blood efficiently, causing fluid back up in the lungs).Review of Resident 5's physician orders printed on 01/06/2026, showed an order for furosemide (a diuretic medication) for fluid retention. It further showed an order to weigh the resident daily and to call the cardiologist [a doctor specializing in treating heart conditions] if the resident gained three pounds (lbs. -a unit of measurement) in 24 hours or five lbs. in a week.Review of Resident 5's CHF care plan, initiated on 05/08/2024, showed the intervention to monitor/document/report to MD [Medical Doctor] .changes in weight.Review of Resident 5's weights from 11/26/2025 through 01/05/2026 showed the following weights:-11/07/2025:139 lbs. and 11/08/2025:146.6 lbs. (7.6 lbs. weight gain in 24 hours)-11/28/2025:139.6 lbs. and 11/29/2025:144 lbs. (4.4 lbs. weight gain in 24 hours)-12/23/2025: 138.8 lbs. and 12/24/2025:145.4 lbs. (6.6 lbs. weight gain in 24 hours)-12/29/2025: 137 lbs. and 12/30/2025: 142.6 lbs. (5.6 lbs. weight gain in 24 hours)In an interview and joint record review on 01/10/2026 at 8:54 AM, Staff J, Registered Nurse, stated that they followed physician orders. A joint record review of Resident 5's physician orders showed an order to call the cardiologist if the resident gained three lbs. in 24 hours or five lbs. in a week. A joint record review of Resident 5's weights from 11/26/2025 through 01/05/2026 showed the above weights. Staff J stated that on 11/08/2025, 11/29/2025, 12/24/2025, and 12/30/2025, Resident 5 had more than a three lb. weight gain in 24 hours. Staff J stated that the cardiologist had not been notified when Resident 5 had more than a three lb. weight gain in a 24-hour period.In an interview and joint record review on 01/10/20206 at 9:19 AM, Staff C, Charge Nurse, stated that if there was physician order to notify a physician for weight gain then they expected staff to notify [the physician] .and document. A joint record review of Resident 5's physician orders showed an order to call the cardiologist if the resident gained three lbs. in 24 hours or five lbs. in a week. A joint review of Resident 5's weights from 11/26/2025 through 01/05/2026 showed the above weights. Staff C stated that on 11/08/2025, 11/29/2025, 12/24/2025, and 12/30/2025, Resident 5 had more than a three lb. weight gain in a 24-hour period. Staff C stated that they expected staff to reweigh the resident if there was a weight gain and I don't [do not] see here that it was done. Staff C further stated that the cardiologist had not been notified when Resident 5 had more than a three lb. weight gain in 24 hours.In an interview and joint record review on 01/10/2026 at 1:16 PM, Staff B, Director of Nursing, stated that staff should follow physician orders and if there was a question, they expected staff to get clarification. Staff B stated that they expected staff to monitor weights for residents on diuretic medications. A joint record review of Resident 5's physician orders showed an order to call the cardiologist if the resident gained three pounds lbs. in 24 hours or five lbs. in a week. Staff B stated that they expected staff to follow the order and call the cardiologist and alert our own doctor. Staff B further stated that it was important to monitor and notify the physician if there was a weight gain in a resident with CHF.Reference: (WAC) 388-97-1060 (1).

Based on interview and record review, the facility failed to notify the State Pre-admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator after a significant change in status occurred for 1 of 1 resident (Resident 9), reviewed for PASRR screening. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, admission Criteria, revised in March 2019, showed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I [or Level 1] PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II [or Level 2] (evaluation and determination) screening process. The social worker is responsible for making referrals to the appropriate state-designated authority.Review of a face sheet printed on 01/06/2026 showed Resident 9 was admitted to the facility on [DATE].Review of the Hospice [compassionate care provided to individuals who are in the final stages of a terminal illness] SNF [Skilled Nursing Facility] Notification Form, dated 11/03/2025, showed Resident 9 started hospice services on 11/03/2025.Review of Resident 9's Level 1 PASRR dated 11/07/2025 showed it was completed due to significant change on 11/03/2025. The Level 1 PASRR Section IA (SMI Indicators) was marked yes for mood disorders. Further review showed, Level 2 evaluation referral required for significant change.Review of the electronic health records (progress notes and miscellaneous/documents tab from 10/21/2025 through 01/07/2026) showed no documentation that Resident 9's Level 1 PASRR form dated 11/07/2025 was sent to the PASRR Coordinator.In an interview and joint record review on 01/09/2026 at 4:32 PM, Staff F, Director of Social Services, stated that Level 1 PASRR forms were completed when residents were admitted to hospice services and then sent to the PASRR Coordinator for Level 2 evaluation. A joint record review of Resident 9's Level 1 PASRR dated 11/07/2025 showed a hospice admission of 11/03/2025 with SMI of mood disorders and it was marked for level 2 evaluation referral for significant change. Staff F stated that Resident 9 was admitted to hospice services and that a new Level 1 PASRR was completed. Staff F further stated that Resident 9's Level 1 PASRR was sent to the PASRR Coordinator on 01/05/2026 and that it should have been sent after it was completed on 11/07/2025.In an interview on 01/10/2026 at 1:05 PM, Staff A, Administrator, stated they expected Level 1 PASRR forms with Level 2 recommendations to be sent to the PASRR Coordinator timely after they were completed.Reference: (WAC) 388-97-1975 (7).

Based on interview and record review, the facility failed to accurately assess 2 of 16 residents (Residents 9 & 19), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding injections and prognosis (an estimate about whether a patient [resident] will recover from an illness) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included .According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. Count the number of days that the resident received any type of injection while a resident of the nursing home. Record the number of days that any type of injection (e.g., subcutaneous [into the layer of fat just beneath the skin], intramuscular [into the muscle], or intradermal [into the middle layer of the skin]) was received in Item N0300. The RAI further showed that to answer item J1400 (Prognosis), Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? required physician documentation.The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period).Review of the facility's policy titled, Hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) Program, revised in July 2017, showed that the facility would obtain a physician certification of terminal illness specific to the resident from the hospice provider.INJECTIONSRESIDENT 9Review of Resident 9's admission MDS dated [DATE] showed, 1 [one] injection (N0300) was marked in Section N (Medications).Review of the October 2025 Medication Record Administration (MAR) showed Resident 9 received one tuberculin (a combination of proteins that are used in the diagnosis of tuberculosis [TB- a bacterial infection that mainly affects the lungs]) intradermal injection on 10/22/2025 and one influenza vaccine (or flu - used to prevent influenza [an infection of the nose, throat, and lungs]) intramuscular injection on 10/23/2025, a total of two injections during the look back period (10/21/2025 to 10/27/2025).In an interview and joint record review on 01/09/2026 at 3:48 PM, Staff G, MDS Coordinator, stated they followed the RAI manual for completion of MDS assessments. Staff G stated that intradermal and intramuscular injections were counted in item N0300 (Injections). A joint record review of Resident 9's admission MDS showed N0300 was marked for one injection. Staff G stated that Resident 9 received one injection. A joint record review of the October 2025 MAR showed Resident 9 received one tuberculin injection and one flu vaccine injection. Staff G stated Resident 9 received two injections and that their MDS was inaccurate.RESIDENT 19Review of Resident 19's admission MDS dated [DATE] showed, 0 [zero] injection (N0300) was marked in Section N.Review of the October 2025 MAR showed Resident 19 received one tuberculin intradermal injection on 10/28/2025 during the look back period (10/27/2025 to 11/02/2025).A joint record review and interview on 01/09/2026 at 3:50 PM with Staff G, showed Resident 19's admission MDS was marked 0 [zero] injections in N0300 and a record review of Resident 19's October 2025 MAR showed they received one injection during the look back period. Staff G stated Resident 19 received one tuberculin injection and that their MDS was inaccurate.PROGNOSISRESIDENT 9Review of the Hospice SNF [Skilled Nursing Facility] Notification Form, dated 11/03/2025, showed Resident 9 started hospice services on 11/03/2025.Review of the electronic health records (progress notes and miscellaneous/documents tab from 10/21/2025 to 01/06/2026) had no documentation to show that Resident 9 had a doctor's note and/or a certification of terminal illness indicating that Resident 9 had a life expectancy of less than six months.Review of the SCSA MDS dated [DATE] showed that J1400 (Prognosis) was marked 1 [yes] indicating that Resident 9 had a condition or chronic disease that may result in a life expectancy of less than six months.In an interview and joint record review on 01/09/2026 at 3:55 PM, Staff G stated that to mark that on the MDS, a resident would have had a prognosis of life expectancy of less than six months, and it required physician's documentation or hospice certification. A joint record review of Resident 9's SCSA MDS showed it was marked 1 [yes] in J1400. Staff G stated that Resident 9 started hospice services on 11/03/2025. A joint record review of Resident 9's progress notes and miscellaneous tab showed no documentation indicating that Resident 9 had a life expectancy of less than six months. Staff G stated they were going to look for Resident 9's hospice certificate.In an interview and record review on 01/10/2026 at 11:08 AM, Staff H, Regional MDS Consultant, stated that item J1400 would be coded 1 [Yes], after verifying that there was a physician's documentation showing that the resident had a life expectancy of less than six months. A joint record review of Resident 9's SCSA MDS showed item J1400 was marked 1 [yes]. Staff H stated that item J1400 would be marked 0 [No] if there was no documentation to show that a resident had a prognosis of less than six months to live during the look back period.In an interview on 01/10/2026 at 2:46 PM, Staff B, Director of Nursing, stated they expected MDS to be completed accurately and timely. Staff B stated that Resident 9 did not have a certification of terminal illness during the look back period. Staff B stated that Staff A, Administrator, obtained Resident 9's certificate of terminal illness today (01/10/2026), just got it today. Staff B further stated that Resident 9's and Resident 19's MDS should have been completed accurately.Reference: (WAC) 388-97-1000 (1)(b).

