Every finding on record at Buena Vista Healthcare

Based on observation and interview, the facility failed to maintain 1 of 1 ice machines (Ice Machine 1) in a sanitary manner. This failure placed the residents at risk of consuming contaminated ice and foodborne illness. Findings included.In the initial observation of the kitchen on 06/08/2026 at 10:45 AM, Ice Machine 1 was observed with thick dust debris covering the vents located on both sides of the machine. Staff D, Dietary Manager, stated the ice machine was cleaned on 06/05/2026.In a second observation of the kitchen on 06/11/2026 at 1:00 PM, Ice Machine 1 continued to be covered with thick dust debris that covered the vents located on both sides of the ice machine. In an interview on 06/11/2026 at 1:50 PM, Staff D stated it was important to keep the ice machine free of dust debris as the dust could enter the ice machine and cause contamination. In an interview and observation on 06/11/2026 at 2:50 PM, Staff E, Maintenance Director, stated the ice machine was cleaned monthly. Staff E observed the ice machine and stated it was important to keep the ice machine clean and to ensure it worked properly. Reference: WAC 388-97-1100(3), 2980

Based on observation, interview and record review, the facility failed to implement the bowel protocol for 1 of 5 sampled residents (Resident 2) reviewed for constipation. This failure put the residents at risk of discomfort and health consequences.Findings included.The facility policy titled, Bowel Protocol revised March 2023, documented staff were to check a resident's bowel record every shift and implement the following interventions if appropriate:1) Four ounces of prune juice to be given in the morning and evening if applicable on the third day with no bowel movement (BM),2) Give two Senna (laxative) or one Bisacodyl (laxative) tablet on the fourth day of no BM,3) If Senna or Bisacodyl were ineffective, Milk of Magnesia (MOM, laxative) was to be given on the next shift (day four), 4) If MOM was ineffective, a stimulant laxative suppository was to be given on the next shift,5) If the suppository was ineffective, an enema was to be given on the next shift,6) If the enema was ineffective, the nurse needed to complete a bowel assessment and notify the physicianThe 04/01/2026 admission assessment documented Resident 2 had diagnoses which included diabetes and depression. Resident 2 was cognitively intact and was dependent on staff for toileting. The 04/06/2026 care plan for Resident 2 did not address constipation, goals or interventions.Review of Resident 2's provider orders showed the following:-House bowel protocol: initiate at second day if no BM unless contraindicated, provider to specify contraindications-Bisacodyl suppository as needed for constipation, given on following shift if MOM was ineffective,-Bisacodyl tablet twice daily as needed for constipation, -Fleets enema as needed for constipation, given on following shift if suppository was ineffective,-MOM as needed for constipation, given on the third day of no bowel movement,-Prune juice twice daily as needed for constipation,Review of Resident 2's bowel record from 05/01/2026 through 06/10/2026 showed no BM from 05/05/2026 to 05/08/2026 (four days), 05/10/2026 to 05/12/2026 (three days), and 06/08/2026 to 06/10/2026 (three days).The May and June 2026 Medication Administration Record (MAR) showed Resident 2 received Prune juice on 05/13/2026. The facility failed to follow the BM protocol.In an interview on 06/12/2026 at 9:15 AM, Staff G, Nursing Assistant, stated BMs were monitored and documented every shift. Staff G stated Resident 2 experienced constipation. In an interview on 06/12/2026 at 10:56 AM, Staff D, Registered Nurse, stated bowel movements were monitored every shift and a small bowel movement did not count. Staff D stated MOM was given on the third day of no BM and if that was ineffective a suppository was administered 24 hours later. Staff D stated it was important to administer bowel medications to prevent bowel obstruction and pain. In an interview on 06/12/2026 at 1:56 PM, Staff B, Director of Nursing, stated nursing printed a bowel report twice daily. Staff B stated prune juice was given on the third day with no BM and if ineffective the physician's bowel orders were followed. Staff B stated it was their expectation nursing administered bowel medications as ordered to prevent obstruction. Reference: WAC 388-97-1060(1)-(3)

Based on observation, interview, and record review the facility failed to implement resident specific interventions to prevent pressure ulcer/injuries for 1 of 4 sampled residents (Resident 2) reviewed for pressure ulcers. This failure placed residents at risk for development of pressure ulcers, medical complications, and unmet care needs. Findings included .Review of the facility's policy titled Skin Integrity updated March 2026, documented if a resident admitted with or developed a skin ulcer/pressure ulcer/wound, care would be provided to treat, heal, and prevent, if possible further development of skin ulcers/pressure ulcers/wounds. Review of the 03/26/2026 Braden assessment, (an assessment that explains the risk of getting skin breakdown) documented a score of 17, which indicated Resident 2 was at risk for skin breakdown. The 03/26/2026 skin integrity care plan showed Resident 2 was at risk for skin breakdown related to incontinence, left foot drop (the inability to lift the front part of the foot) and polyneuropathy (condition where multiple peripheral nerves outside the brain and spinal cord were damaged at the same time and caused numbness, tingling, weakness and pain in the hands and feet). The 03/26/2026 care plan had no documentation of prevention of skin issues or pressure ulcers. The 04/01/2026 annual assessment documented Resident 2 had diagnoses that included diabetes, polyneuropathy and depression. The assessment documented Resident 2 was identified as being at risk of developing pressure ulcers. Review of a progress note dated 04/09/2026 at 3:30 PM, documented Resident 2 complained of left heel pain. A light purple non blanchable area to the back of Resident 2's left heel was found. The 04/09/2026 facility incident investigation showed Resident 2 was found to have a suspected deep tissue injury (SDTI, a severe localized pressure ulcer or injury) to their left heel. A care plan intervention was added at that time to place a pressure relieving boot on Resident 2's left heel while in bed and a non-skid sock was to be worn for transfers. The 06/08/2026 updated care plan showed to float Resident 2's heels and on 06/09/2026 the care plan showed a STDI to Resident 2's left heel. During an observation and interview on 06/08/2026 at 3:02 PM, Resident 2 was lying in bed and had a pillow under their legs. The weight of Resident 2's legs pushed the pillow down and their heels were resting on the bed. Resident 2 stated they had a blister on their heel and acquired it at the facility. Resident 2 stated it was possibly related to their bed because they were large for the size of their bed. In an interview on 06/12/2026 at 10:56 AM, Staff D, Registered Nurse, stated it was determined if a bed was large enough by assessing the resident's height, weight and ensuring their feet were not squished up against the bed. Staff D stated they had never seen Resident 2's heels resting on the foot board of the bed and felt they had enough room. Staff D stated they knew what care to provide the residents with by looking at their notes in their room and by their plan of care. Staff D stated residents who were at risk for breakdown had interventions placed on their care plans. In an interview on 06/12/2026 at 12:12 PM, Staff B, Director of Nursing, stated for residents who were at risk for skin breakdown, their heels were floated, a Braden scale was completed, and interventions were determined after the resident's assessment. Staff B stated all residents had a pressure relieving mattress and acknowledged Resident 2 did not have specific interventions in place to prevent skin breakdown to their heel. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to develop care-planned goals and interventions related to peripheral edema (swelling of the lower legs, ankles and feet due to fluid buildup caused by poor circulation, heart, liver, or kidney conditions or certain medications) for 2 of 2 sampled residents (Residents 5 and 44) reviewed. This failure placed the residents at risk for possible worsening health conditions and decreased quality of life.Findings included. The 03/05/2026 Cleveland Clinic Pitting Edema retrieved at https://my.clevelandlinic.org/health/symptoms/pitting-edema defined pitting edema as a type of swelling where pressure on an affected area left a dent in the skin and was usually the sign of a serious health condition. The extent of the edema was graded on a scale of one to four and included pressing on a swollen body part for five or more seconds and measuring the depth of the indent. Grade 1 edema was defined as an indent depth of 2 millimeters (mm). Grade 2 depth measured 3-4 mm, Grade 3 depth measured 5-6 mm, and grade 4 depth measured 8+ mm. The deeper the dent, the more severe the swelling was. Possible consequences of pitting edema included venous ulcers, pressure injuries or slow wound healing. <Resident 5> The 05/20/2026 baseline care plan had no goals or interventions developed related to Resident 5's lower extremity edema. There were no orders obtained to monitor the edema that was present when Resident 5 was admitted . The 05/26/2026 comprehensive admission assessment documented Resident 5 had diagnoses that included hypo-osmolality (loss of electrolytes in the blood such as sodium, and potassium or water retention forces water into cells and causes them to swell), hyponatremia (low levels of sodium in the blood) and high blood pressure. Resident 5 needed partial assistance of staff for most Activities of daily living (ADLs) and was cognitively impaired. The 05/26/2026 Medical Doctor admission History and Physical documented Resident 5 was admitted to the hospital for severe right hip pain. While there, the resident had mild ongoing hyponatremia related to a diuretic medication (a medication that flushed the kidneys of excess sodium and water from the body that relieved swelling and lowered blood pressure.) The medication was discontinued during the hospitalization to allow sodium levels to recover. The 05/26/2026 admission Nursing Assessment documented Resident 5 had 2+ non-pitting edema of both lower extremities. On 06/09/2026 at 9:33 AM, Resident 5 was observed resting on top of their bed. Resident 5 had a pillow under their knees that elevated their lower