Every finding on record at Birch Creek Post Acute & Rehabilitation

Based on interview and record review the facility failed to provide the choice of routine personal hair hygiene services, free simple haircuts and trims by a facility employee or a professional haircut by a licensed barber or beautician at a cost for 7 of 8 residents (Resident 2, 3, 4, 5, 6, 7 & 8) reviewed for services covered under Medicaid. Failure of the facility to ensure charges were not imposed against personal funds without documenting the residents' choice, including if the residents knew they had the right to simple haircuts and trims included in their room and board costs, and that they chose to have and pay for a professional service, violated residents' rights.Findings included.Review of the facility undated admission Agreement showed an undated Facility Rates sheet with a brief description of facility rates and service charges for your reference. From time to time, these rates may change. You will be provided with a notice in advance of any such changes. The sheet listed the daily room rates and under Additional Services Offered, listed Laundry and Beauty and Barber Shop. Neither of these additional services had listed costs associated.The sections on Covered and Noncovered Services for Medicaid Recipients listed Nursing Facility Services as covered, and Beautician Services as not covered. The Resident was expected to pay for all costs and services not covered by Medicaid. An explanation of what is and is not covered by Medicaid was explained in the Facility's admission Agreement at Exhibit G.Review of Exhibit G showed the facility disclosed offering a variety of services that may not be covered by the daily room rate, including, but not limited to, beauty and barber services.Review of the Welcome Packet, dated 08/25/2025, showed the Beautician was at the facility every other Tuesday, at the beauty shop located across from the dining room. You can pay with cash, card, check or you have a trust with the building you can pay with that. Please sign up at the front reception desk. The services offered were listed but not the associated costs.On 06/03/2026 at 11:23 AM, an undated, posted price list for the professional onsite salon was observed, and included Haircut $40, [NAME] Trim $70, and Shampoo only $12. The posting included additional services and their associated costs, beyond those considered routine services.During an interview on 06/09/2026 at 1:57 PM, when asked how resident's got haircuts, Staff F, Licensed Practical Nurse (LPN) stated they had someone who came to the facility. The residents pay them or it's taken out of their trust fund.During an interview on 06/09/2026 at 2:06 PM, Staff D, Registered Nurse (RN) stated the facility had a beautician that comes and residents pay for shampoo, haircut, beard trimming. Staff D stated there was a sign-up sheet, and the residents get their funds from the business office. When asked if there were staff who cut hair for residents funded by Medicaid, Staff D stated, Not that I know of.Review of the undated Beauty and Barber Sign-Up Sheet on 06/03/2026 at 11:27 AM, showed Resident 2 was on the list for a wash.On 06/03/2026 at 11:56 AM, Resident 2 was observed seated in a wheelchair with long hair. During an interview at that time, Resident 2 stated she receives a bed bath at the facility twice a week and the aide on Friday used towels, water and washed their hair. The aide on the other bath day only offers to clean their hair with a dry cap which Resident 2 refuses and stated they did not like it as it made their scalp feel bad. Resident 2 stated they had gone to the beautician to have their hair washed three times at a cost of $12 each time.During an interview on 06/09/2026 at 1:37 PM, Resident 3 stated if they asked the staff to wash their hair they would, but to get their hair cut, they had to go to the beauty shop. Resident 3 stated, If I feel I really need it, I will go. When asked if the facility offered a haircut free of charge, Resident 3 stated, It's not included, it can come out of my resident funds.During an interview on 06/09/2026 at 1:22 PM, Resident 4 stated they shaved themselves, but they liked their hair cut short and added that it grew fast. Resident 4 stated they gottheir haircut by the beautician and they take the payment out of their personal funds account. Review of receipts showed Resident 4 paid $35 for a haircut from their trust fund on 05/07/2026.Review of the undated Beauty and Barber Sign-Up Sheet on 06/03/2026 at 11:27 AM, showed Resident 5 was on the list for a haircut.During an interview on 06/09/2026 at 1:28 PM, Resident 5 stated their hair had grown out since their last haircut. Resident 5 stated they paid for the haircut out of their personal funds account. Resident 5 stated the facility did not offer a haircut they did not have to pay for.On 06/02/2026 at 10:45 AM, Resident 6 was observed with mid length hair and a long beard. During an interview at that time, Resident 6 stated they had been asking for a beard trim and haircut for a month and a half. Resident 6 stated they were told they have to go to the beautician and pay $70. Review of the undated Beauty and Barber Sign-Up Sheet on 06/03/2026 at 11:27 AM, showed Resident 6 was not on the list.During an interview on 06/03/2026 at 11:44 AM, Resident 7 stated to get a haircut the residents can put their name on the beauty shop list. Resident 7 stated they did not know what the people who could not afford it did. Resident 7 stated they had not gotten their hair cut yet and the aide washed their hair with their bed baths.During an interview on 06/09/2026 at 2:01 PM, Resident 8 stated the evening shift aide shaved them and their hair was washed with their bed bath. Resident 8 stated they went to the facility barber to have their hair cut. Resident 8 stated they were not given other options and paid for the haircut out of their savings (trust funds) account. Review of receipts showed Resident 8 paid $35 for a wash haircut from their trust fund on 05/07/2026Record reviews showed Medicaid was the primary payer for Resident 2, 3, 4, 5, 6, 7 and 8.None of the facility documents reviewed notified the residents of their right to receive routine personal hair hygiene services at no cost to them. On 06/09/2026 at 3:50 PM, the facility was given the opportunity to provide additional information. None was provided.On 06/09/2026 at 3:50 PM, Staff A, Administrator stated they had a beautician once every two weeks, and typically the residents used their personal care allowance to pay the beautician. If the resident had no funds and they were covered by Medicaid, the facility did have a sunshine fund available. Staff A stated they had used the fund in the past for Resident 4. Resident 2 has funds for the beautician. Resident 5 did not want the facility to cut their hair. Staff A stated they were not required to provide a beautician or pay for services.REFER to WAC: 388-97-0340(7)(8)

Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for transportation was provided supervision for a medical appointment. Failure to provide an escort placed the resident at risk of missing their appointment, getting lost, falling or injury.Findings included.A facility policy and procedure regarding provision of escorts for appointments was requested 06/03/2026 and none was received.Review of the 04/05/2026, admission Minimum Data Set (MDS - an assessment tool), Resident 1 had severe cognitive impairment, unclear speech, which was limited to making concrete requests, and Resident 1 sometimes understood others. Resident 1 was assessed as dependent on others for mobility.Review of Resident 1's Care Plan, dated 03/20/2026, showed Resident 1 was at risk for complications related to communication impairment due to garbled speech, was at risk for falls related to right sided flaccidity, used a wheelchair and was dependent on staff for transfers requiring two people.Review of a Grievance Report filed 05/26/2026 showed Resident 1 had a doctor's appointment on 05/21/2026. While at the appointment, the facility was called to send an escort.During an interview on 06/02/2026 at 10:20 AM, Resident 1 was asked if the facility provided an escort for the medical appointment, Resident 1 stated, They didn't. When asked if they sent someone, Resident 1 replied, No.During an interview on 06/02/2026 at 1:37 PM, Staff E, Transportation Scheduler, stated they had held the position for only three weeks. Staff E stated they did not have a list of residents who required escorts, they used prior appointments to determine if a resident needed an escort. If it was a new resident, they asked the nurses if an escort was needed. Regarding Resident 1 specifically, Staff E stated they had looked in their appointment calendar for their previous appointment to the clinic and an escort was not listed. Staff E stated an escort was not sent for the 05/21/2026 appointment and the clinic called and said they needed someone for all future appointments. Staff E stated they now know that Resident 1 needs an escort to all their appointments.During an interview on 06/03/2026 at 12:38 PM, Staff C, Resident Care Manager, and Staff D, Registered Nurse (RN), stated there was no specific assessment to determine if a resident required an escort, and the determination was not care planned.During an interview on 06/03/2026 at 12:38 PM, Staff C stated they would expect an escort to be sent with Resident 1 because they had a stroke, with limited mobility and was transferred with a mechanical lift.During an interview on 06/03/2026 at 1:12 PM, Staff A, Administrator, stated the previous scheduler did not write needs escort in the appointment calendar, so one was not sent. When the clinic called the facility and said they needed someone right away, paratransit was scheduled to pick up the resident in 20 minutes, and it would have taken 25 minutes to get someone to the clinic.REFER to WAC: 388-97-1060(3)(g).

Based on observation, interview and record review, the facility failed to provide care and services to attain or maintain the highest practicable physical, self-care and independence in accordance with their comprehensive assessment and plan of care for 1 of 3 residents (Resident 1) reviewed for quality of care Failure of the facility placed the resident at risk of decreased ability to return to prior level of assistance, decrease level of mobility, decreased participation with functional tasks, falls, further decline in function, increased dependency upon caregivers, limited out-of-bed activity and muscle atrophy. Findings included. Review of hospital documents showed Resident 1 was admitted to the hospital on [DATE]. Resident 1 sustained a significant status change on 03/16/2026 with symptoms of a stroke. Review of a 03/16/2026 hospital Speech-Language Pathologist (SLP) evaluation showed the resident's baseline diet was solid food cut into smaller pieces, due to no lower dentures. On 03/16/2026 Resident 1 was assessed with moderate dysphagia (swallowing disorder) with a diet of ice chips only, no solids. On 03/17/2026 Resident 1 was assessed to have nothing by mouth (NPO) so a nasogastric (NG) feeding tube was ordered. Review of hospital transfer records dated 03/30/2026 showed resident had a Gastrostomy tube (permanent feeding tube placed directly into the stomach) placed on 03/26/2026 while in the hospital. Resident 1 was discharged from the hospital on a Minced & Moist dysphagia diet. Review of the admission Minimum Data Set (MDS - an assessment tool), dated 04/05/2026, showed Resident 1 had functional limitations in range of motion to an upper extremity and a lower extremity on one side, was dependent on staff for eating, oral hygiene, shower, dressing, bed mobility, transfers, had medically complex diagnoses, including but not limited to a stroke. According to the MDS, the resident had a mechanically altered diet, but not nutrition through a feeding tube. The resident received Therapy services including SLP, Occupational Therapy (OT), and Physical Therapy (PT). Review of the Care Area Assessments, dated 04/11/2026, Resident 1 was at center for short term rehab related to stroke with right hemiparesis and dysphagia. These put resident at risk for skin breakdown, pain, falls, social isolation, and activities of daily living (ADL) decline. Resident was working with therapies for strengthening, gait training and ADL retraining. Review of Resident 1's Rehabilitation Care Plan on 06/09/2026 showed an initiation date of 03/30/2026 with a listed goal that the resident would improve their overall function through the review period (06/28/2026). Interventions included skilled occupational therapy, skilled physical therapy, and skilled speech pathology services. Review of the facility physician order Recap Report on 06/18/2026, showed Resident 1 was admitted on a Minced & Moist dysphagia diet with mildly thick fluid consistency. On 04/24/2026 an order was received to start Tube Feedings (TF) from 8:00 PM to 6:00 AM. On 05/20/2026 those TFs were increased to 12 hours for increased intake and weight gain. Review of the facility PT Evaluation and Plan of Treatment, dated 03/31/2026, showed Resident 1's prior level of function was independent ADLs, ambulated with a walker but required assistance with Instrumental ADLS (complex life skills required to live independently). The resident was assessed on 03/31/2026 as requiring substantial/maximal assistance. The treatment plan was to provide PT, five times a week, for 59 days, through the certification period ending 05/28/2026. Review of the facility PT Discharge summary, dated [DATE], showed the resident was discharged from PT due to change in payer source. Under patient progress was written that maximum improvement was yet to be attained. Resident 1 demonstrated progress in functional mobility requiring minimum assistance for bed mobility, indicating positive response to skilled PT interventions. Despite these improvements, Resident 1 continued to be limited in functional mobility. Continued skilled PT interventions were medically necessary to address these deficits to prevent further decline and increase quality of life. According to the discharge recommendations neither a Restorative Program or a Functional Maintenance Program was established as they were not indicated at that time. Review of the facility SLP Evaluation and Plan of Treatment, dated 03/31/2026, showed Resident 1's prior level of function was independent swallowing abilities on soft and bite sized foods, and thin liquids. The resident was assessed with excellent rehabilitation potential. Skilled SLP services for dysphagia were warranted to assess/evaluate for safest level of oral intake in order to enhance patient's quality of life by improving ability to safely sallow without signs/symptoms of aspiration and safely swallow without signs/symptoms of dysphagia. The Treatment plan was to provide SLP 5 times a week, for 60 days, through the certification period ending 05/29/2026. Review of the facility SLP Discharge summary, dated [DATE], showed Resident 1 was safest on mildly thick and minced and moist texture. Had difficulty chewing more complex textures and significant cough at times with thin liquids, even with small sips. Required extra time and information stated simply to assist with expressive and receptive communication. On 06/02/2026 at 10:29 AM and 11:56 AM, Resident 1 was observed in bed with a Tube Feeding (TF) running at 75 cubic centimeter/hr. At 12:53 PM a lunch tray was observed on their bedside table, with very little eaten. In an interview at that time Resident 1 stated they ate a few bites but they did not like the flavor of the food and they did not like to drink the thickened liquids. During an interview on 06/02/2026 at 12:30 PM, Staff H, Registered Dietician, stated that SLP worked with Resident 1 constantly, but their diet could not be upgraded. Staff H stated Resident 1 was on a TF at their Adult Family Home (AFH) prior to admission. During an interview on 06/02/2026 at 1:13 PM, Staff I, MDS Nurse, stated that Resident 1 was on TF at the AFH. During an interview on 06/03/2026 at 12:16 PM, Staff J, Director of Rehabilitation, stated that Resident 1 appealed the insurance decision and lost. Staff J stated they thought Resident 1 were appealing at a second level, for reconsideration and they were waiting to hear if they won or not. Staff J stated they did not continue therapy as the resident could not afford therapy if they lost. When asked if they placed Resident 1 on a Restorative program, Staff J stated no, as they were waiting for the appeal results. Record review showed an insurance notice of denial of continued coverage effective 04/22/2026. Directions for the appeal process were provided and indicated in most cases they would send a decision in writing within 14 calendar days, the insurance company would tell them if they needed more time, no longer than 28 calendar days. During an interview on 06/03/2026 at 1:48 PM, Staff K, Medical Records, stated the appeal was complicated. Staff L, Social Services, assisted Resident 1 to file an appeal on the phone on 04/30/2026 and they should have received an acknowledgement letter within about 10 days. Staff K said that Staff M, Social Services Director, sent them an email asking if they received results of the appeal, but no appeal was uploaded and there was not a case number. They never received an acknowledgement letter. Staff K said they sent supporting documents to the insurance company on 05/20/2026. When asked if they had since heard anything, Staff K stated No, and commented they usually got notification from social services staff regarding the next steps. The supporting documents that were sent were reviewed and there were no therapy documents included. When questioned, Staff K stated Resident 1 did not have therapy at that time. During an interview on 06/03/2026 at 2:05 PM, Staff L stated the appeal results can take several weeks to get back so the facility continued to skill Resident 1 with adjustments to TF and weight loss. Staff L stated Resident 1 was not clinically stable for discharge. During an interview on 06/03/2026 at 2:15 PM, Staff M reviewed their records and stated they did not have any information to provide. During an interview on 06/03/02026 at 2:20 PM, Staff N, Business Office Manager, stated Resident 1 received a denial letter that the insurance would no longer pay for the nursing home staff effective 04/22/2026. Staff N stated if the denial was appealed they usually knew the results before the last covered day happens, but in this case they were not aware of the results and did not see anything uploaded in the resident's record. Staff N stated Resident 1's stay was covered by Medicaid effective 04/22/2026. During an interview on 06/03/2026 at 3:05 PM, Staff O, Speech Therapist, stated an insurance appeal was done and they were still waiting for the details on that. Staff O stated they were not ready to discharge Resident 1 from services as they were making progress on thin liquid trials, and they had not upgraded their diet texture yet. Staff O stated they felt Resident 1 could have gotten upgraded to soft and bite sized foods. Staff O stated they had asked Staff J to continue SLP services three times a week. Staff O stated they checked back weekly to see if they could continue. During an interview on 06/03/2026 at 3:10 PM, Staff J stated for residents on Medicaid they had to obtain permission from Staff A, Administrator, to continue services. During an interview on 06/09/2026 at 3:41 PM, Staff A, Administrator stated they were confident they sent the insurance what was required, within the time frame. Staff A stated Resident 1 was receiving care, but not therapy. Staff A stated they understood they were required to provide services to prevent decline but not to provide therapy services to residents without a payer. REFER to WAC: 388-97-1060(1).

Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed of a long-term medication being discontinued for 1 of 3 sampled residents (Resident 1). This failure disallowed the resident and/or the resident representative to exercise their rights and provide the facility with provider contacts and/or documentation to support continuing the medication.Findings included .Review of the Annual Minimum Data Set (MDS - an assessment tool), dated [DATE], showed Resident 1 was assessed with active diagnoses to include Deep Venous Thrombosis (DVT - blood clot in deep veins), Pulmonary Embolus (PE - blood clot in lungs), or Pulmonary Thrombo-Embolism (PTE - long standing blood clot lodged in pulmonary arteries), and the resident was taking an anticoagulant medication. In addition, Resident 1 was diagnosed with dementia and assessed with severe cognitive impairment.Review of the 2023 Durable Power of Attorney (POA) document for Resident 1 showed the POA was effective immediately, for both financial and health care decision making. Review of the facility face sheet showed the contact information for the POA was listed.Review of admission Orders dated [DATE] showed orders for an anticoagulant (blood thinner) twice a day.Review of the [DATE] Medication Administration Record (MAR) showed the medication was administered through [DATE] and not continued.Record review showed no documentation that the resident and/or representative were notified the medication was not continued.Review of Medical Records showed Resident 1 was hospitalized from [DATE] to [DATE] with diagnoses to include a right lower extremity DVT involving femoral (thigh) veins, and a right external iliac (pelvis) DVT.During an interview on [DATE] at 12:02 PM, Staff D, Registered Nurse, stated in [DATE] they faxed the pharmacy to refill the medication, but the order was not filled. Where there were only two pills remaining, they called the pharmacy, who said the order expired. Staff D stated they called the on-call provider who said Resident 1 did not need anticoagulant medication anymore and did not renew the order. When asked if they notified Resident 1's POA, Staff D stated they did not, but they probably should have.During an interview on [DATE] at 2:56 PM, Resident 1's POA stated that they were not notified that the medication was stopped until they received a call from the facility that Resident 1's leg was swollen. The POA stated they requested the resident be sent to the hospital right away. Resident 1's POA stated if they had told them, or asked them, they could have brought their prior records to show that Resident required anticoagulation therapy for life.During an interview on [DATE] at 1:13 PM, Staff A, Administrator stated Resident 1's POA should have been notified.See WAC 388-97-0260, -300(3)(a).

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for urinary catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for complications associated with indwelling urinary catheters. Failure of the facility to coordinate with urology and monitor for urinary retention following catheter removal, resulted in harm to Resident 1 when they experienced prolonged pain and discomfort as evidenced by crying out and a change in level of consciousness. Findings included.Review of Taber's Cyclopedic Medical Dictionary, 19th edition, showed a bladder has a normal storage capacity of approximately 500 milliliters (ML).Review of the undated Urinary Catheter Care Policy; staff would observe the resident for complications associated with urinary catheters. If the resident indicates that their bladder is full or that they need to urinate, notify the physician or supervisor. Report any complaints a resident may have of burning, tenderness, or pain.<RESIDENT 1>Review of the Minimum Data Set (MDS - an assessment tool), dated 11/26/2025, showed Resident 1 was frequently incontinent of urine, and required substantial assistance with toileting hygiene. Resident 1 was hospitalized [DATE]-[DATE]. Review of the MDS dated [DATE], showed Resident 1 had an indwelling urinary catheter with a diagnosis of obstructive uropathy (a condition where urine flow is blocked, causing it to back up and potentially damage one or both kidneys).Review of a hospital discharge note, dated 12/03/2025, showed the resident had acute kidney injury due to urinary retention, which improved after urinary catheter placement. Discharge instructions included to follow-up with urology for urinary retention and given the resident's significant retention and Acute Renal Failure (ARF), staff should not be attempting Foley removal in the Skilled Nursing Facility.Review of the hospital discharge orders, dated 12/03/2025, showed the indication for catheter use was Acute Urinary Retention, the catheter was placed on 12/03/2025 and was deemed permanent. The orders directed urinary catheter management per nursing protocol.Review of the Catheter Care Plan (CP), dated 12/03/2026, showed the staff were directed to empty catheter as needed and record MLs.Review of the last 30 days of documentation for bladder elimination showed Continence not rated due to indwelling catheter. Further review of the nursing assistant documentation and the licensed nurse documentation on the February 2026 and March 2026 Treatment Administration Records (TAR) showed no documented urinary output in MLs.During an interview on 03/26/2026 at 11:50 AM, Staff F, Resident Care Manager (RCM), reviewed Resident 1's medical record for documented output in MLs and stated, I don't see any.Review of an appointment reminder, dated 12/31/2025, showed Resident 1 had an Urology appointment scheduled for 02/26/2026 at 9:00 AM.Review of progress notes showed a Nursing Note, dated 02/26/2026 at 11:44 AM, that Resident 1 returned from the appointment with no new orders. An Alert Note, timed 2:24 PM, showed the urinary catheter was discontinued at the appointment and staff were monitoring for retention or pain. Review of the progress notes showed no documented bladder assessment, or urinary output.Review of Bladder Elimination documentation by Nursing Assistants showed documentation on 02/26/2026 at 9:10 PM, that Resident 1 did not void on evening shift.Review of the February 2026 Treatment Administration Record (TAR) showed nursing staff documented provision of catheter care on 02/26/2026 second shift, on 02/27/2026 first and second shift, when there was not a catheter in place.An Alert Note, dated 02/28/2026 at 4:18 AM, showed Resident 1 had emesis (vomited) twice (02/27/2026 at 5:00 PM, and 02/28/2026 at 3:30 AM). The provider was notified and SBAR (Situation, Background, Appearance, Review and Notify) reported at 4:00 AM.Review of the SBAR, dated 02/28/2026, showed the resident's pulse was high at 119 beats per minute, Respiratory rate was high at 20 breaths per minute, the resident had an altered level of consciousness, with edema (swelling), nausea and/or vomiting and decreased urine output.Review of a Nursing Note, dated 02/28/2026 at 5:07 PM, showed Resident 1 was in bed and lethargic, unable to eat meals and drink medications. Vital signs at noon showed pulse in the 120s, a low Blood Pressure of 99/70. Provider was onsite and assessed Resident 1. Resident 1 did not urinate during the shift. Bladder scan was completed and noted greater than 2000 ML. Indwelling urinary catheter was inserted by treatment nurse, noted 1000 ML.Review of the meal monitor showed Resident 1 ate less than 25% of dinner on 02/27/2026, refused breakfast, lunch and dinner on 02/28/2026.Review of the provider note on 02/28/2026 at 9:32 PM, showed the provider spoke to the daytime nursing staff and it appeared the resident had not eaten anything since the prior night before leaving to go to the hospital yesterday morning at 8:00 AM, to remove the urinary catheter and has not been able to hold down any fluids with intermittent nausea/vomiting. When asked if the resident had any wet depends (incontinence brief) today, the provider was told no, and staff were unsure if night shift reported resident urinating in their depends. Nursing staff were asked to scan the resident's bladder which revealed over 2500 ML of urine. Nursing staff were directed to place a urinary catheter and give fluids intravenously (IV- fluids injected into a vein) due to severe dehydration. Prior to leaving facility the resident had put out over 800 ML of urine. The provider spoke to the Director of Nursing (DON) who showed documentation that the resident had a wet incontinence brief at 5:00 AM, but no wet diapers since their arrival back from the hospital yesterday afternoon. The provider advised the DON that they were unsure if the documented output was correct due to the resident having so much urine in their bladder during the scan, and that it should require further investigation.Review of progress notes dated 03/01/2026 at 5:30 AM, and 7:01 PM, showed Resident 1 was moaning, staff offered pain medication. Review of a note, dated 03/01/2026 at 3:17 PM, showed there was 300 ML in the urine bag. Staff C, Registered Nurse (RN), documented they flushed the catheter and replaced it an hour later due to continued complaints from Resident 1.A 03/02/2026 late entry showed Resident 1's roommate reported concerns with resident's urinary care. Resident noted with a urology office visit on 02/26/2026, catheter was removed at clinic. Resident 1 returned to facility with no follow-up instructions or orders. Resident placed on alert and monitoring by nurses with documentation on 02/26/2026 and 02/27/2026 with no adverse effects noted. However, Resident 1 had a change of condition on 02/27/2026 on night shift leading into 02/28/2026 day shift. Resident 1 was assessed by provider and noted with urinary retention, catheter was reinserted and IV fluids started. Investigation initiated. Resident now at baseline making needs known. Review of the investigation documents showed the investigation was not initiated until 03/02/2026, following the roommate's concerns, not on 02/28/2026 following the provider's concerns as requested.The care plan was revised on 03/05/2026 to add instructions to monitor signs of urinary retention or bladder discomfort and report changes to the provider.During an interview on 03/20/2026 at 11:17 AM, Resident 2 stated they noticed Resident 1 had not been peeing and commented the day before Resident 1 had their catheter removed at their appointment. Resident 2 stated Resident 1 was moaning and so they told the nurse, Staff C, that Resident 1 didn't feel well, was moaning in pain, and something was just not right. Resident 2 stated the provider saw Resident 1, ordered an ultrasound and said they were surprised Resident 1's bladder didn't burst and the aids should have known. They put a catheter in, and Resident 1 was okay. The next day, there was only 1/4 of a bag of urine, about two inches, and there should have been more urine overnight. Resident 2 was moaning, placing their hands over their stomach. Resident 2 stated they told Staff C and Staff D, Certified Nursing Assistant (NAC). Resident 2 stated Staff C flushed the catheter.During an interview on 03/20/2026 at 11:35 AM, Resident 1 stated the catheter was taken out at their appointment, and three days later it was put back in. Resident 1 stated, I couldn't help crying out.During an interview on 03/20/2026 at 12:08 PM, Staff C stated Resident 1's roommate alerted multiple people, said the catheter was not working properly, but it was draining. Staff C stated they had got another nurse to assist them to put the catheter back in. Staff C stated there was nothing wrong with the catheter, they took it out and put it in another one and there was no gushing of a large amount of urine. Staff C stated it all occurred on the same shift.During an interview on 03/20/2026 at 12:28 PM, Staff D stated they were working evening shift when Resident 2 raised questions about Resident 1's catheter not draining. Staff D stated when they checked the catheter bag there was no fluid, no urine coming out. Staff D said they notified Staff C repeatedly. Later Staff C tried to flush the catheter, but it did not work. So, Staff D called for another nurse, and they put in another catheter and then it was able to drain the urine.During an interview on 03/26/2026 at 11:50 AM, Staff F, RCM, stated if a resident returned from an appointment without any directives the staff would ask the resident and/or call the provider and see if there were any updates or new orders. Staff F stated typically when an urinary catheter is taken out they implement orders for Post Void Residuals (PVRs - determine how much urine is left in the bladder after voiding) every shift and if greater than 300 MLs, then straight catheter (insert a single-use tube to empty the bladder and immediately remove). On the third straight catheter the nurse would notify the provider and put the urinary catheter back in.During an interview on 03/26/2026 at 3:35 PM, Staff B, interim Director of Nursing, stated they would expect staff to try to reach the urologist's office to obtain orders, put on alert, perform PVRs using a bladder scan (non-invasive ultrasound) and document monitoring.Reference WAC 388-97-1060 (3)(c).