Based on observation, interview and record review, the facility failed to comprehensively assess and ensure that timely and appropriate services/interventions were provided to maintain, increase and/or prevent decrease in range of motion (ROM) for 1 of 3 residents (10) reviewed for range of motion and restorative nursing services. This failure caused harm to Resident 10 who developed hand contractures, decreased ROM, and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings included . The National Stroke Association defines [MEDICAL CONDITION] or one-sided (hemi) weakness (paresis) as weakness or the inability to move one side of the body. Side effects of [MEDICAL CONDITION] include muscle [DIAGNOSES REDACTED] (weakness in the muscles), [MEDICAL CONDITION] (loss of muscle strength) and pain. Rehabilitation treatments, ROM exercises and assistive devices can help improve mobility and recovery. RESIDENT 10 Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was able to make self-understood, and able to understand others. Resident #10 needed the assist of two staff members for bed mobility, transfers, toileting, and personal hygiene, and needed one person assist with eating. During an observation and interview on 01/30/19 at 1:57 PM, Resident #10 was in his room and up in his wheelchair. The resident was observed to have limited ROM impairments of his upper and lower extremities that interfered with his daily functioning. The resident was unable to straighten out the fingers on his right and left hand. The resident stated he could not use a regular call light because of his hands, but instead used a special sensor pad call light to call for assistance. Review of the resident's clinical records (care plan, tasks, therapy notes, progress notes) showed no record or evidence that the resident's hands contractures or limitation in ROM was comprehensively assessed, identified or care plan by the facility. In an interview on 01/31/19 at 2:18 PM, with Staff P, Physical Therapist/Director of Rehabilitation, Staff P stated Resident #10's did not have exercise program for his hands and no specific hand splint program. Staff P stated they did not look at the resident's hands the last time the resident was evaluated. According to Staff P, the resident's hands could be at risk for contractures. Staff P further stated they would do a rehabilitation screen on his hands immediately to assess the resident's current contractures. In an interview on 02/01/19 at 11:56 AM, with Staff J, Nursing Assistant Certified/Restorative Aid stated the resident's hands were stiff in the morning. Staff J stated there was no specific exercise or restorative program to the resident's hands. In an interview on 02/01/19 at 12:35 PM, with Staff B, Licensed Practical Nurse/Resident Care Manager, Staff B stated, There is no ROM exercises of his hands. Staff B stated that when the resident was eating, the resident used a little brace to help hold his spoon. Staff B stated, He has limitations on both of his hands and would benefit from ROM exercises. In another interview on 02/05/19 at 12:12 PM, Staff P stated they did not have a record of evaluation or treatment for [REDACTED]. Staff P stated the reason have been that there was no ROM problem with the resident's hands when he was first admitted . Staff P stated they had no record of any assessment, rehabilitation screening, or treatment specific to the resident's hands. Staff P said the facility just recently started a hand ROM and splinting program after the surveyor had inquired about the resident's hands and fingers condition. In an interview on 02/05/19 at 2:38 PM, Resident #10 stated when he was first admitted to the facility, he was able to brush his teeth with little assistance. Resident #10 stated, Now I have trouble holding on the toothbrush, I needed more help. I used to shave myself but now I cannot, I keep dropping the shaver. I feel bad, the things I used to do before and now I can't do them anymore, it bothers me. Further review of the resident's clinical records from admission to (MONTH) 2019 showed no evidence that the facility had comprehensively assessed, monitored, treated or implemented timely interventions to minimize the risks and prevent the development of an avoidable decline in ROM for Resident #10. Reference (WAC): 388-97-1060 (3) (d)

Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, failed to follow written policy and procedures, and failed to implement timely interventions necessary to prevent the development of a facility acquired pressure ulcer for 3 of 4 residents (6, 5 and 10), reviewed for pressure ulcers. These failures caused harm to Resident 6, Resident 5 and Resident 10 who developed pressure ulcers with partial and full thickness skin loss and pain. 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. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. 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 and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 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. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. A review of the facility policy titled, Pressure Ulcer/Injury Risk assessment dated ,[DATE], directed the facility staff to: A. Conduct a comprehensive skin assessment with every risk assessment. B. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. C. The care plan must be modified as the patient's condition changes, or if current interventions are deemed inadequate. D. Notify attending MD (Medical Doctor) if new skin alteration noted. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 08/2018, directed the facility staff to: A. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers: for example, immobility, recent weight loss, and a history of pressure ulcers (s). B. In addition, the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissues, pain assessment, mobility status, current treatments including support surfaces and all active [DIAGNOSES REDACTED].>RESIDENT 6 Resident 6 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's admission assessment dated [DATE], showed the resident was at risk for developing skin breakdown. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident needed 2 person assistance with bed mobility and transfers. The MDS identified the resident to be at risk for developing a pressure ulcer. Review of the resident's skin care plan dated 11/28/18 showed the resident was at risk for pressure ulcer development related to immobility and incontinence. During a joint skin observation and interview on 02/01/19 at 7:45 AM with Staff I, Registered Nurse/Charge Nurse(RN), Staff J, Nursing Assistant (NA), and Staff K, NA, the resident's skin was observed to have a partial thickness skin loss on bilateral ischium area (sit bone/sitting area). The resident was on a regular mattress with no positioning or any pressure reducing devices observed. The right ischium wound was measured by Staff I at approximately 1 centimeter (cm) in length, 1cm wide and 0.1cm depth with mild serosanguineous drainage (drainage containing both blood and the liquid part of the blood/serum). The surrounding skin was macerated (soft/wet/soggy skin from prolonged exposure to moisture) with blanchable redness around measured at 4cm in length and 4cm wide. The left ischium wound was measured by Staff I at approximately 0.5cm in length, 0.5cm wide, and 0.1cm in depth with mild serosanguineous drainage. The surrounding skin was macerated with blanchable redness around measured at 4cm in length and 4cm wide. The resident verbalized and complained of pain during the inspection. The resident stated he had the sore for almost 2-3 weeks now and it was from diarrhea episodes in the last few weeks. The resident added he had about 3-4 loose stools per day and the facility continued to give him stool softeners. During a joint interview at the time of the skin inspection, Staff J stated she was not the regular caregiver for the resident and was not sure when the skin breakdown had developed. Staff K stated he was the one putting the cream to the wound and was not sure when the skin breakdown had developed. Staff I also stated she was not aware on when the wound had started. During a joint interview and record review on 02/01/19 at 8:15 AM, Staff I stated she would call the resident's skin breakdown as an excoriation. When asked why she would identify the wound as an excoriation instead of a pressure injury, based on the definition of pressure ulcer as defined by NPUAP and the open areas were located at a bony prominence area, Staff I stated, Yes, it should have been called a pressure ulcer/injury based on the definition, location and possible cause of the skin breakdown. Staff I also stated the facility had no record of any comprehensive assessment related to the resident's skin breakdown, no wound measurements and description, no documentation that the facility had notified the resident's physician, and the resident's plan of care was not updated. Staff I further stated the resident's weekly skin check had not been not followed as ordered. The resident was missing a skin check for 01/28/19, and there was no evidence of any follow-up notes or clinical progress notes were completed. The facility failed to comprehensively assess the resident's skin breakdown, failed to conduct a full assessment of the resident's skin, failed to notify the physician, and update the resident's plan of care as directed by the facility's policy and professional standards of practice. In an interview and record review on 02/01/19 at 8:56 AM with Staff A, Director of Nursing (DNS) confirmed and stated the facility missed the weekly skin check on 01/28/19, and the facility had no record of a comprehensive assessment related to the resident's skin breakdown. The DNS also stated the resident's care plan was not updated, and there was no evidence that the facility physician and interdisciplinary team (Registered Dietitian, Therapy, etc.) were notified and had assessed or treated the resident's skin breakdown. During a joint interview and record review on 02/01/19 at 12:13 PM with Staff B, Licensed Practical Nurse/Resident Care Manager, Staff B stated the resident initially had a stage 2 pressure ulcer on his bottom that had healed/closed on 01/22/19. Staff B also stated this was the first time she heard the wound had reopened or that the resident had new wounds. Staff B said the facility had no record of a comprehensive assessment, treatment and plan of care to meet the resident's pressure ulcer needs. Review of the nursing progress notes dated 01/22/19, 01/23/19, 01/26/19, and 01/27/19 showed the resident's skin breakdown was described as, Res (resident) bottom still red, coccyx sore, and redness to buttocks. The nursing progress notes were missing an accurate description of the wound including the specific location, stage, measurement, and characteristics of the skin and wound bed as directed by the facility policy and professional standards of practice. In an interview on 02/05/19 at 10:33 AM with Staff Q, Registered Dietitian, stated she was not aware and was notified of the resident's skin breakdown. Staff Q also stated the resident had significant weight loss, and she would follow-up to ensure the resident's nutrition and protein intake was adequate to meet the resident's needs and promote wound healing. In a follow-up interview on 02/05/19 at approximately 11:00 AM, the resident stated his wound had caused him pain and discomfort, and had affected his ability to sleep good at night and quality of life by not being able to stay comfortable in a sitting and lying position. RESIDENT 5 Resident 5 was re-admitted to the facility on [DATE] for long term care. The resident's [DIAGNOSES REDACTED]. Review of most recent Quarterly MDS dated [DATE] indicated Resident 5 required extensive 2- person assistance with bed mobility, transfers, toileting, and personal hygiene. Resident 5 was always incontinent of bowel and bladder. The MDS identified the resident to be at risk for skin breakdown. The MDS showed the resident did not have any pressure ulcers, but did have Moisture Associated Skin Damage (MASD). Review of the resident's skin care plan dated 11/23/2018 showed the resident was at risk for recurrent pressure ulcer to buttock related to impaired mobility, incontinence, preference to sit in wheelchair for long hours and declining to lay down for pressure relief. The care plan also indicated on 01/17/19 there was an Actual pressure injury to Left buttock. During a joint skin observation and interview on 02/01/19 at 7:10 AM, with Staff L, LPN, and Staff J, Nursing Assistant Certified (NAC), a foam dressing was removed from the resident's left buttock area. The dressing was found to have mild to moderate amount of brown discharge on it when it was removed. The resident's skin was observed with a partial thickness skin loss on the left buttock over a boney prominence. The surrounding skin was macerated (soft/wet/soggy skin from prolonged exposure to moisture) with blanchable redness around the open area. The resident verbalized and complained of pain during skin inspection and dressing removal. Resident stated Ouch when the dressing was being removed or area was touched by Staff L and the Resident's body was visibly shaking. The Resident requested to return to laying on her back because she was in pain and uncomfortable. Staff L stated that she reported this concern to her charge nurse who told her to leave the dressing off so the area could get some air and apply a