legs; their heels were resting on the mattress. The resident was barefooted, and their lower legs, ankles, and tops of their feet were puffy. Resident 5 stated they were unsure when their feet became puffy and it was uncomfortable. On 06/10/2026 at 9:04 AM, Resident 5 was resting on their bed visiting a family member. Resident 5's lower legs were elevated with a pillow and their heels rested on the mattress. Resident 5 had on a pair of non-skid slipper socks. The elastic at the top of the socks pressed into their lower leg above the ankle and left very clear indentations. A similar observation of the socks pressing into Resident 5's lower legs was seen on 06/11/2026 at 8:17 AM. On 06/11/2026 at 2:00 PM, Resident 5's lower legs and feet were observed with Staff H, Nursing Assistant. Staff H stated they had showered Resident 5 and the resident returned to rest in their bed. Resident 5's lower legs were elevated on a pillow. The non-skid slipper socks had been removed, and lines where the socks had pressed into the resident's skin could be seen above both ankles. The tops of the feet were puffy. Resident 5 had a family member present. They stated Resident 5's legs had gotten noticeably puffier since their admission. The family member stated the resident's fluid pill had been stopped at the hospital because of their sodium level. The family member stated the same thing had happened in the past and Resident 5's legs became so swollen it affected their ability to walk and they had told one of the nurses about this the week prior. During an interview on 06/12/2026 at 9:23 AM, Staff H stated Resident 5's feet and lower legs had been puffy all of the times they cared for the resident. They stated Resident 5 was at risk for skin breakdown and it was important to keep their heels elevated off the mattress. They stated if they noticed any resident's legs or feet becoming more swollen they reported it to the nurse. During an interview on 06/12/2026 at 10:57 AM with Staff B, Director of Nursing and Staff C, Resident Care Manager, Staff B stated Resident 5 had 2+ edema documented on their admission nursing assessment. Staff C stated they saw a progress note dated 06/04/2026 that documented the resident had a trace amount of edema. Staff B stated follow up blood work had been done to recheck Resident 5's sodium levels before the resident's medication was restarted. Staff B and Staff C agreed that an order to monitor Resident 5's edema should have been obtained and added to Resident 5's plan of care. On 06/13/2026 at 8:08 AM, Resident 5's lower legs were observed with Staff I, Licensed Practical Nurse. Staff I removed non-skid socks from the resident's feet. Fingertip pressure was applied to the tops of the resident's feet, and indentations formed. There were lines across the resident's legs above their ankles where the elastics from the socks had pressed into the skin. Staff I stated the edema was 2+ pitting edema. <Resident 44> The medical record documented Resident 44 had diagnoses that included chronic kidney disease (CKD, when the kidneys are damaged and cannot filter blood properly) and high blood pressure. The 06/02/2026 admission skin assessment documented Resident 44 had generalized edema. The assessment did not specify the grade of edema. The 06/02/2026 base line care plan did not have a care area, goals or interventions developed related to Resident 44's CKD, high blood pressure or edema. A 06/09/2026 physician progress note documented Resident 44 had 1+ edema to their bilateral lower extremities. The note instructed nursing staff to monitor blood pressure, renal function and symptoms of fluid overload. Review of Resident 44's Medication Administration Record and Treatment Administration Record (MAR/TAR) showed no edema monitoring. Review of Resident 44's progress notes from 06/02/2026 through 06/12/2026 showed there was a note on 06/06/2026 that stated the resident had minimal edema. There were no other notes in Resident 44's medical record that addressed their edema. In an observation on 06/08/2026 at 12:54 PM, Resident 44 was sitting in their recliner in their room and their legs were visible. Resident 44's legs were edematous (swollen with an excessive accumulation of fluid), shiny and taut (stretched or pulled tight) in appearance. In an observation on 06/10/2026 at 8:48 AM and 06/11/2026 at 8:13 AM, Resident 44 was sitting in their recliner in their room. Resident 44's legs were edematous, shiny and taut. In an observation with Staff D, Registered Nurse, on 06/12/2026 at 11:53 AM, Resident 44 was sitting in their recliner in their room. Staff D assessed Resident 44's legs. Resident 44's family member was present and stated their edema had worsened. Staff D stated an edema monitor needed to be in place. Resident 44's family member stated they had a prescription from the primary care physician for Lasix (a diuretic that rids the body of fluid) for three days at a time when needed and that was helpful. At 11:57 AM, Staff D stated Resident 44 had 2-3+ pitting edema to their mid-calf. In an interview on 06/12/2026 at 11:58 AM, Staff D stated edema monitoring was placed depending on the resident's admitting diagnoses. Staff D stated if a resident was admitted with edema, an edema monitor was put in place. Staff D stated it was important to monitor edema, so heart failure and vascular compromise did not occur. In an interview on 06/12/2026 at 12:05 PM, Staff B, Director of Nursing, stated edema monitoring depended on the resident's diagnoses and orders. Staff B stated if a resident was admitted with edema, an edema monitor was typically put in place. Staff B stated Resident 44's main admitting diagnosis was a pelvic fracture and that could result in edema. Staff B stated the nurses should have monitored Resident 44 for edema. Staff B stated it was important to monitor edema because it had the potential to cause cardiac and kidney problems. Reference: WAC 388-97-1020(1)(2)(a)(b)

Based on record review and interview, the facility failed to develop a comprehensive plan to prevent the growth of water-borne viruses and bacteria such as Legionella (bacteria that caused a potentially fatal form of pneumonia when water mist or vapor that contained the bacteria was inhaled) for the Water Management Plans reviewed. This failure placed residents at risk of illness and decreased quality of life. Findings included . The 09/30/2025 Centers for Disease Control and Prevention (CDC) Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings toolkit documented healthcare facilities where people with chronic medical problems or weakened immune systems were housed were at increased risk for Legionella. A water management program included the following key steps:-establishing a water management program team,-describing the building water systems using text and flow diagrams,-identifying areas where Legionella could grow and spread,-deciding where control measures should be applied and how to monitor,-establishing ways to intervene when control limits are not met,-making sure the program is running as designed and is effective, and-documenting and communicating the activities.On 06/12/2026 at 12:50 PM, the facility Water Management Plan was reviewed. The plan included a document that identified the facility was at risk for Legionella because of their population served and included a diagram of the facility water systems. A corporate policy was provided that described what Legionnaires disease was and the symptoms when infected with Legionella bacteria. The policy discussed what the facility would do if there was an outbreak and the areas in facility water systems in general created a risk for growth of Legionella. There was no documentation in the plan that showed facility risks for growth of Legionella had been identified, where the risks were in the facility, what the facility did to mitigate their risk, and how the plan was monitored. The plan had no documentation regarding who made up the Water Management Team, what activities the team would undertake and how the team's activities were documented and communicated.The facility Legionella Water Temperature Log 2026 documented resident rooms and areas in the facility where water temperatures were monitored. The log documented Legionella grew best in the range of 77-113 degrees Fahrenheit and if water temperatures were within that range an adjustment was needed. There were no temperatures recorded that warranted an adjustment for each month of 2026.During an Interview on 06/12/2026 at 2:39 PM, Staff A, Administrator, acknowledged areas of the Water Management Plan that needed further development. Reference: WAC 388-97-1320(1)(a)

Based on interview and record review, the facility failed to obtain consent for psychotropic medications (medications that affect the mind, mood, and emotions) prior to administration of the first dose, for 1 of 5 sampled residents (Resident 2), reviewed for unnecessary medications. This failure placed the resident at risk of not being fully informed of the risks and benefits of medications and making a fully informed choice about their medical care.Findings included .On 02/09/2026, a provider order was given to administer risperidone (a medication used to treat PTSD) daily.The March 2026 medication administration record showed Resident 2 received their first dose of risperidone on 03/26/2026.The 04/01/2026 admission assessment documented Resident 2 had diagnoses that included depression and post-traumatic stress disorder (PTSD, a mental health condition caused by an extremely stressful or terrifying event). Resident 2 was cognitively intact and received medication for PTSD. The 04/06/2026 psychotropic medication use care plan documented Resident 2 received psychotropic medications. The care plan instructed nursing staff to administer the medications as prescribed and to obtain informed consent for usage. A review of Resident 2's medical record showed the informed consent for the risperidone was obtained via verbal consent from Resident 2 on 06/04/2026. In an interview on 06/12/2026 at 10:56 AM, Staff D, Registered Nurse, stated they were unsure when psychotropic medication consents needed to be obtained. Staff D stated it would be important to obtain the residents' consent, so they were aware of the risks of the medication. In an interview on 06/12/2026 at 1:56 PM, Staff B, Director of Nursing, stated informed psychotropic consents needed to be obtained the day the medication was started. Staff B stated it was important to obtain the consent prior to administration because the residents could have a reaction to the medication and needed to be aware of the risks. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b).