Based on interview and record review the facility failed to provide adequate supervision, identify fall trends and implement progressive resident centered interventions for 1 of 3 residents (Resident 6) reviewed for falls. Resident 6, who had 5 falls since [DATE] and a decline in their strength/condition, experienced harm when they fell and broke their ankle that required transfer to the emergency department for evaluation and treatment. This failure placed residents at risk of repeated falls and injuries.Findings included.Review of the facility Falls and Fall Risk Management policy, dated [DATE], showed staff would identify interventions related to residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Review of the admission Minimum Data Set (MDS - an assessment tool), dated [DATE], showed Resident 6 was independent with transfers, required supervision walking up to 50 feet, was occasionally incontinent of urine, had fallen prior to admission and had one noninjury fall in the facility since their admission on [DATE].The Care Area Assessment (CAA), dated [DATE], showed Resident 6 was at the facility related to cancer which put the resident at risk for pain, falls, and ADL (Activities of Daily Living) decline. According to the CAA, falls and urinary incontinence would be addressed in the care plan with the overall objective of improvement and to minimize risks. The rationale documented was for staff to assist with ADLS at routine intervals and as needed. Resident was working with therapies for strengthening, gait training, and ADL retraining. Verbal reminders will be provided as needed for the resident to use call lights and wait for staff assistance.Review of the Care Plan (CP), dated [DATE], showed no urinary or ADL care plan, and no plan for toileting. The CP did address that Resident 6 was at risk for falls and instructed staff to remind the resident to use their call light to ask for assistance with ADLS. In addition, the resident should wear footwear to prevent slipping, bedside table/items within reach and bed locked in lowest position.Review of the resident's record showed that on [DATE], Resident 6 fell next to their bed. According to the resident they slipped. The environment was noted to have two sets of shoes next to bedside where the resident fell, there was water on the floor, and the resident's socks were slightly askew from gripper area. The area was cleaned up and extra shoes placed into closet, water cleaned up, and socks were replaced with new ones. Review of the Incident Investigation, dated [DATE], showed the investigation identified environmental factors of clutter, crowding, and items on the floor, and that the resident was using their own skid socks and the walker was in place, but the CP was updated with new intervention to encourage use of their walker with transfers and ambulation.Review of the Fall CP showed a [DATE] additions to remind the resident to use their FWW [front wheeled walker] to perform ADLS. Two additional interventions were added on [DATE], both of which were the same as the original CP interventions, non-skid socks while out of bed, place bed in lowest position while out of bed.During an interview on [DATE] at 3:06 PM, when asked where the walker was located during the fall that occurred on [DATE], Staff B, interim Director of Nursing, stated they didn't know as they were not at the facility at that time, and added that maybe Resident 6 was trying to walk without their assistive device.Review of the Quarterly MDS, dated [DATE], showed Resident 6 had moderate cognitive impairment, was assessed as independent with mobility and toileting, always continent, did not have a condition or chronic disease that would result in a life expectancy of less than six months, and had one non-injury fall since the previous MDS.Review of progress notes showed on [DATE] at 1:00 AM, Resident 6 was found lying on the floor next to their bed. Upon questioning, the resident stated they were getting out of bed to go use the restroom and fell on the floor. The resident's brief was dry. Staff assisted the resident to the bathroom and back to bed.Review of the [DATE] incident investigation showed they concluded the resident was becoming increasingly weaker and had poor insight into their limitations. Staff educated the resident to request assistance as needed. Planned interventions to prevent reoccurrence included keeping wheelchair close by and accessible to resident.During an interview on [DATE] at 3:06 PM, Staff B stated Resident 6 was educated to ask for assistance because they attempted to go to the toilet by themselves. Additionally, Staff B stated they had an Interdisciplinary Team(IDT) meeting regarding the resident's frequent falls.Review of the Risk Review Note, dated [DATE], showed the resident was reviewed because they had a fall in the previous 7-day lookback. Interventions in place were bedside table within reach, footwear to prevent slipping, environment free of clutter, nonskid socks while out of bed. Identified risk factors were progressive disease process of cancer, resident recently decompensated, is also doing radiation treatment. New interventions were planned to keep front wheel walker and wheelchair accessible while in the room.During an interview on [DATE] at 1:38 PM, Staff E, Director of Rehabilitation, stated they were in the IDT meeting, and they tried to discourage Resident 6 from using their walker, to use the wheelchair instead, but Resident 6 always insisted on getting up and walking.Review of the Fall CP, dated [DATE], showed the intervention related to placement of the wheelchair was not added as planned, but the care plan was revised [DATE] to place the bed in lowest position while resident is in bed. Review of an incident investigation, dated [DATE], showed Resident 6 had an unwitnessed fall in their bathroom around 7:00 AM. Resident 6 was found lying on the floor in the bathroom, on their back, with their wheelchair about two feet behind them. Resident 6 stated they were standing to use the toilet and fell backwards. The conclusion written stated the resident was alert but had some confusion, per nurse, the resident was found with skin tears which were treated. The resident had history of cancer and had some weakness which may have contributed to the fall. Per staff, the resident was also known to be impulsive with poor safety awareness. The resident had several interventions put in place including use of proper footwear, non-skid socks, bed in lowest position, items within reach. Per staff interventions at this time included education to request assistance as needed.Review of the Post Fall Assessment, dated [DATE], showed Resident 6 sustained three skin tears.Review of the Fall CP showed on [DATE] the intervention was added to provide resident education regarding safe transfers, ambulation and assistive device use.During an interview on [DATE] at 3:06 PM, Staff B stated staff provided additional education and reorientation to request assistance probably because they were not using the call bell.Review of Progress note, dated [DATE] at 6:05 PM, showed Resident 6 was found in their room, close to the bathroom door. Staff assisted the resident to their wheelchair and then into bed. The post fall assessment showed the resident sustained a skin tear to their left elbow.Review of the investigation, dated [DATE], showed the resident stated their socks were slippery so they fell walking to the bathroom. The conclusion was the resident was noted with impulsive behavior, attempting to stand or use bathroom on their own without assistance, but resident had weakness which inhibited their ability to complete ADLS on their own such as using the bathroom. The above was deduced to have resulted in the fall. Interventions include ensuring resident has proper foot wear when ambulating and gripper socks if footwear is off.Review of the Fall CP showed, on [DATE], the CP was revised to ensure the resident wore shoes when ambulating and provide resident with gripper socks.Review of progress notes, dated [DATE] at 7:22 AM, showed the resident was found in the bathroom on the floor with both legs around the toilet, holding onto the grab bar with their right hand, leaning up against the wall. Resident 6 stated they were in the bathroom taking a pee when they fell. Stated it was their left ankle that made them fall. The staff assisted the resident up into a wheelchair and transferred into bed. Resident reeducated on the importance of the use of call light for any assistance with transfers, resident with understanding at this time. Intervention for nursing staff to round on resident frequently to assisted resident to bathroom, limiting self-transfers and falls. Discussed plan with resident, and resident agreeable.Review of the Fall CP, dated [DATE], showed neither of the interventions regarding frequent rounding and toileting were implemented as planned.During an interview on [DATE] at 3:06 PM, Staff B stated while reading the investigation, showed the facility were not able to do any additional interventions because the resident was transported to the hospital.Review of the [DATE] fall investigation conclusion showed statements obtained from residents aide indicates resident was observed sleeping in his bed less than 30 minutes prior to incident, at which time resident only requested a blanket and did not request to use bathroom. Resident also did not make use of call bell which further indicates resident may have impulsively decided to use restroom on his own, resulting in fall. Previous interventions put in place include keeping items within reach, making sure resident had proper foot wear and non skid socks when appropriate. Education and reorientation given, as additional intervention.Review of the census showed the resident was in the bed furthest away from the bathroom during their whole stay at the facility. Resident 6 fell after getting up to go to the bathroom on [DATE], fell in the bathroom on [DATE], found [DATE] on the floor close to the bathroom door, and on [DATE] found in the bathroom on the floor. None of the facility investigations identified this trend or addressed toileting options.Review of the Comprehensive CP, dated [DATE], showed no toileting plan.A [DATE] Nursing Note showed Resident 6 had an X-ray taken and they had a left ankle fracture. The provider was notified and the resident sent to the emergency room for further evaluation.Review of the discharge return anticipated MDS, dated [DATE], showed the resident had an unplanned hospital transfer, was occasionally incontinent of urine, did not have a condition or chronic disease that would result in a life expectancy of less than six months, and sustained two or more falls since last MDS, one with a minor injury and one with a major injury.Review of Emergency Department (ED) notes, dated [DATE] at 6:56 AM, showed the resident was seen in the emergency department yesterday for evaluation of left ankle pain after a fall. Patient denied head injury or loss of consciousness. ED workup notable for acute mildly displaced fracture of the left distal fibula. A splint was placed on patient's left lower extremity and he was advised to be non weightbearing on the left lower extremity. He was referred to follow-up with orthopedic surgery as outpatient. Patient was discharged back to his care facility. However, he became agitated and aggressive with EMS during transport and therefore brought back to the emergency department for assistance in management of aggressive behavior. Patient arrived in the ED agitated, combative, confused. He was placed in soft restraints and received medications for agitation.Record review showed Resident 6 readmitted to the facility on [DATE]. A [DATE] provider note showed the resident had multiple medical conditions, including cancer, recently hospitalized for acute encephalopathy, ground-level fall found to have an acute mildly displaced right ankle fracture and pelvic fractures. Hospital course complicated by delirium with agitation and increased pain, requiring pharmacological restraints. Orthopedic was consulted for ankle and pelvic fracture but recommended against any surgical interventions. Palliative care was consulted and patient opted for hospice care. He was discharged to the facility with plan for hospice care services. Resident was deceased in the early hours of the morning on [DATE].During an interview on [DATE] at 2:26 PM, Resident 17 stated Resident 6 would get up to go to the bathroom and trip. Often their underwear would be around their ankle. Resident 17 stated they would call out for staff, and they would come, put Resident 6 into bed and remind them to call before getting up. When asked if Resident 6 would call, Resident 17 replied, No.During an interview on [DATE] at 2:38 PM, Staff G, Licensed Practical Nurse (LPN), stated staff were working with Resident 6 to use the call light to go to the bathroom, but Resident 6 was used to being independent and doing things themselves, so they would get up. Staff G stated Resident 6 could demonstrate how to use the call light, they just wouldn't use it. During an interview on [DATE] at 12:01 PM, Staff F, Resident Care Manager, stated most of the time, Resident 6 was falling trying to go to the bathroom. When asked what interventions were implemented, Staff F stated they were having the nursing assistants (NAs) go into the room and offer to assist Resident 6 to use the bathroom. Staff F was informed that intervention was not on the care plan, and when asked how the NAs would know to do that, Staff F replied, We talk to them.During an interview on [DATE] at 1:38 PM, Staff E stated they were working with Resident 6 on walking and safety with transfers. Staff E noted that Resident 6 was impulsive with wanting to get to the bathroom. Staff E stated as Resident 6's body declined they had increased weakness and staff encouraged the resident to use the call light, which according to Staff E, the resident used, occasionally.During an interview on [DATE] at 3:06 PM, Staff B stated with Resident 6 that it would be difficult to ensure they did not fall without providing one-on-one supervision. Even if staff were to ask Resident 6 if they needed to go to the bathroom, they would say no and then impulsively would get up without calling for assistance.During an interview on [DATE] at 4:35 PM, Staff A, Administrator, stated they did not feel there were any meaningful interventions that could have been implemented to minimize Resident 6's fall risk as the root cause was cancer; treatments and subsequent adverse effects.Reference WAC 388-97-1060(3)(g).

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care. The facility failed to ensure the nursing staff (Staff H, Licensed Practical Nurse (LPN), Staff I, Registered Nurse (RN) & Staff G, LPN) administered medications according to professional standards of practice for 10 of 10 residents (Residents 7, 9, 8, 3, 16, 15, 11, 13, 14, & 1) reviewed for medication administration. This failure placed facility residents at risk of medication errors and poor outcomes.Findings included.Review of the facility 01/2023 Medication Administration Policy and Procedure showed medications would be administered as prescribed in accordance with manufacturers' specifications, and good nursing principles and practices. Medications are administered in accordance with written orders from the prescriber. No expired medication will be administered to a resident, certain products such as multi-dose vials have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. Medications are administered within 60 minutes of scheduled time. The individual who administers the medication dose, records the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given.<RESIDENT INTERVIEWS>During an interview on [DATE] at 10:43 AM, Resident 7 stated, sometimes when they had agency nurses their medications were not given at the time they usually got their medications.During an interview on [DATE] at 10:55 AM, Resident 9 stated, the agency nurses don't read the full instructions regarding their medications.During an interview on [DATE] at 11:09 AM, Resident 8 stated, their meds were administered a little bit late, but they only complained a couple of times.During an interview on [DATE] at 12:32 PM, Resident 3 stated, they always received their medications late and they frequently had to ask for them. Resident 3 understood they had to request their as needed medications but said they should get their routinely scheduled medications without asking.During an interview on [DATE] at 10:19 AM, Resident 16 stated that the nurses were frequently slow about bringing their medications.<RESIDENT 15>Review of Resident 15's Diabetes Mellitus Care Plan, dated [DATE], showed an intervention to administer Insulin as ordered.Review of the MAR, dated [DATE], showed an order for sliding scale Humalog/Lispro Insulin to be administered before meals and at bedtime. The Insulin was ordered to be administered at 11:30 AM.On [DATE] at 1:06 PM, Staff H, LPN, was observed during medication observation to draw the physician ordered units of Humalog/Lispro Insulin from a multi-dose vial, that was dated as opened 02/16 (no year included) and thus expired.The Insulin was administered at 1:11 PM, almost one hour and 45 minutes after the dose was due.<RESIDENT 11>Review of Resident 11's CP, dated [DATE], instructed staff to administer medications as ordered. Review of the MAR, dated [DATE], showed orders for Gabapentin oral tablet for pain, orders for Oxybutynin tablet for neurogenic bladder, and orders for Baclofen tablets for Multiple Sclerosis (MS) each to be given three times a day at 8:00 AM, 2:00 PM, and 8:00 PM; and Tizanidine tablet to be given four times a day for spasticity, at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.On [DATE] at 1:14 PM, Staff H was observed to pour all four medications and administer them to Resident 11. In an interview at that time, Staff H acknowledged the Tizanidine was a little late, but that Resident 11 wanted them at that time.During an interview on [DATE] at 1:18 pm, Resident 11 stated that the nurses typically gave all those medications together and that it was not something they requested.<RESIDENT 13>Review of the Diabetes CP, dated [DATE], showed the intervention to administer Insulin as ordered.Review of the MAR, dated [DATE], showed orders for sliding scale Humalog/Lispro Insulin to be administered at 12:00 PM.On [DATE] at 1:51 PM, Staff I, RN, was observed to take Resident 13's blood sugar, and draw up corresponding dose of Insulin, almost two hours after it was due. Resident 13 refused the insulin when offered. In an interview at that time, Resident 13 stated they had finished eating lunch earlier.<RESIDENT 14>Review of Resident 14's Pain CP, dated [DATE], showed interventions to administer medication as ordered.Review of the MAR, dated [DATE], showed orders for Methocarbamol tablet four times a day, scheduled to be administered at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.On [DATE] at 1:59 PM, Resident 14 approached the medication cart and requested methocarbamol and Tylenol for pain. Staff I was observed to administer as needed Tylenol as ordered. Resident 14 then asked, Where's the methocarbamol? and Staff I told Resident 14 they had already given it to them. Resident 14 stated they were supposed to get it at noon, as it was ordered four times a day. Staff I was then observed to administer the Methocarbamol, two hours after it was due.<RESIDENT 1>Review of Resident 1's Risk for pain CP, dated [DATE], showed interventions to administer medication as ordered.Review of the [DATE] MAR showed orders for Tramadol tablet three times a day for pain, scheduled at 8:00 AM, 2:00 PM and 8:00 PM.On [DATE] at 11:54 AM, Staff G, LPN, was observed to retrieve an as needed pain medication requested by Resident 1. Looking at the computer, none of Resident 1's 8:00 AM medications were documented as administered. In an interview at that time, Staff G stated they gave them they just had not yet documented they were administered.During an interview on [DATE] at 12:05 PM, Resident 1 stated their medications were sometimes late, but they had received their morning medication on time.On [DATE] at 2:05 PM, Staff I was observed to prepare the Tramadol dose that was due at 2:00 PM. Review of the narcotic book showed the last dose was documented as administered on [DATE] at 8:00 PM and 42 pills remained, but looking at the card of pills showed only 40 pills remaining.In an interview at that time, Staff I stated they gave the Tramadol at 8:00 AM, as ordered, but did not sign it out at that time. Staff I then proceeded to sign out both the 8:00 AM and 2:00 PM doses.During an interview on [DATE] at 4:35 PM, Staff A, Administrator, stated many of the medication concerns brought forward by residents involved agency/temporary nurses and they were actively recruiting nursing staff. REFERENCE: WAC 388-97-1080(1)

Based on observation, interview, and record review, the facility failed to follow the menus according to Resident Council Minutes for 4 of 6 months (October, November, January, and February 2026) and 1 of 1 kitchen observation (03/22/2026) when reviewed for kitchen. This failure placed residents at risk of inadequate nutritional intake, avoidable weight loss, a decline in clinical condition, and a diminished quality of life. Findings included .Review of the Resident Council meeting minutes for October 2025 showed, Would like to see honesty with the names of foods on the menus and what is served. Review of the Resident Council meeting minutes for November 2025 showed, Menu does not always seem to match what is served. Soup is frequently not what is on the menu for the day and the serving sizes vary. Sometimes the bowl is full and sometimes the bowl is half full and frequently not warm enough. If changes are to be made to the menu or brands, such as the coffee, please notify patients prior to any changes. Review of the Resident Council Minutes for January 2026 showed, Frequently do not get what is on the menu- example: western omelet, only egg and cheese, was not omelet, it was baked. Review of the Resident Council Minutes for February 2026 showed, Request notification on days when the menu needs to be changed for any reason. Review of the menu for 03/11/2026 showed chicken legs would be served as the lunch protein with 4 ounces (oz) of scalloped potatoes and 4 oz of peas. Observation on 03/11/2026 at 11:48 AM showed Staff R, Cook, serving chicken thighs, peas with a long-handled four oz scoop, and potatoes with a green handled scoop. Observation showed Staff R filled the long-handled scoop approximately two thirds full when serving. During an interview on 03/11/2026 at 1:14 PM, Staff R, Cook, stated the long-handled scoop used for peas was four oz and they believed the green handled scoop was also 4 oz. During an interview on 03/11/2026 at 1:16 PM, Staff N, Dietary Manager, stated they were unsure what size the green handled scoop was and would need to check. During an interview on 03/11/2026 at 2:38 PM, Staff U, Registered Dietician, stated the facility ensured the meals had enough nutrition by following the menu, which included portion sizes. Staff U stated the green handled scoop used to serve potatoes at lunch was two and two thirds an ounce and the grey handled scoop was four oz and should have been used. During an interview on 03/12/2026 at 1:58 PM, Staff N, Dietary Manager, stated facility kitchen staff were trained on portion sizes before working in the kitchen. Staff N stated Staff R, Cook, should have filled the long-handled scoop fully when serving. Staff N stated they were unsure whether the scoop used to serve potatoes was correct. Staff N stated chicken thighs were served instead of chicken legs because the facility could not order chicken legs and thighs were the closest they could get. During an interview on 03/12/2026 at 2:42 PM, Staff A, Administrator, stated the kitchen staff should follow the menu designated portion sizes, and the menu should be altered prior to publication if the facility was unable to purchase a product. Reference WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4)

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage and/or preparation for 2 of 2 kitchen observations (Initial and Second) and failed to ensure resident foods were sanitarily stored for 2 of 2 resident refrigerators (North and South) when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included.Initial Kitchen Tour on 03/08/2026 at 9:37 AMObservation showed the walk-in freezer containing a box of raw hamburger patties, bag of breaded fish fillets, bag of chicken tenders, a bag of fries, and a bag of hashbrowns opened without date label and left open to the air. Observation showed numerous boxes of food items stacked on the ground of the freezer with some boxes falling from their stack and laid haphazardly across the freezer. Observation showed a metal container of re-frozen food stacked on a frozen bag of soup which was stacked on a second open container of re-frozen food. Observation of the refrigerator units showed a bowl of tuna salad without date label, three bags of apple slices with a best by date of 03/02/2026, three bowls of salad exposed to the air without date label which appeared wilted, a plastic container of sliced tomato without date label, a cucumber in plastic with a 03/02/2026 use by date, a plastic container of olives with a 02/26/2026 use by date, a plastic container of cubed meat with no date label, hardboiled eggs left uncovered and without date label, a bottle of unknown sauce with no date label, and multiple plastic bins with food items uncovered. Observation showed a box of zucchini on the floor outside of the refrigerator with no temperature controls and two earbud containers and several phone cords next to the steamtable. Second Kitchen Tour on 03/11/2026Observation at 11:35 AM showed staff was already preparing salads and had placed cheese, cubed meat, precut vegetables, and cottage cheese on the salad preparation station. Observation at 11:35 AM showed a bag of fast food on near the steamtable. Observation at 11:38 AM showed the refrigerator had a plastic container of hardboiled eggs with no date and uncovered. Observation at 11:40 AM showed the walk-in freezer had bags of hamburger patties and hashbrown opened without date label and left exposed to the air. Observation showed a metal container of re-frozen food stacked on a frozen bag of soup which was stacked on a second open container of re-frozen food. Review of the dishwasher temperature log for March 2026 showed the washing machine should reach 180 degrees Fahrenheit (F) during the rinse cycle and 03/06/2026 and 03/07/2026 were recorded below this threshold. Observation at 11:56 AM showed Staff R, Cook, taking the temperature of the hot foods and cleaned the thermometer on a dry dishcloth between dishes. Observation at 11:59 AM showed Staff N, Dietary Manager, washing dishes and the washing machine mounted wash temperature gauge did not move and showed 128 F. Staff N ran a second load of dishes and the thermometer continued in place showing 128 F. Observation at 12:04 PM showed Staff R, Cook, continued to measure the temperature of foods on the steamtable. Staff R tested a puree, wiped the thermometer on a dry towel, tested a second puree, ran the thermometer under water at the handwashing sink, then tested a third puree. Observation at 12:08 PM showed Staff R, Cook, had a beard and was not wearing a net over the exposed hair. Observation at 12:10 PM showed the salad station continued with cheese, cubed meat, sliced vegetables, hardboiled eggs, and cottage cheese left out without temperature controls. Observation showed the prepared salads sat at the station wrapped but with no temperature controls. Observation at 12:24 PM showed staff return some items from the salad station to the refrigerator, but cubed meat, sliced vegetables, cottage cheese, and prepared salads continued at the station without temperature controls. Observation at 12:28 PM showed a cellphone stored on a small table near the salad making station. Observation at 12:47 PM showed Staff N, Dietary Manager, returned the cubed meat, sliced vegetables, and cottage cheese to the refrigerator (1 hour and 12 minutes outside temperature control). Observation at 1:06 PM showed a kitchen staff with hair and beard entered the kitchen, moved through the kitchen, moved into the dry storage, and then exited out of the back of the kitchen without performing hand hygiene or donning a hair/beard net. Observation at 1:07 PM showed a staff take out a stack of sliced cheese, removed a slice, and placed the stack on the salad station without temperature controls. The salad station contained two large salads with cubed meat and sliced hardboiled eggs and five side salads. Observation at 1:19 PM at the end of meal service showed one large salad and five small salads continued on the salad station (1 hour 44 minutes without temperature controls). Review of the Resident Council Minutes for September 2025 showed a concern, Salads can be better. Poor quality overall. Tomatoes are mushy, salad is warm not cold, lettuce is wilty. Review of the Resident Council Minutes for December 2025 showed a concern, Hit or miss with the quality of salads. Resident RefrigeratorsObservation on 03/11/2026 at 2:00 PM showed the North Hall resident refrigerator contained the following: three nutrient drinks frozen in the freezer which showed Do not freeze labeling, one bag of fast food with no date label, a blue bag with two containers soup and one plastic food container without date label, one plastic food container without date label, one cardboard box of Asian food with 03/07 date label, one box pecan pie opened with once slice left with no name or date label, and one Tupperware of unidentifiable food without date label. Observation showed no temperature log to monitor the temperature of the refrigerator. Observation on 03/11/2026 at 2:09 PM showed the South Hall resident refrigerator contained the following: two nutrient drinks frozen in the freezer which showed Do not freeze labeling, a large coffee cup wrapped in a plastic bag without name or date label, a bag with three plastic containers of food with a 03/07/2025 date label, a plastic bag with two takeout containers without date label, a bag of grapes dated 02/16 with white film on the product, a large bag of groceries to include cherry tomatoes, grapes, cucumber, and lunch meat without date label, a whole pizza box with three slices of pizza without date label, a box of lemon glycerin swab sticks (used for temporary oral lubrication and refreshing the mouth, often for patients with dry mouth or restricted fluid intake), a plastic container of fried rice without date label, a paper bag with sandwich and fruit with 03/01 date label, and a bag with plastic container of Asian food and chopped salad kit with a best by date of 02/26/2026. Observation showed the temperature log was for February 2026 and had a single temperature logged. During an interview on 03/12/2026 at 1:58 PM, Staff N, Dietary Manager, stated food items should not be stored on the floor of the freezer or kitchen and should be date labeled when opened. Staff N stated food items should be covered when stored and the observations of food left uncovered in the refrigerator and freezer did not meet expectations. Staff N stated personal items, such as cellphones and accessories, should not be in the kitchen. Staff N stated cold foods, such as cubed meat, hardboiled eggs, and cottage cheese should be stored with temperature controls and not left out. Staff N stated Staff R, Cook, should use sanitation wipes between foods and the observation of wiping the thermometer on a dry rag did not meet expectations. Staff N stated staff should use hair/beard nets to ensure hair did not contaminate food, and the observation of Staff R with uncovered beard did not meet expectations. Staff N stated maintenance should have been consulted after the temperatures under the expected range were logged on the washing machine log. During an interview on 03/12/2026 at 2:42 PM, Staff A, Administrator, stated food should be closed and date labeled while stored, and should not be stored on the ground. Staff A stated cold foods should be held in a temperature-controlled environment before being served and staff personal items should not be stored in the kitchen area. Staff A stated staff with beards should have them covered and sanitation wipes should be used between taking the temperature of different food items. Staff A stated when the washing machine was not reaching the required temperature, maintenance should be contacted and chemical cleaners used until repairs were made. Staff A stated nursing staff was responsible for the monitoring and cleaning of the resident refrigerators. Staff A stated the resident refrigerators should be monitored for temperature daily, and the lack of temperature monitoring did not meet expectations. Reference WAC 388-97-1100(3), -2980