prescribed cream to area. Staff L then stated she was going to measure this area later due to the resident's request to sit up. Staff L stated that sometimes the resident was non-compliant with keeping a pillow under her or getting up in her wheelchair to relieve pressure. Staff L also stated, I've been off for a few days, but when I worked with her last week it was not open and there was no dressing at that time. During an interview on 02/01/19 at 7:21 AM, Resident 5 stated that she has had an issue on her bottom for a long time and it hurts sometimes, It stings. Resident 5 also stated, I get up in my wheelchair you know to exercise and just do stuff. During an interview on 02/01/19 at 7:25 AM, Staff J stated that she was the resident's aide today. Staff J stated she also works in restorative, in the dining room, and does showers at times, and said that she was not the resident's full time NAC. Staff J stated she was aware the resident has had skin issues in the past, but since she floats around she doesn't see this resident on a daily basis. Staff J stated, I want to say when I was working with her last week, that's when we discovered this issue and they began to do treatment then because it was open. During an interview on 02/06/19 at 10:47 AM, Staff L stated if a new skin issue was found, they documented on a skin assessment in the computer, and notify the charge nurse or Staff B, Resident Care Manager (RCM). Staff L also stated that they would notify the doctor to get orders to treat the new skin issue. Staff L stated there was an outside consultant wound team that comes to the facility on Tuesdays, They were just here yesterday. Staff J stated she thought the area was measured last week and was approxoximately 1 cm x 1cm in size, and it should be documented under skin assessment. During an interview on 02/06/19 at 10:51 AM, Staff B (RCM) stated the facility used United Wound Healing (UWH) for wound management and UWH was at the facility yesterday. Staff B stated that the wound team only saw 2 people yesterday, and Resident 5 was not one of those residents that was seen by UWH. Review of Treatment Administration Record (TAR) dated (MONTH) 2019 showed an order for [REDACTED].>progress note. Skin assessments were documented as follows: 01/02/19 showed (+). 01/09/19 showed (-). 01/16/19 showed (-). 01/23/19 showed (-). 01/30/19 showed (+). Review of nursing skin/wound note dated 01/17/19 written by Staff B stated, Res buttocks assessed, bilateral redness blanchable, left side with 0.4 x 0.5 area of granulation with surrounding non- blanchable redness. Review of skin observation in the facility computer software for documentation (PCC), dated 01/03/19 through 01/31/19, had multiple days where the NAC's had documented either a red area or open area. On 01/12/19, it was documented that resident had discoloration. In a follow up interview and record review on 02/06/19 at 1:51 PM with the Director of Nursing Services (DNS) stated if Staff B had completed a skin assessment, it would under assessments in PCC. The DNS verbally confirmed that the 1/17/19 PCC assessment was not completed. The DNS stated the most recent assessment in the computer was a Nursing Summary dated 02/01/19. The DNS stated there was a new Pressure Ulcer assessment in PCC under Assessments, and stated that she had just completed designing a new weekly pressure form. The DNS said that previously this assessment had been done on paper, located in the chart, and, I basically took that form and converted it to an online version. The DNS stated when new skin issues arise staff make a referral to UWH, and notify the doctor and family, We would try to determine cause, so that interventions can be put into place. The DNS reviewed the nursing skin/wound note dated 01/17/19, and verified that there was not a comprehensive assessment completed to verify the type of new skin issue. The facility failed to comprehensively assess the resident's skin breakdown, failed to conduct a full assessment of the skin and the resident, and failed to update the resident's plan of care as directed by the facility's policy and professional standards of practice. RESIDENT 10 Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] showed the resident was able to make himself understood and was able to understand others. Resident 10 needed the assist of two staff members for bed mobility, transfers and toileting. The resident had a urine catheter (a tube that drained urine from the bladder into a closed bag) and a [MEDICAL CONDITION] (a surgically created hole in the abdominal wall to allow the passage of stool into a bag or pouch). The MDS also identified the resident was at risk for developing pressure ulcers, and no pressure ulcer was present at the time of the assessment. Review of a 1/22/19 skin assessment/new pressure injury assessment showed Resident #10 had a Stage 2 pressure injury to his Right gluteal fold. The skin assessment revealed a referral to UWH was not marked at the time of the assessment. Resident 10's (MONTH) 2019 Treatment Administration Record (TAR) showed a new order on 01/22/19 for Calzinc (ointment) to the Left gluteal fold every shift for protection. This order was discontinued on 1/27/19 and rewritten for staff to apply the Calzinc to the Right gluteal fold. Therefore, treatment to right gluteal fold was not provided until 01/27/19, 5 days later after the Stage 2 pressure ulcer was initially identified. The TAR also indicated the use of a Roho cushion (pressure-relieving cushion) for resident's wheelchair for pressure relief that was not started until 01/30/19. Review of a UWH wound assessment dated [DATE] showed that Resident 10's right gluteal fold was now an unstageable pressure ulcer. The wound assessment revealed that the base of the wound was covered with 75 percent slough (non-viable yellow, tan, gray, green or brown tissue) and 25 percent granulation (pink-red moist tissue that fills an open wound). The right gluteal fold wound measured 3.2 cm (length) x 2.5 cm (width). The wound assessment showed additional orders to include pressure relief & offloading, encourage repositioning every two to three hours, and to reposition the resident when up in wheelchair every two to three hours for pressure relief. There was no documentation in the TAR or the progress notes to indicate the recommendations were implemented. In an interview on 01/31/19 at 1:45 PM, with Staff O, Nursing Assistant Certified (NAC) stated she was aware the resident had a wound, but she had not seen it because the resident had a [MEDICAL CONDITION] and a Foley catheter and the resident was already cleansed by night shift NAC. In an interview on 02/01/19 at 6:00 AM, with Staff C, RN stated that the resident had a pressure ulcer on his right gluteal fold that was found about a week ago. During an observation and interview on 02/01/19 at 6:07 AM with Staff D, LPN, revealed that Resident 10 had an open wound to right gluteal fold. Staff D was observed measuring the wound, and stated that the wound was approximately 2.5 centimeter (cm) in length x 2.25 cm wide, and the wound base was covered by 100 percent slough. The wound was observed with yellowish dead tissue. During an interview on 02/01/19 at 11:18 AM, Staff B, LPN/RCM, stated the pressure ulcer on the resident's right gluteal fold developed on 1/22/19 and it was a Stage 2 at the time of the assessment. Staff B stated that she was aware that the wound was now an unstageable pressure ulcer. Staff B also stated the resident liked to stay up all day and refused to lay down. Staff B stated that she did not chart or document the conversation with the resident regarding the risk and benefits of when the resident was sitting on his wheelchair for long periods. Staff B added the resident had an air mattress (pressure reducing mattress) that was put in place on 01/31/19 per the care plan. She stated the resident had seen UWH for the first time on 01/29/19, and UWH had recommended the special mattress. Staff B further stated she could not find any documentation regarding the resident's refusal to lay in bed. In another interview on 02/01/19 at 12:20 PM, Staff B, stated licensed nurses documented in the TAR, a plus sign (+) if skin was intact and a minus sign (-) if skin was not intact. The weekly skin assessment on the TAR for 01/01/19 and 01/15/19 showed there were skin problems identified by the licensed staff. However, there were no skin documentation in the progress notes to clearly describe and identify what type of skin problems were seen. In an interview with Resident 10 on 02/05/19 at 2:46 PM, the resident stated his wound caused pain and discomfort. The resident stated when he was told he had a wound on his right gluteal fold, he stated, Here it goes again, there's always something, I hope that my wound is not too bad and it will heal better. Resident stated he felt disappointed. In an interview on 02/05/19 at 3:01 PM, Staff E, LPN/Evening Supervisor, Staff E stated she did not know if they have a specific documentation and if the Roho cushion was functioning well. She stated that usually the therapist monitored the Roho Cushion. In an interview on 02/06/19 at 1:51 PM, the DNS stated that there was a new pressure ulcer assessment in PCC (electronic medical record) that the facility had recently initiated. The DNS also stated the facility should have notified and send a referral to UWH to assess the resident's wounds. The DNS stated, I do not have a documentation of when was the pressure relieving mattress was applied to Resident 10. She stated that Resident 10 had a history of [REDACTED]. The DNS also stated the facility removed the air mattress when the wound had previously healed and the resident was put back on a regular mattress. Lastly, the DNS stated staff needed to figure out why the resident was refusing and should re-approach/document the resident's reason for refusal of care and should have offered alternative as needed. The facility failed to comprehensively assess, develop and implement timely interventions to Resident 10 to minimize the risk and prevent the development/deterioration of an avoidable pressure ulcer. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to develop and implement an effective discharge plan, failed to ensure that the post-discharge destination and continuing care provider could meet the resident's needs for 1 of 3 residents (25) reviewed for discharge planning process. The failure to ensure all necessary medications and tube feeding supplies were readily available upon discharge caused harm to Resident 25 who developed severe hypoglycemic reaction (a severe form of low blood sugar) that required hospitalization . Findings included: Resident 25 admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident had mild cognitive impairment, and required 2 person assistance with bed mobility, transfers and toileting. The resident received all nutrition and medications by tube feeding or injection. A review of the physician orders [REDACTED]. A. Continuous tube feeding of Fibersource HN Liquid, 53 milliliters (mL) per hour for 22 hours via PE[DEVICE] (abdominal tube) one time a day for severe dysphagia (difficulty swallowing), starting time is 1200 (12:00 PM) and stop at 1000 (10:00 AM). B. Administer 22mL per hour of water for 22 hours while on tube feeding. In an interview on 01/30/19 at 10:21 AM, the resident's spouse stated the resident was discharged from the nursing home and arrived at the AFH on 1/3/19. Shortly after Resident 25's AFH arrival, the spouse went home and picked up medications for Resident 25 because they (her medications) were not available at the pharmacy and the (nursing home) facility did not send anything with her. According to the resident's spouse, She is a very brittle (unstable blood sugars) diabetic and needed her blood glucose monitor and insulin. She was not connected to the feeding tube for four hours after discharging from the facility. The resident's spouse further stated, The AFH called the paramedics due to (extremely low) blood sugars in the 20's and then up to the 300's (high blood sugar). The tube feeding supplies that arrived at the AFH were different than what she was on. Review of the resident's clinical records from 12/28/18 to 01/03/19 showed the following: A. A Physician Assistant (PA) progress note dated 12/31/18 showed when Resident 25's feeding tube was stopped for PT/OT (physical therapy and occupational therapy), her blood sugars dropped. B. A PA discharge visit conducted on 01/03/19, the day resident discharged from the facility to the AFH, showed Pt (patient) is on tube feeding 22 hours/day. Has a 2 hour break from 10-12 (10:00 AM to 12:00 PM) to have PT/OT. C. A Social Service (SS) progress note on 12/28/19 showed the resident had a tentative discharge date of [DATE]. The note further stated, This date may be delayed due to the holiday and late notice arranging home health and tube feeding. D. An SS entry on 01/01/19 showed the resident's discharge was delayed until 01/03/19 at 11:00 AM. It indicated the tube feeding supplier changed from Tube Feeding Supplier #1 to Tube Feeding Supplier #2 due to logistical complications related to the holiday and the AFH request for teaching related to the tube feeding equipment. Review of a late entry progress notes from SS, documented on 01/07/19 for the discharge event occurring on 01/03/19 (4 days after discharge) showed the resident discharged from facility on 01/03/19 at 11:00 AM. The SS entry indicated the AFH had reported the