Based on observation, interview and record review, the facility failed to ensure a urinary catheter system (a tube inserted into the bladder that drained urine into a collection bag) was maintained in a clean manner for 1 of 1 sampled residents (Resident 22) reviewed. This failure placed the resident at risk for infection and injury if the collection bag and tubing were damaged. Findings included.The 05/04/2026 quarterly assessment documented Resident 22 had diagnoses that included obstructive uropathy (blockage in the urinary tract that prevents urine flow) and urinary retention. The resident had an indwelling catheter and required a wheelchair for mobility.The 03/13/2020 bowel and bladder care plan documented Resident 22 had a suprapubic catheter (a surgical opening above the pubic bone with a tube inserted through it into the bladder) because of urinary retention. Staff were instructed to clean the catheter every shift, ensure the urinary collection bag was hung below the bladder (to prevent backflow of old urine) and that there were no kinks in the tubing. Staff were to maintain the resident's dignity with a dignity bag that covered and were to make sure the tubing to the catheter was secured to prevent the catheter from being pulled out. On 06/08/2026 at 2:28 PM, Resident 22 was observed scooting in their wheelchair. A urinary collection bag was in a canvas dignity bag and was hung on the frame under the seat of the resident's wheelchair. The tubing from the collection bag was dragging on the floor next to the front small wheels of the resident's chair, went under their pant leg and up to the catheter insertion site. The dignity bag was dark blue and had greyish colored dirt smears and a wad of lint on the outer bottom part of the bag.Similar observations of the dignity bag showed greyish colored dirt smears and the catheter dragging on the floor were made on 06/10/2026 at 8:41 AM, 06/11/2026 at 8:20 AM, and 06/12/2026 at 9:23 AM. During an interview on 06/12/2026 at 9:23 AM, Staff H, Nursing Assistant, stated that when Resident 22 was assisted into their wheelchair, they hung the collection bag under the seat of the wheelchair in the dignity bag. Staff H stated the resident wore a strap around their leg to prevent the tubing from getting pulled and they had to make sure the tubing was not wrapped around anything. Staff H stated the dignity bag was made of heavy fabric. They stated there was no schedule to change the dignity bag with a clean one, but there probably should have been because it hung so low. Staff H stated the bag could be sent to the laundry to be washed and the resident's got lint and stuff on it.On 06/12/2026 at 1:21 PM, Staff H was observed emptying Resident 22's urinary collection bag. Staff H put on a gown and gloves and removed the collection bag from the dignity bag. The dignity bag remained below the seat of the wheelchair and was on the floor. The tubing dragged on the floor as the collection bag was drained. Staff H placed the collection bag in a basin and removed the dignity bag from the frame of the wheelchair. The bag had a large wad of lint stuck to the bottom, and the fabric was covered on the bottom with dirt and debris from the floor and it was no longer pliable. Staff H replaced the dignity bag with a new, clean one. During an interview on 06/12/2026 at 3:10 PM with Staff B, Director of Nursing, and Staff C, Resident Care Manager, Staff B stated it was not recommended to have the dignity bag and catheter tubing dragging on the floor. Staff C stated the floor was not sanitary, and there was a risk of running over the tubing with the wheelchair, risk of breaking the bag open, and increased risk of infection. Staff B stated if the dignity bag and tubing were noticed on the floor, they expected staff to clean the tubing and replace the dignity bag with a clean one and keep them off of the floor. Reference: WAC 388-97-1060(3)(c)

Based on observation, interview, and record review, the facility failed to ensure the immediate environment of 5 of 6 sampled residents (Residents 18, 16, 24, 3, and 21) reviewed for environment, was free from visible clinical information prior to assessing if it violated the resident's privacy. Findings included . <Resident 16> An observation and interview in Resident 16's room on 02/11/2025 at 09:09 AM showed signage on the overhead light that read, 2 per FWW [ a walker], Do not bend more than 90 degrees, and Please float right heel. Additionally observed was a laminated sign on the wall and under the overhead light for posterior hip precautions. Review of a 01/27/2025 admission assessment showed the staff assessed Resident 16's cognition was intact. Resident 16 had a roommate. When asked about knowledge of the signage with care directives, Resident 16 stated, I don't know what they are. I can't read them anyway. I don't know what they say. <Resident 24> An observation and interview in Resident 24's room on 02/11/2025 at 9:13 AM showed signage on the overhead light that read, 2 per [NAME] [ a mechanical lift]. Progress notes review from 10/04/2024 to 02/14/2025 showed the staff assessed Resident 24 was, alert and oriented, able to make [their] needs known. Resident 24 had a roommate. <Resident 21> An observation and interview in Resident 21's room on 02/11/2025 at 9:42 AM showed signage on the overhead light that read, 1 per FWW bed [to] wc [wheelchair] and 1 per grab bar wc [to] toilet. A 12/20/2024 quarterly assessment showed the staff assessed Resident 21's cognition was intact. Resident 21 stated, I can't read it. Is it about me? Resident 21 had a roommate. <Resident 3> An observation and interview in Resident 3's room on 02/11/2025 at 9:20 AM showed signage on the overhead light that read, 1 or 2 person (Gait belt), L [left] extremely weak. Resident 3 stated, That was for the person who was here before. I didn't ask for it. Review of progress notes from 10/01/2024 to 02/14/2025 showed the staff assessed Resident 3 was alert and oriented and able to make needs known and sometimes minimally confused. Resident 3 had a roommate. <Resident 18> An observation and interview in Resident 18's room on 02/11/2025 at 9:52 AM showed signage on the overhead light that read, Supervision only (no fww, no w/c). Resident 18 stated, I don't know what the sign is for. Review of the medical record showed Resident 18's cognition was impaired and had a designated Power of Attorney. The above information was shared with Staff B, Director of Nursing, on 02/13/2025 at 8:49 AM. Staff B acknowledged the visibility of the clinical information on the overhead lighting was not limited to the staff, but visible to visitors, roommates, and outside vendors. Staff B stated that the use of the signage was, basically like a bedside care plan. Staff B was asked for documentation that showed the residents or their representatives were involved in opting for the signage, to include ascertaining whether they wished to have signage with clinical information posted in visible areas in their room and other alternatives discussed to ensure clinical information was kept private. No information was provided to show the residents or their representatives directed the use of the signage. No further information was provided. Reference WAC 388-97-0360, -0500(1).

Based on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (Residents 16 and 24) reviewed for hospitalization s. This failure placed the residents at risk for a disruptive and ineffective transition from the facility to the hospital setting. Findings included . <Resident 16> Review of a 01/17/2025 progress note showed Resident 16 experienced a change in condition which required a transfer to the hospital. Review of the medical record showed no documentation the facility communicated to the hospital basic information of the resident's status necessary for a safe transition of care, such as contact information for their provider, family or representative, code status, advanced directives, plan of care and treatment, current medications and the reason for the hospital transfer, as required. <Resident 24> Review of a 6/10/2024 progress note showed Resident 24 experienced a change in condition which required a transfer to the hospital. Review of the medical record showed no documentation the facility communicated to the hospital adequate and required communication at the time of the resident's transfer. The above information was shared with Staff B, Director of Nursing, on 02/13/25 at 9:12 AM. Staff B acknowledged the medical record showed no documentation of what the staff communicated to the hospital at the time of the transfer. No further information was provided. Reference WAC 388-97-0120.

Based on observation, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when staff were observed serving food without using appropriate hand hygiene for 1 of 3 dining observations. Staff were also observed carrying cups with bare hands touching the rims of drinking surfaces. This failure increased the resident's risk for food borne illness. Findings included . Review of the facility's policy titled, Handwashing/Hand Hygiene, dated May 2015, showed use of an alcohol-based hand rub before and after direct contact with residents, before and after handling food and before and after assisting a resident with meals. During the lunch time dining observation on 02/10/2025 at 11:18 AM, staff J, Nursing Assistant, was observed bringing residents into the dining room, moving in and out of the kitchen without performing hand hygiene. Staff J was also observed serving beverages with bare hand contact touching the rim of the cups without performing hand hygiene. At 12:20 PM, Staff J was observed touching dirty dishes, toughing their face and clothing, then touching residents, tables, and wheelchairs while continuing to serve their lunch meal, no hand hygiene observed. This staff member was also observed removing oxygen tubing from around a resident's wheelchair, then resumed serving drinks without performing hand hygiene. At 11:37 AM, Staff L, Nursing Assistant, was observed serving cocoa and coffee to residents having bare hand contact with the rim of the cups. During this lunch meal observation, multiple observations were made of Staff L touching their face, facial hair, and clothing, going in and out of the kitchen, adjusting resident glasses, oxygen tubing and wheelchairs without performing hand hygiene. At 12:11 PM, Staff I, Nursing Assistant, brought a resident into the dining room in a wheelchair and served them cocoa touching the rim of the cup with bare hands, no hand hygiene was observed. This staff member then began picking up dirty dishes, then without performing hand hygiene, began assisted with serving lunch. During this observation they were touching utinsels, cups, and the computer tablet which was under her arm, then washed a residents face without performing hand hygiene. At 12:23 PM, Staff A, Administrator, was observed going in and out of the dining room without performing hand hygiene. This staff member was also observed serving residents their lunch meal without performing hand hygiene. In an interview on 02/14/2025 at 12:13 PM, Staff J, NAC, when asked about hand hygiene, stated you should wash your hands any time you touch something, when you put on or take off gloves, when you take out the trash, and between trays when serving meals. Staff J further stated they were very nervous on the first day of survey during lunch and probably didn't wash their hands enough. WAC 388-97-2980 & [PHONE NUMBER]0