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 sampled residents (Residents 1, 9, and 67) reviewed for respiratory care. Failure to obtain and/or follow provider orders for oxygen (O2) therapy, ensure O2 tubing was appropriately maintained, regularly changed and dated, and O2 concentrator (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for avoidable respiratory disease, unmet needs, and potential negative outcomes. Findings included.Resident 1Review of the electronic health record (EHR) showed Resident 1 readmitted to the facility on [DATE] with diagnoses to include heart failure, respiratory conditions due to unspecified external agent (a lung disease or breathing problem triggered by something inhaled or exposed to from the environment), and cerebral infarction (stroke, blood flow to part of the brain is blocked preventing oxygen from reaching brain tissue, causing cells to die). Resident 1 was able to make needs known. Observation on 03/09/2026 at 2:00 PM showed Resident 1 lay in bed with the head of the bed elevated, O2 being delivered at 1.5 liters through a nasal canula (NC, a flexible tube with two prongs used to provide O2 through the nose) via an O2 concentrator. Review of the EHR showed Resident 1 had a provider order dated 03/09/2026 to have continuous O2 at 2 liters to maintain O2 saturation (Sats, measuring the percentage amount of O2 in the blood) greater than 92% every shift for O2 maintenance. Review showed no orders or documentation to change O2 tubing or to clean the filter on the O2 concentrator routinely. During an interview on 03/11/2026 at 2:25 PM, Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM), stated O2 tubing should be changed and dated weekly; however, they were not sure where that was getting documented. Staff L stated they were not sure about the O2 concentrator filter and when or how that was cleaned. Observation and interview with Staff L, LPN/UM, on 03/11/2026 at 2:47 PM showed Resident 1 laid in bed receiving O2 at 1.5 liters through a NC via an O2 concentrator. Staff L stated the O2 liter flow should be at 2 liters and increased the liter flow per provider's order. During an interview on 03/11/2026 at 4:17 PM, Staff B, Director of Nursing Services (DNS), stated they were not aware that Resident 1 had O2 liter flow provided outside of provider's order and the expectation was that provider orders were followed. Staff B stated they were unable to locate orders or documentation for Resident 1's O2 tubing to be changed or for the O2 concentrator filter to be cleaned and there should have been. Staff B stated O2 tubing changes and O2 concentrator filter cleanings should be documented by the licensed nurse in the medication administration records (MAR) or treatment administration records (TAR). Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), dementia (a decline in mental abilities, severe enough to interfere with daily life), and chronic obstructive pulmonary disease (COPD, restricted airflow making it difficult to breathe). Resident 9 was usually able to make needs known. Observations on 03/10/2026 at 10:06 AM, 03/11/2026 at 10:49 AM, 03/11/2026 at 2:53 PM and on 03/12/2026 at 11:27 AM showed Resident 9 receiving O2 at 2 liters through a NC via an O2 concentrator. Review of the EHR showed Resident 9 had a provider order dated 02/25/2026 to have O2 inhalation at 3 liters per minute to keep O2 Sats above 88% every shift. Review showed no orders or documentation to change O2 tubing or to clean the filter on the O2 concentrator routinely. During an interview on 03/11/2026 at 4:39 PM, Staff B, DNS, stated they were unable to locate provider orders for Resident 9 to have O2 tubing changed or to clean the filter on their O2 concentrator and there should have been. Observation and interview on 03/12/2026 at 11:32 AM with Staff O, Assistant Director of Nursing (ADON), showed Resident 9 laid in bed receiving O2 at 2 liters through a NC via an O2 concentrator. Staff O stated the liter flow should be at 3 liters and then increased the liter flow to 3 liters per provider's order. Resident 67 Review of the EHR showed Resident 67 admitted to the facility on [DATE] with diagnoses to include COPD, cerebral infarction/stroke, and chronic (lasts for an extended period or consistently recures) respiratory failure. Resident 67 was usually able to make needs known. Observation on 03/10/2026 at 11:10 AM showed Resident 67 laid in bed receiving O2 at 4 liters through a NC via an O2 concentrator. Resident 67's O2 tubing was not dated. Review of the EHR showed Resident 67 had a provider order dated 03/09/2026 to have O2 at 2-4 liters continuous via NC to keep O2 above 92% every shift. Review showed no orders or documentation to change O2 tubing or to clean the filter on the O2 concentrator routinely. During an interview on 03/11/2026 at 2:43 PM, Staff B, DNS, stated Resident 67 was missing orders to change O2 tubing and to clean the O2 concentrator filter and they needed to be obtained from the provider. Reference WAC 388-97 -1060(3)(j)(iv)-(vi)

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 4 of 21 sampled residents (Residents 1, 9, 10, and 26) when reviewed for comprehensive care plans. Failure to develop care plans that accurately reflected resident care needs related to oxygen therapy, wound/skin impairment, use of an indwelling catheter (a thin flexible tube that is inserted through the urethra/tube like structure into the bladder to continuously drain urine), and antidepressant medication use placed residents at risk of unmet care needs and potential negative outcomes. Findings included.Resident 1 Review of the electronic health record (EHR) showed Resident 1 readmitted to the facility on [DATE] with diagnoses to include heart failure, respiratory conditions due to unspecified external agent (a lung disease or breathing problem triggered by something inhaled or exposed to from the environment), and cerebral infarction (stroke, blood flow to part of the brain is blocked preventing oxygen from reaching brain tissue, causing cells to die). Resident 1 was able to make needs known. Observation and interview on 03/08/2026 at 2:53 PM showed Resident 1 with an oxygen (O2) concentrator (a device used for O2 therapy) located in the room not in use. Resident 1 stated they did not need O2 at that time. Review of the February 2026 medication administration record (MAR) showed Resident 1 was prescribed O2 at 0-2 liters as needed (PRN) to maintain O2 saturation (Sats, measuring the percentage amount of O2 in the blood) greater than 92% for O2 maintenance. Documentation showed Resident 1 received O2 almost every shift. It further showed this order was discontinued on 03/09/2026. Review of the March 2026 MAR showed Resident 1 was prescribed continuous O2 at 2 liters to maintain O2 Sats greater than 92% for O2 maintenance. Documentation showed it was provided starting on 03/09/2026 on the evening shift. Review of the current care plan showed no documentation related to Resident 10's O2 therapy. During an interview on 03/11/2026 at 2:25 PM, Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM), stated they were unable to locate a care plan for Resident 10's O2 therapy and there should have been one in place. During an interview on 03/11/2026 at 4:17 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that residents on O2 therapy have a care plan in place. Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), dementia (a decline in mental abilities, severe enough to interfere with daily life), and chronic obstructive pulmonary disease (restricted airflow making it difficult to breathe). Resident 9 was usually able to make needs known. Review of the February and March 2026 treatment administration records (TAR) showed documentation that Resident 9 was being treated for a chronic ulcer/open wound to the left foot. Review of the current care plan showed there was a focused care plan for Resident 9's risk for pressure ulcers and skin impairment, initiated on 12/24/2024; however, there was no documentation to show Resident 9 had an actual skin impairment to the left foot. During an interview on 03/13/2026 at 10:03 AM, Staff M, Staff Development/Infection Preventionist (SD/IP), stated Resident 9's wound to the left foot had not been care planned and it should have been. During an interview on 03/13/2026 at 10:12 AM, Staff B, DNS, stated Resident 9 did not have a care plan for their chronic wound to the left foot and there should have been one in place when it was first identified. Resident 10 Review of the EHR showed Resident 10 readmitted to the facility on [DATE] with diagnoses of neurogenic bladder (a condition that prevents the bladder from working property, leading to poor bladder control), stage 3 chronic kidney disease (moderate kidney damage, with kidneys functioning at 30-59% capacity, causing waste to build up in the blood), and dementia. Resident 10 had an indwelling catheter in place. Review of the nursing progress note dated 03/04/2026 showed Resident 10's indwelling catheter was flushing and draining well. Review of the Admission/Readmission, progress note dated 03/07/2026 showed Resident 10 continued to have their indwelling catheter draining clear yellow urine. Review of the February and March 2026 TAR showed documentation that Resident 10 received catheter care every shift while in the facility. Review of the EHR showed a focused care plan for Resident 10's indwelling catheter had been initiated/created on 03/09/2026. During an interview on 03/11/2026 at 2:08 PM, Staff L, LPN/UM, stated Resident 10's focused care plan for their indwelling catheter was developed too late. During an interview on 03/11/2026 at 4:03 PM, Staff B, DNS, stated Resident 10's care plan for their indwelling catheter should have been initiated sooner. Resident 26 Review of the EHR showed Resident 26 was admitted to the facility on [DATE] with diagnoses to include diabetes, end stage renal disease (kidney failure), and dependence on renal dialysis (life sustaining treatment that filters waste and excess fluid from the blood). Resident 26 was able to communicate their needs. Observation on 03/08/2026 at 10:13 AM, showed Resident 26 sitting in their room, using oxygen via nasal cannula (clear tube that enters nose) taking oxygen at 2 liters per minute. Review of the providers' orders showed Resident 26 was prescribed trazodone (antidepressant medication) dated 02/09/2026 for insomnia. Review of Resident 26 care plan dated 01/28/2026 showed no directions or goals for oxygen use or antidepressant medication use for insomnia. During an interview on 03/11/2026 at 11:48 AM, Staff B, DNS, stated the care plan should be developed based on the assessment and needs. Reference WAC 388-07-1020(1)(2)(a)(b)

Based on interview and record review, the facility failed to screen residents for additional mental health supports on admission and/or after a change in mental health diagnoses for 7 of 8 sampled residents (Residents 32, 13, 2, 11, 88, 89, and 9) when reviewed for Pre-admission Screening and Resident Review (PASSAR, a mental health screening tool). This failure placed residents at risk of not having needed mental health supports, increased adverse behaviors, and a diminished quality of life. Findings included.During an interview on 03/11/2026 at 11:08 AM, Staff J, Social Services Director (SSD), stated residents were screened for mental health needs on admission using the PASSAR assessment. Staff J stated any resident with a mental health diagnosis would have a positive PASSAR and be referred for a level two PASSAR. Staff J stated if a hospital submitted an inaccurate PASSAR the facility would re-complete it accurately. Staff J stated the PASSAR should be re-completed if a resident received a new mental health diagnosis. Resident 32Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses to include chronic lymphocytic leukemia (a slow-growing cancer of the blood and bone marrow, primarily affecting older adults), dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion), depression, and violent behaviors. Resident 32 was unable to make needs known. Review of a PASSAR, dated 06/13/2024, showed Resident 32 had no mental health diagnoses. Review of a PASSAR, dated 04/21/2025, showed Resident 32's PASSAR was re-completed accurately, and they were referred for a level two PASSAR (10 months after admission). Resident 13Review of the EHR showed Resident 13 admitted to the facility on [DATE] with diagnoses to include anxiety disorder, dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion), and schizophrenia (a chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness, causing individuals to lose touch with reality). Resident 13 was able to make needs known. Review of a level two PASSAR, dated 02/01/2022, showed Resident 13's diagnosis of schizophrenia was not included. Review of the diagnosis list showed Resident 13 received a diagnosis of schizophrenia on 04/29/2024. During an interview on 03/12/2026 at 11:45 AM, Staff J, SSD, stated Resident 13 was diagnosed with schizophrenia on 04/29/2024 and they could not locate a PASSAR was re-completed after this new mental health diagnosis. Resident 2Review of the EHR showed Resident 2 admitted to the facility on [DATE] with diagnoses to include cancer, kidney transplant, and anxiety. Resident 2 was able to make need known. Review of the EHR did not show a PASSAR had been completed for Resident 2's 11/22/2025 admission. During an interview on 03/12/2026 at 11:52 AM, Staff J, SSD, stated they could not locate a PASSAR for Resident 2's 11/22/2025 admission. Resident 11Review of the EHR showed Resident 11 admitted to the facility on [DATE] with diagnoses to include schizophrenia and diabetes (high blood sugar). Resident 15 was able to make needs known. Review of the PASSAR, dated 01/22/2026, showed Resident 11 was assessed approximately one year after admission. Resident 88Review of the EHR showed Resident 88 admitted to the facility on [DATE] with diagnoses to include pressure ulcer of the right buttock, anxiety, and depression. Resident 88 was able to make needs known. Review of the PASSAR, dated 01/21/2026, showed it was completed by the admitting hospital and did not include any of Resident 88's mental health diagnoses. Resident 89Review of the EHR showed Resident 89 admitted to the facility on [DATE] with diagnoses to include encephalopathy (a broad term for any disease, damage, or malfunction that affects the brain's structure or function, resulting in an altered mental state), hallucinations, depression, and bipolar disorder (a chronic mental health condition characterized by intense, alternating mood swings between extreme highs and lows). Resident 89 was able to make needs known. Review of the PASSAR, dated 10/02/2025, showed it was completed by the admitting hospital and did not include any of Resident 89's mental health diagnoses. Resident 9Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a progressive, long-term lung disease that restricts airflow, making it difficult to breathe), depression, bipolar disorder, and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events). Resident 9 was able to make needs known. Review of the PASSAR, dated 09/18/2024, showed it was completed by the admitting hospital and referral for a level two PASSAR was not needed as the resident was expected to stay in the facility for less than 30 days. During an interview on 03/13/2026 at 9:27 AM, Staff A, Administrator, stated if the PASSAR was completed by the hospital prior to admission, the facility would re-complete the PASSAR if it was inaccurate. Staff A stated if a resident received a new mental health diagnosis, social services would re-complete the PASSAR. Reference WAC 388-97-1915(1)(2)(a)-(c)

Based on observation, interview, and record review, the facility failed to ensure a thorough investigation to rule out abuse/neglect was conducted after resident accidents for 2 of 4 sampled residents (Residents 5 and 32) when reviewed for abuse/neglect. This failure placed residents at risk of continued abuse, continued neglect, and a diminished quality of life. Findings included.According to the Nursing Home Guidelines also known as the Purple Book, sixth edition, dated October 2015, All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated . 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. Resident 5Review of the electronic health record (EHR) showed Resident 5 admitted on [DATE] with diagnoses to include Parkinson's disease (a progressive movement disorder that occurs when nerve cells in the brain die) and adult failure to thrive. Resident 5 was able to make needs known. During an interview and observation on 03/08/2026 at 10:46 AM, Resident 5 stated a staff member had been transferring them from the bed to a wheelchair and the resident's leg had been scratched on the wheelchair. Observation showed Resident 5's leg was bandaged from ankle to knee. Review of the Accident and Incident Log showed an incident for Resident 5 on 02/27/2026 with superficial injury and related to the resident's condition. Review showed the incident was not reported to the state agency. Review of the care plan showed a focus area, initiated 02/27/2026, for skin impairment to the left lower leg with an intervention for referral to an outside wound care provider. Review of the incident report, dated 03/03/2026, showed, Nursing Description: Resident observed with a skin tear to [their] left lower leg, and Resident Description: Resident stated [they] accidently bumped [their] leg on the side of [their] bed railing. Review did not show a resident statement or witness statements were included. Review showed the conclusion was Resident 5 hit their leg on the bed rail and the new intervention was referral to an outside wound care provider. Review showed abuse/neglect was ruled out. Review of the outside wound care provider's wound assessment progress note, dated 03/04/2026, showed Resident 5 reported they were injured getting into their wheelchair. During an interview on 03/12/2026 at 8:47 AM, Resident 5 was able to accurately describe how they were injured as previously given on 03/08/2026 and stated Staff K, Certified Nursing Assistant (CNA), was the staff member assisting them when the injury occurred. During an interview on 03/12/2026 at 11:04 AM, Staff K, CNA, stated they were assisting Resident 5 transfer into a wheelchair on 02/27/2026 when the resident's leg was scratched by the wheelchair. Staff K stated they were not interviewed as part of the investigation and were not asked to write a statement of events. During an interview on 03/12/2026 at 12:29 PM, Staff B, Director of Nursing Services, stated they had started at the facility two weeks prior and had walked into about 30 investigations to complete and some of the uninvestigated incidents dated all the way back to January. Staff B stated when a resident was injured the facility would generally interview the resident and staff, collect statements, and review the record. Staff B stated abuse/neglect was ruled out by Basically, looking over the incident and data sources for making this decision was interviews and record review. Staff B stated Resident 5's incident investigation needed to be re-completed because it did not include statements from CNA. Staff B stated they felt abuse/neglect had adequately been ruled out based on the original information provided by the resident. During an interview on 03/12/2026 at 12:46 PM, Staff A, Administrator, stated the incident investigation of Resident 5's 02/27/2026 injury should have had more detail and abuse/neglect was inadequately investigated. Resident 32Review of the EHR showed Resident 32 admitted to the facility on [DATE] with diagnoses to include chronic lymphocytic leukemia (a slow-growing cancer of the blood and bone marrow, primarily affecting older adults) and dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion). Resident 32 was unable to make needs known. Review of the incident log showed Resident 32 had unwitnessed falls on the following dates: 10/04/2025, 10/05/2025, 10/11/2025, 10/31/2025, 11/12/2025, 11/24/2025, 12/08/2025, 12/17/2025, 12/18/2025, 12/21/2025, 12/22/2025, 12/24/2025, 01/01/2026, 01/10/2026, 01/21/2026, 01/25/2026, 01/27/2026, and 02/20/2026. Review of Resident 32's incident reports for the above dates showed the following investigations did not include witness statements and/or interviews with assigned facility staff members: 10/05/2025,10/11/2025, 11/12/2025, 11/24/2025, 12/17/2025, 12/18/2025, 12/21/2025, 12/22/2025,12/24/2025, 01/01/2026, 01/21/2026, 01/25/2026, and 01/27/2026. Review of two incident reports for unwitnessed falls by Resident 32, which were not included in the incident log, dated 12/05/2025 and 02/14/2026, showed they did not include witness statements and/or interviews with assigned facility staff members. During an interview on 03/13/2026 at 9:28 AM, Staff A, Administrator, stated staff should be interviewed after an unwitnessed fall to assist in ruling out abuse/neglect. Reference WAC 388-97-0640(6)(a)(b)

Based on interview and record review, the facility failed to monitor for adverse side effects and behaviors for 3 of 5 sampled residents (Residents 26, 89, and 88) when reviewed for unnecessary medications. These failures placed the residents at risk for poor clinical outcomes and a decreased quality of life. Findings included .Resident 26 Review of the electronic health record (EHR) showed Resident 26 was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), end stage renal disease (kidney failure), and dependence on renal dialysis (life sustaining treatment that filters waste and excess fluid from the blood). Resident 26 was able to communicate their needs. Review of the providers' orders showed Resident 26 was prescribed trazodone (antidepressant medication) dated 02/09/2026 for insomnia. Review of the EHR showed no monitoring for adverse side effects and behaviors for the use of the medication. During an interview on 03/11/2026 at 11:46 AM, Staff B, Director of Nursing Services (DNS), stated they were not sure why there was no monitoring for adverse side effects and behaviors, but there should be. Resident 89 Review of Resident 89's EHR showed the resident admitted on [DATE] with diagnoses of dementia (a group of symptoms that effects memory), depression, and bipolar disorder (a chronic mental health condition characterized by intense, long-lasting shifts in mood, energy, and activity levels). The resident was able to make needs known. Review of the provider orders for Resident 89 showed an order for quetiapine (an antipsychotic medication) with a start date of 02/10/2026 and an order to monitor orthostatic blood pressure (blood pressure taken when lying, sitting and standing) every two weeks. Review of the medication administration record for the months of January 2026 and February 2026 showed no documented orthostatic blood pressures. During an interview on 03/10/2026 at 2:43 PM, Staff B, DNS, stated it was their expectation that adverse side effects such as orthostatic blood pressures be monitored as ordered and this did not meet expectations for Resident 89. Resident 88 Review of the EHR showed Resident 88 admitted to the facility on [DATE] with diagnoses of anxiety and depression. The resident was able to make needs known. Review of the provider orders showed an order for citalopram (an antidepressant medication) with a start date of 01/30/2026 and an order for buspirone (an antianxiety medication) with a start date of 01/29/2026. Review of the provider orders and the medication administration record showed no documented monitoring of the adverse side effects of the medications and no documented monitoring of Resident 88's behaviors. During an interview on 03/10/2026 at 9:55 AM, Staff D, Licensed Practical Nurse, stated Resident 88 should have had orders to monitor behaviors and adverse side effects of psychotropic medications but did not. During an interview on 03/10/2026 at 2:43 PM, Staff B, DNS, stated it was their expectation that Resident 88 be monitored for adverse side effects of antianxiety and antidepressant medications and should have had a behavior monitor in place. Reference WAC 388-07-1060(3)(k)(i) -0620(1)(a)

Based on observation, interview, and record review, the facility failed to provide care and services that met professional standards of practice for 2 of 22 sampled residents (Residents 2 and 26) when reviewed quality of care. Failure to provide wound care for Resident 2 and failure to follow provider orders for parameters when administering blood pressure medications for Resident 26 placed the residents at risk for complications, poor clinical outcomes, and a decreased quality of life. Findings included .Resident 2 Review of the electronic health record (EHR) showed Resident 2 admitted to the facility on [DATE] with diagnoses of head/face and neck cancer. The resident was able to make needs known. Observation and interview on 03/09/2026 at 11:15 AM showed Resident 2 was pointing at bandages on their left wrist and right hand and stated that the bandages were bothering them. The bandages were undated and had hard dried drainage on them and were soiled. Review of the EHR showed orders to monitor left hand, cleans with skin prep, apply bandage and monitor left forearm, cleanse with skin prep and apply bandage with start dates of 03/05/2026. These orders did not show on the treatment administration record. Observation and interview on 03/09/2026 at 2:03 PM showed Staff H, Licensed Practical Nurse (LPN), looked at the bandages and stated the resident should have an order in place the cleanse and change the dressings to Resident 2's right and left wrist and left elbow. Staff H reviewed Resident 2's treatment administration record and stated they did not see any orders to change the bandages and Resident 2 should have had orders in place for that. During an interview on 03/09/2026 at 2:14 PM, Staff D, LPN, stated Resident 2 should have active orders that showed in the treatment administration record to care for these wounds but did not. During an interview on 03/09/2026 at 2:19 PM, Staff G, Regional Nurse Consultant, stated it was their expectation that Resident 2 had orders in place to care for the wounds on their hands, elbow and wrist, and the current orders should be clarified and scheduled for daily care. Resident 26 Review of the EHR showed Resident 26 was admitted to the facility on [DATE] with diagnoses to include heart failure, end stage renal disease (kidney failure), and dependence on renal dialysis (life sustaining treatment that filters waste and excess fluid from the blood). Resident 26 was able to communicate their needs. Review of provider orders dated 01/28/2026 showed order for: 1) Metoprolol (medication for high blood pressure) extended release 25 milligrams (mg) to be given once a day and hold when the systolic (upper) blood pressure (SBP) was less than 110 or the pulse was under 60. 2) Hydralazine (medication for high blood pressure) 10 mg to be given three times a day and hold the medicine for SBP below 110. Review of the medication administration record (MAR) for March 2026 showed Resident 26 was administered Metoprolol on 03/04/2026 at 8:00 AM despite SBP of 105. Hydralazine was administered two times on 03/04/2026, one time on 03/08/2026 and one time on 03/11/2026 when the SBP was under 110. Review of February 2026 MAR showed Resident 26 was administered hydralazine on seven occasions at the evening administration time when the SBP was under 110. During an interview on 03/11/2026 at 11:43 AM, Staff B, Director of Nursing Services (DNS), stated the medications were to be administered following the orders and holding the medications per the provider's order. Reference WAC 388-07- 1060(1)-(3)

Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN, a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) were provided timely and/or completed as required for 2 of 3 sampled residents (Residents 18 and 54) when reviewed for Beneficiary Notification. Failure to provide SNF ABN notification at least two calendar days before the Medicare coverage ended placed the residents and/or the residents' representative at risk of not having adequate information to make financial decisions related to a continued stay in the facility. Findings included. Resident 18Review of a Notice of Medicare Non-Coverage (NOMNC), dated 10/23/2025, showed the facility informed Resident 93 and/or representative that skilled nursing services would end on 10/27/2025. Review of Resident 18's SNF ABN dated 03/09/2025 showed, Beginning on 10/28/2026 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. However, the section of the form that was to list Care was blank. Review showed the form was provided and signed by Resident 18 on 03/09/2026. Resident 54Review of a NOMNC, dated 02/13/2025, showed the facility informed Resident 54 that skilled nursing services would end on 02/16/2025. Review of Resident 54's SNF ABN dated 03/09/2025 showed, Beginning on 02/17/2026 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. However, the section of the form that was to list Care was blank. Review showed the form was provided and signed by Resident 54 on 03/09/2026. During an interview on 03/11/2026 at 12:06 PM, Staff J, Director of Social Services, stated Resident 18's SNF ABN and Resident 54's SNF ABN both dated 03/09/2026 did not meet expectations because the section for Care on both forms had no care listed and should have been provided and signed by Resident 18 and Resident 54 sooner than 03/09/2026. During an interview on 03/11/2026 at 12:18 PM, Staff A, Administrator, stated Resident 18's SNF ABN dated 03/09/2026 was missing listed Care on the form and should have been provided when their NOMNC was provided on 10/23/2025. Staff A stated Resident 54's SNF ABN dated 03/09/2026 was missing listed Care on the form and should have been provided when their NOMNC was provided on 02/13/2025. Staff A stated their expectation was that SNF ABN forms were filled out completely and provided as required when NOMNCs were issued. Reference WAC 388-97-0300(1)(e)(5)(6)

Based on observation and interview, the facility failed to make needed repairs to maintain a homelike environment for 1 of 4 halls (200 hall) when reviewed for environment. This failure placed residents at risk of decreased mood and a diminished quality of life. Findings included.Observation and interview on 03/08/2026 at 1:07 PM showed room [ROOM NUMBER]'s bathroom with a gouge in the floor at the entry way and two large scrapes and gouges, black scrapes, and chipped paint on the wall to the right of the sink. Resident 11 stated they were surprised the gouge in the floor did not interfere with entering or leaving the bathroom when using their wheelchair. Observation of room [ROOM NUMBER] on 03/08/2026 at 1:13 PM showed Resident 31's closet was missing a door exposing all items in the closet. During an interview on 03/13/2026 at 9:14 AM, Resident 31 stated they were not aware that their closet door was missing. Observation of room [ROOM NUMBER] on 03/08/2026 at 1:18 PM showed both closets were missing doors exposing Resident 71's and Resident 98's items in the closets. During an interview on 03/13/2026 at 9:17 AM, Resident 71 stated they would prefer to have a closet door, but the closet had not had one since being admitted to the facility. During an interview on 03/13/2026 at 1:20 PM, Resident 98 stated the closets in the room had been missing for about a year. Resident 98 stated, It would be nice to have closet doors if they had any to spare. Observation and interview on 03/08/2026 at 2:22 PM showed a closet door in room [ROOM NUMBER] was missing, exposing Resident 121's personal items. Resident 121 stated they would like to have a closet door and did not know why they did not have one. During an interview on 03/13/2026 at 9:23 AM, Staff S, Certified Nursing Assistant, stated room [ROOM NUMBER]'s bathroom entry was missing a piece out of the floor and the wall was dented, had chipped paint and scrapes. Staff S stated they had not noticed it before and did not document it in TELS (electronic system to put in a work order for items/issues to be fixed, repaired, or replaced). Staff S stated that closet doors were missing in rooms [ROOM NUMBER], and that they had been that way for a while. Staff S stated they did not document it in TELS because maintenance should have been checking the environment for those issues and fixed them. During an interview on 03/13/2026 at 9:33 AM, Staff T, Maintenance Director, stated if staff were to notice items in need of repair or replacement then they should put in a work order in the TELS system. Staff T was able to show the TELS system on their mobile device and stated they checked work orders throughout the day to resolve reported issues. Staff T stated that closet doors were missing in rooms [ROOM NUMBER], and they were only aware of room [ROOM NUMBER]'s missing closet door; however, they were not aware of the other missing closet doors on the 200 hall. Staff T stated these issues did not create a homelike environment and should have been addressed sooner. During an interview on 03/13/2026 at 9:46 AM, Staff A, Administrator, stated their expectation was for staff to put in a work order into TELS when there were issues needing to be fixed/repaired or replaced. Staff A stated they were not aware of areas in need of repair in room [ROOM NUMBER]'s bathroom or of missing closet doors on the 200 hall. Staff A stated issues on the 200 hall should have been addressed with a work order completed in TELS and these issues were not their idea of a homelike environment. Reference WAC 388-97-0880, -2040

Based on observation, interview, and record review, the facility failed to ensure care conferences occurred timely for 1 of 3 sampled residents (Resident 32) when reviewed to care conferences and accurately reflected a resident's eating status for 1 of 3 sampled residents (Resident 87) when reviewed for tube feeding. This failure placed the residents at risk of not providing input into the plan of care, impaired nutritional status, and a diminished quality of life. Findings included. During an interview on 03/11/2026 at 11:01 AM, Staff J, Social Services Director (SSD), stated residents were able to provide input into their plan of care through care conferences. Staff J stated care conferences should occur on admission and with the minimum data set (MDS) assessment schedule (quarterly and with change of condition). Resident 32 Review of the electronic health record (EHR) showed Resident 32 admitted to the facility on [DATE] with diagnoses to include chronic lymphocytic leukemia (a slow-growing cancer of the blood and bone marrow, primarily affecting older adults) and dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion). Resident 32 was unable to make needs known. Review of a Multidisciplinary Care Conference form, dated 10/02/2025, showed it was Resident 32's most recent care conference and only the Activities Department was in attendance. Review showed it was signed by Staff W, Director of Activities, on 12/12/2025. Review of the MDS schedule showed Resident 32 had a significant change MDS on 12/23/2025. During an interview on 03/12/2026 at 11:55 AM, Staff J, SSD, stated Resident 32 had their last care conference on 10/02/2025 and should have had a new care conference around 12/23/2025 with the significant change MDS. During an interview on 03/13/2026 at 9:27 AM, Staff A, Administrator, stated their expectation was care conferences would occur quarterly with the MDS. Resident 87 Review of the EHR showed Resident 87 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (blockage of blood flow to the brain causing cell death), gastrostomy (feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition and medication), anxiety, and depression. Resident 87 could not communicate their needs. Observation on 03/08/2026 at 12:20 PM, showed Resident 87 lying in bed and a pole holding tube feeding formula next to the bed. Observation on 03/10/2026 at 1:12 PM showed Resident 87 in bed with tube feeding formula being infused trough the gastrostomy. Review of the care plan with focus area enteral feeding dated 03/05/2026 with interventions Resident is NPO (nothing by mouth), dated 02/16/2026, and Resident receives a tray in addition to tube feedings, dated 02/16/2026. During an interview on 03/10/2026 at 1:27 PM, Staff D, Licensed Practical Nurse, stated Resident 87 was not NPO and the care plan was not updated. During an interview on 03/11/2026 at 11:52 AM, Staff B, Director of Nursing Services, stated the expectation was for the care plans to be updated timely. Reference WAC 388-07 -1020(2)(c)(d)

Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 3 of 21 sampled residents (Residents 9, 6, and 40) when reviewed for accuracy of assessments. Failure to accurately reflect Resident 9's skin/wound status, Resident 6's mental health screening status, and Resident 40's medication use status placed the residents at risk for unmet care, inaccurate medical record data, and a diminished quality of life. Findings included.Resident 9 Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses of diabetes (too much sugar in the blood), dementia (a decline in mental abilities, severe enough to interfere with daily life), and chronic obstructive pulmonary disease (restricted airflow making it difficult to breathe). Resident 9 was usually able to make needs known. Review of the February 2026 and March 2026 treatment administration records showed Resident 9 was being treated for a chronic ulcer/open wound to the left foot. Review of the significant change MDS, dated [DATE], showed Resident 9 had no pressure ulcer/injuries or other wounds or skin problems. During an interview on 03/12/2026 at 2:32 PM, Staff F, MDS Coordinator/Licensed Practical Nurse (MDSC/LPN), stated Resident 9's significant change MDS, dated [DATE], should have been coded for an open lesion on the foot and needed to be modified. During an interview on 03/12/2026 at 2:39 PM Staff B, Director of Nursing Services (DNS), stated Resident 9 had a wound to the left foot and their significant change MDS, dated [DATE], should have been coded for that and needed to be modified/corrected. Resident 6 Review of the EHR showed Resident 6 admitted to the facility on [DATE] with diagnoses of bipolar disorder (a mental disorder characterized by periods of depression and abnormally elevated mood) and schizoaffective disorder (a mental health condition). The resident was able to make needs known. Review of the EHR showed Resident 6 had a level two preadmission screening and resident review (PASSAR, a screen for mental health services) completed on 07/26/2023. Review of the annual MDS, dated [DATE], showed no level 2 PASSAR was completed. During an interview on 03/12/2026 at 11:58 AM, Staff E, MDSC/Registered Nurse, stated Resident 6 should have been marked as yes for the level 2 PASARR. Resident 40 Review of the EHR showed Resident 40 admitted to the facility on [DATE] with diagnoses of stroke (when blood flow is blocked to part of the brain) and heart failure. The resident was unable to make needs known. Review of the annual MDS, dated [DATE], showed Resident 40 was taking an anticoagulant medication (blood thinning medication). Review of the provider orders showed Resident 40 had received an anticoagulant medication that was discontinued on 06/14/2021. During an interview on 03/12/2026 at 11:58 AM, Staff E, MDSC/Registered Nurse, stated Resident 40 should not have been marked Yes for anticoagulant. Reference WAC 388-97-1000(1)(a)(b)(4)(a)

Based on interview and record review, the facility failed to periodically review and provide assistance with advanced directives (legal documents that appoints a trusted person to make healthcare decisions on your behalf if you become unable to communicate or incapacitated) for 2 of 3 sampled residents (Residents 5 and 4) when reviewed for advanced directives. This failure placed residents at risk of not having a healthcare decisionmaker, inability to control care received when incapacitated, and a diminished quality of life. Findings included.Resident 5Review of the electronic health record (EHR) showed Resident 5 admitted on [DATE] with diagnoses to include Parkinson's disease (a progressive movement disorder that occurs when nerve cells in the brain die) and adult failure to thrive. Resident 5 was able to make needs known. Review of a Multidisciplinary Care Conference form, dated 07/23/2025, showed Resident 5's advanced directive was reviewed and assistance offered. Review of a progress note, dated 03/11/2026, showed Resident 5 believed they had established a durable power of attorney, but the facility had not obtained this document. Resident 4Review of the EHR showed Resident 4 admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a chronic autoimmune disease of the central nervous system) and dementia (a decline in mental ability, such as memory loss, poor judgment, or confusion). Resident 4 could not make needs known. Review of a Social Service Initial Evaluation, dated 12/03/2025, showed Resident 4 did not have an advanced directive, but would like to establish one. Review of a progress note, dated 03/11/2025, showed Resident 4 believed they had an advanced directive, but was unsure. During an interview on 03/11/2026 at 11:05 AM, Staff J, Social Services Director, stated the facility asked residents about their advanced directive during the initial care conference and would obtain a copy of any advanced directive a resident had established. Staff J stated if a resident did not have an advanced directive, they would provide information on how to establish one using an advanced directive information sheet. Staff J stated residents' advanced directive choices would be reviewed quarterly with care conferences. During a follow-up interview on 03/12/2026 at 12:13 PM, Staff J stated Resident 5 had not had an advanced directive review between 07/23/2025 and 03/11/2026 and Resident 4 had not had follow-up on their advanced directive between 12/03/2025 and 03/11/2026. During an interview on 03/13/2026 at 9:26 AM, Staff A, Administrator, stated advanced directives should be reviewed quarterly with care conferences. Reference WAC 388-97-0280(3)(c)(i)(ii), -0300(1)(b)(3)(a)-(c)

Based on interview and record review, the facility failed to take timely action for 1 of 3 who experienced a significant change in their baseline condition. Resident 1 experienced harm when the serious changes in cognition, blood pressure and temperature were not addressed timely, and they had to eventually be hospitalized . Findings included . The facility's Fall Management Guideline, dated 05/10/2023, documented facility staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and to try to minimize complications from falling. Guidance on Post-Fall Evaluation Considerations documented changes from baseline in orientation and cognition, as well as changes in communication, could be indicative of acute neurological or cardiovascular changes. Resident 1 was admitted to the facility on [DATE] for rehabilitation after hospitalization for a fall at home. Review of the admission Minimum Data Set (MDS), an assessment tool, dated 11/23/2023, showed Resident 1 admitted to the facility with multiple diagnoses including bladder cancer and required staff assistance with activities of daily living. Review of a Morse Fall Scale assessment, dated 11/16/2023, documented Resident 1 was at high risk for falling. Resident 1's score was 75 (high risk was considered 45 and above). Morse Fall Scale instructions included: Complete on admission, quarterly, at change of condition, and after a fall. Review of the Resident 1's care plan, initiated 11/22/2023, showed Resident 1 was at risk for falls related to gait/balance problems and deconditioning and had actual falls on 11/16/2023 and 11/18/2023. Care interventions included following the facility fall protocol to monitor, document and report to the provider signs and symptoms including pain, bruises, changes in mental status, new onset confusion, sleepiness, inability to maintain posture, and agitation. Review of the facility incident reporting logs for November 2023, December 2023 and January 2024 showed Resident 1 had falls on 11/16/2023, 11/18/2023, 12/28/2023, 01/02/2024 and 01/03/2024. Review of Resident 1's electronic health record (EHR) showed after the non-injury falls on 12/28/2023, 01/02/2024, and 01/03/2024, the resident was monitored and assessed to be at baseline. On 01/04/2024 at 6:45 AM, Nursing documented Resident 1 was observed coming out of the bed and crawling on the floor. Nursing noted the resident was agitated all throughout the shift, denied pain, and a mattress was placed on the floor for safety. On 01/04/2024 at 1:50 PM, Nursing documented Resident 1's neurochecks were unchanged except for their level of orientation, the patient was alert to self that morning compared to their baseline of alert and oriented x3-4 (aware of the person, place, time and situation). The note also documented Resident 1 had increased weakness and required a mechanical lift transfer with the assist of two staff. On 01/06/2024 at 2:00 PM, Nursing notified the provider that Resident 1 did not eat when the food was set in front of them but would eat when left to themself, and just looked at the food confused. The note requested to change the resident's level of assistance to being fed by staff. On 01/07/2024 at 1:23 PM, Nursing documented Resident 1 was more confused and disoriented than they had been in the past, unable to answer any questions, unable to feed themselves, and required staff assistance for eating. Medications were crushed and mixed with applesauce for administration. Staff notification to the provider documented Resident 1's vital signs at 9:00 AM had included a pulse of 48 (typical range 60-100), blood pressure of 125/74 (within normal range), and that the resident's temperature only read as 'low.' On 01/08/2024 at 8:54 AM, Resident 1's blood pressure was recorded as 85/57. No documentation of other actions taken or notification to the provider was located. On 01/08/2024 at 5:08 PM, Resident 1's blood pressure was recorded at 76/42, temperature 90.2. No documentation of other actions taken or notification to the provider was located. On 01/09/2024 at 7:15 AM, a nursing note to the provider documented, (Resident 1) running low blood pressure since yesterday, 74/49, heartrate 51, oxygen level 98% on room air, please advise. The provider response included a BMP (basic metabolic panel), CBC (complete blood count) (labs to be drawn), and a urinalysis. On 01/10/2024 at 1:45 PM, Nursing documented Resident 1 was assessed during the night shift to be cold to touch, the thermometer read low, the resident did not speak or respond to stimuli, and their vital signs included a pulse of 48 and a blood pressure of 83/56. The provider was notified and the resident was transported by emergency services to the hospital for evaluation. Review of EHR showed a urinalysis was ordered on 01/04/2024. A Lab Results Report, dated 01/14/2024, showed the urinalysis was collected on 01/07/2024, three days after the order date, and received by the laboratory on 01/09/2024 at 5:30 PM, five days after the order was written and two days after the sample was collected. The sample showed out of range levels of bacteria and other organisms. On 03/22/2024 at 2:57 PM, Staff D, a nurse aide, said vital signs were taken every day, and if a resident's reading seemed too high or too low, they would take it again and if they had concerns they would go and tell the nurse. On 03/22/2024 at 1:24 PM, Staff C, a Registered Nurse, said after a fall the resident is assessed and the provider notified of their assessment. When asked, Staff C said they are looking if the resident's baseline is out of normal, and that if their vital signs or other parameters are too high or too low, that would be alarming. When asked how nursing responded to a change in a resident's condition, Staff C said, you get the know the residents here and you would know if something was different for them. Then you would also let the family know and find out, depending on what is going on, if they wanted to have them sent out to the hospital or not. On 03/22/2024 at 3:02 PM, when asked about expectations for nursing staff after a fall, Staff E, a Licensed Practical Nurse and Unit Manager, said the nurse should do an assessment, interview the resident, do the incident report. The main thing was to implement something to aid and prevent another fall. Neuro checks were to be done with any unwitnessed fall. When asked what changes staff look for when doing neuro checks, Staff E said, neurological changes, you are really looking at any changes or changes from their baseline. Staff E said there was a provider at the facility Monday through Friday and an on-call provider available by phone. When asked, Staff E said for urgent concerns, you would want to call right away rather than wait for a response to a note. Staff E recalled Resident 1 and said they were alert and oriented most of the time, and they made their own decisions. When asked about the 01/04/2024 nursing note that documented resident crawling on the floor and agitation, Staff E said that would have been different behavior for the named resident that needed to be evaluated and followed up on. Staff E reviewed documentation of Resident 1's temperature of 90.2 F on 01/08/2024. When asked, Staff E said staff should have re-checked it and used a different thermometer to be sure. And then if it was still like that to notify the provider. Staff E reviewed Resident 1's blood pressures on 01/08/2024 and 01/09/2024. When asked whether those were within the resident's normal parameters, Staff E said no, for the resident to have blood pressures in 70s and 80s you would definitely need to notify and implement. First you would re-check, then elevate feet and head, notify the doctor and might need to start an IV (intravenous line to administer fluids). Staff E said nursing was expected to clarify physician orders. Staff E reviewed the response from the provider when notified of Resident 1's low blood pressure of 74/49, and said yes, you would do something to get the blood pressure up and not wait for labs. Staff E reviewed nursing notes regarding Resident 1's falls, including changes noted in the resident's level of orientation, increasing confusion, inability to feed themselves, decreasing verbal response and changes in vital signs. When asked, Staff E said she definitely can see the changes. Staff E said they notified the provider but we have to use nursing common sense and we have to advocate for our patients. Staff E said she thought the pieces were not put together. On 03/22/2024 at 4:15 PM, Staff A, the facility administrator, said they thought Resident 1 was very depressed and did not believe Resident 1 would have wanted any interventions. Reference WAC 388-97-1060 (1).

Based on observation, interview and record review, the facility failed to implement key components of an effective infection prevention and control program by failing to use personal protective equipment (PPE) while entering the rooms of residents on transmission-based precautions (TBP) and failing to disinfect shared resident equipment between use by residents on TBP in one of four halls (400 Hall) reviewed for infection control. Additionally, the facility failed to ensure infection control practices were followed for two of two residents (Residents 58 and 145) reviewed for urinary catheters. These failures placed residents and staff at risk of potential exposure to COVID-19, increased the likelihood of serious harm or death, increased chance of infection and a diminished quality of life. Additionally, the failure related to lack of use of TBP and disinfecting of resident equipment constituted an Immediate Jeopardy (IJ). On 08/12/2021 at 6:46 PM, the facility was notified of an IJ at CFR 483.80 (a)(2)(iii) F880 related to the facility's failure to ensure staff properly utilized PPE and disinfected shared resident equipment. Findings included . LACK OF PPE USAGE AND SANITIZING OF SHARED EQUIPMENT Review of the Washington State Department of Health Contingency Strategies for PPE Use During COVID-19 Pandemic, updated 04/29/2021, showed that Health Care Professionals in close contact with residents presumed or confirmed COVID-19 positive, and in close contact with new admissions, readmissions, or potentially exposed persons, should wear N95 respirators, eye protection, gown, and gloves. According to Chapter 2 of the Facility's 07/2021 Infection Control (IC) Manual, in the Subsection Patient Care Equipment, staff must disinfect reusable equipment between patients (e.g., lifts, scissors, blood pressure cuffs, etc.) with an [Environmental Protection Agency (EPA) registered] disinfectant or hypochlorite solution. Review of Resident 49's electronic health record (EHR) showed that the resident admitted to the facility on [DATE] and was placed in room [ROOM NUMBER], where the resident remained throughout their stay. Review of a progress note dated 08/12/2021 at 11:21 AM showed that Resident 49 had a temperature of 100.4 Fahrenheit (F) and an increased blood pressure. Resident 49 was placed on isolation/droplet precautions for developing symptoms associated with COVID-19. Observation and interview on 08/12/2021 at 2:47 PM showed that Staff X, Nursing Assistant Certified (NAC), applied a gown, face shield, gloves, and a surgical mask prior to entering room [ROOM NUMBER] which had a sign directing staff to use TBP when entering the room. The sign directed staff to apply a gown, eye protection, gloves and an N95 respirator prior to entry and to remove used PPE prior to exiting the room. After exiting room [ROOM NUMBER], Staff X, NAC, stated that he did not use an N95 and confirmed that the sign directed staff to use an N95 respirator. Observation on 08/12/2021 at 2:51 PM showed Staff X, NAC, entered room [ROOM NUMBER] which had posted signage which indicated to use an N95 respirator. Further observation showed that Staff X, NAC, applied a surgical mask rather than an N95 respirator. Observation on 08/12/2021 at 3:18 PM showed Staff X, NAC, in room [ROOM NUMBER] providing care to Resident 49 without a gown, as directed by the sign outside the door. Staff X, NAC, then left the room without performing hand hygiene. Further observation showed Staff X, NAC, immediately returned with a sit-to-stand device (a mechanical device used to assist residents to stand from a seated position). Staff X, NAC, still wore a surgical mask, then applied a gown prior to re-entering room [ROOM NUMBER]. Staff X, NAC, then failed to secure the gown around his neck prior to entry of room [ROOM NUMBER]. Continued observation showed Staff X, NAC, provided care to Resident 49 and the unsecured gown was observed to fall from Staff X's, NAC, shoulders and draped over the resident. During an interview and observation on 08/12/2021 at 3:31 PM, Staff M, Licensed Nurse (LN), stated that it was necessary to use an N95 respirator in room [ROOM NUMBER] as the resident was on TBP and added that she had directed Staff X, NAC, to change PPE while they both provided care due to inappropriate PPE usage. Observation showed Staff X, NAC, then exited room [ROOM NUMBER] before removing his surgical mask. Staff X, NAC, then placed his soiled surgical mask and gloves on the PPE cart outside the room. Further observation showed that Staff N, Nursing Assistant (NA), then assisted Staff X, NAC, with resident care utilizing the sit-to-stand in room [ROOM NUMBER]. After exiting the room, at 3:39 PM, Staff N, NA, stated that she and Staff X, NAC, had not disinfected the sit-to-stand and added, I'll be honest, I don't think anyone does. During an interview on 08/12/2021 at 5:32 PM, Staff B, Director of Nursing Services (DNS), stated that staff should review and apply required PPE prior to entering an isolation/quarantine room, remove all PPE at the doorway prior to exiting the room, and then apply a new surgical mask upon exit of the room. URINARY CATHETER TUBING RESIDENT 58 Observation and interview on 08/12/2021 at 6:38 PM, showed Resident 58 sat in a wheelchair near the 300/400 halls' nurses station talking with Staff B, DNS. Further observation showed that Resident 58's urinary catheter tubing was hung below the wheelchair and touched the carpeted floor. Staff B, DNS, stated that the tubing was in contact with the carpet and that the catheter tubing which touched the carpet was an infection control concern. RESIDENT 145 Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 08/20/2021, showed that Resident 145 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the resident required extensive assistance with activities of daily living, transferring and was able to make needs known. Review of Resident 145's medical records showed that a providers order dated 08/13/2021 was for staff to maintain an indwelling foley catheter (a tube inserted into the bladder to allow for bladder/urine drainage). Review of Resident 145's care plan initiated 08/16/2021, showed that the resident had an indwelling urinary catheter needed due to urinary retention (a condition in which you cannot empty all the urine from your bladder), [CONDITION(S)] ([CONDITION(S)], an enlargement of the prostate gland common in older men) and that staff were to secure the catheter with a securement device. Review of a document titled, Catheter Care: Indwelling Catheter, dated 04/2019 showed staff were to provide hygiene for patients with indwelling catheters, catheter bags should be covered with a catheter dignity bag to preserve the dignity of the patient, a securement device or Velcro leg strap device used and for staff to check that the tubing was not kinked, looped, clamped, or positioned above the level of the bladder and off the floor. Observation on 08/16/2021 at 12:15 PM, showed that Resident 145 sat in a wheelchair and was shown being escorted down a long hallway from the 300/400 hall to the facility's therapy room by two therapy staff. While Resident 145 sat in the wheelchair, the indwelling urinary catheter tubing was observed dragging along the length of the carpeted hallway floor with no urinary catheter dignity bag covering the container. During an interview on 08/16/2021 at 12:49 PM, when asked about the unsecured urinary catheter tubing, Staff G, Therapist, stated that she did assist in transferring the resident to therapy and noted that she should have secured the tubing with a clip adequately prior to the residents transfer as well as used a privacy bag. During an interview on 08/16/2021 at 1:15 PM, Staff B, DNS, stated that it was her expectation that staff secure the urinary catheter tubing with a clip prior to transport and should not be allowed to drag along the floor. In addition, Staff B, DNS stated that the urinary catheter bag should have been placed in a privacy bag. Reference WAC 388-07-1320 (1)(a)(c)