resident came with the wrong enteral tube feeding products and doctors orders, and onsite teaching was not provided to the AFH as requested. Furthermore, the AFH reported to the SS that the resident's medications were not available at the pharmacy of choice for pick-up on the day of discharge. Review of the discharge packet sent by the nursing facility to the AFH showed two different and conflicting methods of tube feeding orders and administration: One order showed the resident should receive tube feeding via bolus and one order showed the resident should get the tube feeding via continuous. The discharge packet had no confirmation to show if and when it was sent or received by the AFH and the AFH's pharmacy of choice. Further review of the physician orders, discharge medications, and treatment orders showed the nursing home physician had communicated an phone order to change the tube feeding to the SS. The SS received a verbal order from the physician and carried out without an oversight and/or confirmation/supervision from a licensed nursing personnel. (Refer to F684 - Quality of Care for more information.) In an interview on 02/05/19 at 1:36 PM with Staff B, Licensed Practical Nurse (LPN), Staff B stated, We usually fax physician orders [REDACTED]. I was told the tube feeding supplies would be there when the resident arrived to the AFH. The resident was on continuous tube feeding here, but the order was changed to gravity feeding on discharge because most AFH's want gravity feed. We discussed the orders to the AFH. Staff B stated there was no documentation of these conversations and communications in the resident's clinical record. In an phone interview on 02/05/19 at 2:44 PM, AFH Staff A stated the resident was seen by their nurse to do an assessment on 12/28/18. AFH Staff A stated, I did not have any communication with the (nursing home) facility until 01/01/19 when (Staff I, Registered Nurse) called me over the phone and said the resident was discharging today to my AFH. I informed Staff I that we did not have any equipment or supplies to care for the resident. According to AFH Staff A, she received a call from Staff G, Social Service Director (SSD) later that day who informed her that the resident was not coming today, but would be discharged on [DATE]. The social worker faxed some paperwork, and stated he would be back in touch with me to confirm. The next two days I did not hear anything from him to confirm the date, and the next thing I knew, the resident arrived at the (AFH) door at approximately 11:15 AM. AFH Staff A stated the evening before the resident's nursing home discharge, Tube Feeding supplier #2 contacted me to let me know the tube feeding orders for the resident had conflicting information and they needed to get clarification from the facility doctor. AFH Staff A also stated she did not hear back from the supplier #2 until they showed up at my door around 2:00 PM on the day of discharge. AFH Staff A added, they dropped off bolus gravity feeding supplies, they did not provide any teaching, they just dropped off the supplies and left. AFH Staff A further stated, The facility did not let us know that they were changing her tube feeding orders. When we accepted her she was on continuous 22 hours feeding, we were surprised to see her orders had changed to gravity/bolus feeding. AFH Staff A stated the nursing home facility had not informed the AFH as to the resident's estimated time of arrival or called when she discharged to let the AFH know the resident was on her way, I was not expecting her due to no communication or confirmation from the facility social worker. According to AFH Staff A, she was also scrambling to get the resident's medications into the pharmacy because the facility did not send the orders to her pharmacy of choice. Staff A further stated she was told by the facility that the resident was disconnected from her tube feeding at approximately 10:00 AM, the transportation picked her up at 11:00 AM, and the resident arrived at the AFH at approximately 11:15 AM but the feeding supplies were delivered at approximately 2:00 PM (according to the invoice left by the supplier). In an interview on 02/06/19 at 4:26 PM, AFH Staff B stated they were not contacted by the facility to confirm the discharge date and time of the resident to the AFH, When she arrived we were still waiting to hear from the tube feeding supplier, as to when they would be able to deliver the supplies and regarding the clarification on the tube feeding orders, due to the contradicting tube feeding orders. According to AFH Staff B, the tube feeding supplier arrived at approximately 2:00 PM, dropped off the supplies, and stated, We do not do training, and there are instructions in the box on how to use the equipment. AFH Staff B said there was not much communication from the facility, and the coordination of tube feeding supplies and medications had not been confirmed by all parties. AFH Staff B stated they were shocked because they were expecting the resident to be on a tube feeding pump, but arrived to the home without any tube feeding supplies. AFH Staff B further stated the AFH received cans and the AFH staff were confused on when the orders had changed and if the resident could tolerate a change in tube feeding orders. During a meeting on 02/06/19 at 9:40 AM with the nursing home Administrator, Staff A, Director of Nursing Service (DNS), and Staff G, SSD, the Staff A DNS stated she was not aware the order had changed from continuous to gravity bolus feeding. The DNS also stated the orders should have not changed, and the facility had no confirmation on when and what tube feeding supplies arrived at the AFH. Staff G stated he took the tube feeding orders from the doctor and he was not aware that anything had changed, it was of absolute importance she remained on continuous tube feeding. Staff G further stated he should have not taken an order from the physician. Staff G said he did not inform the resident, spouse or AFH that there was a change because he did not know that gravity/bolus feeding was not the same as continuous feeding, The tube feeding order should have not changed and the resident should have remained on a continuous tube feeding instead of bolus feeding. Staff G explained the tube feeding suppliers had changed at the last minute; it was originally with one company but due to the training request, Staff G changed suppliers at the last minute to another company. Staff G also stated he did not realize the tube feeding supplies arrived approximately 3 hours after the resident arrived at the AFH, the supplies were supposed to be there in the morning. Staff G was not able to provide any confirmation from the pharmacy and/or the tube feeding suppliers as to when the medication orders were faxed to the AFH's pharmacy and when the tube feeding supplies arrived to the AFH. The DNS stated they had concerns about Resident 25 discharging to a lesser care setting due to her complexity, but there was no documentation in the record that the resident or spouse were informed of the risks and benefits regarding the discharge to the AFH. The DNS further stated the facility did not have a thorough and completed investigation into an allegation of neglect related to poor discharge planning for Resident 25. (Refer to F610 - Investigate/Prevent/Correct Alleged Violation for more information.) Review of the Hospital Discharge Summary report dated 01/11/19 and an electronic document provided by the DNS, dated 01/05/19, showed the resident was admitted to the hospital on [DATE] after discharging from the facility. The hospital notes documented, Pt (patient) was seen by medics at 1600 (4:00 PM) for a BG (Blood Glucose) of 21 medics treated pt and brought pt sugar up to 350. The notes went on and documented, Caregiver states pt is normally on 22HR (22 hours) of continuous feeding, but pt was only sent over with 5 cans of gravity feeding cans and due to pt not being sent over with pump required for that, and now not having enough food, AFH (Adult Family Home) is concerned that pt BG dropped too low due to lack of food . Summary: The facility failed to develop, implement and coordinate an effective discharge plan for Resident 25 who discharged to a lesser level of care. Resident 25 had an unstable blood sugar and was dependent on continuous tube feeding to regulate and maintain her blood sugar while on insulin therapy. The facility failed to ensure the resident received the correct and necessary tube feeding supplies immediately upon discharge which resulted in the resident's blood sugar to drop to an unsafe level that required emergency medical personnel interventions and hospitalization . The discrepancies with the tube feeding orders, lack of an effective communication to the post-discharge destination and suppliers/community partners, and the facility's failure to ensure all post-discharge needs (nursing services, medical equipment's and medications) were readily available at the time of discharge caused harm to Resident 25 and caused the resident to fail and ineffectively transition to her preferred discharge location. Reference: WAC 388-97-0080 (6)(7)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure Licensed Nurses met qualifications to respond to a medical emergency when a resident (#3) was suspected of choking in the dining room. Failure to initiate an immediate response to a suspected choking incident, may have contributed in Resident #3's death and placed other residents at the likelihood for a similar incident and outcome which constituted immediate jeopardy. Findings Include: On 05/11/2017 between 9:30 a.m. and 12:15 p.m. interviews were completed with three Licensed Nurses (Staff D, Staff G and Staff K). At 9:30 a.m., Staff K, the LN providing care on the second floor was interviewed about responding to a choking incident in the dining Room. Staff K said they would respond immediately and stated the suction machine was located in the dining room, located on second floor. When asked about the location of the suction machine, Staff K led the investigator to a cupboard in the dining room. The suction machine was assembled and ready to use if necessary. The sterile wrap for the tip was opened at one end, and wrap remained in place to protect the tip from contamination. Staff K said the device was routinely checked each night to ensure proper function by the LN who worked nights she then commented resident safety is first. On 05/11/17 at 10:00 a.m. Staff E, a licensed nurse on the first floor, was not able to locate a suction machine. Staff E first looked in resident rooms, checked in the central supply room, and medication room. The Resident Care Manager (Staff D) who was seated in the area provided Staff E with verbal cueing to look for the device in the utility closet. Staff E then went to the closet and found the device. The suction machine located on a cart in the closet was assembled and ready to use with a suction tip in place, protected by a sterile wrap in the same manner as the suction machine observed in the second floor dining room. Staff E was not aware there were suction machines located in the dining rooms. After the staff was alerted there were suction machines located in each dining room on the first floor, the investigator accompanied the staff to check on their location. After entering the dining rooms, staff E did locate the machines, but neither of the devices were assembled or ready to use. On 05/11/17 at 11:30 a.m. an interview was completed with Staff D, who provided oversite over the unit where Resident #3 resided. When asked how staff were trained to respond to a choking incident in the dining room, she stated the NA's were trained to do the HLM, and the reported suction machines were located in the dining room. Staff D said the staff were trained to respond immediately to a choking event and expected the NA's to attempt the HLM in the dining room. When asked about the suction machines Staff D, stated the LN's on the unit would operate the suction machines. Staff D reported the machines in the dining room should be assembled and ready to use. When asked about Resident #3's choking incident and subsequent death, Staff D reported she was on vacation at the time of the incident. On 05/15/17 at 3:30 p.m., Staff B reported the LNs moved the resident out of the dining room because they could not do the HLM while the resident was seated in her wheelchair. She then explained the staff found a better way to do it and stated they put the resident on the floor and doing chest compressions. When asked if the staff should have tried the HLM immediately, Staff B stated staff could not have effectively carried out the HLM in the dining room where the resident was at. When asked about the location of the event, Staff B reported at the time of the event, Resident #3 was seated in the alcove area of the dining room next to the window. Which was in close proximity to where the suction machine was located in the dining room. In addition during the interview (on 05/15/17) the Administrator, Staff C and Staff B reported they did not have a written policy to direct staff about what steps to take if a resident choked in the dining room. And Staff C stated the facility did not have a policy in place related to maintaining and monitoring the suction machines to ensure they were functional. Not ensuring staff were adequately consistently trained, able to locate the emergency equipment, and ensure equipment was ready for use in the first floor dining rooms, may have contributed to Resident #3's death. WAC 388-97-1080(1)