Based on observation, interview, and record review, the facility failed to provide grooming for 1 of 3 sampled residents (Resident 35), reviewed for activities of daily living (ADLs). This failure placed the resident at risk for poor personal hygiene and a diminished quality of life. Findings included . According to the 01/23/2025 Baseline care plan, Resident 35 required assistance from staff to complete ADLs such as personal hygiene, dressing, and grooming. Observations of Resident 35 were made while they were sitting in their wheelchair in their room and during group activities with the same clothes on, long facial hair and long jagged fingernails, were made on 02/11/2025 at 09:32 AM, 02/12/2025 at 09:51 AM, and 02/13/2025 at 08:56 AM and again at 02/13/2025 at 01:24 PM In an interview on 02/12/2025 at 09:51 AM, Resident 35 stated they had been in the same clothes for three or four days, since their shower on 02/09/2025. They further stated that the clothes belonged to the facility because their clothes were being laundered at the time of their shower. Resident 35 said their daughter had brought in clean clothes on 02/11/2025, but no one had offered to change her into them. When asked if they changed into night clothes, Resident 35 stated no. When asked if they had been asked to have their fingernails trimmed or their facial hair shaved, Resident 35 stated no. In an interview on 02/13/2025 at 01:15 PM, Staff O, Nursing Assistant, Bath aide, stated the residents were shaved and their nails were trimmed at least weekly during their bath. They further stated that those tasks were a scheduled task for the Nursing Assistants to document. When asked about Resident 35, Staff O stated they were unfamiliar with that resident because they preferred female caregivers and further stated that Occupational Therapy (OT) had given them their shower that week. In an interview on 02/13/25 at 01:24 PM, Staff M, Nursing Assistant, stated Resident 35 frequently refused baths and ADL cares and it should be documented on their task screen. During this same conversation, Staff N, Nursing Assistant, stated Resident 35 refused to change into different clothes that morning. In review of Resident 35 ADL documentation, no documentation related to nail care or shaving was found. Additionally, one refusal to change clothes had been documented by Staff N on 02/13/2025 at 1:59 PM, after having the above conversation, no other refusals were documented. In an interview on 02/13/2024 at 2:32 PM, Staff B, Director of Nursing, stated it was their expectation that residents were offered to change into their night clothes. Staff B further stated the OT staff should shave and trim nails if they provided the shower. Reference: (WAC) 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to coordinate hearing services for 1 of 1 sampled resident (Resident 24) reviewed for communication. This failure placed the resident at risk for unmet needs and a diminished quality of life. Findings included . Review of a nursing admission evaluation showed Resident 24 admitted to the facility on [DATE]. The evaluation showed the staff assessed Resident 24 was hard of hearing in both ears. An observation on 02/10/2025 at 3:06 PM showed Resident 24 in bed. Resident 24 had difficulty hearing and answered written questions. A Caption Telephone (CapTel) was on the bedside table to the resident's right side. The CapTel transcribed what the caller said into written words. Captions can be read if the resident cannot hear what the caller was saying over the telephone. An observation on 02/11/2025 at 11:15 AM showed Staff E, Licensed Practical Nurse (LPN), preparing medications to administer to Resident 24. Staff E stated that they when they had difficulty communicating with Resident 24, they would, write stuff down on a pad. Works well. In an interview on 02/10/2025 at 5:34 PM, a Resident Representative (RR) stated that Resident 24, has a set up on his telephone. It types things. The RR stated that the facility tried a hearing aid and Resident 24 also asked the RR to buy them a hearing aid, in the past. The RR stated that they were unsure how the staff communicated with Resident 24. On 02/12/2025 at 3:43 PM, Staff F, LPN, stated Resident 24 was hard of hearing. Staff F stated that they communicated with the resident by, we just speak loud and clear and make eye contact, and at other times use hand gestures. Staff F stated that the facility offered the resident a hearing aid, but the resident refused it, like within the last month. Staff F stated that they would report changes in communication to the Social Services Director (SSD). On 02/12/2025 at 3:53 PM, Staff G, Nursing Assistant, stated Resident 24 was, definitely hard of hearing. Staff G described the facility provided like the brand-new hearing aids to the resident that enabled them to hear, but the resident didn't like them. Staff G described how the staff had to get close to and make good eye contact to communicate with the resident as the resident was, usually really good at reading lips. Staff G stated that when changes in communication were identified, they would immediately go to the nurse and from there tell the higher-ups. Review of progress notes from 10/04/2024 to 02/13/2025 showed no documentation of the hearing aid the facility provided to Resident 24, as mentioned by Staff F and G in the 02/12/2025 interviews. Review of a 04/08/2024 Communication care plan showed no acknowledgment of Resident 24's specific difficulty hearing. The care plan showed a goal of, The resident will be able to make basic needs known through the review date, and instructed the staff to, Refer [the resident] to Audiology for hearing consult as ordered, Refer to speech therapy for evaluation and treatment as ordered, and, Report to Nurse changes in: Ability to communicate, Possible factors which cause/make worse/make better any communication problems. All the interventions in the Communication care plan were dated 04/08/2024 and showed no indication the staff re-assessed their effectiveness and revised them; to include the presence of a CapTel and the role it served in aiding Resident 24 hear better, or staff use of hand gestures or written communication to compensate for the resident's hearing deficits. Review of Quarterly Social Services progress notes dated 06/25/2024, 09/25/2024 and 12/25/2024 showed the staff identified, Sensory Concerns of Hearing. On 02/13/2025 at 10:49 AM, Staff D (SSD) stated Resident 24, is just hard of hearing. It's definitely progressed in the last few months I think. Staff D stated Resident 24 had, some hearing troubles when [they] first came in but worsened now. Staff D stated when they communicated with the resident, Sometimes I have to repeat myself. I think it's also the tone of voice, too, the frequency. I just get closer to [their] ear so [they] can hear me better. Staff D was asked about the CapTel device in Resident 24's room and stated the Resident, had a friend in New Jersey who ordered it. Staff D stated the CapTel phone had been in use since 08/30/2024 but, have not seen [the resident] use it. Staff D stated the use of the CapTel, is probably something that could be added to the care plan. Staff D stated they did not know of the hearing aid trial the RR and staff mentioned in the interviews. Staff D reviewed Resident 24's medical record and stated, I do not see anything about this hearing aid trial, to include why the hearing aids failed or were refused by the resident, or what other alternatives were explored to facilitate the resident's hearing ability. When asked if the facility coordinated an audiology referral as instructed by the care plan, Staff D stated, Not yet. On 02/13/2025 at 1:35 PM, Staff H, Speech Therapist, stated, About 5 years I've been working in this building, and I've actually never worked with [the resident]. Staff H stated that they did not recall a referral being sent to them to evaluate Resident 24's communication deficits. Staff H stated that for hearing concerns, the resident, would be sent out to the audiologist for recommendations. No further information was provided by the facility to show it assisted Resent 24 or their representative in locating and utilizing available resources to facilitate and address Resident 24's hearing needs. Reference WAC 388-97- 1060(3)(a).

Based on observation, interview and record review, the facility failed to develop the care plans for 2 of 12 sampled residents (Residents 16 and 24) whose care plans were reviewed. This failure placed the residents at risk for inadequate care and a diminished quality of life. Findings included . <Resident 16> Observations on 02/11/2025 at 8:55 AM, 02/12/2025 at 8:49 AM, 11:18 AM, and 2:47 PM, and 02/13/2025 at 8:32 AM, showed Resident 16 had an abductor wedge between their legs. An abductor wedge helped to stabilize the hip joint after hip surgery and reduced this risk of the hip joint dislocating. Review of Resident 16's care plan and February 2025 Treatment Administration Record showed no directions to the staff for the use of the abductor wedge. The above information was shared with Staff C, Minimum Data Set Coordinator/Registered Nurse (RN) on 02/13/2025 at 11:46 AM. Staff C acknowledged Resident 16's care plan did not include the direction to the staff to use the abductor wedge and stated, It should include the wedge cushion. Review of a provider note dated 02/11/2025 showed, Patient has a history of atrial fibrillation [a heart rhythm disorder] and CHF [congestive heart failure, a chronic condition where the heart muscle is weakened and cannot pump blood efficiently throughout the body leading to buildup of fluid or edema in the lungs, legs, and other organs]. The provider note showed the resident, is currently on Furosemide [a medication that increases urine output] and instructed the staff to monitor the resident's weights and adjust the Furosemide dose accordingly. The note also showed Resident 16 transferred from the facility to the hospital on 01/17/2025 and required treatment for the atrial fibrillation. Review of the care plan showed no documentation the staff acknowledged the active and treated diagnoses of atrial fibrillation or congestive heart failure and identified the resident's nursing needs related to the diagnoses or the interventions required to meet associated needs and goals. On 02/13/2025 at 11:51 AM, Staff C acknowledged the staff should have developed the care plan to show nursing management of active and currently treated disease process. Review of Resident 16's February 2025 Medication Administration Record showed the staff administered Trazodone (an antidepressant) daily at bedtime for depression since 01/15/2025. Review of the care plan showed no documentation how the depression manifested, the goals directly related to the currently treated depression, or how the staff helped the resident achieve the goals. In an interview on 02/13/2025 at 10:45 AM, Staff D, Social Services Director, acknowledged the care plan was not resident-centered. <Resident 24> Review of a 02/05/2025 care plan showed, The resident has a mood problem r/t [related to] insomnia with a goal of, The resident will have improved sleep patterns through the review date. The care plan carried two interventions, Administer medications as ordered. Monitor/document for side effects and effectiveness and Monitors [sic] hours of sleep via sleep monitor per facility protocols. The care plan showed no documentation of what disturbed Resident 24's sleep or what non-pharmacological interventions improved sleep patterns. In an interview on 02/13/2025 at 10:34 AM, Staff D acknowledged the care plan showed no resident-centered interventions to help attain better sleep hygiene. Reference WAC 388-97-1020(1), (2)(a)(b).