Based on observation, interview and record review, the facility failed to ensure it was free from accident hazards for two of six residents (Residents 38 and 443) reviewed for accidents. Failure to identify/address all risk factors and ensure care planned interventions implemented to provide supervision and assistance were consistently provided resulted in harm when Resident 38 had multiple falls that resulted in fractures to the right foot and Resident 443 experienced a right hip/femur fracture after falling on 08/08/2021. These failures placed residents at risk for unmet needs, avoidable injuries, and diminished quality of life. Findings included . RESIDENT 38 Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 06/24/2021, showed that Resident 38 readmitted to the facility on [DATE] with diagnoses to include arthritis, [CONDITION(S)], and broken bones in the right foot. This MDS further showed that Resident 38 was independent with transfers, required supervision of one-person physical assist with the use of the toilet and mobility devices used included a walker and a wheelchair. The resident was able to make needs known. Review of Resident 38's orthopedic consultation document dated 04/19/2021 showed that recommendations included, Hard soled shoe, due to acute fractures [broken bones] of right metatarsals 2-5 [toes, second through fifth toes]. Review of the care plan on 08/20/2021 at 9:52 AM, showed a care plan for, at risk for falls, that included an intervention dated 04/20/2021 that showed that Resident 38 was to have weight bearing as tolerated (WBAT) to the right foot with orthopedic hard soled shoe. In further review, the care plan showed a focus area for, Alteration in musculoskeletal status, that had an intervention dated 04/19/2021 that showed that Resident 38 was to have an orthopedic shoe to the right foot. Additionally, review showed that a care plan for, ADL [Activities of Daily Living] Self-care deficit, had an intervention dated 05/17/2021 that showed, Active range of motion of lower extremities during ADLs. Use orthopedic shoe to the right leg. Observation on 08/18/2021 at 1:39 PM, showed Resident 38 sat on the side of the bed with slippers on and no orthopedic hard soled shoe present on resident's right foot. During an interview and observation on 08/19/2021 at 9:58 AM, Resident 38 stated that she fell again yesterday (08/18/2021) and that maybe the resident had sat to close to the edge of the bed and slipped to the floor. Resident 38 further stated that the resident picked themself up and did not get hurt. Resident 38 sat on the side of the bed, dressed in pajamas, and had on slippers. Resident 38 did not have an orthopedic hard soled shoe placed on the right foot. During an interview and observation on 08/20/2021 at 9:10 AM, Resident 38 sat on the side of the bed with bare feet on the floor and non-skid slippers next to feet. When asked why non-skid footwear was not on, Resident 38 stated that they were on earlier but liked to take them off from time to time but would put them on if the resident stood up and walked. Resident 38 then put on the left slipper but not on the right foot. There was no orthopedic hard soled shoe found near or on the resident's right foot. During an interview and observation on 08/25/2021 at 9:23 AM, when asked if Resident 38 had ever worn anything other than slippers on feet, the resident stated that the resident used to wear a boot but that was a long time ago and that the boot was given to family to take home. Resident 38 further stated that the resident used to wear a shoe but thought that may have been given to a family member because the resident had not worn the shoe for a couple of months. During an interview and observation on 08/26/2021 at 10:23 AM, Resident 38 stated that the orthopedic shoe for the right foot was unable to be located. Resident 38 further stated that resident did not want to walk on the right foot very much because it really hurt and wanted to have the orthopedic shoe to wear for support. Review of Resident 38's following ten incident report investigations (of which nine were falls) showed: 1) Incident report dated 04/10/2021 showed that on 04/10/2021 at 3:39 AM, Resident 38 stood up on the side of the right foot and immediately sat back down on the side of the bed due to pain. First aid provided and pain medications given. Results of x-ray obtained on 04/10/2021 showed, Conclusion: Age-indeterminate [unsure how long ago] fractures [broken bones] of the third and fourth metatarsals, likely of the second and fifth as well. Probable fracture at the base of the first proximal phalanx [the base of the big toe]. Resident 38 was sent to the hospital emergency room and returned with a soft cast, non-weight bearing to the right leg, and was to have follow-up with orthopedics (field of medicine concerned with the study and treatment of the musculoskeletal/muscle and bone systems). Resident 38 had a history of right ankle arthroplasty [ankle replacement surgery]. An attached care plan dated 04/12/2021 for alteration in musculoskeletal status showed a goal and interventions dated 04/12/2021 that included, non-weight bearing right leg and soft cast. 2) Incident report dated 04/15/2021 showed that on 04/15/2021 at 6:00 PM, staff found Resident 38 sliding off the bed and staff gently guided the resident onto the floor without injury. Resident 38 stated she was transferring self to the wheelchair but was not used to the soft cast. A fitting nonskid sock was placed on top of the cast to prevent the resident from sliding. The resident was reminded to use the call light, encouraged not to sit at the edge of bed, and to use wheelchair. 3) Incident report dated 04/17/2021, showed that on 04/17/2021 at 5:30 PM, Resident 38 had slid off the bed and was found sitting on the floor with the resident's back against the bed, and had on non-skid socks. Resident 38 stated that the resident slid off the bed and ended up on the floor sitting on the resident's bottom. Interventions included non-slip strips/tape on the floor to the right side of the bed, and after orthopedic office visit on 04/19/2021 Resident 38 was cleared for weight bearing as tolerated (WBAT) to the right foot with orthopedic hard soled shoe. 4) Incident report dated 05/12/2021 showed that Resident 38 had a witnessed fall on 05/11/2021 at 11:30 AM, while walking around the foot of the bed with no nonskid sock or orthopedic hard soled shoe or the use of a walker. Resident 38 stated the resident's pain had improved and thought could walk without the walker and the hard shoe. 5) Incident report dated 05/15/2021 showed that on 05/15/2021 at 6:30 PM Resident 38 was found sitting on the floor. Resident 38 stated that while walking without using a walker the resident had lost balance, fell , and hit head on the floor. Attached staff witness statements did not show if or what type of footwear the resident had on when found on the floor. It further showed that Resident 38 had stated was wearing footwear; however, did not indicate what type of footwear. 6) Incident report dated 06/10/2021 showed that on 06/10/2021 at 12:30 AM, Resident 38's roommate reported that Resident 38 had fallen, and Resident 38 was found by a nursing assistant sitting on the floor. Upon a licensed nurse assessment, Resident 38 was found with a skin tear and a scratch on the lateral right thigh, four centimeters (cm) apart. This incident report did not address if the orthopedic hard soled shoe to the right foot was in place or not at the time of the fall. 7) Incident report dated 06/26/2021 showed that on 06/26/2021 at 12:40 PM, Resident 38 was found sitting on buttocks on the floor with knees bent between the sink and the bathroom door, front wheel walker (FWW, a device used to help walk) noted at the bedside, call light not on, and resident was wearing shoes. Resident 38 stated that the resident had forgotten to use the walker. This incident report showed that Resident 38 was non-compliant with fall interventions; however, it did not specify which interventions and did not show what type of shoes resident had on at the time of the fall (did not address orthopedic hard soled shoe to the right foot). 8) Incident report dated 07/17/2021 showed that on 07/17/2021 at 5:30 AM, Resident 38 was found sitting on the floor between the toilet and the sink, right elbow was bleeding slightly, was fully dressed, dry and had on furry slippers. Resident 38 stated that the resident's legs got weak and fell . The fall resulted in a skin tear to the right elbow. This incident report did not address that the resident did not have on an orthopedic hard soled shoe to the right foot. 9) Incident report dated 08/18/2021 showed that on 08/18/2021 at 11:30 PM, Resident 38 was found on the floor and had sustained three superficial skin injuries that were treated. Resident 38 stated that the resident was sitting on the edge of the bed and fell , got self-up and was wearing nonskid footwear. The staff witness statement dated 08/18/2021 did not address what type of or if any footwear was observed on Resident 38 at the time of the fall. This incident report did not address if the orthopedic hard soled shoe to the right foot was in place or not at the time of the fall. 10) Incident report dated 08/23/2021 showed that on 08/23/2021 at 11:30 PM, Resident 38 was found holding the lower board of roommate's bed while kneeling on right knee trying to get up from the floor and complained of right knee and great toe pain after a while. On 08/24/2021 an x-ray was obtained and showed Recent, broken bones of the second through the fifth toes on the right foot and noted to be subacute (an injury moves into the subacute phase several days after it occurred and first sought treatment. It usually begins four days or so after the event and can last up to three months. It is an intermediary phase between acute injury and chronic injury). This incident report did not address if the orthopedic hard soled shoe to the right foot was in place at the time of the fall. During an interview on 08/26/2021 at 12:47 PM, Staff K, Director of Rehabilitation (DOR), stated that Resident 38 had received therapy in April 2021 for a broken foot. When asked about Resident 38's care plan intervention dated 04/19/2021 that showed to use an orthopedic shoe and if Staff K, DOR, could explain what the shoe was used for, Staff K, DOR, stated that the shoe was to immobilize the foot and ankle which allowed Resident 38 to walk, put weight on the foot while protecting the bones in the foot and ankle which provided support and protection. When asked what could happen if Resident 38 were to walk without the orthopedic shoe, Staff K, DOR, stated that it would put the resident at risk for reinjury and that the doctor ordered the orthopedic shoe for a reason and if the resident were to refuse to wear it then the doctor needed to be notified. During an interview on 08/26/2021 at 1:38 PM, Staff H, Nursing Assistant (NA), stated that she had provided care to Resident 38 for quite some time and had worked at the facility for three years. Staff H, NA, stated that Resident 38 used a front wheel walker and was encouraged to wear slippers or non-skid socks because the resident has had falls because of not wearing the proper footwear. When asked if Resident 38 had ever worn a boot or orthopedic shoe, Staff H, NA, stated I don't think so. During an interview on 08/26/2021 at 1:48 PM, when asked if Resident 38 was to wear an orthopedic shoe, Staff J, NA, stated he was not aware of it but the resident had worn normal shoes. Staff J, NA, further stated that there was a time when Resident 38 had a fractured lower leg and wore an orthopedic shoe for about a month and could not recall which month; however, he had not seen the resident wear it since. During an interview on 08/26/2021 at 2:23 PM, Staff D, Licensed Practical Nurse/Unit Manager (LPN/UM), stated that Resident 38's care plan showed that as of 04/19/2021 the resident was to wear an orthopedic shoe to the right foot. In addition, Staff D, LPN/UM, stated that Resident 38's orthopedic shoe was to give a good grip and stability when walking. When asked if Resident 38 walking without the orthopedic shoe would increase the risk for falls, Staff D, LPN/UM, stated, Yes. During an interview on 08/27/2021 at 12:06 PM, Staff D, LPN/UM, stated that Resident 38's room had been checked and the orthopedic shoe for the right foot was not found, and was not sure how long the shoe had been missing. During an interview on 08/27/2021 at 12:14 PM, Staff B, Director of Nursing Services (DNS), stated that she was not aware that Resident 38's orthopedic shoe had not been worn during the survey period from 08/12/2021 to current time nor that Resident 38's orthopedic shoe was not available to wear at this time. When asked if the orthopedic shoe should have been addressed during fall investigations as a potential risk when not worn, Staff B, DNS, stated, Yes, it should have been. During an interview on 08/27/2021 at 12:48 PM, when asked if the care plan that showed to have orthopedic shoe to Resident 38's right foot and incident report investigations related to multiple falls should have addressed the use of the orthopedic shoe in the investigations, Staff A, Administrator, stated, We certainly should have looked at the use of the post op [operation] shoe and the root cause of why [Resident 38] was not wearing the shoe. RESIDENT 443 Review of Resident 443's electronic health record [EHR] on 08/12/2021 showed that the resident admitted to the facility on [DATE]. Further review of the EHR showed that Resident 443 was placed in room 411 located at the far end of the 400 Hall from the nurse's station. Resident 443 was placed on quarantine as the resident was a new admit who had not been fully vaccinated against COVID-19 at the time of admission. This required staff to keep the resident's door closed except for entering and exiting for the provision of care, and that Resident 443 was expected to always remain in their room for the duration of quarantine. Review of a progress note dated 08/03/2021 showed that Resident 443 had gone to the emergency roiagnom on [DATE] related to increased weakness with frequent falls and confusion. Review of a Admissions assessment dated [DATE] showed that Resident 443 had a history of falls, and identified Resident 443's [CONDITION(S)] (chronic obstructive pulmonary disease, a respiratory disease) diagnosis, use of opioids and medicines that lower blood pressure as risk factors for falls. Review of Resident 443's 08/08/2021 Admissions MDS stated that Resident 443 had a history of falls. Review of a facility fall investigation for a fall on 08/08/2021 at 2:30 PM, showed that Resident 443 was found on the floor of the resident's room, having had an unwitnessed fall walking to bathroom unassisted without deploying the call light. Resident 443 lost balance [,] fell on to rt [right] hip, bumped back of head . Paramedics were called due to concerns for right hip and leg discomfort. Resident 443 was sent to the emergency room and remained at the hospital for treatment. Review of Resident 443's EHR on 08/16/2021 showed that Resident 443 readmitted to the facility on [DATE] with a diagnosis of a displaced intertrochanteric fracture of the right femur (a fracture to the top of the right femur that effects hip function) because of the fall on 08/08/2021. Resident 443 was again placed in Room 411 at the end of the 400 Hall. Resident 443 remained on transmission-based precautions (TBP) from readmission on 08/11/2021 until 08/25/2021. Review of the facility's fall investigation for a fall on 08/21/2021 at 10:30 PM showed that Resident 443 experienced a second unwitnessed fall in the facility. According to the investigation, Resident 443 was found on the floor by their bed with the call light activated. Resident 443 informed staff that the resident had bumped head. Review of Resident 443's care plan showed a focus area for At Risk For Falls ., last revised on 08/29/2021, showed that the facility identified the following interventions to prevent falls: encourage to transfer and change positions slowly, initiated 08/04/2021; have commonly used articles within easy reach, initiated 08/04/2021; provide assistance to transfer and ambulate as needed, initiated 08/04/2021; reinforce need to call for assistance, initiated 08/04/2021; and therapy evaluation and treatment per orders, initiated 08/04/2021. During an interview on 08/27/2021 at 1:41 PM, Staff B, DNS, stated that for a resident assessed as a fall risk upon admission, basic interventions should be put in place, and identified non-skid socks and placing the resident in a room close to the nurse station for supervision, as examples. Staff B, DNS, identified medical conditions and a history of falls as factors that would place a resident at risk for falls. Staff B, DNS, stated that non-skid socks were not included as a fall intervention on Resident 443's Care Plan, that no new interventions were added to Resident 443's At Risk For Falls focus area after Resident 443's 008/8/2021 fall, and that Resident 443 was moved to room 418 after the resident's 08/21/2021 fall in order to be closer to the nurse station for supervision. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to ensure staff provided care and services that were necessary to avoid physical harm to residents due to a cumulative effect of multiple individual failures that led to an environment that promoted neglect. Care was not provided as outlined in the plan of care or as directed by the physician's orders [REDACTED].#s 10, 11 & 12) for allegations of care concerns. These failures resulted in harm for Resident #10 and #12. Resident #10 developed a pressure injury and was hospitalized with low blood sugar and Resident #12 was hospitalized with fluid overload. Findings include . RESIDENT #10 - SKIN MONITORING Resident #10 admitted to the facility on [DATE]. In an interview on 12/12/19 at 12:40 PM, Resident #10 stated she had a concern about the wound she had developed on buttocks. Resident #10 stated the wound was painful. Review of Resident #10's admission skin assessment dated [DATE] showed her skin had a blanchable (when the skin is discolored, and lightens in color when pressure is applied, but immediately returns to pink in color when pressure is removed, indicating the area has good blood flow) on her coccyx (the area of skin which covers the tailbone). The assessment did not indicate how large the blanchable area was. The skin assessment did not show documentation of a pressure injury. Review of Resident #10's medical record showed nursing progress notes dated 11/14/19 which indicated the resident had a blanchable area on her coccyx. A nursing progress note dated 11/15/19 documented the area over the coccyx was an open area, indicating the blanchable area had turned into an open wound. Further review of Resident #10's medical record showed the next progress note related to the wound was dated 11/22/19, a week later, which stated wound care had been done. Resident #10's medical record showed the next skin assessment was dated 11/25/19, which indicated the open wound on her coccyx was now 3cm (centimeters) long, by 1 cm wide, and 0.2 cm deep, and was identified as being a Stage 3 (wound that is open through the entire thickness of the skin and into the tissue under the skin) pressure injury. In an interview on 12/16/19 at 11:00 AM, Staff B, Director of Nursing, DNS, stated the blanchable area identified at the time Resident #10 admitted should have been measured at the time it was identified. Staff B, DNS, also stated the wound should have again been measured at the time it was identified as being open. In addition to being measured, Staff B, DNS, stated the wound should have been described as far as appearance, drainage and depth. Review of the admission Minimum Data Set (MDS - an assessment tool used to plan care) dated 11/18/19 showed Resident #10 was assessed as having a stage 3 pressure ulcer present at the time she admitted . In an interview on 12/16/19 at 9:00 AM, Staff M, MDS Nurse, MDS, stated it was not clear when reading the chart if the wound was present when the resident was admitted . In an interview on 12/16/19 at 11:00 AM, Staff B, DNS, stated an area of blanchable redness should not be coded on the MDS as being a pressure ulcer. During the same interview Staff B, DNS was asked if she had completed an investigation to identify the potential cause of what contributed to the blanchable area progressing to a stage 3 pressure injury. Staff B, DNS, stated she had completed an investigation at the time the pressure injury was identified and reported to her. During an interview on 12/16/19 at 11:38 AM, Staff B, DNS, provided an investigation which indicated the pressure injury was identified on 11/25/19, although the nursing progress notes indicated the stage 3 pressure area was noted on 11/18/19, a week before. Additionally, the investigation provided by Staff B, DNS, included a section indicating that she had completed the investigation and a section titled Date/time created. The investigation was time stamped as being created 12/16/19 at 11:12 AM, the same day it was requested, and more than a month after the pressure injury had developed. The investigation was not completed timely and did not identify if the pressure injury was avoidable or unavoidable. Failure to timely complete the investigation placed Resident #10 at risk for staff not identifying potential causes and a delay in implementing new interventions to prevent the wound from worsening. RESIDENT #10 - INSULIN ADMINISTRATION Resident #10 was admitted to the facility on [DATE]. Review of Resident #10's medical record showed physician's orders [REDACTED]. 1. [MEDICATION NAME] (short acting insulin that works fast, but only lasts 2-4 hours) to be injected at 7:00 AM, 11:00 AM, and 4:00 PM. The order for [MEDICATION NAME] states to give 15 units of insulin if blood sugar is 0-120, and to give 20 units if blood sugar is 121-170. The order also stated to notify the physician if her blood sugar was less than 60. 2. Basaglar (a long acting insulin that works evenly in the body over 24 hours) to have 25 units each night at 8:00 PM. There was no directives for staff to check the resident's blood sugar prior to administering the medication. In an interview on 12/12/19 at 12:40 PM, Resident #10 stated that prior to coming to the facility she always checked her blood sugar and only took insulin if her blood sugar was over 150. Resident #10 stated she does not always eat at night and her blood sugar drops during the night so her sugar levels become too low if she takes insulin when her sugar is not at least 150. Observations on 12/12/19 at 12:10 PM showed Resident #10 in bed, staff came into her room and placed her lunch tray on the bedside table and exited the room. Due to Resident #10's size and her injury, she is not able to sit straight up in bed. Resident #10 was not able to reach her lunch tray from her position in bed, and was not able to reposition enough to reach the tray. Resident #10 stated she can only reach her trays if she in her wheelchair where she can be straight up. Resident #10 stated not being able to reach her food has affected her blood sugars as she should eat after receiving her insulin. Review of Resident #10's Medication Administration Record (MAR) for Novermber 2019 showed on 11/26/19 at 7:00 AM, Resident #10's blood sugar was 59, significantly lower than normal. The nurse documented giving Resident #10 15 units of [MEDICATION NAME]at 7:00 AM. There was no documentation to show the nurse had notified the physician of the low blood sugar as directed in the physician's orders [REDACTED].>The MAR showed the same day 11/26/19 a 4:00 PM Resident #10's blood sugar was 44. Again the nurse documented giving 15 units of insulin but did not document notifying the physician. During an interview on 12/16/19 at 11:45 AM, Staff B, DNS, reviewed the MAR and the nursing progress notes and stated the nurses should have notified the physician prior to administering the medication, but the record did not show that they had on either occasion. Further review of the November 2019 MAR showed the long acting insulin ordered to be given at 8:00 PM did not include directives to check the resident's blood sugar prior to administering the medication. In an interview on 12/16/19 at 11:45 AM, Staff B, DNS, stated that the nursing staff did not need to check Resident #10's blood sugar because it was not included in the physician's orders [REDACTED]. Staff B, DNS, again stated the nurse was not required to recheck the blood sugar as it was not included in the order. Staff B, DNS, was then asked if in her professional nursing judgement, a nurse should know when a resident is not safe to administer a medication to. Staff B, DNS, then agreed that a nurse should use professional judgement prior to administering medication. Further review of Resident #10's November MAR showed on 11/27/19 at 4:00 PM, her blood sugar was 140. The nurse documented administering 20 units of fast acting insulin, even though the resident had stated she did not like to take insulin in the evenings if blood sugar is less than 150. Four hours later, at 8:00 PM, nursing staff documented administering 25 units of long acting insulin without check the resident's blood sugar. Review of the nursing progress notes showed a note dated 11/28/19 at 1:10 AM, that stated Resident #10 was found nonresponsive, diaphoretic, cool to the touch at 11:00 PM, three hours after giving the insulin. The nursing progress note stated Resident #10's blood sugar was 36, critically low. The nursing staff called 911 and Resident #10 was transported to the emergency room and admitted to the hospital. RESIDENT #11 - FALLS Review of Resident #11's medical record showed the following nursing progress notes; 11/30/19 at 11:00 AM- Resident on alert for a fall during day shift. 11/29/19 at 9:26 AM- Resident had a fall from his wheelchair on 11/29/19 while trying to get to his closet. 11/29/19 at 2:17 AM- Resident had a non-injury fall on 11/26/19. Review of the facility's incident log showed Resident #11 had a fall on 11/27/19. In an interview on 12/16/19 at 11:00 AM, Staff B, DNS, reviewed the notes and stated she was only aware of Resident #11 having one fall, on 11/27/19. Staff B, DNS, stated she believed the three other documented falls, 11/26/19, 11/29/19 and 11/30/19 must have been documented in error. Inaccurate documentation placed Resident #11 at potential risk for further falls/injury related to not investigating for the cause of falls if they happened, or placed staff at risk for having an inaccurate picture of the resident's history when developing a plan of care. RESIDENT #12 - TRANSPORTATION In an interview on 12/11/19 at 8:45 AM, Staff from an outside medical provider stated Resident #12 routinely visits the medical office she works in and is usually is not accompanied by an escort. The staff member reported recently Resident #12 had an appointment that was from 3:30 PM to 3:52 PM, however the transportation company was not scheduled to pick her up until 5:09 PM, and the office was scheduled to close at 4:00PM. Additionally, the office staff member reported Resident #12 attempted to take herself to the bathroom and had started to fall from her wheelchair. Resident #12 was in the bathroom banging on the wall to get assistance from staff before she had completely fallen to the floor. In an interview on 12/11/19 at 8:40 AM, Staff N, Appointment Scheduler, AS, stated she does no schedule an escort to accompany Resident #12 to outside appointments because the resident stated she can do it by herself and the physicians can provide all care while the resident is seated in her wheelchair. In an interview on 12/16/19 at 3:30 PM shuttle service stated they provide transportation for Resident #12 to and from the facility to her medical appointments. The shuttle service staff stated they do not escort the resident to the medical office, the just drop off and pick up at the designated location. Review of Resident #12's medical showed a neurological care plan dated 09/13/19 indicating she had a [DIAGNOSES REDACTED]. Further review of Resident #12's care plan showed an activities section dated 09/12/19 which described the resident as being legally blind with poor safety awareness and has a [MEDICAL CONDITION] disorder. Review of Resident #12's Minimum Data Set (MDS an assessment tool used to plan resident care) dated 12/17/19 showed Resident #12 relies on a wheelchair for locomotion. The MDS showed Resident #12 requires extensive assistance from 2 people for transferring and toileting, and extensive assistance from one person with locomotion of her wheelchair. Review of Resident #12's care plan for respiratory impairment dated 09/13/19 showed due to her [MEDICAL CONDITION], Resident #12 easily becomes short of breath. Interventions listed included directives for staff to provide assistance with activities of daily living in order to conserve energy. Additionally, Resident #12's care plan included directives for the resident to be assisted with toileting every two hours. Resident #12's chart indicated she was dependent on staff for locomotion, and toileting, had a history of [REDACTED]. RESIDENT #12 - WEIGHT MONITORING Resident #12 was no longer in the facility, and had been admitted to the hospital. Review of Resident #12's record showed she was seen by the cardiac specialist on 10/14/19. Paperwork sent back to the facility included directions for staff to monitor for weight changes of more than 2 pounds in a day or 5 pounds in a week. Additionally, the paperwork directed staff to increase the dose of diuretic medication if the resident did have weight gain. Review of Resident #12's medical record showed a physician's orders [REDACTED]. The order did not specify any further directions of what weight fluctuations needed to be reported to the physician. The order did not contain the directions to increase the dose of diuretic medication when the resident did have weight gain. Review of Resident #12's care plan dated 09/19/19 showed interventions for staff including Review weights and notify physician and responsible party of significant weight change. Review of Resident #12 weight history showed when the new order for daily was entered on 10/16/19, the weight was not checked until 10/18/19, and the next weight after that was done 10/27/19, more than a week later. Review of weights between the order date of 10/16/19 and the last recorded weight dated 12/7/19 showed nine different occasions when Resident #12 had a significant change in weight. The weight changes varied in amount from 2 pounds to over 13 pounds. There was no documentation to evidence the physician had been notified of the weight changes. During an interview on 12/16/19 at 11:00 AM, Staff B, DNS, reviewed the weights and the nursing progress notes and stated the physician should have been notified, and had not been as. Staff B, DNS, stated the staff did not follow the recommendations of the cardiac specialist when they entered the new order and did not notify the physician as directed. Failure to notify the physician of significant weight gain for a resident with [MEDICAL CONDITION] placed the resident at risk for fluid overload and a delay in treatment, therefore resulting worsening symptoms of heart failure, such as shortness of breath, decreased oxygen, and confusion. WAC Reference 388-97-0640(1).

Based on observation, interview and record review the facility failed to ensure resident environment remained as free of accident hazards as possible and failed to provide adequate supervision for Resident #1. The failure to provide adequate supervision resulted in resident sustaining a chemical burn injury, an avoidable accident. Findings include RESIDENT #1 Resident #1 had [DIAGNOSES REDACTED]. According to the same ED notes, Resident #1 was evaluated on 10/31/19 and was diagnosed with [REDACTED]. Observations on 12/12/19 at 8:07 AM revealed Resident #1 had a dressing to the right hand. Resident #1 was not interviewable due to cognition. On 12/11/19 at 07:31 AM, during an interview Staff F, Housekeeper reported on 10/31/19 she witnessed Staff H, Maintenance Director, pour an abrasive toxic chemical into a clogged sink which was filled with water. The staff witnessed the employee leave the resident room, with the sink still full of water and the chemical and without ensuring the chemical enzymes drained fully. The Staff F, Housekeeper, also saw a bottle of the chemical left in the trash within resident's room. Staff F, Housekeeper, stated at the end of the shift that she tried using a plunger to unclog the drain, but she was unsuccessful and the water splashed burning her arms. During the same interview Staff F, Housekeeper, reported the next day she saw a fork inside resident room sink, which was still full of liquid. Staff F, Housekeeper, reported that resident had a habit of hand washing dishes and clothing within the sink based on prior life experience. The facility's original investigation dated 10/31/19 concluded this was unexpected, unintentional event . and unintentional accident. The facility showed serious disregard of resident safety by not protecting the resident from an avoidable accident. WAC Reference 388-97-1060(3)(g)

Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 3 Residents ( #1 & 7 ) received care in accordance with professional standards related to pressure injury prevention from medical devices (indwelling urinary catheters.) This failure placed Resident #7 at risk for harm and resulted in repeat physical harm to Resident #1 when he developed penile and urethral damage from pressure of a medical device. Additionally, Resident #1 sustained psychological harm based on a reasonable person concept. Review of National Pressure Ulcer Advisory Panel, pressure ulcers that reach full thickness, are considered never events; that is they should never happen. Lippincott Nursing Procedures, 8th edition, includes the following about caring for indwelling catheters:: -Inspect peri-urethral area for signs of inflammation and infection, make sure catheter is properly secured. -Assess the securement device daily and change it when clinically indicated. (The rationale is to prevent tension/pressure from the tubing which could injure the urethra.) - Document patient teaching and the patient's comprehension of your teaching RESIDENT #1 Resident #1 admitted on [DATE], according to the hospital discharge orders. The Admission/Readmission Screen assessment dated [DATE], identified Resident #1 admitted with an indwelling urinary catheter. The same assessment showed Resident #1 did not have any open wounds or pressure injuries. On 03/06/19 Physician Notes, showed Resident #1 had blood around urethral meatus surrounding the catheter. The physician made a recommendation for a wound team evaluation of a penile lesion. On 03/14/19 the wound team assessment documented Resident #1 had a pressure ulcer underneath the tip of his penis that was a full length, indicating the open wound extended from the tip of his penis, and down the length of the shaft. On 3/28/19 wound team notes showed the penis pressure injury had resolved, meaning it was now healed and closed. Review of Resident #1's record showed the (MONTH) 2019 and (MONTH) 2019 Treatment Administration Record (TAR) showed staff were doing body audits (head to toe skin assessments) weekly. Additionally, the (MONTH) and (MONTH) 2019 TARs showed staff were monitoring Resident #1's urinary catheter each shift from 04/17/19 to current review. Teh TARs did not include providing care to the catheter, just monitor the catheter. On 05/22/19 at 1:32 PM, Resident #1 was observed in bed. Resident had an indwelling catheter which was not secured or anchored. The catheter was pulling at the insertion site of the penis creating tension and/or pressure. Staff F, Nursing Assistant and Staff H, Licensed Nurse were present during the observations. When Staff F lifted resident's penis, it appeared disfigured. There was an irregularly shaped penile split (full thickness erosion) through the head of the penis down to the shaft. Resident grimaced from pain and said ouch . ouch. Resident #1 said he was afraid he might lose his sex life. Staff H, LN, on 5/22/19 at 1:35 PM said that he did not know about Resident's skin problem ( penile erosion/ pressure injury.) In an interview on 05/22/19 at 4:05 PM, Staff J, Registered Nurse, RN, stated the wound on Resident #1's penis should be monitored either on the skin sheets, or in the United Wound team notes. Staff J, RN, reviewed skin notes and stated she was not able to locate notes related to the wound. Record review showed on 5/22/19 at 3:51 PM, a physician's orders [REDACTED]. The order instructed staff to ensure catheter leg strap was in place and properly secured. Review of a physician's note dated 05/20/19 showed the physican described the wound extended from the glans down to the shaft of the penis, and was full thickness (extended through all layers of skin and the tissue under it, to the urethra). The physician documented Resident #1 was in need of an emergency consult to urology. Review of treatment records between 3/01/19 and 5/22/19 there was no documentation or evidence showing staff had used a device to secure the catheter tubing in order to prevent it from pulling on the tip of the penis. Additionally, if an anchor device had been used there was no documenation to indicate if nursing staff had assessed the effectiveness of the device or assessed the resident's compliance with using the device. Physician notes dated 5/20/19, showed Resident #1 had full thickness penile erosion in the glans down to the shaft through head of the penis related to chronic catheter use. In an interview on 05/22/19, Staff H, LN, confirmed the pressure injury observed on Resident #1's penis is the wound referred to in the 05/20/19 physician's note. Interview with Staff B, Director of Nursing (DNS) on 5/22/19 at 3:57 PM, said the investigation was not started when penile injury was identified on 5/20/19. Resident #1 developed a full thickness pressure injury extending the majority of the length of his penis related to the use of a urinary catheter. After the catheter was removed and the wound was healed, another catheter was placed. Resident #1 again developed a pressure injury, extending down his penis, in the same spot. Observations showed the facility staff were not implementing any measures such as an anchor for the tubing to prevent pulling, to prevent the second wound from developing, and did not implement measures to prevent the wound from worsening once it developed. RESIDENT #7 Observation on 5/22/19 at 1:42 PM, revealed Resident #7 in bed with eyes closed. Resident had a indwelling urinary catheter. The catheter was not secured or anchored and was pulling at the site of insertion. In an interview on 5/22/19 at 3:27 PM Staff B, DNS said that straps should be used to secure catheter to the leg. Staff B confirmed the staff were not implementing prevention measures to prevent a pressure injury from forming on the resident's penis where the catheter was pulling against the skin of the glans. Refer to F610 for failure to conduct a thorough investigation to determine whether the pressure ulcer was avoidable or unavoidable and to rule out neglect for Resident #1.