Based on observation, interview, and record review, the facility failed to ensure staff provided a timely response to provide basic life support for a suspected choking incident for 1 of 1 resident (Resident #3). Failure to immediately respond to Resident #3's suspected choking incident may have contributed to a resident's death and placed other residents at a likelihood for a similar incident and/or outcome which constituted an immediate jeopardy. Findings include: Resident #3 had resided in the facility since 2010 and died in the facility on [DATE]. A progress note entry dated [DATE] at 13:48 documented the resident was in the dining room while a Nursing Assistant (NA) helping with the meal, reported Resident #3 sneezed and took in a deep breath and developed a blank stare and her lips started turning blue. The NA alerted the Licensed Nurse (LN) who assessed the resident, noted a different breathing pattern and documented she heard audible gurgling from the mouth. The progress note entry documented Resident #3 was moved from the dining room to her room, where the staff attempted the [MEDICATION NAME] Maneuver (HLM) several times and attempted to clear the resident's airway with a suction machine. Emergency medical response was called, and also attempted the HLM without clearing the airway. The entry noted the resident's physician was in the facility and pronounced the death. Observations on [DATE] between 12 noon and 1:00 p.m., found the first floor main dining room had an alcove in an entry way, with two resident tables. Within four feet of the table, which was next to the window, the suction machine was observed not assembled and not ready for use if a resident was choking. Two residents were observed seated at the table during lunch meal. On [DATE] at 4:00 p.m. during an interview with Director of Nursing Services (Staff B), Staff B explained the resident's room was directly across from the dining room door. When asked why the staff moved the resident, Staff B stated it was a short distance, and explained the resident was moved to provide additional room for staff to work with the resident. On [DATE] between 9:30 a.m. and 12:15 p.m., interviews with 3 Nursing Assistants (Staff F, G, and H) were completed. Each NA interviewed reported they were trained to alert the nurse and perform the HLM. When asked if a choking incident occurred in the dining room, the NA's reported they might move the chair away from the table, or try to shield other residents from coughing if food was expelled. The staff reported they would respond to the emergency in the dining room. On [DATE], at 10:30 a.m., a LN Staff E, stated they would attempt the HLM if a resident was choking and could not breathe, and was not coughing in the dining room. When asked about using a suction machine to clear the airway, Staff E said the resident would have to be moved to their room to use a suction machine. Then explained they were available in some of the residents' rooms. When asked to locate a suction machine, Staff E was not able to locate a suction machine in any resident room on the first floor. Staff E explained she usually worked on the second floor of the facility and reported the devices were located in some of the rooms. Staff E was asked about the location of the suction machine on the first floor, and opened two different doors looking for the emergency equipment, but was not able to find a suction machine. The Resident Care Manager, Staff D, who was seated at the nurse's station, intervened and cued Staff E to another closet on the unit where the suction machine was located. The equipment was assembled and ready to use. Staff E, who was supervising resident care, was not able to locate a suction machine without cuing from a supervisor. Staff E reported she was not aware suction machines were located in the dining room. Staff E was accompanied by the surveyor to locate the machines in the dining rooms however neither of the units were assembled and ready to use. On [DATE] at 11:30 a.m. Staff D was interviewed about how staff were trained to respond to a choking incident in the dining room. Staff D said staff would do the HLM and a suction machine was located in the dining room that was set up and ready to use. Staff D reported the NAs were trained to do the HLM and the LN's would operate the suction machine. According to Staff D, staff were expected to respond to a choking event where it occurred, the dining room. Staff D explained, the suction machines were in the dining rooms and the nocturnal shift LN monitored the machines, to ensure they were functional. When asked to provide documentation the staff checked the equipment, Staff D was not able to locate any check list for the two machines located in the dining rooms. Staff D provided a suction machine monitoring check list for the suction machine on the emergency cart. In interview on [DATE] at approximately 3:30 p.m., Staff B and Staff C said Resident #3 was moved to a different room before initiating the HLM, as there was not enough space in the dining room. According to Staff B and Staff C, there was an alcove and a table and it was crowded with wheelchairs and too many other residents. Although Resident #3 was seated in a wheelchair at the time of the incident, Staff B and Staff C said (licensed nurses who responded) it could not have been done effectively where she was. According to Staff B, during the choking incident, licensed nurses who responded, wheeled the resident to a room across the way from the dining room, placed the resident on the floor, and began performing chest thrusts. Staff B said the HLM was not initiated until the resident was moved to the other room. WAC 388 -97- 0300(3)(b-c)

Based on observation, interview, and record review, the facility failed to ensure the policies for the prevention of abuse and neglect were implemented for 4 of 4 residents (#1,#2,#3, and #4) reviewed for abuse and neglect issues. This resulted in actual harm to Residents #1, #2, #3, and #4. Failure to conduct thorough investigations, take steps to protect residents during investigations of neglect, report incidents involving substantial injuries and unexpected deaths, placed all residents in the facility at risk for unidentified abuse and neglect. Findings include: Facility policy The facility policies for the prevention of abuse and neglect found the policy addressed all of the required components for screening and training employees, the protection of residents, prevention, identification, and reporting of abuse and neglect, mistreatment and misappropriation of personal property. Although the policies addressed all the required components, the facility staff did not implement them consistently. Failure to identify incidents of neglect, conduct thorough investigations, protect residents during investigations, and report substantial injuries and unexpected deaths, was demonstrated by the incidents described below. Resident #1 Resident #1 was admitted to the facility in 2016 with multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE], noted the resident was alert and oriented and needed extensive assistance of two staff with transfers. The resident care plan and resident status sheet noted the resident required assistance with transfers from 1 to 2 staff as needed. The directives identified Resident #1 had fragile skin and alerted the staff to use caution during transfers and bed mobility to prevent legs, arms, and hands from striking any sharp or hard surfaces or to handle with care. Review of the incident reporting log noted the resident was involved in an incident described as other on [DATE] at 09:45 p.m. (2145) which resulted in a 911 call and transfer to an emergency room (ER) for a deep laceration requiring medical treatment. The incident report stated the laceration occurred during a staff assisted transfer, the form offered an option to identify injury during handling, but the incident was coded incorrectly as other. The incident report documented the source of the injury was established and noted staff training/counseling was required. The Licensed Nurse (LN) documented being called to the room by the Nursing Assistant (NA), Staff A, and found a deep laceration on the right calf that was bleeding. The LN noted the laceration was due to the leg being pressed against the bed side rail during a transfer. The report documented Resident #1 warned Staff A she was too close to the bed. The incident report included Staff A's statement, and the LN who filled out the report. The summary noted the resident was transferred to the emergency room and required stitches, however the substantial injury was not reported to the state hotline as required. On [DATE] at 1:00 p.m. during an interview, the Director of Nursing Services (Staff B) stated the incident was not reported to the state hotline because the source was established. The report did not substantiate neglect occurred. Staff B was asked if she had observed the staff completing transfers, she stated she trusted the aide's judgement to complete the transfer regardless of the resident expressing verbal concerns about the safety of the transfer. On [DATE] at 2:00 p.m., Staff B clarified the directive to use 2 staff during transfers as needed. Staff B explained two staff should be present if requested by the resident or if she was tired. Although the time of the transfer at 9:45 p.m. was late at night, and the resident verbally expressed concerns about positioning for the transfer, Staff A proceeded without requesting assistance. On [DATE], the Administrator (Staff C) provided information, Staff A continued to work with residents until [DATE], when the staff took a leave of absence. The investigation was concluded within 24 hours. It did not include interviews with other residents who may have received care delivered by Staff A, and did not include other staff who may have heard or witnessed the events leading up to the injury. The facility failed to recognize, report, and thoroughly investigate neglect, which is defined by CMS as failure to provide goods and services necessary to avoid physical harm . In addition, the facility failed to protect residents when Staff A was not suspended pending the outcome of the investigation, and instead, continued to provide direct care to residents. Resident # 2 Resident # 2 was admitted to the facility in 2014 with multiple [DIAGNOSES REDACTED]. The MDS quarterly assessment dated [DATE] noted the resident needed extensive assistance with most activities of daily living, including transfers, bed mobility, dressing and toileting. The care plan identified the fall risk and listed interventions, keeping call light in reach, personal items in reach, use non-skid socks, bed in a low position with mat on floor. The care plan indicated Resident #2 stayed in her room all the time and ate meals in her room. It also directed staff to assist the resident with toileting before and after meals. The report dated [DATE] at 1:25 p.m., documented an LN who was in close proximity to the resident's room, heard a loud sound and found Resident #2 on the floor. The statement reported Resident #2 was eating lunch while seated in her wheelchair with the bedside table before her. According to the incident report, Resident #2 fell forward out of the wheelchair landing on top of the over bed table. Resident #2 sustained a deep laceration on the head and was transferred to the emergency room via 911 call, and required staples to a head wound. The facility incident report contained conflicting statements from staff , one reported the resident was eating lunch and another stated the fall occurred after lunch. The incident report did not provide information about what time the resident received her tray, or how long she had been left alone in her room with the tray before her. In interview on [DATE] at approximately 11:00 a.m., Staff B said the lunch tray arrived to the resident at 12:30 p.m. The incident report did not identify the location of the phone, which according to Staff B, had been a concern during previous falls. According to the statement of the NA, Resident #2 was assisted with toileting before lunch, but not after the meal. On [DATE], an Advanced Registered Nurse Practitioner (ARNP) assessed the resident on [DATE]. The entry documented; fell out of bed trying to reach phone and sent to ER for [MEDICAL CONDITION]. On [DATE] at 1:00 p.m., during an interview, the DNS stated she was not aware of the progress note entry by the ARNP dated [DATE]. When asked about conflicting statements from staff who heard the fall, Staff B stated she would have to ask the staff. She later clarified the ARNP was referring to a different fall, and stated the resident lunch tray was on the over bed table during the incident. The incident report did not include interviews with other staff or residents who may have heard or witnessed the events. There was no information about the location of the phone at the time of the fall, or how long the resident had been sitting in her room with the tray before her. There was no indication the facility attempted to identify the resident's needs at the time of the fall, such as attempting to get up, self propel, the need to lie down. This report concluded the incident was reasonably related to the condition and or event. Not conducting a thorough investigation left the facility without sufficient information to rule out neglect. Resident #4 Resident #4 expired in the facility on [DATE]. The log noted on [DATE] the resident was found at 08:00 a.m. in the morning with a substantial injury, described as a bruise of deep color / depth on the right side of the chest, which is an area not generally vulnerable to trauma. The report noted the bruising measured 24 centimeters (cm) by 12 cm to the right side of breast/chest. Review of the MDS assessment found Resident #4 needed extensive assistance with transfers and bed mobility and used a wheelchair for mobility. The assessment noted Resident #4 was alert and oriented and displayed verbal behaviors directed towards others described as yelling or screaming, which interfered with care and/or were disruptive to the environment. The [DIAGNOSES REDACTED]. The care plan indicated the resident's heart condition required management with a blood thinner, [MEDICATION NAME] therapy. It also identified the resident had a history of [REDACTED]. The care plan also noted the resident needed repositioning every two hours while in bed and used bilateral side rails. The incident report had two staff statements attached; one from the NA and the other was from the LN. The LN's entry stated a bruise which was noted to be 24 by 12 cm large. The statements indicated the injury was found when the NA was assisting the resident with morning care at 08:00 a.m. The LN indicated bilateral side rails when in bed and documented the resident was resistive to care had a history of [REDACTED].