Based on observation, interview, and record review the facility failed to implement interventions to prevent pressure ulcer/injuries for 1 of 3 sampled residents (8). Resident 8 experienced harm when they developed avoidable pressure ulcers.This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs. Findings included . <Resident 8> Review of the facility's policy titled Skin Integrity updated October 2022, documented if a resident admitted with or developed a skin ulcer/pressure ulcer/wound, care would be provided to treat, heal, and prevent, if possible further development of skin ulcers/pressure ulcers/wounds. Review of the annual assessment, dated 02/16/2024, showed Resident 8 had diagnoses which included dementia, contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused joints to shorten and become very stiff) to the left and right knees and a contracture to the right ankle. The assessment documented Resident 8 was identified as being at risk of developing pressure ulcers and had a Stage II pressure ulcer (a shallow open ulcer with a red or pink wound bed) on their right great toe. Review of Resident 8's care plan dated 11/14/2019, documented Resident 8 was high risk for skin breakdown related to limited mobility, contractures to bilateral feet, left second toe abrasion and fragile skin. The care plan had been updated to reflect a pressure ulcer to Resident 8's second toe on 11/23/2023 and a pressure ulcer to their third toe on 02/28/2024. Review of the care plan showed no interventions specific to Resident 8's care needs were documented regarding treatment and prevention of pressure ulcers to their toes. Review of a progress note dated 11/23/2023 at 10:23 AM, documented a pressure ulcer was found on Resident 8's right great toe due to the second toe being pressed up against it. Review of the 11/23/2023 Braden assessment, (an assessment that explains the risk of getting skin breakdown) documented a score of 13, which indicated Resident 8 was a high risk for skin breakdown. Review of a progress note dated 12/09/2023 at 10:40 AM, documented Resident 8's right great toe was observed to have an indentation from pressure placed on it from direct contact of the second toe. No documentation was found to show that interventions were implemented to prevent further skin breakdown. Review of a progress note dated 12/17/2023 at 10:11 AM, documented Resident 8's right great toe did not have an open wound, but an indentation was present due to continuous pressure against the second toe. The note documented the left side of the second toe was red with no broken skin. No documentation was found to show that interventions were implemented to prevent further skin breakdown. Review of a progress note dated 12/31/2023 at 10:44 AM, documented Resident 8 had a bandage on their right great toe to provide a cushion against pressure caused from the second toe, and the left side of the second toe had a very thin scab. Review of a progress note dated 01/14/2024 at 1:25 PM, documented the area between Residents 8's the right great toe and second toe was dark red, and a double layer of foam dressing had been applied. Review of a progress note dated 01/25/2024 at 11:35 AM, documented Resident 8's right great toe had a foul smell, drainage and yellow slough (a yellowish, moist, stringy substance that can delay wound healing) inside the indentation where the second toe had pressed into the side of the great toe. Review of a progress note on 02/25/2024 at 9:07 AM, documented Resident 8's right great toe, second and third toes had pressure wounds. The wounds were between the toes and were the result of the toes curling up and putting pressure on the insides of the toes, which created open oozing wounds. Review of a progress note dated 02/28/2024 at 2:05 PM, documented two new pressure areas to Resident 8's toes during weekly skin observation assessment. New areas were observed to the inside of the right second toe, and to the inside of right third toe. These areas were caused from the toes crossing over each other. Review of Resident 8's Braden assessment on 02/28/2024, documented a score of 15, which indicated they were high risk for skin breakdown. The assessment showed the resident had an increased risk for skin breakdown from the previous assessment on 11/23/2023. During an observation on 04/09/2024 at 8:55 AM, Resident 8 was sitting in their wheelchair and had socks on both feet. When asked if the nurses had placed anything between their toes prior to the development of the right toe wounds, Resident 8 stated, No, I wish they would have. During an observation of the wound with Staff K, Registered Nurse (RN), on 04/11/2024 at 9:04 AM, Resident 8 was observed with gauze between their toes. The right great toe, second and third toe were all bunched together, with the right great toe and third toe overlapping across the top of the second toe. Pressure ulcers were observed on the inside of the right great toe, inside and outside of the second toe, and on the inside of the third toe. In an interview on 04/12/2024 at 8:30 AM, Staff K, stated Resident 8 had pressure ulcers between their toes and non-adherent strips were placed between them. Staff K added that toe spacers had been ordered but had not yet arrived. Staff K stated nothing had been placed between Resident 8's toes until they had complained about the issue, and a shower aide had reported the resident had breakdown between their toes. In an interview on 04/12/2024 at 11:26 AM, Staff B, Director of Nursing, stated they had many interventions in place for skin breakdown, but not for Resident 8's toes. Staff B added it would have been helpful to have put an intervention in place prior to the skin breakdown. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review the facility failed to consistently implement effective preventative measures for falls, by evaluating the effectiveness of current interventions and the need for increased supervision for 4 of 4 sampled residents (Residents 31, 33, 36, and 51), reviewed for accidents. Resident 51 experienced harm when they sustained a hip fracture requiring hospital treatment and Resident 36 experienced a pattern of frequent falls. These failures placed residents at risk for repeat falls, major injury, and diminished quality of life. Findings included . Review of the facility titled Fall Evaluation and Management dated 02/2000, showed the facility was to implement a fall management plan based on the resident's medical history and resident evaluation. The policy instructed nurses to complete a Morse fall scale (assessment that scored a residents fall risk) assessment upon admission, with each fall, and with a significant change in condition. A score greater than 45, identified the resident as a high potential for falls and staff should implement appropriate safety interventions for fall management. A score less than 45, identified the resident as a low to moderate potential fall risk and the interdisciplinary team was to determine if safety interventions were needed. The policy further showed nursing staff was to review and update a resident's care plan with newly identified interventions as needed after a fall was sustained. <Resident 51> Review of the admission assessment, dated 03/10/2024, showed Resident 51 admitted to the facility on [DATE]. Resident 51 had diagnoses including dementia and recent thoracic spine fusion (surgical procedure where two or more spine bones are joined together to eliminate movement between them). Resident 51 had moderate cognitive impairment and was able to make their needs known. Review of Resident 51's baseline care plan, dated 03/08/2024, showed they were alert but confused and forgetful. Resident 51 required moderate up to substantial assistance for bed mobility and moderate assistance of one staff for transfers using a front wheeled walker. Falls or risk for falls or fall interventions were not documented on the baseline care plan. Review of the March 2024 through April 2024 facility incident log showed a 03/10/2023 fall entry for Resident 51 with the injury listed as a fracture. Review of Resident 51's progress notes showed they had high anxiety about their admission to the facility, wanted to leave and had family at bedside the first two days. On 03/10/2024 Resident 51 called out for help and was found alone down on the floor lying on their right side. They complained of right hip pain and guarded their hip while grimacing. Resident 51 was then transferred to the hospital for further evaluation and was found to have a right hip fracture. Review of the 03/10/2024 facility fall incident report showed Resident 51 had an unwitnessed fall at 12:45 PM. Resident 51 was found on the floor parallel to their bed lying on their right side while they moaned and complained of right hip pain. Weakness, forgetfulness, admission within the last 72 hours after a spinal procedure were listed as predisposing factors. Resident 51 was noted to have significant complaints of right hip pain, right leg was externally rotated and appeared shorter than the left leg. Staff then used the Hoyer lift to transfer the resident off the floor. Resident 51 was then sent to the hospital for further evaluation and was found to have a right hip fracture. Review of the Interdisciplinary team (IDT) fall review showed Resident 51 overestimated their own ability to self-transfer, attempted to transfer from their recliner and fell on to the floor. Resident 51 had dementia and was adjusting to their new surroundings. The assessment showed the fall on 03/10/2024 was the first fall since their admission to the facility two days prior and the need for initial interventions would be evaluated once the resident returned to the facility. Review of Resident 51 nursing progress note, dated 03/11/2024, showed they did not return to the facility after their hospitalization for right hip fracture. In an interview on 04/12/2024 at 3:35 PM, Staff B, Director of Nursing, stated baseline care plans typically included how much assistance a resident required for their activities of daily living (ADL), but a falls care plan was typically not initiated until the comprehensive care plan was completed (up to 21 days after admission) and the resident's fall risk was determined by completing the Morse fall assessment. Staff B further stated staff had up to five days to implement and re-evaluate safety interventions after a fall occurred. Staff B acknowledged if a resident had increased complaints of pain or showed possible signs and/or symptoms of a fracture such as increased pain, inward or outward limb rotation or limb shortening they should not be moved. Staff B reviewed Resident 51's medical record. Staff B acknowledged Resident 51 was not cognitively intact and had an unwitnessed fall two days after their admission that resulted in a right hip fracture. Staff B further stated that Resident 51 did not return to the facility after they sustained their fracture. <Resident 36> Review of the comprehensive admission assessment dated [DATE] documented Resident 36 had diagnoses including stroke with hemiplegia and hemiparesis (paralysis and weakness) on the left non-dominant side. Resident 36 was cognitively intact, had limited range of motion in both upper and lower extremities on both the left and the right, and required partial/moderate assistance for transferring from a lying to sitting position, sitting to standing, transferring to a chair, toileting, and walking 10 feet. The resident used a walker and wheelchair for ambulation and had no history of falling prior to admission. Review of the baseline care plan, dated 