Based on interview and record review, the facility failed to ensure freedom from a significant [MEDICATION NAME]-related medication error for one of two residents (Resident #267) reviewed for anticoagulant use and hospitalization . This failure resulted in harm to the resident, as evidenced by abnormal laboratory results, internal bleeding and the need for hospitalization . Findings included . According to Lippincott Manual of Nursing Practice, Eighth Ed., 2006, [MEDICATION NAME] is an anticoagulant (blood thinning) medication that can be used to disrupt the blood's natural clotting function, when there is a risk of blood clots forming. Such a risk is present with a [DIAGNOSES REDACTED]. International normalized ratio (INR) is a coagulation test used to monitor the anti-coagulation effect of [MEDICATION NAME]. The higher the INR, the longer it takes the blood to clot, or the 'thinner' the blood. Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 02/26/19, showed that Resident #267 admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS further showed that Resident #267 was alert and was able to make his needs known. Review of a progress note dated 02/22/19 showed that Resident #267's [MEDICATION NAME] dose was increased and there were physician orders [REDACTED]. Review of a progress note dated 02/28/19, showed that Resident #267's INR was critically high at 5.8, and that the physician gave orders to hold the [MEDICATION NAME] for two days and recheck the INR on 03/02/19. Review of the (MONTH) and March, 2019, Medication Administration Records (MARs) showed that Resident #267 continued to receive his dose of [MEDICATION NAME] on 02/28/19 and 03/01/19. Review of a progress note dated 03/02/19 showed that Resident #267's INR had risen to 7.3, and that the physician gave orders to administer Vitamin K (a medication that counteracts the effects of [MEDICATION NAME]) and recheck his INR on 03/04/19. Review of a progress note dated 03/04/19 showed that Resident #267's INR had dropped to 1.2, and that the physician gave orders to restart [MEDICATION NAME] dosing. Review of the progress notes dated 03/05/19 showed that Resident #267 did test positive for blood in his stool. In addition, other laboratory results for the resident showed critically low values, indicating that he was anemic. The physician ordered the resident to be transferred to an acute care hospital for GI bleeding. During an interview on 03/05/19 at 11:07 AM, Resident #267 stated that he took [MEDICATION NAME] for his a-fib, and that a couple of nights ago his INR had been high. He went on to report a concern that he may have had blood in his stool, which the facility was in the process of determining, and that it may have been related to his high INR. During an interview on 03/08/19 at 10:18 AM, Staff B, Director of Nursing Services, stated that Resident #267 should not have been given [MEDICATION NAME] on 02/28/19 and 03/01/19, in accordance with the physician's orders [REDACTED].#267's GI bleed and hospitalization . WAC reference 388-97-1060 (3) (k) (iii)

Based on observation, interview and record review the facility failed to organize discharge medications, treatments and transportation for two of four residents (Resident #s 2 and 4) reviewed for discharge practices. This failure placed residents at potential risk for complications with medications and/or treatments and potential re-admission. This failure resulted in Resident #2 missing scheduled [MEDICAL TREATMENT] procedures, which led to her having fluid overload, and eventually being hospitalized for [REDACTED]. Findings included . Refer to F580 for failure to notify phsyician of change in discharge location for Resident #2. Refer to F 658 for failure to obtain current medication orders and clarifying oxygen orders for Resident #2. RESIDENT #2 Resident #2 discharged from the facility on 01/31/19. Resident #2's medical record showed she had [DIAGNOSES REDACTED]. In an interview on 02/21/19 at 12:25 PM, Staff L, Registered Nurse, RN, stated Resident #2 was mainly in the facility to manage her electrolytes due to her kidney disease. Staff L, RN, stated [MEDICAL TREATMENT] treatments were imperative to Resident #2's care due to her kidney disease. DISCHARGE ON 1/31/19 In an interview on 2/15/19 at 1:00 PM, at the hospital, Resident #2, stated on 1/31/19 she was smoking on the sidewalk in front of the facility when she was approached by the Director of Nursing. Resident #2 stated she was told she was being kicked out that day due to not following the smoking policy. Resident #2 stated the facility staff kept her smoking materials locked up, but gave them to her on the days she went to [MEDICAL TREATMENT] so that she could smoke while out of the facility. Resident #2 stated she had always smoked in that area in front of the facility, however, when the new administrator started there, he would no longer allow her to smoke there. In an interview on 2/21/19 at 1:00 PM, Staff B, Director of Nursing Services, DNS, stated the resident had been following the smoking policy but had smpoked outside the facility two seperate times earlier that week, and the policy is that the third time the resident would be given a 30 day notice. Review of the Resident #2's medical record showed a 30 day notice dated 1/31/19, however it was not signed by the resident or her family. According to the discharge notice, the resident was to be transferred to a homeless shelter (Nativity House) on (MONTH) 2, 2019. Soon after, the resident was required by facility staff to give them her cigarettes and cigarette lighter. At this point, the resident decided to leave rather than give these items to the facility. The facility immediately began assisting the resident with the discharge process. In an interview on 2/14/19 at 2:14 PM, Staff E, Social Services, SS, stated when they decided to discharge Resident #2 to a homeless shelter he had made several phone calls to the shelter but never actually spoke to anybody prior to the resident leaving the facility on her way to the shelter. A call placed to the homeless shelter on 02/14/19 at 12:05 PM, showed the phone is not answered but goes directly to message. The message states that there is currently a waiting list to get a bed at the shelter and any person who wants a bed must come to the shelter in person and add their name to the waiting list. The message indicated anybody can visit the shelter during the day, but everybody who does not have a bed must leave by 4:30 PM for the remainder of the night. In an interview on 2/15/19 at 3:00 PM, Staff H, RN, stated Resident #2 was discharged to the homeless shelter. When she was not able to get a bed at the shelter, her son was directed by social services to pick her up and take her to a specified hotel where the facility said they would pay for two nights stay. When they got to the hotel the room had been reserved but not paid for, so the son was not able to check the resident in. The resident's son then drove her back to the facility where he dropped her off and left. Staff H, RN, stated she called the Director of Nursing Services, DNS, who called the administrator, who then directed staff to send Resident #2 back to the hotel in a cab and the administrator would go to the hotel and pay for the two nights. In an interview on 2/15/19 at 1:00 PM, at the hospital, Resident #2 stated she stayed at the hotel for two nights on 1/31/19 and on 2/1/19. Resident #2 stated on 2/2/19 when she had to check out of the hotel she walked to a second hotel next door because it was the closest place and she did not know what else to do. Resident #2 stated she sat in the lobby all day while the hotel staff attempted to contact a relative who would be willing to help her pay for a room to stay in. Review of Resident #2's medical record showed a progress note dated 1/31/19 at 2:15 PM, which Staff G, Social Services, SS, documented Resident #2 stated she did not want to go to a hotel. In an interview on 2/21/19 at 1:00 PM, Staff B, Director of Nursing Services, DNS, was asked why Resident #2 was sent to a hotel when she specifically stated she did not want to go to a hotel. Staff B, DNS, stated she was not aware the resident had made that statement. In an interview on 2/14/19 at 3:00 PM, Staff C, Licensed Practical Nurse (LPN), , was asked how Resident #2 was supposed to obtain food and drinks while staying in the hotel since she did not have money to pay for a room. Staff C, LPN, stated he did not know how she would get food or beverages. PHYSICIAN'S ORDERS FOR DISCHARGE Review of Resident #2's medical record showed a physician's order signed on 1/31/19 to discharge Resident #2 to the homeless shelter. In an interview on 2/14/19 at 3:00 PM, Staff C, Licensed Practical Nurse (LPN), , stated a physician's order is required to discharge a resident. Staff C, LPN, also stated it the date or the location of the discharge is changed, a new order must be obtained. Staff C, LPN, stated Resident #2 did return to the facility after being discharged to the homeless shelter and it was decided the facility would send her in a cab to a hotel. Staff C, LPN, stated the facility did not receive a new order for the discharge to a hotel. There was no documentation in the record to indicated the physician had been notified of the change in discharge location. TRANSPORTATION Review of Resident #2's record showed she left the facility every Monday, Wednesday and Friday on a shuttle van to go to scheduled kidney [MEDICAL TREATMENT] treatments. Review of a progress note dated 1/31/19 at 2:54 PM, written by social services staff, showed staff contacted the shuttle company and arranged to have Resident #2 picked up at the homeless shelter and be transported to her [MEDICAL TREATMENT] treatments on Mondays, Wednesdays, and Fridays. Further review of the progress notes showed no documentation to indicate the shuttle service was notified after Resident #2 was discharged to a hotel instead of the shelter. Review of Resident #2's discharge instructions showed the contact name and phone number to the shuttle company was not listed. In an interview on 2/21/19 at 3:50 PM, Staff E, SS, stated he thought Resident #2's son would help her get the transportation arranged after he was informed she would need to go to the hotel instead. Staff E, SS, stated after Resident #2's son left the faciity on [DATE] he quit answering his phone so the staff were not able to speak with him to check on Resident #2's status. There was no documentation in Residnet #2's record of social services staff educating Resident #2's son related to her discharge or necessary care needed after discharge. Review of a nursing progress note dated 2/1/19 at 12:52 PM, written by Staff E, SS, showed Staff E, SS, attempted to call Resident #2 but her phone is not active at the moment. There was no evidence Staff E, SS, attempted to call the hotel, or the shuttle to ensure Resident #2 was able to go to her [MEDICAL TREATMENT] treatment. In an interview on 2/18/19 at 1:55 PM, Staff from the [MEDICAL TREATMENT] center confirmed Resident #2 did not show up for her scheduled treatment on 2/1/19. [MEDICAL TREATMENT] center staff stated Resident #2 had a history of [REDACTED]. In an interview on 2/14/19 at 10:15 AM, hotel staff reported Resident #2 was confused and was talking about needing transportation but she was not able to tell them who to contact to help her. Hotel staff also stated Resident #2 was upset because she wanted to call the transportation but her phone battery was dead and she did not have a charger. In an interview on 2/15/19 at 8:49 AM, a caseworker from another state agency, stated she had gone to the second hotel that Resident #2 had stayed in to check on her. The caseworker stated that during the visit she asked Resident #2 to please call her so that the resident's contact number would register on her cell phone. The resident was not able to dial her phone without assistance from the caseworker. The facility failed to arrange the correct pick up locations for Resident #2, and did not ensure she had the contact phone number or a functioning phone to arrange for own transportation. SUPPLIES Review of Resident #2's medications showed a physician's order dated 10/3/18 for [MEDICATION NAME] (a medication used to widen the airway, making it easier to breath) to be given via nebulizer (a machine that turns liquid medication into an aerosol so that it can be breathed into the lungs). Review of Resident #2's transition home discharge instructions on page nine showed a section to list medical equipment that would be needed upon discharge. A nebulizer was listed under equipment. Further review of the discharge paperwork showed no documentation that Resident #2 received a nebulizer, or was given information on how to obtain a nebulizer, or how to use it once obtained. Further review of physician's orders showed an order dated 10/25/18 continuous oxygen at 3 liters via NC (nasal cannula) every shift for [MEDICAL CONDITIONS]. Review of Resident #2's transition home discharge instructions showed no documentation of oxygen use. There was no documentation of how to apply oxygen with tubing, if the resident was given oxygen or tubing, and did not show how to get more oxygen and tubing once the current supply ran out. In an interview on 2/21/19 at 1:00PM, Staff B, DNS, stated she did not know if Resident #2 had a nebulizer or oxygen with her when she left the facility. Staff C, RN, and Staff E, SS, were also asked if Resident #2 was discharged with as supply of oxygen and a nebulizer, however, none of the staff knew if she did receive the supplies at the time of discharge. MEDICATIONS In an interview on 2/15/19 at 3:00 PM, Staff H, RN, stated when Resident #2 discharged on [DATE] she removed all the resident's medications from the medication cart, put them in large envelopes and gave them to the resident. Staff H, RN, stated there were medications that were controlled substances (medications that are stored under a double lock system and routinely accounted for due to being highly addictive) so she told Resident #2 to keep them hidden. Review of the narcotic count log showed Staff H, RN, signed out seven [MEDICATION NAME] pills (a narcotic pain reliever) and 28 [MEDICATION NAME] pills (a sedative) and gave to Resident #2 with a note sent to Nativity House (homeless shelter) with patient. In an interview on 2/21/19 at 12:00 PM, Staff K, Licensed Practical Nurse, LPN, reviewed Resident #2's record and stated at the time she discharged from the facility, Resident #2 did not have current orders to take [MEDICATION NAME] or [MEDICATION NAME], and therefore, they should not have been given to her to take out of the facility. In an interview on 2/14/19 at 3:00PM, Staff C, Licensed Practical Nurse (LPN), , stated Resident #2 had a long history of substance abuse, hoarding medications, and pretending to take medications when nursing staff gave them, to her, but was actually hiding them and saving them for later. Review of the facility policy Discharge: Home or Non-non-institutional Setting, dated 12/2009, showed the facility staff should conduct training sessions with regards to treatments and medications to ensure the resident is able to perform these tasks independently. In an interview on 2/14/19 at 3:00PM, Staff C, Licensed Practical Nurse (LPN), , stated Resident #2 did not complete the self-medication training. In an interview on 2/15/19 at 8:49 AM, the case worker from another state agency, stated she went to see Resident #2 at the second hotel she stayed in and Resident #2 was not able to demonstrate how to take her medications, as she was not able to get the pills removed from the individual bubble packaging they had been supplied in. In an interview on 2/18/19 at 1:55 PM, the nurse from the [MEDICAL TREATMENT] center stated when Resident #2 did arrive to the clinic on 2/5/19 her blood pressure was very high, 209/102, requiring additional treatments with medications to lower her blood pressure. The nurse stated in talking with the resident, Resident #2 was more confused than normal, and had not been taking her medications, and did not understand what to do with the medications. [MEDICAL TREATMENT] center staff stated Resident #2 missed her schedule treatment 2/1/19 and again on 2/8/19. On 2/8/19 the staff filed a missing person report with the local police department. In an interview on 2/14/19 at 10:15 AM, staff of the second hotel hotel reported on 2/8/19 the housekeeper found Resident #2 in her room and she was not able to speak, only moaning, so they called emergency services who transported Resident #2 to the hospital. Review of hospital records showed on 2/8/19 Resident #2 arrived in the emergency room with [MEDICAL CONDITIONS] (fluid build-up around the lungs making it difficult to breath) secondary to fluid overload as a result of missing her [MEDICAL TREATMENT] treatments. Records showed Resident #2 had a systemic infection, had low oxygen levels, severely elevated potassium levels. Resident #2 required intubation (a tube placed down the airway in order to breath) and was admitted to the critical care unit. The facility discharged Resident #2 to a hotel without a physician's order. The resident did have a physician's order to have continuous oxygen, but was not sent with oxygen or directions on how to obtain oxygen. The resident was sent to a homeless shelter with two medications, both controlled substances, which she did not have an active physician's order to take. The facility did not have Resident #2 demonstrate that she understood and was able to take her medications independently. The transportation shuttle was arranged by the facility to pick up the resident at the homeless shelter, but the facility sent her to a hotel instead. There was not documentation to indicate the facility attempted to contact the shuttle service to update the resident's location. Review of the resident's discharge instructions showed she was not provided the phone number to contact the shuttle to make arrangements to get her to [MEDICAL TREATMENT] treatments. The discharge instructions were not signed by the resident, and there was no evidence Resident #2 was ever given the written discharge instructions. These factors contributed to Resident #2 not taking her discharge medications, and missing her [MEDICAL TREATMENT] treatments, which led to her being hospitalized . RESIDENT #4 Resident #4 discharged from the facility on 02/08/19. Review of the Transition Home discharge instruction packet showed it was electronically signed by the nurse on 02/08/19, however the section designated for the resident to sign indicating he/she had received a copy of the instructions was blank. In an interview on 02/14/19 at 2:45 PM, Staff C, Licensed Practical Nurse (LPN), confirmed the resident is to sign in the box to indicate the instructions had been given to them and that they understand the discharge instructions. Staff C, LPN, confirmed there was no signature to show Resident #4 had received the instructions. Resident #4's discharge paperwork indicated he needed six different prescription medications at the time of discharge, including two for high blood pressure and one for stroke prevention. Further review of Resident #4's discharge paperwork showed the physician's order for medications to be filled was not faxed to the pharmacy until the following day. The form was date and timed stamped by the fax machine as 02/09/19 at 7:07 AM. In an interview on 02/14/19 at 2:45 PM Staff C, Licensed Practical Nurse (LPN), reported typically medication orders are faxed at the time of discharge. After reviewing the date and time stamp, Staff C, RN, stated he/she was not sure why the medication orders were not sent to the pharmacy until the next day. There was no other documentation in the record to show the medication orders had been sent earlier. Review of discharge paper work showed no meds were sent home with Resident #4 at the time of discharge. In an interview on 02/21/19 at 4:55 PM Staff M, Medical Records, MR, reviewed Resident #4's medical record and confirmed he did not have documentation on medications sent home, and due to the type of medical coverage the resident had the facility would not have sent any of his extra medications home with him. Review of Resident #4's medical record showed no progress notes related to discharge, when he discharged or where he discharged to. The record did not show Resident #4 was given discharge instructions, instructions regarding his medications or if anybody had verified he had his prescribed medications. WAC reference: 388-97-0080

Based on observation, interview and record review, the facility failed to ensure licensed staff provided care and services to maintain gastric (stomach) tube patency and followed safe replacement gastric tube protocols for 2 of 7 Sampled Residents (#s 1 & 3), who were reviewed for gastric (stomach) tube care and services. For Resident #3, staff failed to administer medications individually through a gastric tube. This had the potential to place Resident #3 at risk for adverse medication interactions from mixing multiple medications together prior to administration. For Resident #1, the facility failed to deliver medication through a MIC gastric tube (MIC, type of stomach tube) according to manufacturer's instructions to prevent it from clogging. When the tube clogged with medication, staff placed a temporary urinary Foley catheter into Resident #1's unhealed gastric tube site for three days; used the Foley catheter to infuse formula and medications and failed to conduct consistent thorough assessments and monitoring of resident condition. Following attempts to replace the Foley catheter with a MIC tube, the MIC tube became displaced outside the resident's stomach into the abdominal cavity, resulting in peritonitis [MEDICAL CONDITION] requiring abdominal surgery. The facility failed to self-identify they did not follow safe gastric tube procedures and correct them, which resulted in harm for Resident #1 and Immediate Jeopardy situation. Findings include: On 10/28/16 at 5:40 p.m., the facility provided a list of six residents in the facility who had gastric tubes; Resident #2; Resident #3; Resident #4; Resident #5; Resident #6 and Resident #7. discharged RESIDENT #1 Former Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A provider note dated 10/17/16 identified the resident discharged from the hospital on [DATE] following complications and treatment for [REDACTED]. Cardiac effusion is a medical condition in which blood or fluids fill the space between the sac that surrounds the heart. Pleural effusion is excess fluid that accumulates in the space that surrounds the lungs. A hospital note dated 10/25/16 at 3:02 a.m., identified Resident #1 had a history of [REDACTED].) Hospital notes identified the resident had the gastric tube placed on 9/27/16, approximately 20 days prior to admission to the facility. Resident #1's plan of care for feeding tube, initiated 10/17/16, directed staff to administer tube feeding formula, flushes, provide ostomy (gastric tube entry location) site care, check tube placement and residuals per guidelines or physician order. A Physician Encounter Note written 10/17/16 after Resident #1 admitted to the facility, identified the resident transferred to the facility for skilled rehabilitation, medical monitoring and transition planning. A social service note dated 10/16/16 documented Resident #1 planned to return to the community. A discharge planning note dated 10/24/16 identified the resident had family support and the facility discussed home nursing services and therapies with the resident and family. On 10/24/16, Resident #1 required re-hospitalization for complications related to gastric tube care. During a hospital visit on 11/2/16 at 10:55 a.m., the resident sat up partially elevated in bed using a suction catheter to suction secretions from his mouth. When questioned regarding care received at the facility, Resident #1 stated Stop, Stop, Stop! emphatically. When asked what he wanted stopped, the resident stated I didn't want it and could not respond further to simple questions. GASTRIC TUBE PHYSICIAN ORDERS/ASSESSMENT AND MONITORING Physician orders [REDACTED].#1's gastric tube included the following: - Glucerna formula, continuous at 75 cc per hour starting at 8:00 p.m. until 1500 milliliters (ml, a liquid measurement) infused and to flush with 35 cc (1 cc = 1ml) of water concurrent with the formula. Type of tube was identified as MIC tube (type of gastric tube); size of tube 14 French. The diameter of a feeding tube is measured in French units (each French unit equals 0.33 millimeters). - Check the placement of the gastric tube and residual volume (amount of stomach contents) every shift. (Placement check of the tube verifies it is in the stomach.) - If residual volume is greater than 100 cc prior to feeding, hold and call the provider. - Flush the tube with 30 ml of water before and after medication administration and 5 - 10 ml of water between each medication. On 10/17/16, the physician increased the total amount of tube feeding administered to 1800 ml a day, and increased the amount of water flushed to 40 cc every hour. The time to start the infusion remained at 8:00 p.m. and the rate of the infusion increased to 100 cc/hour until completed. The physician also directed staff to not administer anything by mouth. Oral medications ordered by the physician 10/16/16 and 10/17/17 given through the gastric tube in tablet form included: - Medication to treat low blood pressure given three times a day; - Medication to treat constipation and a diuretic twice a day - Medication to assist with sleep nightly as needed - Medication given once a day to treat gout - Nutritional supplements given once a day - Medication once a day to treat enlarged prostate Physician orders [REDACTED]. (Crushing medications allowed staff to mix them in liquid to administer through the gastric tube into the stomach.) The physician also ordered to flush the gastric tube with 30 ml of water before and after medication administration and 5 - 10 ml of water between each medication. Facility policy and procedure (P&P) titled Enteral Tube; Gastric Tube stated to verify gastric tube placement according to Enteral Tubes; Residual Checks and Irrigations/Flushes procedure. Facility P&P titled Enteral Tubes; Residual Checks and Irrigations/Flushes, identified gastric residual volume checks were done prior to hanging the first tube feeding for the day and before medication administration. The policy stated residual volume should always be interpreted along with a careful history for symptoms of intolerance (bloating, abdominal pain, nausea, vomiting) and a careful bedside exam of physical signs of intolerance. Assessment for signs and symptoms of intolerance of feeding included respiratory distress, abdominal discomfort or distention and constipation. The P&P stated, if symptoms were present, hold feeding and notify physician. Facility P&P titled Enteral Tubes: Medication Administration, directed staff to verify placement of the gastric tube prior to administering medications. Monitoring recommendations included respiratory status and to report increased respiratory rate, wheezing, cyanosis, or potential signs of aspiration such as temperature greater than 100 degrees Fahrenheit and suspected stomach contents in lung secretions. During an interview on 10/31/16 at 3:00 p.m., Staff K reported assessment of residents with a gastric tube included assessing the tube site; checking for residual and listening to the stomach while inserting air into the gastric tube. During interviews on 10/31/16 at 3:25 p.m. with Staff L, and at 3:35 p.m. with Staff M, both reported before they started a tube feeding, they checked placement of the tube by pushing a small amount of air into the tube and listen with a stethoscope, and checked the amount of residual (stomach contents) amount in the stomach before. Staff M stated he/she would listen for bowel tones. During interviews on 11/1/16 at 3:30 p.m., Staff AA reported, he/she would push 10 ml of air into the tube and listen with a stethoscope placed below the sternum and check for residual. Staff U reported, he/she would aspirate for stomach contents and if didn't get any back would insert air into the tube and listen with a stethoscope. Resident #1's October 2016 Medication Record documented staff checked the residual volume of stomach contents at 6:00 a.m.; 2:00 p.m. and 10:00 p.m. The medication record did not contain evidence staff conducted residual checks just prior to 8:00 p.m., when staff documented they began infusion of tube feeding formula. The medication record identified staff continued the tube feeding until 1800 ml infused, but did not identify the time the tube feeding finished. During an interview on 11/3/16 beginning 4:1 p.m., Staff B reported, staff should document the amount of tube feeding infused in progress notes. Staff documented on October 2016's Medication Record they administered medications at 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; 5:00 p.m.; and 8:00 p.m. Medication records documented staff checked placement of the tube every shift at 6:00 a.m.; 2:00 p.m.; and 10:00 p.m., at times that did not coincide with times staff documented they administered medications. Resident #1's progress notes, medication records and interviews with staff, did not contain evidence staff consistently monitored the resident for signs and symptoms of tube feeding intolerance, such as bloating, abdominal pain, distention, nausea, vomiting; respiratory distress and signs of aspiration or temperature. Refer to F 309 for additional information related to inconsistent monitoring of Resident #1 for signs and symptoms of potential complications for a gastric tube and pain. GASTRIC TUBE OCCLUDED BY MEDICATION On 10/17/16, the physician ordered for staff to administer a medication to treat gastric reflux, ([MEDICATION NAME]), into the stomach tube once a day. The order directed to administer a dissolvable form of the medication. Staff D documented in a nursing note on 10/21/16 at 5:17 p.m., Resident #1's gastric tube became plugged and staff could not free clog from tube. During an interview on 11/1/16 at 4:45 p.m., Staff D reported [MEDICATION NAME] came in a packet and looked like little beads. Staff D reported the beads wouldn't crush and let them sit in hot water. Staff D stated he/she hesitated to give it to Resident #1 because it did not dissolve. Staff D reported, the [MEDICATION NAME] did plug the gastric tube and attempts to dislodge it failed. Staff D stated he/she informed Provider F and Staff H, the [MEDICATION NAME] plugged the tube. Manufacturer Instructions for [MEDICATION NAME] delayed-release oral suspension (granules) for gastric tube administration state the following: For patients who have a nasogastric tube or gastrostomy tube in place, [MEDICATION NAME] for Delayed-Release Oral Suspension can be given as follows: · Remove the plunger from the barrel of a 2 ounce (60 ml) catheter-tip syringe. Discard the plunger. · Connect the catheter tip of the syringe to a 16 French (or larger) tube. · Hold the syringe attached to the tubing as high as possible while giving [MEDICATION NAME] for Delayed-Release Oral Suspension to prevent any bending of the tubing. · Empty the contents of the packet into the barrel of the syringe. · Add 10 mL (2 teaspoons) of apple juice and gently tap and/or shake the barrel of the syringe to help rinse the syringe and tube. Repeat at least twice more using the same amount of apple juice (10 ml or 2 teaspoons) each time. No granules should remain in the syringe. Facility P&P titled Enteral Tubes: Medication Administration stated to verify tables/capsules are approved for crushing, as often crushing is contraindicated in medications with [MEDICATION NAME] coating or extended release properties. During an interview on 11/2/16 at 4:15 p.m., Staff H reported, [MEDICATION NAME] should be mixed with water and dissolved and can't be crushed. During an interview on 11/3/16 at 11:52 a.m., Pharmacy Staff O reported, on 10/17/16, the pharmacy dispensed [MEDICATION NAME] granules which could be mixed according to directions. Staff O read aloud manufacturer instructions and stated they directed to mix granules in 10 ml of apple juice. Staff O then mixed the granules in water and reported, the granules did not dissolve and stated they were tiny, tiny and did not clump, and would check with the manufacturer to inquire further about their instructions. Later during interviews on 11/3/16 beginning 4:10 p.m., Staff C reported, Staff D said he/she smashed the [MEDICATION NAME] and mixed it in water. Staff B reported, delayed release medication should not be smashed and mixed in hot water. Staff D did not prepare [MEDICATION NAME] according to manufacturer instructions to not crush and dissolve in apple juice. Resident #1's gastric tube size (14 French) was smaller than the size of gastric tube the manufacturer recommended (16 French or larger). The record did not identify if staff discussed the size of the tube with the physician and pharmacy to determine if the size of the tube affected likelihood of [MEDICATION NAME] to clog the tube. During an interview on 11/3/16 beginning 4:10 p.m., when asked if facility nursing staff were responsible to read manufacturer's instructions regarding medications, Staff C responded, no. Staff C stated the facility relied on the pharmacy to give instructions and they only gave brief directions. GASTRIC TUBE REPLACEMENTS After Resident #1's gastric tube occluded on 10/21/16, Provider F wrote an order on 10/21/16 at 3:37 p.m. The order stated, ok to use 14 French Foley catheter (urinary catheter) for gastric tube until the 14 French (MIC) gastrostomy tube comes in. During an interview on 10/31/16 at 4:10 p.m., Licensed Staff H reported the facility did not have the correct size of gastric (MIC) tube needed to replace Resident #1's tube that clogged, and used the Foley catheter until the correct tube size arrived. A nursing noted written 10/21/16 at 5:17 p.m., documented Staff D replaced Resident #1's (MIC) gastric tube with a Foley catheter after the tube plugged and unable to free clog from tube. The note identified the resident was on alert status for new admit and for gastric tube feeding change and tolerated well with no C/O (complaint of) nausea or vomiting, for pain monitoring with resident C/O pain x 2 (twice) with PRN (as needed) given and appears to be helpful. Staff D's nursing note written 10/21/16 at 5:17 p.m., regarding the gastric tube replacement, did not identify staff conducted a thorough assessment of the resident's condition prior to or following the procedure, such as assessment for respiratory status, vital signs, description of the procedure; how staff confirmed placement of the new Foley catheter or resident response during and after the procedure. The resident's record did not identify the location, description or type of pain the resident had on 10/21/16, and if it was associated with the gastric tube, or another medical condition. After changing the MIC gastric tube with a Foley catheter, medication records identified staff provided tube feedings at 8:00 p.m. every evening and medications multiple times throughout 10/21/16; 10/22/16 and 10/23/16. Resident #1's medical record did not contain evidence staff conducted consistent, thorough assessments of the resident's status or maintained alert charting procedures, to determine if complications occurred and were timely identified. The resident's record identified staff did not document they assessed the resident's condition once on 10/22/16 at 1:24 p.m., the day after they replaced the tube, and once on 10/23/16 at 12:30 p.m. and once 10/24/16 at 8:05 a.m. Resident #1's record did not contain evidence staff consistently conducted monitoring for signs and symptoms of tube feeding intolerance or potential complications prior to tube feedings or before administration of medications through the newly inserted Foley catheter used as a gastric tube. No notes were found to describe how staff secured the Foley catheter to ensure it did not dislodge. During an interview on 11/1/16 at 4:45 p.m., Staff D reported, residents who had gastric tubes replaced, were put on alert charting following the procedure. Facility P&P titled Alert Charting Log, stated its purpose provided guidelines for monitoring documentation that may be needed following a change in condition or status. The policy stated the Alert Charting Log was a tracking and communication system to alert licensed nurses to changes in a resident's condition that warranted continued observation. The policy stated residents were placed on alert charting when they were identified as requiring continued follow up and documentation that may include, but not limited to, patient evaluation findings for a minimum period of 72 hours. The policy did not identify the frequency staff should document the status of resident conditions when on alert charting. On 11/2/16 at 4:15 p.m., Staff H reported alert charting should be done every shift and documented in nursing notes every eight hours. Staff H stated he/she did not know why Resident #1 got dropped from alert charting. Staff H reported charting should include how the resident was assessed, such as amount of residual (stomach) volume; bowel tones; patency of the gastric tube; abdominal distention; pain or discomfort; what sound was heard while listening for air being inserted into the gastric tube (part of gastric tube placement check); how the resident felt throughout the day; chart specifically what happened during procedures and how the resident felt after the procedure. Three days later, on 10/24/16, nursing staff documented they replaced Resident #1's Foley catheter with a MIC gastric tube at 8:00 p.m. The resident's record did not contain evidence staff conducted a thorough assessment of Resident #1 immediately prior to inserting the MIC tube or identify events that occurred after tube insertion. Refer to F 309 for related to failure to conduct thorough assessments and monitoring of Resident #1 for pain and prior to gastric tube procedures. LACK OF AWARENESS OF FACILITY POLICIES AND PROCEDURES Facility policy and procedure (P&P) titled Enteral Tube: Gastric Tube dated 5/2009 stated in the section Purpose: Gastric tubes less than 6 weeks post placement are NOT replaced in the nursing center setting. The tract is immature and the tube is reinserted by a Physician in an acute care setting. The Procedure portion of the P&P for tube insertion stated urinary catheters such as Foleys are not used. Not all staff interviewed regarding their knowledge of policies and procedures for gastric tubes knew where they could locate them. Not all staff knew a recently inserted gastric tube less than six weeks old should not be replaced in the facility and Foley catheters used as a replacement. Facility nursing staff did not know when Resident #1's gastric tube had been initially place. Between 10/21/16 and 10/24/16, seven licensed nurses (Staff D; Staff E; Staff R; Staff T; Staff W; Staff X & Staff Y) performed nursing procedures that included replacing Resident #1's gastric tube which was less than six weeks old, or performed nursing care that included tube feedings and/or medication administration through a Foley catheter tube. No evidence was found facility licensed staff questioned using a Foley catheter violated facility policy and procedure and safe practice. Refer to F 353 for additional interviews and information related to facility failure to ensure licensed staff were qualified to provide care and services related to gastric tubes. GASTRIC TUBE COMPLICATIONS A nursing note documented on 10/24/16 and written at 11:00 p.m., documented when staff replaced Resident #1's Foley catheter placed in the gastric tube site and replaced it with a MIC gastric tube, the resident complained of too much pain even when the balloon was inflated. The note stated the house supervisor checked the resident and requested orders to send the resident to the emergency room and an ambulance picked up the resident around 10:00 p.m. emergency room (ER) encounter notes dated 10/24/16, documented Resident #1 arrived in the emergency room and had dull pain in the left upper and lower abdomen. A CT (specialized x-ray procedure) abdominal scan performed at the hospital identified, the gastrostomy tube was located in the peritoneal cavity (a potential space between the two membranes that separate the organs in the abdominal cavity from the abdominal wall), outside the stomach. The conclusion noted the findings were suggestive of peritonitis. Physician notes documented the physician deflated the tube and removed the gastric tube and provided critical care. ER notes documented, according an ER nurse who called the facility, Resident #1's gastric tube was replaced during the evening at the facility and tube feedings and medications were administered into the tube. ER notes identified Resident #1 had peritonitis [MEDICAL CONDITION] and admitted the resident to the hospital. An operative note dated 10/25/16, documented Resident #1 had an exploratory laparotomy, requiring a midline incision. The surgeon found 850 ml of clear yellow fluid in the peritoneal cavity that was aspirated and irrigated the abdomen with saline. The note identified the resident had a ventilator in place (following surgery) when taken to a surgical unit. During an interview on 11/1/16 at approximately 3:30 p.m., Staff U reported, if a resident complained of pain with a tube feeding, I would stop the tube feeding and assess the resident and call the physician. During an interview with the Medical Director (M.D.) on 11/3/16 at 1:21 p.m., the M.D. reported, he spoke with a specialist who felt complications with the gastric tube probably happened the day Resident #1 was sent to the emergency room . The Medical Director also stated Resident #1's gastric tube site was definitely not mature enough and the site was only about four weeks old. The M.D. reported, if a catheter is used to maintain a tube opening it is in for a few hours and would not leave it in for three days. Later on 11/3/16 at 2:25 p.m., when asked what the rationale was to not keep a Foley catheter in a gastric tube site, the Medical Director reported the material could be irritating to the site and cause problems. It is made from a different substance and can cause inflammation. The M.D. also reported it was likely erosion occurred due to the presence of the Foley catheter. Refer to F 224 and F225 for additional interviews and information regarding facility failure to immediately report, investigate and protect residents and failures that resulted in neglect for Resident #1. FAILURE TO SELF-IDENTIFY FACILITY PRACTICE CONCERNS RELATED TO CARE PROVIDED FOR RESIDENT #1'S GASTRIC TUBE Seven licensed nursing staff were either aware of provider orders to replace Resident #1's MIC gastric tube with a Foley catheter and later replace it with another MIC tube, and/or performed replacement procedures or administered tube feedings and medications through the Foley catheter during a period of four days between 10/21/16 and 10/24/16. Administrative staff were aware the resident's gastric tube was replaced on 10/21/16 and did not identify concerns related to replacing the tube with a Foley catheter. Administrative staff did not identify replacing a gastric tube with a Foley catheter, or replacing a gastric tube that was less than six weeks post placement violated facility P&P guidelines. During an interview on 10/28/16 beginning 5:56 p.m., Staff B reported the 24 hour nursing report reviewed on Monday (10/24/16), identified Resident #1's gastric tube clogged (on 10/21/16) and staff replaced it with a Foley catheter. Staff B stated, replacing the resident's tube did not raise a concern and the nurse followed physician orders. During this interview, Staff B read the facility policy and procedures for gastric tubes and reported, the policy stated, gastric tubes less than six weeks old, were not placed in the nursing home setting. When asked how old Resident #1's gastric tube site was, Staff B stated, not really sure. The facility failed to self-identify a potential for concern associated with insertion and extended use of a Foley catheter in Resident #1's gastric tube site and use it for tube feeding and medication administration. Neither staff or administration self-identified these nursing services provided to Resident #1 violated facility policy and procedure and should have been questioned. On 10/24/16, Staff E documented in nursing notes he/she changed Resident #1's Foley catheter tube with a MIC gastric tube at 8:00 p.m. The note identified the resident had pain even when the balloon was inflated. The resident's medication record identified staff initiated tube feeding at 8:00 p.m. Staff contacted the health provider and sent the resident to the hospital by ambulance for evaluation. Administration did not initiate further investigation regarding events and procedure performed by staff just prior to sending Resident #1 to the hospital for emergency services. Failure to self-identify staff practices and rule out if abuse or neglect occurred, prevented the facility from identifying corrective actions related to gastric tube care and services that were required to prevent further occurrence. During an interview on 11/2/16 at 4:03 p.m., when asked what the facility concluded when they completed an investigation, Staff C reported, we didn't follow policy and replaced a catheter less than six weeks old and used it. RESIDENT #3 Resident #3 admitted to the facility 7/24/14 with [DIAGNOSES REDACTED]. A physician order [REDACTED]. between each medication. A physician order [REDACTED]. During an interview on 10/31/16 at 3:00 p.m., Staff K discussed preparations made to administer medications through Resident #2's gastric tube. Staff K reported, he/she allowed meds to sit in lukewarm water to let them dissolve first so they didn't clog the tube. Staff K stated, I don't know if all nurses do that. Staff K reported Resident #3 would be getting medications at 4:00 p.m. and to return later to observe the medpass. Later at 4:39 p.m., Staff K stood at the medication cart with a half a cup of red colored liquid in a drinking cup that measured approximately 60ml to 80 ml. Staff K reported six different medications in tablet form were crushed and mixed with liquid [MEDICATION NAME]. Medications crushed included [MEDICATION NAME], for a gastrointestinal condition; two Cranberry tablets and; [MEDICATION NAME] for itching; Vitamin C; an antidepressant medication; and acidophilus. Staff K reported medications were prepared ahead of time so they could dissolve. Following placement and residual checks and flushing Resident #3's gastric tube, Staff K administered the pre-mixed cup of medications through the tube by gravity drainage and flushed them with 60 ml of water while the resident remained elevated in bed approximately 30 to 45 degrees. Facility policy and procedure titled Enteral Tubes: Medication Administration identified to keep each medication separate when dissolving in water. During an interview on 10/31/16 at 6:10 p.m., Staff B reported each medication should be administered separately to prevent interaction between the medications. Refer to 42CFR 483.13(c) F 224 Prohibit Mistreatment/Neglect for facility failure to provide gastric tube services to avoid harm to Resident #1 during provision of nursing care and services provided during replacement of a gastric tube. Refer to 42CFR 483.13(c)(i)-(iii)(c)(2)-(4) F 225 Prohibit Mistreatment/Neglect/ Misappropriation for facility failure to identify potential neglect; immediately report and protect all residents; and thoroughly investigate an incident related to gastric tube nursing care provided that resulted in harm for Resident #1. Refer to 42CFR483.20 (k)(3)(i) F 281 Services Meets Professional Standards for failure of licensed nursing staff to question a provider order for gastric tube replacement that contradicted practice according to facility policy and procedure; and failure to ensure staff performed duties per accepted professional standards of practice for Resident #1. Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for failure to conduct thorough and consistent assessment and monitoring of Resident #1 before, during and after gastric tube procedures and for pai. Resident #1 developed serious complications following insertion of a Foley catheter and MIC gastric tube requiring emergency treatment and surgery determined to be an Immediate Jeopardy. Refer to CFR 42.30 F 353: Qualified Nursing Services: for failure to failed to ensure licensed staff were qualified to perform gastric tube care and services for Resident #1; failed to identify facility policies and procedures prohibited use of a Foley catheter to replace an occluded gastric tube that was initially inserted less than six weeks previously; maintained insertion and use of the Foley catheter for three days; failed to confirm through demonstration, skills required by licensed nursing staff to perform all gastric tube procedures and failed to ensure licensed nurses performed comprehensive assessment and monitoring of resident condition. These failures resulted in harm to Resident #1 and represented Immediate Jeopardy.