#4 reported she did not know how the bruise occurred, and denied any falls, rough handling and/or mistreatment. The investigation concluded the injury was reasonably related to her condition and event, and noted the resident's use of blood thinning medications. There was no evidence the investigation included interviews with other staff who worked with the resident the previous day. The progress note entries found the last entry prior to the discovery of the bruise on Resident # 4 breast and/or chest area was dated [DATE]. On [DATE], at 3:50 p.m., Staff B reported the bruising in an area not vulnerable to trauma was not reported. And commented it was necessary because the ARNP indicated the resident was bleeding internally and the bruising was related to the use of blood thinners and the elevated PT/INR time. Staff B stated she did not view the resident's death as unexpected, even though the resident died within 48 hours after the bruising was discovered. Not ensuring a thorough investigation was completed which included interviews with staff providing care prior to the discovery of the bruise, left the facility without sufficient information to rule out abuse or neglect. Resident #3 Resident #3 had resided in the facility since 2010. The record noted the resident died in the facility on [DATE]. A progress note entry dated [DATE] at 13:48 (1:38 p.m.) documented the resident was in the dining room while an NA helped with the meal she sneezed and took in a deep breath and developed a blank stare and her lips started turning blue. The NA alerted the LN, who also noted the resident breathing pattern was different and heard an audible gurgling sound from the mouth. The staff moved the resident from the dining room to her room, which was close by. The incident was not investigated, documented in the facility log or reported as an unexpected death and was not reported to the state hotline. In addition, according to [DATE] interview with Staff C, there was no written policy and procedure for responding to a choking event. Staff C said the facility staff followed American Heart Association guidelines when responding to choking events. On [DATE] at 03:50 p.m. during an interview, the Staff B stated the incident and subsequent death were not reported because the medics and physician believed the resident experienced a sudden cardiac event and believed the incident did not have to be reported. On [DATE] at 01:00 p.m., when asked why she did not view the event as an unexpected death, the DNS responded it was not reported because Resident #3 had multiple comorbidities. The Physician was also interviewed and provided verbal assurance she believed the resident had a cardiac event or a stroke. Staff B provided the last progress note entry made by the Physician which was dated [DATE] at 3:07 p.m. and noted: The patient passed away after an aspiration event possibly linked [MEDICAL CONDITION](stroke) or silent dysphasia for end stage Alzheimer's type dementia. Failure to implement policies to recognize and report abuse and/or neglect as evidenced by staff interviews: On [DATE] between 9:30 a.m. and 12:15 p.m., interviews about reporting abuse and neglect were completed with 7 staff members (3 NA's and 3 LN's and a Social Worker). Five of the staff interviewed stated they would report the incident to the hotline if they suspected abuse and neglect. On [DATE] at 9:50 a.m., Staff I, a Social Worker (SW) who identified she was responsible for investigations and resolution of grievances, was interviewed. When asked about reporting abuse and neglect to the state hotline, she stated issues were reported depending on the investigation. Then commented the facility follows the guidelines in the purple book which is published by the state agency and acknowledged Staff B is the person responsible for reviewing grievances and investigations when completed. On [DATE], at 11:30 a.m., the RCM assigned to the unit where Resident #1, #2 and former Resident #3 resided, was interviewed. She stated all the staff were mandatory reporters and had the number for the hotline on the back of their ID badges. Staff D she would report to the hotline if they suspected abuse or neglect. When asked to describe neglect, she stated not meeting a resident's needs. When asked if not implementing care plan directives was considered neglect, she stated it would depend on the situation/or what it is. When asked, Staff D said she had worked in the facility for the past 6 years and had never had the occasion to report any incidents to the state hotline. The facility failed to implement screening processes and ensure Background Inquiries (BGI) were conducted as required. On [DATE], at 12:30 p.m. review of the screening record for 5 direct care staff interviewed and/or observed working in the facility, found one BGI was expired. Staff G's background inquiry expired on [DATE]. In addition, Staff H, had a criminal conviction sheet attached to the documents returned from the BGI unit, but there was no evidence the character, competence, and suitability review required was completed. On [DATE] at 12:30 p.m. the Business Office Manager, Staff J, was interviewed at 12:30 p.m. When asked about the expired BGI, she stated she was waiting until [DATE] and then would submit all of them for processing. Staff J later requested staff G sign the request for a renewal of BGI. Staff J, who was responsible for maintaining the records did not have a system to identify and monitor for the expiration dates to ensure they were renewed every two years. On [DATE] at 12:30 p.m., Staff C was interviewed about the results of Staff H's BGI. Staff C stated the facility had not done the character, competence, and suitability review mandated by state law, because the employee was hired by the facility before the requirement was a statute in law. Even though the facility had resubmitted the BGI every two years the suitability review was not completed. Refer to WAC [DATE](2)(a)(b)

Based on observation, interview, and record review, the facility failed to self identify deficient facility practice and failed to ensure the Quality Assessment and Assurance (QAA) committee functioned efficiently and effectively after quality deficiencies were identified concerning the abuse and /or neglect prevention policies. Failure to thoroughly investigate, report, and identify abuse and/or neglectmay have contributed to the death of Resident #3 and #4, and substantial injuries which resulted in actual harm for Residents #1 and #2, and increased the risk of harm to other residents. Findings include: On 5/11/17 between at 12:30 p.m., the Director of Nursing Services, Staff B was interviewed about the QAA committee. Staff B reported the meetings were routinely held monthly with the participation of the Medical Director, Department heads, and the Pharmacists participated in the quarterly meetings. When asked to describe an action plan for falls the facility was working on, Staff B said the reduction of alarms and prevention of falls. When asked if the facility had identified quality issues related to the abuse and neglect reporting she stated no. When asked about a statement of deficiencies that was issued in December of 2016 which identified failed practice under F 226, for lack of identifying, investigation and protecting a resident from neglect, Staff B denied the validity of the findings. On 5/11/17 at 1 p.m., the Administrator, Staff C was interviewed. He reported the abuse and neglect system had been reviewed by the committee. He stated in-service training was completed in December of 2016 and stated the mandatory reporting requirements were discussed during monthly meetings with staff. Even though the staff reported an action plan was implemented to correct the quality deficiencies, the two residents experienced substantial injuries from falls and handling during a transfer, the other two resident incidents resulted in death and lacked documentation concerning circumstances preceding the death to rule out neglect, and were not reported to the state hotline. None of the staff reported the incidences or recognized the potential for neglect which had occurred. This failure contributed to a finding of substandard care concerning resident behavior and facility practices. Failure to ensure the staff were trained how to respond to and ensure a suction machine was assembled in the dining room to respond to a choking incident may have contributed in a resident's death and a determination by the department of Immediate Jeopardy. Not ensuring the QAA committee, developed an effective action to ensure the policies and procedures to identify abuse and neglect, investigate incidents/and or accidents and take steps to protect other residents during investigations contributed to the facilities failure to protect residents. WAC 388-97-1760(1)(2)

Based on observation interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 2 (#1, #2) residents reviewed who experienced falls, and failed to find root cause analysis of falls to prevent recurring falls. Failure to ensure residents were provided with adequate supervision and failure to prevent falls, resulted in substantial injuries, a subsequent emergency room visit (ER) and actual harm. Findings include: Resident # 1 was admitted to the facility in 2016 with multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment, dated 03/09/17, noted the resident was alert and oriented and needed extensive assistance with transfers from two staff. The resident care plan and resident status sheet noted the resident was transferred with 1 to 2 staff as needed. In addition, the care directives instructed the nursing assistants (NA) that Resident #1 had fragile skin and to use caution during transfers and bed mobility to prevent legs, arms, and hands, from striking any sharp or hard surfaces and to handle with care. On 04/27/17, at 11:00 a.m., the resident was observed napping in bed and was easily awakened. When asked about the laceration and emergency room (ER) visit, Resident #1 reported at the time of the incident she alerted Staff A she was too close to the bed and expressed concern about the transfer. Resident #1 stated Staff A did not listen and proceeded with the transfer. The resident identified Staff A by name and reported the staff had not been assigned to provide care for her since the injury occurred. According to Resident #1, the laceration was so deep, the resident required weekly wound treatments to assist with healing. Review of the resident's clinical record found wound consult progress notes confirming the resident's interview statement. The facility event/incident report noted the injury occurred while the resident was being transferred from the wheelchair to the bed. The report documented when asked she warned the NAC who was assisting her that (she) was too close to the bed. The investigation noted a laceration was found on the right calf which was 6 cm by 5 cm and a depth of 2 cm. The Nurse also noted the side rail had a broken piece of plastic that may have contributed to the injury. On 04/27/2017, at 1:00 p.m. during an interview with the Director of Nursing services (Staff B) was asked if Staff A had received any counseling, she commented I did talk to her. She stated at this time Staff A was on a leave of absence. On 04/28/17 at 2 :00 p.m., when asked about the care plan directive to use 2 staff for transfers, Staff B reported the directive should be followed if the resident is tired or if she requests 2 staff to complete the transfer. Although the resident expressed concern about her positioning to Staff A proceeded with a one person transfer, and did not seek any additional assistance. The time of the transfer noted on the investigation was 9:45 p.m. Not following the care plan to provide 2 staff assist when requested, caused the resident to sustain injury during transfer and a subsequent ER visit. Resident #2 Resident #2 was admitted to the facility in 2014 with multiple [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] noted the resident