10/26/2023, showed Resident 36 needed minimal/moderate assistance of one staff to move from lying to sitting, transferring to the toilet, moving from sitting to standing, and transferring from the bed to the wheelchair. Review of the care plan, revised on 11/02/2023, showed Resident 36 had a potential ADL performance deficit related to stroke with left-side weakness. Staff were instructed to make sure shoes were comfortable and not slippery, encourage the resident to use the call bell and wait for assistance, and physical and occupational therapy were to evaluate and treat. A review of the facility Incident logs documented the following for Resident 36: -a fall on 11/06/2023 at 10:30PM, -a fall on 11/18/2023 at 4:50PM, -a fall on 11/22/2023 at 10:30PM, -a fall on 11/23/2023 at 5:00PM, -a fall on 11/30/2023 at 2:45AM, -an incident on 12/12/2023 at 10:00AM that resulted in a fracture, and -a fall on 12/22/2023 at 2:00AM. A nursing progress note, dated 11/06/2023 at 10:25 PM, showed Resident 36's call light was activated. The resident was on the floor beside their bed and stated they attempted to self-transfer to brush teeth, then slipped and fell . There was no injury. An IDT fall review completed on 11/07/2023, showed the cause of the fall was Resident 36's mood or mental status; the resident over-estimated their ability to safely transfer without assistance. On 11/06/2023, the care plan was updated to include Resident 36 was high risk for falls related to left sided weakness and gait/balance problems. Staff were instructed to anticipate and meet the resident's needs, make sure the call light was in reach and encourage the resident to use it, the resident needed prompt response to requests for assistance, educate the resident about safety reminders, encourage the resident to participate in activities that promote exercise, strength and mobility, ensure the resident was wearing appropriate footwear, fall evaluation on admit, quarterly and as needed by the licensed nurse, and physical therapy evaluate and treat. An IDT fall review completed on 11/18/2023 documented Resident 36 fell in their room again. The cause of fall was attributed to the resident's mood/mental status; the resident over-estimated their own ability and slid off their bed to the floor. The review documented that the team determined the resident was going to continue to self-transfer, the resident was educated to use their call bell with understanding and the care plan was updated. On 11/20/2023, the fall risk care plan was updated and instructed staff to educate Resident 36 on the importance of using the call light and waiting for assistance, already part of the care plan. Review of Resident 36's nursing progress notes November 2023 through December 2023 showed the following: There was no nursing progress note related to the fall on 11/18/2023. On 11/21 2023, it was noted the resident was to be discharged on [DATE]. On 11/22/2023 at 10:10 PM, the resident was found on the floor next to their wheelchair after they fell out of their wheelchair and complained of left hip pain. On 11/23/2023, the resident continued to complain of left hip pain and refused their shower. They told the shower aide they thought they broke their hip when they fell . When questioned, Resident 36 declined to go to the hospital for further treatment. At 5:29 PM, Resident 36 was found on the floor leaning against their nightstand. They reported they were afraid to go home and did not know what they would do if they fell at home. On 11/24/2023 at 2:22 AM, Resident 36 refused transfers with one assist as care planned and stated they were afraid they would fall. The resident complained of left hip pain rated 9 out of 10, the pain was worse with movement, and they winced when returning to bed. At 9:10 AM, the resident again slipped out of bed and did not want to go home and was notified they would not be going home. At 8:29 PM, Resident 36 was reluctant to transfer on their own and did not get out of bed that shift. An IDT fall review completed on 11/23/2023 regarding the fall on 11/22/2023 at 10:10PM documented Resident 36 was forgetful of their left-side deficit from their stroke, the resident was educated to use their call bell for assistance, and the care plan was updated. Review of Resident 36's record showed there was no evaluation done to determine the need for additional interventions after the Resident fell on [DATE], 11/23/2023, and 11/24/22023. The fall on 11/24/2023 was not entered on the facility incident log. On 11/27/2023, Staff B, Director of Nursing entered a progress note that Resident 36 requested an x-ray related to pain in their hip, possibly from the fall that occurred on 11/23/2023. The x-ray was negative for a fracture and concluded Resident 36 had degenerative changes and osteoarthritis of the left hip. Review of a nursing progress note, dated 11/30/2023, documented Resident 36 fell in their bathroom at 2:45AM, hit their arm on the sink which caused an abrasion and landed on their left hip. The resident then crawled to the door and was found by a nursing assistant. This note was struck out (a line drawn through the entry) on 12/04/2023 and noted as incorrect documentation. A 12/02/2023 nursing progress note documented Resident 36 had adequate safety awareness but appeared to backslide recently and had several falls from over-estimating their abilities. They were encouraged to get up and ambulate only when staff were present. On 12/04/2023 at 8:08 AM, a nursing progress note documented Resident 36 fell in their bathroom, hit their arm on the sink that caused an abrasion and landed on their left hip. An IDT fall review completed on 12/04/2023 regarding the fall that occurred on 11/30/2023 documented the resident fell in their room. The cause again was that Resident 36 over-estimated their ability to safely ambulate without assistance. Resident 36 was again encouraged to use their call light and wait for staff assistance. The care plan was updated to include 1:1 activities related to the resident not wanting to leave their room. The IDT team concluded the resident was alert and oriented and would likely continue to self-transfer. On 12/12/2023 at 3:56 AM, the nursing progress note showed the resident asked for an early dose of pain medication for pain rated 10 of 10 (on a scale of zero to 10, zero being no pain and 10 being the worst pain), then requested to go to the emergency room for pain medication. Resident 36 was told there was less than one hour before their next dose of pain medication was due, and the resident stated they would tough it out until the next dose. The resident was told to put on their call light if they wanted to go to the hospital. On 12/12/2023 at 1:01 PM, Staff B documented Resident 36 continued to complain of left hip pain and had several falls, the last one occurred on 11/30/2023. When assessed, the resident's left leg was externally rotated and this was not new, but the resident grimaced when attempts were made to straighten or move the left leg. An Xray of the left hip and femur were to be obtained. On 12/13/2023 at 10:24 AM, a nursing progress note showed Resident 36 had an acute fracture of their left femur at the neck (top part of the thigh bone.) The resident was transferred to the local hospital. An incident report completed on 12/13/2023 showed Resident 36 stated they thought they slept wrong, and my legs kind of slid off the bed and I felt a pop at the same time. Predisposing factors for the incident included the resident had a history of self-transfers and had been previously educated to not self-transfer. Under other information, it was documented there had been no immediate fall noted since 11/30/2023, the resident states that likely occurred the night of 12/07/23 or 12/08/23. There were no witnesses. The investigation documented that when interviewed, Resident 36 stated that on 12/11/2023, they had tried sleeping on their left side and in doing so, their legs slid off the mattress and they felt a pop at that time. There were no entries on the incident log for Resident 36 on 12/07/2023 or 12/08/2023 and no nursing progress notes. Review of a nursing progress note, dated 12/21/2023, showed Resident 36 returned from the hospital after surgical repair of their hip fracture. A 12/22/2023 at 2:00AM nursing progress note showed Resident 36 was found on the floor sitting against the door frame after a fall. Resident 36 stated they got up themselves because no one answered their call light. Resident 36 stated they caught the wheel of their walker on a chair, started to fall, the guided themselves to the floor and scooted to their door. An incident report dated 12/22/2023 showed Resident 36 was notified they required two staff and a gait belt to assist them when being transferred. When asked why they were up without assistance, Resident 36 reported they were independent when at the hospital and thought they were also independent at the facility. The report documented the care plan was reviewed and updated, the current plan of care would continue, and interventions would be implemented as indicated. In an interview on 04/12/2024 at 2:56 PM, Staff G, Nursing Assistant Registered, stated residents that were at risk for falls had a laminated star sign that was placed on their door and that was how they were aware of a resident's fall risk. Other residents might have a sign in their bathroom that instructed staff to not leave a resident unattended in the bathroom. They stated they had access to each resident's care plan, and there might be communication on the board in the breakroom if there were changes for a resident. Staff G stated they remembered Resident 36 and believed most of their falls occurred on the evening shift. Staff G stated they did not remember being told to do anything different after Resident 36 kept falling, they just remembered the resident being forgetful and thinking they were able to do more than they were capable of. In an interview on 04/12/2023 at 3:35PM, Staff B stated care plans were usually reviewed the next day after a resident fell , but they had five days to do so. Staff B stated Resident 36 had initially been doing well working with therapy, but when discussions about discharge started it seemed that was when the resident began falling and did not use their call bell. The resident's care plan was updated on 11/30/2023, to include 1:1 activities in their room to distract them from falling. Staff B stated they had not been notified that Resident 36 had increased pain and that the resident had told staff they thought they broke their hip after the 11/22/2023 fall. Staff B expected staff to notify them when any resident had increased pain after a fall. Staff B stated they did not consider the incident when the resident heard a pop on 12/12/2023 a fall; the resident repositioned themselves in their bed, their legs came off the bed and they heard a pop. When asked if the resident's care planned interventions were reassessed after Resident 36's falls, Staff B stated there would not be documentation showing care plan interventions were reassessed. <Resident 33> According to the 10/25/2023 quarterly assessment, Resident 33 had diagnoses including cervical spinal stenosis (narrowing of the spinal canal in the neck that may cause pain, tingling, numbness, and muscle weakness below the area of narrowing), and dementia (loss of thinking, remembering, and reasoning that interferes with a person's daily life and activities). Resident 33 had a range of motion impairment to bilateral upper extremities and required moderate assistance of staff for bed mobility. The assessment further