Based on interview and record review the facility failed to ensure licensed staff conducted thorough and consistent assessments and monitoring of resident condition for pain and gastric tube care for 1 of 7 Sampled Residents (#1) reviewed who received tube feedings through gastric tubes. Failure to comprehensively assess and monitor resident condition prevented staff from identifying staff should not replace Resident #1's occluded gastric tube since that was recently placed. Staff also failed to identify pain Resident #1 experienced at the time of a gastric tube replacement procedure signaled complications and the procedure should be immediately stopped. Following attempted replacement of a gastric tube, Resident #1 required emergency treatment and surgery determined as Immediate Jeopardy. Findings include: Refer to 42CFR483.25 (k) F 328 - Treatment Care for Special Needs for additional resident medical history, interviews and record review related to facility failures related gastric tube insertions on an unhealed gastric wound site; and lack of consistent assessment and monitoring of resident condition related to gastric care. PAIN ASSESSMENT Resident #1 ' s admission physician orders [REDACTED]. An admission nursing note written 10/16/16 at 8:41 p.m., identified Resident #1 was alert and oriented. A Minimum Data Set assessment (required assessment tool) dated 10/23/16, identified the resident did not have significant long or short term memory impairment; difficulty with hearing or speech or understanding others. An admission pain assessment dated [DATE], identified Resident #1 experienced generalized pain in all four quadrants of the abdomen with recent onset during the previous five days. The assessment did not contain further detailed information regarding the source of abdominal pain; description of pain; impact of pain on the resident or interventions that assisted with pain relief. October 2016's Medication Record identified staff administered pain medication to Resident #1 two times on 10/17/16 and 10/18/16 and once on 10/19/16. Staff identified the location of the pain once out of five times they administered the pain medication. A medication nursing note written 10/17/16 at 10:18 a.m., documented the resident had pain in both feet described as a level 6 out of 10 on a one to ten pain scale (10 is the worst pain.) The record contained no further assessment of source or description of foot pain. The initial pain assessment conducted 10/16/16 did not identify the resident had foot pain. On 10/20/16, staff documented they administered narcotic pain medication to Resident #1 seven times. On 10/20/16 at 4:49 a.m., staff documented the resident received the pain medication for back and shoulder pain. Resident #1's medical record did not contain evidence staff fully assessed the source, onset, or described the pain the resident had in back and shoulders. The initial pain assessment conducted previously on 10/16/16 did not identify the resident had back and shoulder pain. Staff documented in medication and progress nursing notes they administered pain medication to Resident #1 two times on 10/21/16 before inserting the Foley catheter into the gastric tube site, and three times the following day on 10/22/16. On 10/23/16, staff administered narcotic pain medication to the resident five times. Nursing staff identified only one out 10 times the location of the Resident #1's pain (back and shoulder) during 10/21/16 through 10/23/16. During an interview on 11/2/16 at 2:30 p.m., when asked how staff should assess for pain, Staff E reported, nursing should identify the location of pain and describe the pain using a scale of one to 10. During interviews on 11/3/16 at 8:40 a.m. with Staff B and Staff C, Staff B reported pain assessment depended on the site of the pain. Staff B stated staff would look at the type of pain, location, if pain traveled, what triggers precipitated the pain. Staff C reported staff should document the location, intensity in progress notes and use a numeric pain scale. Following a request for the facility policy and procedure for pain, Staff B provided a Pain Practice Guide Flowchart. The flowchart did not identify how or what to include when staff assessed resident pain. ASSESSMENTS RELATED TO GASTRIC TUBE CHANGES On 1/21/16 nursing staff documented in nursing notes at 5:17 p.m., they removed Resident #1's clogged MIC gastric tube and replaced it with a Foley catheter. The note identified the resident had pain twice during the shift. Medication notes identified the resident received pain medication at 12:36 p.m. and 4:07 p.m. The record did not identify the location or description of the resident's pain that day; evidence staff conducted a thorough assessment of the resident's medical condition before or after the procedure or how the resident responded to the procedure. On 10/24/16 staff replaced the Foley catheter with a MIC tube. The resident ' s record did not contain evidence staff conducted comprehensive assessments of Resident #1's condition prior to or after the procedure. Resident #1's record did not indicate if the resident had abdominal pain; distention; nausea or vomiting; guarding; respiratory symptoms; bowel tones or gastric issues. The record did not describe how staff performed the second gastric tube replacement procedure or how the resident responded during the procedure. During an interview on 10/31/16 at 4:10 p.m., Staff H reported, during the day shift, before Resident #1 went to the hospital (10/24/16), the resident did not have pain around the gastric tube site, abdominal distention or nausea during the day,. Staff H reported he/she left the facility before staff reinserted the MIC tube that evening. On 10/24/16 at 11:00 p.m., staff documented in nursing notes, at 2000, (8:00 p.m.,) Foley cath (catheter) tube was changed (with) MIC gastrostomy tube but patient was c/o (complaining of) too much pain even when the balloon was inflated, house supervisor checked and still c/o pain and noted tenderness around the stoma. Resident #1's medical record did not contain evidence staff comprehensively assessed the resident's pain when it occurred. The nursing note written on 10/24/16 at 11:00 p.m., identified, staff sent Resident #1 to the hospital by ambulance around 10:00 p.m. that evening. During an interview on 11/2/16 at 2:30 p.m. when asked to describe the procedure followed to insert the MIC tube, Staff E reported, the tube went through but the resident complained of pain. Staff E stated he/she did not ask Resident #1 to describe the type, location or intensity of pain and the resident yelled out loud and said it's painful. ALERT CHARTING Resident #1 admitted to the facility on [DATE] to receive care and services that included gastric tube care and infusions, a urinary catheter, medications following acute care provided in the hospital. A Hospital History and Physical dated 10/25/16 identified the resident had a recent [DIAGNOSES REDACTED]. A facility policy titled Alert Charting Log, stated its purpose provided guidelines for monitoring documentation that may be needed following a change in condition or status. The policy stated the Alert charting Log was a tracking and communication system to alert licensed nurses to changes in a resident's condition that warrants continued observation. Examples of situations included for alert charting included: -new admission monitoring needs; acute changes in condition; situations that are expected to stabilize or resolve within 14 days such as a change in condition. The policy stated residents were placed on alert charting when they were identified as requiring continued follow up and documentation for a minimum period of 72 hours. Facility policy stated documentation in the electronic medical record may include; patient evaluation findings; new orders or instructions received; and licensed nurses can review the Dashboard in PCC (electronic charting system) for documentation of vital signs; and progress notes etc. Resident #1's medical record did not identify staff followed consistent alert charting procedures upon admission or following gastric tube replacement procedures. Licensed nursing staff documented alert charting notes regarding Resident #1's condition only five times since admission on 10/16/16 to 10/20/16. Staff documented parital assessment notes once on 10/16/16 at 8:41 p.m.; once on 10/17/16 at 8:23 p.m.; once on 10/18/16 at 11:03 p.m.; once 10/19/16 at 8:37 p.m.; and twice on 10/20/16 at 1:56 p.m. and 5:47 p.m. Progress alert charting notes did not identify staff addressed frequent assessments specific to all of the resident ' s medical conditions and complications the resident had while in the hospital prior to admission to the facility. Resident #1's medical record did not contain evidence staff followed the alert charting process and conduct full assessments and monitoring of the resident's condition and before and after gastric tube procedures on 10/21/16 and 10/24/16. The record did not identify staff consistently assessed for pain; distention; respiratory status; for signs and symptoms of aspiration; bowel tones or constipation; nausea; vomiting; or described details of the procedure and resident response. During an interview on 10/28/16 beginning 5:56 p.m., Staff B reported alert charting was conducted every eight hours/every shift and there should be nursing notes written every nursing shift. Staff B also reported, the facility discussed residents on alert charting during stand up meeting. Staff A stated, nursing should have known to the place Resident #1 on alert charting and he was not. During an interview on 10/31/16 at 3:50 p.m., Licensed Staff N reported alert charting included documenting the assessment of the resident and would include to listen to bowel tones; check patency of gastric tube; and how much tube feeding infused. During an interview on 10/31/16 at 4:10 p.m., Staff H reported, when changing a MIC tube, staff should assess the resident's abdomen for distention, listen for bowel tones, check the tube site; check for residual (amount of stomach contents), pain and place the resident on alert charting. Staff H reported staff should chart what they did. During an interview on 11/2/16 at 4:15 p.m., Staff H reported, any nurse can update alert charting and night shift usually did the updates and each shift handed it over to the next shift. Staff H also reported, the alert charting report was printed out and got thrown away later and got deleted from the computer. When asked if he/she could locate evidence nursing staff ever placed Resident #1 on alert charting, Staff H stated he/she did not think it was saved.

Based on observation, interview and record review the facility failed to ensure licensed staff were qualified to perform gastric tube care and services for 2 of 7 Sampled Residents (#1 & 3) reviewed who had gastric tubes. The facility also failed to ensure licensed nursing staff knew facility policies and procedures stated to not replace gastric tubes in sites that were less than six weeks post placement, and to not replace gastric tubes with a Foley catheter. Licensed staff replaced Resident #1's occluded MIC gastric tube (MIC, type of stomach tube) with a Foley catheter and used it to administer tube feedings and medication. Three days later, licensed staff also replaced the Foley catheter with another MIC tube. Following MIC tube replacement, the resident developed peritonitis,[MEDICAL CONDITION], and required emergency treatment and surgery when the tip of the MIC tube was determined located in the resident's abdominal cavity and not the stomach. The facility failed to confirm licensed nurses' demonstrated skills necessary to follow and perform gastric tube insertion. The facility failed to ensure licensed nurses performed comprehensive assessment and monitoring of Resident #1's condition before, during and following gastric tube procedures. These failures placed all residents with gastric tubes at risk for harm and resulted in harm for Resident #1 and represented Immediate Jeopardy. Findings include: On 10/28/16, the facility had a total census of 114 residents. Six current residents had gastric tubes staff used to infuse tube feeding to administer medications. Rooms assigned to current residents with gastric tubes were located on the 100 hall; 200 Hall and 400 Hall. Review of former Resident#1 for gastric tube care and services, identified he resided on the 300 hall prior to transfer to the emergency room following gastric tube complications on 10/24/16. Residents with gastric tubes require skilled nursing services to prevent infections, aspiration and injuries to tube sites. Additional skilled nursing services required include, but not limited to, comprehensively assessment and monitoring of resident conditions; skills required to administer tube feedings and medication, and replacement of certain types of gastric tubes when appropriate and medically indicated. LACK OF KNOWLEDGE OF MANUFACTURER INSTRUCTIONS AND FACILITY POLICIES AND PROCEDURES On 10/21/16, Staff K failed to follow manufacturer instructions to dissolve a form of medication supplied in small beads prior to administering them through a gastric tube. Facility policy and procedure (P&P) titled Enteral Tube: Gastric Tube dated 5/09 stated in the section Purpose: Gastric tubes less than 6 weeks post placement are NOT replaced in the nursing center setting. The tract is immature and the tube is reinserted by a Physician in an acute care setting. The Procedure portion of the P&P for tube insertion stated urinary catheters such as Foleys are not used. Not all licensed nurses were aware of or followed facility policy and procedure titled Enteral Tube: Gastric Tube directed staff to not use a urinary Foley catheter for a gastric tube insertion and to not replace a gastric tube if the site was less than six weeks post placement. On 10/21/16, Staff D replaced Resident #1's gastric tube with a Foley catheter. On 10/24/16, Staff E replaced the resident's Foley catheter in the gastric tube site with a MIC tube (type of gastric tube.) Between 10/21/16 and 10/24/16, seven licensed nurses (Staff D; Staff E; Staff R; Staff T; Staff W; Staff X & Staff Y) performed nursing procedures related to tube feedings and/or medications through the Foley catheter tube and did not question it was against facility policy to use a Foley for gastric infusions and an unsafe practice. During an interview on 10/28/16 at 6:30 p.m., Staff A reported it was not a normal occurrence to replace a gastric tube. During an interview on 11/3/16 at 4:10 p.m., Staff C reported, Staff D did not know to question the order given to insert the Foley catheter into the gastric tube site and should have known the policy stated to not do that. Staff C also reported Staff D did not know the age of the gastric tube site and its implications since it was new. During an interview on 10/31/16 at 2:00 p.m., Outside Provider F, who wrote the order to replace the gastric tube with a Foley catheter reported, the facility had not shown her where to find their policies. When asked how nurses would know how old Resident #1's gastric tube site was, Provider F reported, it should be in our progress notes. Provider F looked in progress notes and did not locate it and stated the date would be in Resident #1's hard chart. Provider F reported, if nursing informed her facility policy stated to not replace a gastric tube less than six weeks old, she would have sent the resident to the emergency room . On 10/31/16 at 4:10 p.m., Staff H stated I was not aware of the policy to not change a gastric tube when it was less than six weeks old. Staff H reported she gave the replacement MIC tube for Resident #1 to another nurse, to be given to Staff E so the tube could be changed on 10/24/16. During an interview on 11/3/16 at 4:10 p.m., Staff C reported, Staff D did not know to question the order given to insert the Foley catheter into the gastric tube site and should have known the policy stated to not do that. Staff C also reported Staff D did not know the age of the gastric tube site and its implications since it was new. Other licensed staff responded differently regarding their knowledge of facility practice and scope of practice to replace gastric tubes. During an interview on 10/31/16 at 3:00 p.m., Licensed Staff K reported she knew from experience if a gastric tube was new and less than six weeks old, she would get an order to send the resident out to have the tube replaced because the stomach was not healed. Staff K reported in the past she had replaced a gastric tube in the facility and did not recall when. During an interview on 10/31/16 at 3:25 p.m., Licensed Staff L reported he/she would send a resident out to replace a gastric tube and felt it not within scope of practice to replace a gastric tube. On 10/31/16 at 3:50 p.m., Licensed Staff N also stated gastric tube replacmentents were not in my scope of practice to do so as an LPN. COMPETENCY EVALUATIONS The facility Skills and Techniques Evaluation checklist for nurses listed specific skills requiring proficiency for licensed nurses to perform. The form indicated for the facilitator to enter the date, full signature of skill validation or demonstration completion a column on the form. The form stated skills and evaluation were completed during job specific orientation and were revalidated annually. Skills listed on the checklist included gastrostomy tube (gastric) replacement. On 10/24/16, Staff E replaced Resident #1's Foley catheter located in the resident 's gastric tube site with a MIC (type of gastric tube). The resident experienced pain from the procedure and staff sent to the emergency room . Staff E's Skills and Techniques Evaluation signed by Staff E and a facilitator on 12/4/15, contained a check mark for validation/return demonstration next to gastrostomy tube replacement. During an interview on 11/2/16 at 2:30 p.m., Staff E reported facility staff had not observed him/her replace a gastric tube. Staff K administered seven different medications crushed, and mixed together in one cup through Resident #3's gastric tube on 10/31/16 at 4:39 p.m. Staff K's Medication Management Skills Evaluation signed by Staff K and a facilitator on 9/1/15, did not contain any checkmarks to indicate return demonstrations or validations had been completed for administering medications through gastric tubes according to manufacturer instructions. Staff D replaced Resident #1's gastric tube on 10/21/16 with a Foley catheter without obtaining and reading facility policies and procedures related to gastric tubes. During an interview on 11/1/16 at 4:45 p.m., Staff D reported a former staff asked if he/she replaced a gastric tube before and checked it off and not be return demonstration. Staff D's Skills and Technique Evaluation contained a checkmark next to gastrostomy tube insertion dated 3/17/16. Skills Evaluation checklist and Medication Management Skills Evaluations did not identify staff reviewed facility policies and procedures with staff for specific skills such as, those pertaining to gastric tube replacements. During an interview on 11/2/16 at 4:15 p.m., Staff H reported he/she would check off on the skills checklist anything he/she felt comfortable doing and the facility did not always observed by demonstration. During an interview on 10/31/16 at 12:30 p.m., Staff A reported all nursing staff had skills checklists done before and were trained on tube feedings. During interviews on 11/3/16 beginning 4:45 p.m., Staff A reported the facility never asked licensed nurses if they were ever observed performing a tube replacement. Staff C also stated, it is not our process to have staff check off their own skills on the skills checklist. It needs to be a personal observation and staff need to demonstrate skills. Staff C reported the facility had just obtained a dummy from a nursing school for staff to demonstrate their skills. Refer to the following failures of the facility to ensure all nursing staff were qualified to perform duties related to gastric tube care. Not all nursing staff were aware of facility policies and procedures necessary to ensure delivery of safe nursing care that included administration of medications per manufacturer instructions to prevent gastric tubes from occluding; management of gastric tubes when removal and replacement was required; and thorough assessments required resident conditions. 1)Refer to 42CFR 483.13(c) F 224 Prohibit Mistreatment/Neglect for facility failure to prevent harm to Resident #1 during provision of nursing care and services provided during replacement of a gastric tube. Nursing staff failed to identify replacement of a gastric tube did not meet standards of facility and professional practice to ensure safe care and prevent insertion of a MIC replacement tube into a gastric tube site less than six weeks old. Staff failed to stop the procedure when Resident #1 experienced pain and failed to conduct a thorough assessment of the resident's condition and pain and resulted in harm for Resident #1. 2) Refer to 42CFR 483.13(c)(i)-(iii)(c)(2)-(4) F 225 Prohibit Mistreatment/Neglect/ Misappropriation for facility failure to identify potential neglect may have occurred; immediately report complications that arose when nursing procedures were performed to replace a gastric (MIC) tube; failure to protect residents pending results of a facility investigation; and failure to thoroughly investigate an incident related to gastric tube nursing care provided that resulted in harm for Resident #1. Facility also failed to thoroughly investigate circumstances that resulted in a fall for Resident #8. 3) Refer to 42CFR483.20 (k)(3)(i) F 281 Services Meets Professional Standards for failure of licensed nursing staff to question a provider order for gastric tube replacement that contradicted practice according to facility policy and procedure; failure to ensure staff performed duties per accepted professional standards of practice for Residents (#1 & 3). Licensed nursing staff also failed to identify safe nursing practices related to gastric tube feedings and medication administration and failure to thoroughly and consistently assess and monitor for significant changes in condition. These failure represented a lack of vigilance in quality of care and system error breakdown that placed all residents at risk for the same/similar deficient practices as Resident # 1, determined to represent Immediate Jeopardy. 4) Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for facility failure to conduct thorough and consistent assessment and monitoring of Resident #1 before, during and after gastric tube procedures and for pain. Resident #1 developed serious complications following insertion of a Foley catheter and MIC gastric tube requiring emergency treatment and surgery determined to be an Immediate Jeopardy. 5) Refer to 42CFR483.25 (k) F 328 Treatment Care for Special needs for facility failure to ensure Residents (#1 & 3) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with professional standards of safe clinical practice. Failures included not following manufacturer recommendations for administration of medications; performing gastric tube on an unhealed gastric wound site; and lack of consistent assessment and monitoring of resident condition related to gastric care. The facility also failed to ensure all staff had knowledge of policies and procedures to not replace gastric tubes less than six weeks old. This avoidable failed practice placed all residents with gastric tube feedings at risk for harm and represented Immediate Jeopardy. 6) Refer to 42CFR483.75 (l)(1) F 514 Clinical Records Meet Standards for facility failure to maintain medical records in accordance with professional standards of practice to ensure complete and accurate documented records for Sampled Resident #This failure resulted in facility inability to identify the physical, psychosocial and relevant outcome to Residents #1 who experienced complications as a result of nursing services provided during gastric tube care. Lack of accurate and timely information in the clinical record had the potential to affect all residents in the facility when records did not contain all information necessary that described resident condition and care and services the facility provided.