needed extensive assistance with most activities of daily living, including transfers, bed mobility, dressing, and toileting. The resident care plan identified Resident #2 was at risk for falls and noted one of the interventions stated ensure items are within reach at all times. On 4/21/17, at 1:25 p.m., Resident #2 was observed lying in bed wearing a hospital gown, with the bed side table and meal tray before her. When asked about the meal, she commented she was really very hungry. When asked if anyone assisted her with grooming and dressing, she reported she wanted to stay in bed. The record indicated Resident #2 fell on [DATE] at 1:25 p.m., sustained a deep laceration on the head, which the facility identified as a substantial injury on the incident report. The report indicated the resident was sent to the emergency room (ER) and the head laceration required staples. The log entry noted the event was reasonably related to condition or event, stated care plan changes were implemented. The investigation report indicated the resident was seated in a wheelchair beside her bed in front of the over bed table. Resident #2 was found on the floor and had fallen on top of the over bed table which had fallen to the floor. Although the care plan in place at the time of the fall stated the resident personal use items should be in reach at all times, including the phone, this directive had been in place since 05/24/16, the facility incident report did not note the location of the the phone during the event. In addition, the facility did not attempt to identify the resident's needs at the time of the fall, or what the resident may have been attempting to do. In interview at approximately 3:00 p.m. on 04/28/17, Staff B did not know if the resident needed to lay down for a nap, or if perhaps the resident falling out of the wheelchair was caused by actually falling asleep, or perhaps the resident attempted to self propel to the bathroom. The facility did not complete a root cause analysis into the resident's fall to determine the circumstances in order to prevent her from falling, and the facility was unable to identify how the fall was prevented. Although the facility did not determine the cause of the fall, the care plan was updated and the resident was referred to skilled therapy to determine if a tilt in space wheelchair would be appropriate. On 05/08/17 at 11:00 a.m. during an interview, Staff B reported the fall was related to weakness and the skilled therapy evaluated the resident wheelchair. It was reported the seat on the wheelchair was adjusted and that it could be placed in a tilted position. When asked what the resident's needs were at the time of the fall, Staff B reported she agreed the resident should be offered assistance with toileting after the meals. The facility accident/ incident log found the resident had experienced falls in the past, one on 10/23/16, and another on 12/13/16. Review of the incident report dated 10/23/16 found the resident fell out of bed at 1300 (1:00 p.m.), while her lunch tray was on the overbed table and the report dated 12/13/16, noted the resident was trying to reach the phone, which according to the care plan should be placed in reach. Not conducting thorough investigations to determine the root cause of falls, may have contributed to the additional fall and subsequent injury sustained on 02/21/17. Refer to WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to formulate, implement and evaluate a safe pain management plan for Resident # 5. This failure resulted in the Resident being unable to participate in his therapy and rehabilitation and ultimately suffering respiratory compromise on 02/01/2014, requiring emergency transport to the hospital and an inpatient stay due to narcotic overdose. Findings include: The Resident was a [AGE] year old male who was admitted to the facility on [DATE] with a history of chronic back pain. He had also sustained acute fractures of the spine which increased his pain and discomfort. He suffered from [DIAGNOSES REDACTED] (a weakening of the heart muscle leading to heart failure), [MEDICAL CONDITION], high blood pressure, [MEDICAL CONDITION], and other medical conditions. The Resident had previously worn a back brace to assist with comfort. On 01/27/2014, the physician admission orders [REDACTED] [MEDICATION NAME] ER (extended release) 15 mg, (milligrams) once a day in the morning (total dose 15 mg. per day). [MEDICATION NAME] 2.5 mg. every two hours around the clock. This was a short acting, concentrated, oral solution (total dose of 30 mg. daily) [MEDICATION NAME] (an adhesive patch which contains slow release, non- narcotic medication) to his back to be applied in the morning and removed in the evening. Tylenol 325 mg. tabs, 1-2 tabs orally every 4 hours PRN (as needed) for pain or increased temperature. [MEDICATION NAME] 10 mg. orally three times a day PRN for muscle spasm. There were no orders for a PRN narcotic pain medication or use of his back brace. The nursing notes for 01/27/2014 on admission at 4:00 PM revealed the Resident was admitted for chronic back pain. At 9:00 PM the note states that the Resident rated his pain at 1 ? (using a 0-10 scale, 0 being no pain and 10 being severe pain) but "moans loudly with any movement." There was no assessment of his level of sedation or any interventions implemented to increase his comfort level. There was no nursing assessment from 9:00 PM on 01/27/2014 until 06:00 AM on 01/28/2014. On 01/28/2014 at 06:00 AM, the notes state "routine [MEDICATION NAME] given, no complaints of pain." Nursing notes for 02:00 PM say nothing about his pain or level of sedation. The MAR (medication administration record) for 01/28/2014 revealed his pain to be zero, but the OT (occupational therapy) notes states his pain was 8/10. The Resident had Tylenol and [MEDICATION NAME] ordered PRN (as needed) but none was administered. There was no evidence of any other interventions to help reduce his pain. On 01/29/2014 at 2:15 PM, the nursing notes state nothing about his level of discomfort or sedation. The MAR indicated [REDACTED]. A nursing note entry for "PM" states nothing about his pain or sedation level. There are no nursing notes for the date of 01/30/2014, the day that significant medication changes were made and implemented. There was a late entry made on 02/20/2014 (the date after the survey started on 02/19/2014) for 01/30/2014 that stated, "Not getting out of bed for therapy. Nurse assessed and found that any movement was causing his discomfort. Resident stated he is uncomfortable, back hurts most of the time, especially with movement." A review of the MAR (Medication Administration Records) for 01/28/2014 through 01/31/2014 showed documentation of pain levels at 0-5 and no record of his level of sedation. The OT (occupational therapy) notes from 01/28/2014 states pain was 8/10 and "anticipate until pain get (sic) better under control, pt. will progress slowly." OT notes from 01/29/2014 at 12:20 PM states "pain 0/10" , " back support when OOB (out of bed)." Notes from 01/30/2014 rates the Residents pain at 10/10 and that pain "limits his functional activities." The note goes on to say that he had difficulty staying seated after complaints of "severe pain in lower back." The note states the Resident was "screaming in pain with every movement. Nursing aware." There was no documentation that the therapy or nursing staff ever notified the physician of the Residents pain and his inability to fully participate in therapy due to discomfort until 01/30/2014. A review of the medication administration records for 01/27 through 01/29/2014 revealed the Resident received the following for pain control: 01/27/2014: Total [MEDICATION NAME] dose of 7.5 mg. 01/28/2014: Total [MEDICATION NAME] dose of 45 mg. plus [MEDICATION NAME] 01/29/2014: Total [MEDICATION NAME] dose of 45 mg. plus [MEDICATION NAME]. No PRN doses of Tylenol or [MEDICATION NAME] had been administered. From 01/27/2014 through 01/29/2014 there was no evidence of any coordination between the physician, nursing, and therapy to attempt to pre-medicate the Resident for pain prior to therapy or to administer the PRN doses of medication (Tylenol and [MEDICATION NAME]) when the Resident complained of pain during therapy. There was no evidence that adjunct therapies such as heat, cold packs, positioning, use of his back brace or other therapies were attempted. His back brace was never ordered. The Residents care plan stated "evaluate the effectiveness of pain management regimen" and "monitor for probable cause of each pain episode." The care plan goes on to state, "Provide patient with reassurance that pain is time limited. Encourage to try different pain relieving methods including but not limited to positioning, heat and cold application." The plan goes on to say "monitor for signs and symptoms of adverse drug reaction .... Lethargy." Encourage/ supervise/ assist the Resident with the use of supportive devices back brace as recommended." There was no evidence that his back brace was ever applied, alternative therapies to assist with pain relief were ever attempted or that a plan was developed to specifically address pain needs before and during physical therapy. On 01/30/2014 the Resident was seen by Staff G, PA (physician ' s assistant). His note stated "patient seen today for follow up visit at the request of the nursing staff for pain control." The notes go on to say that the patient has been having "severe pain with any movement or nursing care." The notes state, "His long acting [MEDICATION NAME] was increased at this visit, however this will not take effect until this evening, the patient's immediate acting [MEDICATION NAME] was also increased, hold for sedation. Continue to monitor and follow up as needed." During that visit the following medication changes were made: [MEDICATION NAME] ER (extended release) 15 mg. daily was increased to twice a day (30 mg. per day) [MEDICATION NAME], short acting, was increased from 2.5 mg. every two hours to 5 mg. every two hours around the clock. (Total of 60mg. per day). [MEDICATION NAME] was ordered 10 mg. by mouth every 8 hours, scheduled (total of 30 mg. per day)rather than only PRN (as needed). [MEDICATION NAME] 5 mg. orally every hour PRN for pain was added to the pain regimen. These orders were transcribed by an LN (licensed nurse) and hand written on the MAR. On 01/30/2014 the Resident received a total of 52.5 mg. and [MEDICATION NAME] 20 mg. On 01/31/2014 the Resident received a total of 60 mg. of [MEDICATION NAME] and 20 mg. of [MEDICATION NAME]. On 02/01/2014 the Resident received a total of 45 mg. of [MEDICATION NAME] and 10 mg. of [MEDICATION NAME]. These medication adjustments reflected a 200% increase in the dose of [MEDICATION NAME] and an almost 100 % increase in the dose of [MEDICATION NAME] the Resident received. On 02/01/2014 (Saturday) the OT note at 5:13 PM stated the Resident had a pain level of 0/10. The note states that the patient was "very lethargic" and "on [MEDICATION NAME]." The note states the family was present and stated "he has been like this since he's been back." The note goes on to say that he was "very lethargic (sic)" and "unable to tolerate head of bed raised higher than 50-60 degrees due to back pain. Nursing came in to give more meds. Patient became even more lethargic after that." In an interview with Staff E, OT on 02/19/2014 at 1:30 PM, she stated that when she came into the room to see the Resident, the family voiced concerns about lethargy and that his medication dose might be too high. She stated she tried to put him up (raise the head of the bed) but he was in too much pain. She stated he opened his eyes and was able to wash his face. She did not have any recall of any observation or overhearing any conversation related to his possibly being over sedated. She stated she did not feel he was in any danger. She stated his color was good; he was breathing, and was able to answer questions. The nursing note for 02/01/2014 at 07:00 PM stated "eve (evening) sleeping soundly. No response with repositioning. Therapy and family at bedside 1 hour. Pt. sleeping. Was given MS ([MEDICATION NAME] sulfate) 5 mg, sol (solution) at 16:00 (04:00 PM) as ordered. This LN (licensed nurse) re-assess (sic) prior to eve (evening) meal, pupils pinpoint, resp. (respirations) 7, periods of apnea (no breathing). Sats (oxygen saturation level) 94% RA (room air). Called Phy (physician) noted order to send to ER Overlake ER (sic) for eval. Amb. (ambulance) service advised call 911 (sic). They are in room with Pt. at this time. Left at 19:05 (07:05 PM)." On 03/10/2014 at 2:10 PM in an interview with Staff F, LPN (licensed practical nurse) she verified that she was the nurse caring for the resident on the date he was taken to the hospital. She stated that the Resident would state that he was having no pain but did have pain when the head of his bed was elevated. She stated that the big focus for him was getting him to eat and drink. She stated that her normal practice is to ask and observe for signs and symptoms of pain. She stated that she had taken care of this Resident three times. Staff F stated that the day nurse had given the Resident his 2:00 PM dose of medication and she was responsible for the 4:00 PM dose. She stated she told the CNA (certified nursing assistant) that she wanted to get him up for dinner. She stated that the CNA reported to her that the Resident was lethargic but she was not concerned because he had been up for