showed Resident 33 had a memory problem but was able to verbalize their needs. Review of the October 2023 through April 2024 facility incident log showed a 11/15/2023 fall entry for Resident 33 with the injury listed as a fracture. Review of Resident 33's nursing progress notes showed: - 11/01/2023 at 3:08 PM, Resident 33 had slight to moderate range of motion limitation in their elbows and moderate range of motion limitations in their shoulders. Resident 33 required extensive verbal/visual cueing and prompting to stay on task. - 11/11/2023 at 10:40 AM, Resident 33 showed increased confusion, accusatory and paranoid behaviors towards staff. Staff would obtain a urine sample to determine the root cause of the behaviors. - 11/13/2023 at 8:45 AM, Resident 33 showed unusual paranoid and suspicious behaviors times two. A urine sample was collected that morning and was negative for a bladder infection. Staff would continue to monitor behaviors and implement interventions as indicated. - 11/15/2023 at 10:25 PM, yelling was heard from Resident 33's room. Resident 33 was found on the floor next to their bed and complained of right hip pain. Resident 33 was assisted to their bed with use of the Hoyer mechanical lift (machine that allows a person to be lifted and transferred with minimal physical effort). Resident 33 continued to complain of right hip pain and was unable to straighten out their right leg due to pain. Resident 33 was then transported to the hospital for further evaluation. - 11/16/2023 at 2:28 AM, a call was received from the hospital which stated Resident 33 had a right hip fracture and required surgery. There were no nursing progress notes or other monitoring documentation found for Resident 33 between 11/13/2023 8:45 AM and 11/15/2023 10:25 PM. Review of the 11/15/2023 facility fall incident report showed Resident 33 had an unwitnessed fall out of bed at 10:35 PM. Resident 33 was found on the floor and complained of right hip pain, no lower extremity inward or outward rotation was noted at that time. Staff transferred Resident 33 back to bed using a Hoyer lift and reassessed them for injuries, Resident 33 was now unable to straighten their right leg due to hip pain and winced in pain if their right hip was touched or right leg was repositioned. Resident 33 was then sent to the hospital for further evaluation and was found to have a right hip fracture. The facility incident report contained no resident or staff interviews. The investigation showed Resident 33 had their call light within reach, but it had not been activated and was last seen by staff at 9:30 PM (one hour and five minutes prior to their fall). The incident report summary showed the fall appeared to be an isolated incident, and staff were educated on positioning residents in bed, completing a post fall assessment and showed the care plan had been updated. Review of Resident 33's care plan, dated 10/30/2017, showed they required maximal assistance of one staff member for bed mobility. A behavioral care plan initiated 10/31/2017 identified Resident 33 had occasional delusions with an intervention for staff to monitor behavioral episodes and attempt to determine the underlying cause. The 10/31/2017 behavioral care plan did not show any new behavioral interventions were added for Resident 33's increased confusion, paranoia, suspicious or accusatory behaviors which occurred November 2023. The Dementia care plan further showed Resident 33 had cognitive loss, short term memory issues, confusion, and was disoriented at times. A pain care plan initiated 10/30/2017 showed Resident 33 had limited range of motion to their right arm and an artificial elbow joint with an intervention for staff to monitor for increased risk for falls. The falls care plan initiated 10/31/2017 showed Resident 33 was at risk for falls related to confusion, deconditioning, and inability to walk with interventions for staff to anticipate the resident needs, ensure the call light was within reach, quarterly fall evaluations, and to follow the facility fall protocol. Review of the care plan showed no new fall interventions were added since October 2021. Review of a 11/16/2023 hospital progress note showed Resident 33 had advanced dementia and was essentially noncommunicative. The notes documented Resident 33 sustained a fall out of bed that resulted in right hip pain and imaging confirmed a right hip fracture. In an interview on 04/12/2024 at 3:35PM, Staff B reviewed Resident 33's care plan and acknowledged staff education was the only intervention completed for their unwitnessed fall that resulted in a right hip because Resident 33 already had several fall interventions in place prior to their fall on 11/15/2023. <Resident 31> Review of the admission assessment, dated 02/07/2024, showed Resident 31 admitted to the facility on [DATE] and required moderate up to maximal assistance for most activities of daily living including dressing, transfers, and toileting. The assessment showed Resident 31 had a history of falls prior to admission and sustained two or more falls since their admission to the facility. Resident 31 had moderate cognitive impairment but was able to make their needs known. Review of the 01/24/2024 Morse fall assessment identified Resident 31 as a high fall risk related to a history of falls, weakness, and overestimates/forgets limitations. Review of the 01/24/2024 baseline care plan showed Resident 31 was a high fall risk related to a history of fainting and falls, with interventions of a perimeter mattress and bed against the wall initiated. The baseline care plan further showed Resident 31 required moderate assistance of two staff for toileting and transfers. Review of the 01/25/2024 Staff D, Medical Doctor, progress note showed Resident 31 was hospitalized after they sustained a fall at home on 01/17/2024 and was down about 24 hours. Review of the January 2024 through April 2024 facility incident log showed the following entries for Resident 31: - 01/28/2024 fall at 8:07 PM - 01/30/2024 fall at 5:00 AM - 01/31/2024 fall at 12:57 PM - 02/01/2024 fall at 2:45 PM - 02/03/2024 fall at 6:00 PM - 02/07/2024 fall at 4:30 AM - 02/16/2024 fall at 9:52 AM Resident 31 had seven falls listed on the incident log in 19 days. Review of January 2024 through April 2024 nursing progress notes showed Resident 31 was confused, forgetful and safety education was ineffective related to poor cognition: - 01/28/2024 at 7:40 PM, was found on the floor in front of their wheelchair when they attempted to self-transfer into bed. Resident 31 did not call for staff assistance. - 01/30/2024 at 7:48 AM, was found sitting on the floor undressed with a soiled brief rolled up under them. Resident 31 stated they needed to use the bathroom and had not activated their call light. - 01/31/2024 at 12:55 PM, sitting on the floor in the dining room. Fall unwitnessed by staff in the dining room. - 02/01/2024 at 3:45 PM, was found sitting on the floor in their room. - 02/03/2024 at 6:14 PM, Resident 31 self-propelled out of the dining room and fell in the hallway. Resident 31 stated they slipped out of their wheelchair. - 02/07/2024 at 5:18 AM, Resident 31 was found sitting on the floor leaning against their bed wrapped in blankets with wet clothing sitting next to them. Resident 31 stated they slid to the floor to remove their wet clothing. - 02/07/2024 at 1:32 PM, a nursing assistant observed resident slide to the floor from bed without hitting their head. - 02/09/2024 at 9:50 PM, was found sitting on the floor in the bathroom. Resident 31 stated they slid to the floor from their wheelchair. Staff educated not to leave resident unattended in the bathroom. - 02/14/2024 at 11:30 PM, found sitting on the floor with back against the bed. - 02/16/2024 at 9:43 AM, found sitting on floor next to wheelchair. Resident 31 stated they needed to use the bathroom. Resident 31 was found on the floor 10 different times in 19 days. Review of facility fall incident reports showed incident reports completed for seven of 10 falls: - 01/28/2024 at 8:07 PM, Resident 31 was found on floor with their back against wheelchair, attempted to self-transfer into bed. Memory deficit, confusion, gait imbalance, and impaired memory listed as predisposing factors. Was previously educated to not self-transfer. The call light was within reach but not activated. The care plan was updated to add frequent visual checks for safety. - 01/30/2024 at 5:00AM, Resident 31 was found on the floor with a soiled brief behind them and stated they needed to void. Confusion, impaired memory, incontinence, overestimation of physical abilities and only 1 wheelchair break locked was listed as predisposing factors. The care plan was updated to add nonskid socks while in bed. - 01/31/2024 at 12:57 PM, Resident 31 slid off their wheelchair onto the floor in the dining room. Noisy environment and impaired memory were listed as predisposing factors. Resident 31 thought their legs got tangled up which caused them to slide to the floor. Velcro was added to wheelchair cushion to keep it from sliding. - 02/01/2024 at 2:45 PM, Resident 31 was found sitting on the floor in their room and stated they slid down when they tried to reach for something. Confusion, impaired gait/memory, weakness/fainting were listed as predisposing factors. Falling star was placed outside of room to help staff identify as a high risk for falls. - 02/03/2024 at 6:00PM, Resident 31 slid out of their wheelchair and sustained a large abrasion to their back. The wheelchair was assessed. - 02/07/2024 at 4:30 AM, Resident 31 slid off the bed while it was in a low position, found wrapped in blankets and stated they wanted to take their wet clothes off. The call light was within reach but had not been activated. - 02/16/2024 at 9:52 AM, Resident 31 was found sitting on the floor next to their wheelchair and stated they needed to use the bathroom. The call light was within reach but had not been activated, neither wheelchair brake was locked, and the resident was barefoot. Review of Resident 31's care plan, dated 01/29/2024, showed they were a high fall risk related to poor balance, poor communication, poor comprehension, and unsteady gait. The facility identified seven non injury falls and implemented the following interventions: 01/29/2024- frequent visual checks, 01/30/2024- nonskid socks on while in bed, 01/31/2024- provide activities that promote exercise and strength, 02/12/2024- bring to nurses station for safety monitoring if up in wheelchair, 02/05/2024- pharmacy consult to evaluate medications, falling star placed outside of room to help staff identify hall fall risk, ensure call light is within reach when in room, proper footwear when up for the day and nonskid socks on when in bed as allowed. A 02/05/2024 intervention showed Resident 31 would sometimes sit or lay on the floor for comfort and instructed staff to allow them to stay on the floor if they were found sitting and appeared safe and uninjured. Review of Resident 31's nursing progress notes from January 2024 through April 2024 showed: - Resident 31 was very confused and is only oriented to self, has very poor safety awareness and has fallen here several times with no injuries. Resident will most likely continue to fall as they do not believe they have any mobility issues. - Resident 31 was very confused and needs monitoring, does not redirect well, does not use call light appropriately. - Resident 31 does not remember the redirection after just a few minutes, needs almost constant supervision, tries to transfer by self very quickly, education is not effective, and collapses to floor without warning during transfers. - Resident 31 was a fall risk and tried to self-transfer many times during a 24-hour period, does not participate well during transfers, loses concentration and folds to the floor during transfers. - Resident 31 was noncompliant/unable to understand the call light system. - Resident 31 was unable to use call light appropriately, attempts to self-transfer and ends up sitting on the floor. - Resident 31 overestimating their abilities and has poor balance resulting in high fall risk, with several falls since admit. In an interview on 04/11/2024 at 8:40 AM, Staff B, Director of Nursing acknowledged there were no fall incident reports for Resident 31 for the 02/09/204 or 02/14/2024 falls. In an interview on 04/11/2024 at 11:43 AM, Staff C, Licensed Practical Nurse, stated a fall occurred when there a resident had a change in plane (change in position resulting in coming to rest on the ground or at a lower level) and a fall packet should be filled out. Staff C further stated that a new intervention should be implemented, and care planned right after a fall occurred because the same incident could reoccur if a new intervention was not added. In a follow up interview on 04/11/2024 at 12:10 PM, Staff B, stated any change in plane was considered a fall and they expected staff to complete a fall packet each time that occurred. Staff B further stated they expected staff to implement a new fall safety intervention as soon as possible after a fall. Reference WAC 388-97-1060 (3)(g) 46033