Based on interview and record review the facility failed to ensure staff followed standards of professional practice related to gastric tube care and services that included: management of recently inserted gastric tubes; administration of medications; consistent assessment and monitoring of residents for changes in condition; and gastric tube replacement procedures for 2 of 7 Sampled Residents (#s 1 & 2) reviewed who had gastric tubes. These failures represented a lack of professional vigilance to provide quality care and system error breakdown that placed all residents with gastric tubes at risk for the same/similar deficient practices as Resident # 1 and Resident #2. Resident #1 experienced complications following a gastric tube reinsertion requiring emergency care, hospitalization and surgery representing Immediate Jeopardy. Findings include: The Washington State Nurse Practice Act, WAC 246-840-710 (2) in part indicates nurses violate standards by: (b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or legibly: (d) Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards (c) Willfully or repeatedly failing to make entries .pertaining to the giving of medication, treatments, or other nursing care . (i) Failure to protect clients from unsafe practices or conditions . and (8) The nurse shall have knowledge of the statutes and rules governing nursing practice . RESIDENT #1 Refer to 42CFR483.25 (k) F 353 Treatment Care for Special needs for facility failure to ensure Residents (#1 & 2) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with professional standards of safe clinical practice. Failures included not following manufacturer recommendations for administration of medications; performing gastric tube on an unhealed gastric tube site. The facility also failed to ensure all staff had knowledge of policies and procedures to not replace gastric tubes less than six weeks old. This avoidable failed practice placed all residents with gastric tube feedings at risk for harm and represented Immediate Jeopardy. 1. Licensed staff did not know when Resident #1 had the gastric tube initially placed on 9/27/16. During an interview on 10/28/16 beginning 5:56 p.m., when asked how long Resident #1 had a gastric tube, Staff B reported, I'm not really sure. Staff B also reported he/she found out on Monday (10/27/16) staff replaced the tube. When asked if that raised a concern, Staff B reported, I asked the nurse and the nurse reported physician orders [REDACTED]. During interviews on 11/3/16 beginning 4:10 p.m., both Staff B and Staff C reported Staff D did not know the age of the gastric tube site and the implications since it was new. 2. Licensed staff did not know the facility policy and procedure stated to not replace a gastric tube within six weeks of surgical placement. Licensed staff replaced Resident #1's gastric tube on 10/21/16 and on 10/24/16 when the tube site was less than six weeks post placement. During an interview on 10/31/16 at 4:10 p.m., Staff H reported he/she was not aware facility policy stated to not replace a gastric tube that had been in for less than six weeks. On 11/1/16 at 4:45 p.m., Staff D did not know where facility policies and procedures were located. On 11/3/16 at 4:45 p.m., Staff C reported Staff D should have known facility policies stated to not insert a catheter tube into a gastric tube site. On 11/2/16 at 2:30 p.m. Staff E reported he/she did not know the facility had a policy that stated to not change gastric tubes less than six weeks old. Staff E reported Staff H, told Staff EE to tell me to change the tube. 3. Licensed nursing staff failed to identify a provider order to replace a gastric tube with a Foley catheter violated facility policies and procedures for gastric tube care. Staff also failed to question a physician order [REDACTED]. During an interview on 11/3/16 at 1:21 p.m. the Medical Director reported Resident #1's tube site was not mature enough and from a physician's point of view it wasn't a good order. During an interview on 11/3/16 at 2:25 p.m., when asked how nursing staff should have responded when they received the order to place a Foley catheter into Resident #1 ' s tube site, the Medical Director stated the nurse who took the order should have questioned the order and follow the chain of command and discuss it with the Director of Nursing and the Director of Nursing could call me. During interviews on 11/3/16 beginning 4:10 p.m., Staff C reported facility policies and procedures should guide nursing staff to not carry out orders that are against our facility policies. Staff C stated if an issue arose, nursing staff should notify the Administrator and the Medical Director. Staff C stated Staff D did not know to question the order to insert a catheter into Resident #1 ' s gastric tube site and should have known it was in our policies to not do that. 4. Licensed staff did not conduct consistent assessment and monitoring related to Resident #1 ' s gastric tube. Refer to 42CFR483.25 F 309: Care and Services/Highest Practicable for facility failure to conduct thorough and consistent assessment and monitoring of Resident #1 before, during and after gastric tube procedures and for pain. Resident #1 developed serious complications following insertion of a Foley catheter and MIC gastric tube requiring emergency treatment and surgery determined to be an Immediate Jeopardy. RESIDENT #3 According to nursing literature, Safety is the main concern in medication administration .preparing medications carefully and recording their administration. Use of the Medication Administration Record [REDACTED]. (2009) Lippincott, Williams and Wilkens, Chapter 32, page 771). 1. Resident #1: Licensed staff did not clarify physician orders [REDACTED]. The manufacturer recommended a 16 French size gastric tube to administer [MEDICATION NAME]. 2. Resident #1: Licensed staff failed to prepare [MEDICATION NAME] according to manufacturer's instructions prior to administering the medication in Resident #1's gastric tube. 3. Resident #3: Licensed staff failed to prepare and administer each medication separately followed by physician ordered tube flushes between each medication.

Based on interview and record review the facility failed to prevent injury related to care provided when a gastric tube (MIC, a type of stomach tube) became occluded for 1 of 7 Sampled Residents (#1) reviewed who received tube feedings. Nursing staff failed to follow safe standards of facility and professional practice and replaced the MIC tube with a Foley catheter into an immature gastric tube site less than six weeks old, and used it to infuse tube feedings and medications for three days. When staff replaced the Foley catheter with another MIC tube, Resident #1 experienced pain and staff did not stop or comprehensively assess the resident's condition and began a tube feeding infusion. Following continued pain, staff discontinued the tube feeding, removed the MIC tube and reinserted it again before notifying the physician to request transport to the emergency room . These failures resulted in harm and constituted neglect for Resident #1 when the MIC tube was found in the peritoneum with a large amount of fluid in the abdominal cavity, and the resident developed peritonitis,[MEDICAL CONDITION] and required surgery. Findings include: Refer to CFR483.25(k)(2) F 328: for information related to Resident#1's medical history, interviews and record review related to staff failures associated with gastric tube care; and facility policies and procedures related to replacement of gastric catheters. Nursing notes dated 10/21/16 at 5:17 p.m., identified staff replaced an occluded gastric tube (MIC) with a Foley catheter. October 2016 Medication Records identified staff infused tube feedings and medications into the Foley catheter over a period of three days. Facility policy and procedure for Gastric Tubes identified, gastric tubes less than six weeks post placement, should not be replaced in the nursing center setting. During an interview on 11/3/16 at 1:21 p.m., the facility Medical Director reported a Foley catheter should be used only for a few hours to keep the opening patent and not left in for three days. The Medical Director also reported Resident #1's gastric tube site was not mature enough to use. During an interview on 11/3/16 at 4:25 p.m., Staff C reported the facility confirmed use of a Foley catheter in a gastric tube site could cause erosion, and we don't use them. Nursing notes dated 10/24/16 written at 11:00 p.m., documented Staff E replaced the Foley catheter with a MIC tube into Resident #1's gastric tube site at 8:00 p.m. The note documented the resident complained of too much pain even when the balloon was inflated. A hospital discharge planning update note dated 10/27/16 written at 2:01 p.m., by Hospital Provider P, documented Resident #1 was well known to the writer from a previous hospitalization . Patient stated that he is very upset about the person at the facility who tried to re-insert the gastric tube. The resident stated, I told her three times not to do it. Now I'm the one who has to suffer. During an interview on 11/3/16 at 12:29 p.m., Hospital Provider P reported she saw Resident #1 in the hospital on [DATE], and knew the resident for a month while previously hospitalized . Staff P stated, during the interview, the resident was clear as a bell, and looked me straight in the eye during the interview. When asked why Resident #1 wanted the nurse to stop, Staff P stated I think the resident said it hurt. During an interview on 11/2/16 at 2:30 p.m., Staff E reported, Resident #1 complained of pain when the MIC tube was inserted. Staff E also reported, Resident #1 yelled aloud and said it's painful and it hurt inside. Staff E reported he/she did not ask the resident the location or intensity of the pain and did not ask Resident #1 to describe the pain. Staff E stated he/she started the tube feeding because air pushed into the (replaced) gastric tube made a gurgling sound, and also checked for residual return and did not get any. Staff E reported he/she heard Resident #1 yelling aloud while standing at the end of the hall at the medication cart and asked an aide to get Staff T to check on the resident. Staff E did not return to the resident's room with Staff T, although the resident was heard yelling from down the hall right after Staff E replaced the tube. During an interview on 11/3/16 beginning 4:25 p.m., Staff C and Staff B discussed events when Resident #1 had the gastric tube reinserted 10/24/16. Staff C stated, during further interview with Staff E, the facility learned Resident #1 received the tube feeding while in pain. During an earlier interview on 11/2/16 at 6:32 p.m., Staff C stated, staff should not continue the tube feeding if the resident was in pain. Staff C also stated, since staff did not stop the procedure, the facility saw it as abuse. Staff C also reported a concern that Staff E left Resident #1 in pain and told an aide to get another nurse. During this same interview, Staff C reported facility staff provided conflicting reports regarding the events that evening. Initially, Staff C stated, we never thought to ask if the tube feeding got started because we didn't think the gastric tube had been inserted. During an interview on 11/2/16 at 8:30 a.m., Staff A reported, the facility just opened a new investigation based on neglect and called it in to the State. Licensed staff provided care to Resident #1's gastric tube site and replaced it on two different occasions. Staff should have known, per facility policies and procedures to not replace the tube since the tube site was less than six weeks old. During the second insertion, Resident #1 experienced pain and staff failed to stop the procedure and prevent further pain to the resident. Licensed staff failed to implement safe gastric tube care and services and stop a procedure when it caused pain to the resident.

Based on interview and record review the facility failed to identify staff practices related to gastric tube care required investigation to determine if neglect occurred; immediately report information to facility administration and the State when complications occurred following a gastric tube reinsertion. The facility failed to immediately protect residents pending results of an investigation. The facility also failed to conduct thorough investigations related to gastric tube care or falls for 2 of 9 Sampled Residents (#s 1 & 8) reviewed for gastric tube care or falls. Failure to thoroughly investigate following a fall for Resident #2, prevented staff from determining what additional fall prevention measures were required to prevent further falls. Failure to identify and thoroughly investigate why Resident #1 had complications following a gastric tube replacement, prevented the facility from determining what corrective actions were required to prevent reoccurrence placing all residents with gastric tubes at risk for harm. Resident #1 developed peritonitis,[MEDICAL CONDITION] and required surgery, following a gastric tube replacement constituting harm. Findings include: Refer to F 328 for information related to Former Resident #1's medical history, record review and interviews associated with staff failures related to gastric tube care. Refer to F 224 for additional information related to facility failure to self-identify a preventable life threatening event related to Resident #1's gastric tube. Licensed staff replaced Resident #1's clogged gastric tube (MIC, type of tube) on 10/21/16 with a Foley catheter when the resident's gastric tube site was less than one month old. Staff infused tube feedings and medications into the Foley catheter over a period of three days and later replaced the Foley catheter with another MIC tube on 10/24/16. The facility had knowledge on 10/24/16, Resident #1's gastric tube became clogged with medication and was replaced with a Foley catheter on 10/21/16. The facility did not initiate an investigation why the tube clogged and why staff replaced he tube when the resident's tube was less than six weeks old. During an interview on 10/28/16 beginning 5:56 p.m., Staff B reported the 24 hour nursing report reviewed on Monday (10/24/16), identified Resident #1's gastric tube clogged (on 10/21/16), and the provider told the nurse to replace the clogged gastric tube with a Foley catheter. Staff B also stated, replacing the resident's tube did not raise a concern and the nurse followed physician orders. When asked what facility policies and procedures identified regarding replacing gastric tubes in the facility, Staff B did not know and read the policy. Staff B reported the policy stated gastric tubes less than six weeks old, were not placed in the nursing home setting. When asked how old Resident #1's gastric tube site was, Staff B stated, not really sure. Three days later on 10/24/16, Staff E documented in a nursing note, he/she replaced Resident #1's Foley catheter in the gastric tube site with a MIC gastric tube. Staff E wrote, the resident had pain even when the balloon was inflated. Staff contacted the health provider and sent the resident to the hospital by ambulance for evaluation. After the facility sent the resident to the hospital following the replacement 10/24/16, hospital emergency room (ER) records dated 10/25/16 written at 1:55 a.m., documented hospital staff spoke with a facility nurse two times, and explained how important it was for the hospital to speak with Resident #1's primary nurse at the facility. An ER note written later on 10/25/16 at 2:11 a.m. documented, a facility nurse informed emergency room staff, Resident #1 received a tube feeding at 8:00 p.m. through the Foley and then attempted to replace the tube and did not know if the tube was in the correct place and transferred the resident to the ER. Resident #1's medical record did not contain documentation regarding conversations facility nursing staff had with hospital staff after the resident went to the emergency room . During interviews on 10/28/16 beginning 5:56 p.m. with Staff A and Staff B, Staff B reported the facility did not conduct an investigation because they didn't know there was a problem. Staff B reported they were aware Staff E attempted to replace Resident #1's gastric tube and inflate a balloon. Staff A reported they (facility) knew the resident complained of pain at the time, and the house nursing supervisor checked and noted the resident had tenderness around the tube site. Staff A reported, Resident #1's care provider informed the facility yesterday (10/27/16) via email regarding care concerns for Resident #1 and the facility attempted to call Resident #1's family and did not make contact with them. On 11/3/16 at 4:25 p.m., Staff C reported Staff R took the call from the emergency room and was informed the tip of the tube was in Resident #1's peritoneal (abdominal) cavity. Staff R did not think it was abuse or neglect but a procedural issue. Staff C also reported, nursing staff did not inform administration they received telephone calls from the hospital and should have. During an interview on 11/4/16 at 12:00 p.m., Staff B reported night shift staff did not pass anything on in report hospital staff called them regarding Resident #1's gastric tube care at the facility. The facility became aware on 10/27/16 during stand up meeting, Resident #1 had complications following a MIC tube replacement on 10/24/16. The facility also had knowledge on 10/27/16, the hospital reported care concerns with the resident's care provider. The facility failed to initiate an investigation to determine events that occurred at the facility that led to Resident #1's hospitalization . The facility did not initiate an investigation until State agency staff informed the facility during a meeting on 10/28/16 at 5:56 p.m., Resident #1's MIC tube was found in the abdomen and the resident developed peritonitis [MEDICAL CONDITION]. INCOMPLETE INVESTIGATION The facility initiated an investigation following meeting with State staff 10/28/16 and provided a copy of their completed investigation on 11/2/16. During an interview on 11/2/16 at 4:03 p.m., Staff C reported, the facility concluded staff did not follow policy and placed a catheter into Resident #1's gastric tube site less than six weeks old when the policy said to not do that. The initial investigation did not address or evaluate how or why Resident #1's gastric tube initially became clogged with medication on 10/21/16 which led to the first gastric tube replacement with a Foley catheter. On 10/28/16, Staff B provided a list that identified there were six current residents in the facility that had gastric tubes. The investigation identified on 10/28/16, the facility conducted interviews with five residents and asked them if they felt nurses provided them with care and services they needed; if anyone neglected them and if they felt safe. The investigation contained only one interview from a family member of a resident who had a gastric tube (Resident #5). Resident interview questions did not focus on care specific to gastric tubes and include other residents or family members who received gastric tube care. Resident #1's October 2016 Medication Record identified seven licensed nursing staff documented they either administered tube feedings and/or medications through the Foley catheter tube. The investigation did not contain statements or interviews with two of the seven licensed staff, Staff R and Staff Y, who provided care to Resident #1. None of the staff statements obtained, addressed what nurses knew, or did not know, regarding facility policy and procedure that prohibited use of a Foley Catheter in a gastric tube site. The investigation did not address why licensed staff did not question the provider's order to replace a gastric tube with a catheter and to administer tube feedings or medications through the Foley catheter. The investigation did not address care related to the second gastric tube replacement staff performed on 10/24/16, just prior to sending Resident #1 to the hospital emergency room . Investigation notes did not contain further interviews with staff present the evening of 10/24/16 to determine what details they were aware of regarding the sequence of events that occurred that preceded sending Resident #1 to the hospital 10/24/16. The facility conducted an interview with Staff T on 10/29/16. Staff T, administered tube feeding through the Resident #1's Foley gastric tube on 10/22/16. The investigation notes did not identify if or what Staff T knew about facility policy to not use a Foley catheter in a gastric tube site less than six weeks old and why he/she did not question the use of a Foley catheter for tube feeding. The investigation did not contain further interview with Staff T, who was also on duty the evening Resident #1 went to the hospital 10/24/16. During an interview on 11/2/16 at 4:45 p.m., Staff T reported a staff member asked him/her to assess Resident #1 following the MIC tube insertion since the resident had pain. Staff T reported, upon entering the resident's room that evening, the tube feeding infused and stopped it due to the resident's report of pain. The investigation identified the facility suspended Staff F pending results of the investigation. The facility investigation did not identify or address all additional staff who were involved in writing, receiving and executing orders for Resident #1's gastric tube care to determine if additional suspensions were required pending results of a full investigation to ensure all residents were protected. On 11/2/16 at 6:32 p.m., Staff C reported the facility identified Staff E began a tube feeding infusion for Resident #1 following insertion of the MIC tube (10/24/16). Staff C reported Staff E should not have started the tube feeding when the resident had pain and the facility just suspended Staff E pending further investigation. Staff C confirmed no other staff involved with Resident #1's care were suspended. During an interview on 11/3/16 at 4:25 p.m., Staff C reported the facility took the situation seriously, and due to conflicting statements they were taking a whole new look. Staff C reported the facility did not ask enough detailed questions during the first investigation and not sure the facility asked the right questions. Staff C stated the first facility investigation focused on the insertion of the Foley catheter (into the gastric tube site) and they did not necessarily focus as much as they should have on the MIC (gastric) tube replacement. During an interview on 11/3/16 beginning 4:25 p.m., Staff C reported facility staff provided conflicting reports regarding the events that evening. Initially, Staff C stated we never thought to ask if the tube feeding got started because we didn't think the gastric tube had been inserted. It is unclear why the facility did not pursue more timely further investigation and staff interviews when Resident #1's Medication Record identified staff documented they started Resident #1's tube feeding on 10/24/16 at 8:00 p.m. During further interview on 11/3/16 at 4:25 p.m., Staff C stated the facility later learned Staff S observed Staff T deflate the balloon in Resident #1's MIC tube and remove it. Staff C stated, when the resident arrived in the emergency room the tube was in place and the facility still needed to know what happened when Staff T was left alone in the room with Resident #1. Staff C also stated the facility needed to find out what happened when emergency personnel (EMTs) arrived and EMT staff and Staff E were alone in the room with Resident #1 for a good 10 minutes before the resident left for the hospital. RESIDENT #8 Former Resident #8 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment (MDS, a required assessment tool) dated 9/29/16 identified, Resident #8 required extensive assistance from two staff for toileting. A care plan dated 10/3/16, identified Resident #8 had cognitive loss with confusion and forgetfulness. Interventions included for staff to explain to the resident activity/care procedures prior to beginning them. Staff initiated a plan of care for fall risks on 9/23/16 due to the resident's history of falls, impaired balance and poor coordination. Interventions included providing assistance with transfers; ambulation; changing positions slowly; and keeping items in reach. On 9/29/16, staff added an intervention for two staff (care in pairs) to provide care for Resident #8. The care plan identified staff created the intervention on the care plan on 9/30/16, the following day. A copy of Resident #8's aide directive provided by the facility identified for staff to provide care in pairs, did not identify the date nursing staff added the directive to the aide care plan. A facility incident report identified on 9/30/16, Resident #8 had a witnessed fall with Staff CC present. The investigation documented, the resident stood up and got off the toilet, lost balance and fell backwards and accidentally hit her head on the wall, while Staff CC was in the process of putting on gait belt. A Fall Scene Investigation Report dated 9/30/16 noted the resident wore gripper socks, had no increased cognitive confusion and said just prior to the fall, I slid on floor - I was reaching for w/c (wheelchair.) The investigation did not contain further interview with Resident #8 to determine why she did not wait for help, or ask if staff reminded her to wait for assistance. Staff DD documented an interview with Staff CC in the investigation report. Staff CC reported when he/she answered the call light and observed Resident #8 in the process of getting up, he/she immediately tried to put the gait belt on but the resident immediately continued to fall. The investigation identified Resident #8 did not have a gait belt on at the time, and Staff CC should have been working in pairs. The investigation did not identify why Resident #8 did not have a gait belt on already, and if Staff CC used the gait belt to initially transfer the resident to the toilet. The investigation did not contain further interview with Staff CC to determine if he/she may have been able to prevent Resident #8 from falling backwards, if the resident already had the gait belt on for staff to immediately use to stabilize the resident when standing up. The investigation did not identify if Staff CC knew Resident #8 required care in pairs or why two staff were not present. The investigation did not identify if or when Staff CC reminded the resident to ask for assistance and wait before getting up off the toilet. No further interviews were included in the investigation to determine if or how licensed staff supervised care Staff CC provided to the resident. During an interview on 11/2/16 at 7:20 p.m., Staff B reported he/she did not ask Staff CC why the resident did not already have the gait belt on Resident #8. Staff B provided notes from an interview conducted with Staff CC on 11/4/16, approximately four and a half weeks after Resident #8 fell . Staff CC reported he/she removed the gait belt after transferring the resident to the toilet in order to use it to help another resident. Staff CC stated he/she reminded the resident he/she would come back. The interview statement did not indicate Staff CC reminded the resident to wait for assistance before getting up on own. Summary notes in the investigation indicated for staff to continue to use the gait belt and explain tasks prior to transfer. The investigation identified the facility ruled out abuse and neglect. Failure to conduct a thorough investigation and identify all staff actions preceding a fall, prevented the facility from determining the following: -if the aide directive identified to provide care in pairs prior to the fall and if staff followed the care plan; - if Resident #2 needed staff to provide more timely and detailed reminders to wait for staff to return when left in the bathroom; -if licensed staff failed to adequately supervise resident care; - if the facility needed additional gait belts to provide for staff use so they did not have to remove them from residents during toileting. Without a thorough investigation, the facility could not conclusively rule out neglect occurred. Refer to 42CFR 483.13(c) F 224 Prohibit Mistreatment/Neglect for facility failure to provide gastric tube services to avoid harm to Resident #1 during replacement of a gastric tube. Staff failed to stop the procedure when Resident #1 experienced pain and failed to conduct a thorough assessment of the resident's condition resulting in harm for Resident #1.

Based on observation, interview, and record review administration failed to effectively and efficiently manage resources to ensure facility compliance with federal regulatory requirements. Failure to ensure compliance related to gastric tube care and services resulted in harm for Resident #1 as referenced in F 224 and F 225 and Immediate Jeopardy in F 281; F 309 F 328 and F 353. Findings include: Administration failed to ensure licensed staff were qualified to provide gastric tube care and services and prevent neglect for Resident #1. Administration failed to ensure staff were aware of safe practices related to gastric tube care and recognized the potential for neglect and followed requirements for reporting, protecting residents and conducting a thorough investigation. Administration also failed to ensure staff conducted comprehensive assessments and monitored resident condition; licensed staff performed services according to professional standards of practice; staff completed accurate medical records. Administration failed to coordinate and ensure an outside provider program, which directed care for facility residents, understood facility policy and procedures. During an interview on 10/31/16 at 12:30 p.m., Administrative Staff Z reported he/she did not recall sharing facility policies and procedures with the outside provider when the facility got a contract with them. Findings include: The administrator is responsible for overall operations to ensure the facility meets and maintains compliance with regulations at all times and nursing services provide care and services that meet resident needs. HARM LEVEL CITATIONS: 1) Refer to 42CFR 483.13(c) F 224: Prohibit Mistreatment/Neglect for facility failure to provide services to prevent harm for Resident #1 during replacement of a gastric tube. Nursing staff failed to identify gastric tube replacements with a Foley catheter and in a gastric tube site less than six weeks old did not meet standards of facility and professional practice for safe care. The facility also failed to prevent extended us of a Foley catheter to infuse tube feedings and medications and immediately stop a tube resinsertion procedure when Resident #1 experienced pain. 2) Refer to 42CFR 483.13(c)(i)-(iii)(c)(2)-(4) F 225: Prohibit Mistreatment/Neglect/ Misappropriation for failure of staff to identify potential neglect or abuse may have occurred; immediately report complications that arose when nursing procedures were performed to replace a gastric (MIC) tube; failure to protect residents by removing all staff involved pending results of a facility investigation; and failure to thoroughly investigate gastric tube complications that resulted in harm for Resident #1 and thoroughly investigate a fall for Resident #2. IMMEDIATE JEAPORDY 3) Refer to 42CFR483.20 (k)(3)(i) F 281: Services Meets Professional Standards for facility failure to ensure staff performed duties per accepted professional standards of practice for Residents (#1 & 2); identify safe nursing practices related to gastric tube medication administration and management of newly inserted gastric tubes and tube replacement; and thoroughly and consistently assess and monitor for significant changes in condition. This failure represented a lack of vigilance, quality of care and system error breakdown that placed all residents at risk for the same/similar deficient practices as Resident #1, determined to represent Immediate Jeopardy. 4) Refer to 42CFR483.25 F 309: Care and Services/Highest Practicable for facility failure to conduct thorough and consistent assessment and monitoring of Resident #1 before, during and after gastric tube procedures and for pain. Resident #1 developed serious complications following insertion of a Foley catheter and MIC gastric tube requiring emergency treatment and surgery determined to be an Immediate Jeopardy. 5) Refer to 42CFR483.25 (k) F 328 Treatment Care for Special needs for facility failure to ensure Residents (#1 & 2) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with professional standards of safe clinical practice. Failures included not following manufacturer recommendations for administration of medications; replaceing a gastric tube on an unhealed gastric wound site; and lack of consistent assessment and monitoring of resident condition related to gastric care. The facility also failed to ensure all staff had knowledge of policies and procedures to not replace gastric tubes less than six weeks old. This avoidable failed practice placed all residents with gastric tube feedings at risk for harm and represented Immediate Jeopardy. 6) Refer to 42CFR483.30 F 353: Qualified Nursing Services: the facility failed to ensure licensed staff were qualified to perform gastric tube care and services for 2 Sampled Residents (#1 & 2) who had gastric tubes. Staff lacked knowledge facility policies and procedures; failed to confirm through observation, licensed nurses' demonstrated skills necessary to perform gastric tube reinsertion. The facility failed to ensure licensed nurses performed comprehensive assessment and monitoring of resident condition related to gastric tube procedures and throughout the resident's skilled nursing stay. These failures resulted in harm for Resident #1 and placed all other residents at risk for harm related to gastric tube care and represented Immediate Jeopardy. ADDITONAL FAILURES 7) Refer to 42CFR483.75 (l)(1) F 514 Clinical Records Meet Standards for facility failure to maintain medical records in accordance with professional standards of practice to ensure complete and accurate documented records for Sampled Resident #1. This failure resulted in facility inability to identify the physical, psychosocial and relevant outcome to Resident #1 who experienced complications from nursing care of a gastric tube. Lack of accurate and timely information in the clinical record had the potential to affect all residents in the facility when records did not contain all information necessary that described resident condition and care and services the facility provided.