both breakfast and lunch and she (Staff F) thought he was tired. Staff F stated that at 4:00 PM she went in to give him his scheduled medication. She stated she was able to wake him up, he was able to take his medication and drink his health shake. She stated there was "a room full of people" present and she did not recall anyone saying anything about his being too sleepy. She stated that when she came in to give him his 18:00 PM (6:00 PM) medication, she found him lethargic, with a decreased respiratory rate of 7, periods of apnea (no breathing) and pinpoint pupils. She stated she did not give him any more medication and called the doctor. The physician note from the hospital stated the Resident suffered from an overdose of [MEDICATION NAME] and was treated with [MEDICATION NAME] (a narcotic reversal agent), IV (intravenous) fluids and monitoring. He remained in the hospital until 02/04/2014. The discharge summary from the hospital dated 02/04/2014 stated the Resident had been over sedated at the SNF (skilled nursing facility) and his mental status cleared when the medications were held. The note stated that he was started on scheduled Tylenol and his brace was obtained from the SNF. Pain management had been consulted and he was managed well on scheduled Tylenol, [MEDICATION NAME] and with [MEDICATION NAME] PRN. The patient was to wear brace when moving around for comfort. The SNF staff to contact family for consent before making any medication changes. In an interview with Staff A, the administrator and Staff B, the director of nursing on 02/19/2014 at 01:00 PM, Staff B stated they first became aware of the Resident suffering from over sedation on the following Monday when they got a report back from the hospital. Staff B stated that she spoke with the family who had a concern that there was a medication error and she told them that they had orders for all the medications that had been given. Both Staff A and B stated they looked through the orders and determined there was no med error. When asked if they were concerned about the incident, Staff B stated she was not really concerned and Staff A stated "you were concerned." When asked if an investigation had been done, Staff B stated "honestly, I do 't have an investigation." Both stated they looked into it but really did not do an investigation. Both staff A and B stated they did not view this as a medication error. When asked about the policy for alert charting, Staff A stated that part of alert charting was to check for sedation. A review of the facility "Alert Charting Documentation Guidelines" states that residents should be monitored every 8 hours for 72 hours until resolved or stable for change in condition. Staff A stated that the medication changes for this Resident would have been considered a change in condition. A review of the facility "Alert Charting Documentation Guidelines" list three medications that require the initiation of alert charting: IV fluids, antibiotics and psychoactive medications. Neither Staff A or B were able to state why no monitoring had been done on 01/30/2014, the date these medication changes were made. There was no evidence that the Resident had been monitored for sedation. When asked what was done following the event, Staff A stated they gave verbal direction to the nurses and the charge nurses that the resident could not have any medication changes prior to notifying the family. The facility was unable to provide any documentation of a review or an evaluation of the event and there was no evidence of an analysis or recommendations to prevent future events of this nature. On 03/11/2014 at 3:20 PM, in an interview with Staff C, Medical Director she stated she became aware of the event when the staff called her to get an order to transport the Resident to the hospital. She stated she spoke with the PA the following day and discussed the increase in medication doses that the Resident had been given. She stated that she felt the [MEDICATION NAME] should have been left as a PRN and the dose should have been 5 mg. She stated he had made these medication changes without consulting with her. She stated that the PA expressed frustration that the Resident had not been given the PRN medications that had been ordered so he placed the Resident on scheduled doses. Staff C went on to say that the documentation of the Residents pain level was poor. She stated that when he was lying still he was having almost no pain. She stated that when she spoke with the Resident directly, he stated he was having pain at 8-10/10 level with movement. She expressed concerns over the poor documentation and was aware there was no documentation of any monitoring by the nursing staff on 01/30/2014 when all the medication changes were made. She stated they should have started an investigation right away after the event occurred. On 03/10/2014 the facility provided policies and procedures that were written by their consulting pharmacy service. Staff A stated that these are the policies used in the facility with regard to medications and medication administration. The facility policy "Medication Monitoring and Management: Preventing and detecting Adverse Consequences" stated, "when a resident has a change in condition, medication- related problems are considered. Significant medication related problems are assessed, documented, and reported as appropriate." The policy goes on to say, "facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur:..."unexplained decline in function or cognition" and "change in dose" among other details. The policy goes on to identify an event as a "medication related-error or adverse consequence" and identifies hospitalization as a significant event. The policy states, "the following information is documented in the resident's clinical record and or incident report: factual description of the error or adverse consequence" along with other actions. The facility medication error policy states that an error includes any medication that is given at the "incorrect strength for drug selected for client" . The policy states that an "error, harm" includes "initial or prolonged hospitalization and caused temporary patient harm." Under the policy "Medication Issues of Particular Relevance in Older Adults" in the section under opioid [MEDICATION NAME], the policy states, "longer acting opioid [MEDICATION NAME] is not recommended unless shorter acting opioids have been tried unsuccessfully" and goes on to list adverse consequences as "sedation, lethargy, and unintended respiratory depression" among others. The Resident had also been given [MEDICATION NAME], a muscle relaxant medication that has "significant [MEDICATION NAME] properties" (a classification of drug that inhibits certain neurotransmitters in the brain). The facility policy states that these drugs can have a "cumulative effect" and listed drowsiness, lethargy, muscle weakness, mental status changes and breathing difficulty as some of the adverse side effects. The FDA (Federal Drug Administration) in information obtained from the Drugs.com website on 02/21/2014 states that [MEDICATION NAME] is extensively metabolized and excreted in the kidney with a half-life (the time it takes for the body to metabolize half the drug) of 18 hours. The "concentration is generally higher in the elderly." The article goes on to say that the medication is contraindicated in patients with [MEDICAL CONDITION] and "may enhance the effects of other CNS (central nervous system) depressants." The article also states that the elderly may also be more at risk for CNS adverse events and for these reasons it should only be used clearly if needed and should be initiated at a 5mg. dose and titrated slowly upward." The reference " harmacological Management of Persistent Pain in Older Persons from the American Geriatric Society, 2009, states "use of opioids in older patients with persistent pain should be prescribed on a trial basis with clearly defined therapeutic goals. The trial may involve serial attempts to titrate the opioid to an efficacious dose without intolerable adverse effects." The article goes on to say that "patients and their care givers must understand that opioids are not a panacea for substitute for nonpharmacological therapies." Under the heading "Risks and Benefits of Long Term Opioid Therapy" it states, "respiratory depression, is the most serious adverse event that therefore deserves special consideration." Respiratory depression usually results from excessively rapid dosing increases, drug-drug interactions with other CNS depressants and drug accumulation." The facility failed to implement adjunct pain treatment modalities for Resident #5 to potentially reduce the need for increased medication doses. The facility failed to follow their own internal policies and procedures and failed to follow established standards of nursing practice for the administration and monitoring of medications. In addition, the facility failed to recognize, and demonstrate staff evaluated, and monitored Resident #5's risk for potential and actual adverse consequences from rapid dose increases of [MEDICATION NAME] and [MEDICATION NAME]. Following the event, the facility failed recognize the event as significant, and failed to review and investigate the incident as required under facility policy, federal and state regulations. Failure to recognize, assess, document and report significant medication events places residents at risk for further harm if similar events occur in the future. .

Based on interviews and record reviews, the facility failed to identify and recoginize a new onset of headaches as a significant change for one of five residents (#1) with a known head injury after a fall and on anticoagulant (medication to prevent the formation of blood clots) therapy. In addition, the facility failed to notify the physician of the change of condition of the new onset of headache. Failure to evaluate and notify the physician of the resident's headaches may have contributed to the resident's death. Findings include: According to the [DATE] admission assessment, minimum data set (MDS), Resident #1 was admitted to the facility on [DATE] with a recent history of blood clots. Review of the [DATE] hospital discharge summary revealed the resident was on medications to prevent clotting. The resident's clot time was checked on [DATE] and was 3.7 according to the INR flow sheet (INR is the name of the blood test for checking the blood clotting status), this is a prolonged clotting time, and outside the desired range of ,[DATE]. According to the physician's orders, the clot prevention medication dose was reduced. Record review of facility investigations for falls revealed that on [DATE] at approximately 7:15 a.m. Resident #1 fell and sustained a head injury. The vital sign flow sheets and neurological evaluation documentation found the resident was monitored for changes in neurological status. However, there was no documentation to show headaches were being monitored. Review of the facility policy for head injuries revealed neurological assessments included assessing for headache pain, and any signs of neurological changes would be reported to the physician immediately. Included in the facility head injury policy was a statement that headaches were to be expected, but if they increased in severity, medical advice should be sought. In addition to the specified intervals for neurological evaluations, the facility policy stated that the frequency of neurological checks was determined by the stability of the neurological signs. On [DATE], the Director of Nursing (DNS) said that on [DATE] in the morning Resident #1 preferred to stay in bed and rest. The resident was found on [DATE] at 9:50 a.m. unresponsive, with fixed, dilated pupils and was transported to the hospital where she died . In interview on [DATE], Staff A said that on the night shift of [DATE] Resident #1 complained of headache pain, so Staff A gave the resident Tylenol. Thirty minutes later the resident requested something stronger to help relieve her headache so she would be able to sleep. Staff A gave the resident a narcotic medication for headache pain. Staff A said the physician was not notified of Resident #1's headaches as the headaches were localized to where the resident bumped her head. Staff A said he did not notice a worsening of the headaches. Review of Resident #1's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the [DATE] MAR, on [DATE] at 2100, Resident #1 complained of headache pain and was given Tylenol. No neurological evaluation was done at this time. The neurological evaluations for Resident #1 were changed from every two hours to every four hours around the time of the resident's first complaint of headaches, according to the neurological evaluation flow sheet. According to the [DATE] and [DATE] MAR indicated [REDACTED]. Thirty minutes later (midnight), the resident was given a narcotic for headache pain as the resident asked for something stronger. The resident's neurological evaluations were changed to every eight hours, there was an evaluation done at 2400, then again at 0950 according to the flow sheet. Although the vital signs flow sheet showed vital signs were checked at 0515, a neurological evaluation was not conducted until more than eight hours later. The facility failed to follow standards of practice by not evaluating changes in a resident's condition with a frequency consistent with the resident's needs related to a head injury and prolonged blood clotting time.