Based on observation, interview, and record reviewthe facility failed to provide cueing and meal assistance, monitor for significant weight loss, and risk of skin integrity for nutrition for 1 of 1 sampled residents (29). The resident experienced harm when they had an unplanned severe weight loss, nutritional decline, and breakdown of skin integrity with wound development. This failure placed other residents at risk for unplanned weight loss, medical complications, and unmet care needs. Findings icluded . <Resident 29> Review of the 03/25/2024 significant change assessment, showed Resident 29 had diagnoses which included stroke, anemia, and ataxia (impaired coordination). The assessment also documented Resident 29 had moderate cognitive impairments, required partial to moderate assistance from staff with eating, had experienced significant weight loss, and was at risk for developing pressure ulcers. Review of skin care plan, the 01/25/2024, showed Resident 29 was at risk for skin breakdown related to incontinence, and low body weight. The care plan documented on 03/10/2024, the resident had suspected deep tissue injuries (SDTI, purple or maroon localized areas of discolored intact skin or a blood-filled blister caused from pressure) to the coccyx, and moisture associated skin damage (MASD, inflammation or skin erosion caused by prolonged exposure to moisture such as urine or stool). An air mattress was added as an intervention on 03/11/2024. Review of nutrition care plan, dated 01/11/2024, showed Resident 29 was a nutritional risk and the interventions instructed nursing staff to give a substitute meal or a supplemental drink if less than 50% of meal consumed. Review of the nutrition/hydration review, dated 03/13/2024, documented Resident 29 had two SDTI's on their coccyx (tailbone) and that an air mattress had been added. Resident 29 was consuming 45 percent (%) of their meals and the cause of the pressure ulcers was decreased nutritional intake and decreased mobility. Resident 29's weight was 97.8 pounds (lbs.) on 02/13/2024 and on 03/06/2024 89lbs, a 9.0 % loss. No additional nutritional interventions were implemented. The weekly skin evaluation on 03/19/2024 documented the area to Resident 29's tailbone was changed from SDTI's to MASD. A review of the weight record for Resident 29 documented the following: 01/07/2024 102lbs. 01/11/2024 95lbs. 02/13/2024 89lbs. 12.75% loss in one month 03/05/2024 90.5lbs. 11.2% loss in two months 04/02/2024 88.5lbs. 13.2% loss in three months Review of Resident 29's medical record found no nutritional interventions had been implemented for the significant weight loss until 04/09/2024. On that date a liquid supplement was added to be given twice daily. During an observation of the wound on 04/09/2024, with Staff K and Staff L, Nursing Assistant, Staff K stated Resident 29 had a stage III pressure ulcer (an ulcer that extends through the skin into deeper tissue and fat, but does not reach the muscle, tendons, or bone). The pressure ulcer contained slough and was approximately the size of a pea, the surrounding tissue was red and blanched. During an observation of a meal service on 04/10/2024 showed the following: 12:29 PM, Resident 29 attempted to take a bite of their food with their fork and was unable to do so independently. The resident attempted to use spoon and fork and was unable to get the food onto their utensils. There were two aides at this table assisting residents to eat their meal. This table was used for residents who needed assistance with their meals. 12:32, the resident had taken a bite of their beets and was now trying to use a butter knife to eat with. 12:36 PM, the resident was unable to take a bite of their food and attempted to use the butter knife again. Resident 29 put the knife down and ate a piece of meat with their fingers. 12:39 PM, The resident was able to take a bite of rice with their fork. When the resident attempted to take a bite of their egg roll, they were unable to and began eating bites of broccoli with their fork. 12:42 PM, the resident attempted to cut up their egg roll with a spoon. 12:47 PM, the resident picked up their egg roll and put it down. The resident was not cued or assisted during the meal service. 12:54 PM, Resident's spouse gave them a bite of their egg roll, 25 minutes after the meal had begun. Resident 29 ate approximately 40% of their food and was not cued or helped during the meal service and was not provided a liquid supplement as instructed on their tray card. During an observation of the breakfast meal on 04/11/2024 showed the following: 7:59 AM, Resident 29 was in the dining room and had toast, eggs, fruit juice and water. Resident 29 consumed bites of their toast. 8:02 AM, Resident 29 attempted to take a bite of their eggs with their fork and dropped the fork on the table, picked up the fork and attempted to get a bite and was unsuccessful. 8:05 AM, Resident 29 continued trying to use their fork for their eggs and decided to take a bite of toast instead. 8:08 AM, Resident 29 tried to use their fork again and put it down and drank some juice. 8:16 AM, Resident 29 was able to take some bites of their eggs. The resident then decided to use their spoon for their eggs and was unable to. Resident 29 consumed a piece of toast, half of their eggs and three quarters of a cup of their juice. Resident 29 was not cued or helped during the meal service. In an interview on 04/12/2024 at 8:40 AM, Staff L stated they reported to the nurse if the resident did not consume any of their meal or supplement, otherwise the nurse could look at the meal intake that was charted. Staff L stated if a resident had poor intake an alternate meal or supplement would have been offered. Staff L added that Resident 29 required supervision and cueing with their meals as they were confused and became distracted with their utensils. In an interview on 04/12/2024 at 9:10 AM, Staff B, Director of Nursing, stated Resident 29 was underweight upon admission to the facility, and had been doing well until they had a stroke, and now required more assistance. Staff B stated the initial assessment showed the wound was MASD but has developed into a pressure ulcer. In an interview on 04/12/2024 at 12:34 PM, Staff O, Speech Therapist, stated Resident was confused and would benefit from cueing and supervision with meals. In an interview on 04/12/2024 at 12:57 PM, Staff M, Registered Dietician, stated once a resident had poor intake or weight loss, nutritional interventions would be added to increase the resident's protein. After discussion of Resident 29's pressure ulcer and weight loss, Staff M stated the resident's weight was significantly down on 03/05/2024, and it would have been helpful to have added protein. In an interview on 04/12/2024 at 2:15 PM, Staff B stated when a resident had significant weight loss or wounds, the Registered Dietician (RD) is notified via email. Staff B stated the RD had access to place orders into the system and can do so at any time. Staff B stated the expectation was for interventions to be placed the same week that a change had occurred. Staff B added that Resident 29 was in the hospital from 03/15/2024 through 03/19/2024 and it would have been helpful for the supplement to have been initiated earlier to assist with weight loss and skin breakdown. Staff B stated nursing was also able to initiate a supplement and did not have to wait for the RD to do so. Reference: WAC 388-97-1060(3)(h).

Based on interview and record review the facility failed to implement bowel management protocol when indicated for 2 of 5 sampled residents (Resident 26 and 31), reviewed for constipation. In addition, the facility failed to monitor and implement interventions for edema (swelling) management for 1 of 3 sampled residents (31), reviewed for edema. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Bowel Protocol, revised 03/2018, documented nursing staff was to review a resident's bowel monitor daily. The policy instructed nursing staff to implement the bowel program if a resident did not have a bowel movement (BM) for three days. The policy showed nursing staff was to administer Milk of Magnesia (MOM) on day four, a laxative suppository was to be administered the next shift if no results from MOM, an enema was to be administered the next shift if no results from the suppository, and the provider was to be notified if there were no results from the enema. Bowel Management <Resident 26> According to the 02/15/2024 quarterly assessment, Resident 26 required maximal to total assistance for most activities of daily living including dressing, transfers, and toileting. Resident 26 was incontinent of bowel. The assessment further showed Resident 26 had severe cognitive impairments and was able to make their needs known. Review of the 02/20/2023 bowel and bladder care plan documented interventions for Resident 26 to have an unobstructed path to the bathroom and have a bowel/bladder evaluation completed upon admission and quarterly. The care plan instructed staff to monitor, document, and report possible causes of incontinence such as constipation, as needed. Review of Resident 26's medical record documented a bowel evaluation had been completed on 08/15/2023, which documented no constipation. Review of Resident 26's provider orders documented active orders for: - 10/23/2023 Prune juice to be given twice daily as needed for bowel care - 10/23/2023 Miralax (powder laxative mixed with water) to be given twice daily as needed for constipation - 10/23/2023 Bisacodyl (stimulant laxative) tablet to be given twice daily as needed for constipation - 10/23/2023 MOM (liquid laxative) to be given as needed on day four if the resident did not have a bowel movement for three days - 10/23/2023 Bisacodyl suppository to be given as needed the following shift, during waking hours only, if there were no results from MOM - 12/25/2023 Bisacodyl tablet to be given every 12 hours as needed for constipation Review of Resident 26's physician orders, documented the resident was not on routine medication for constipation. Review of Resident 26's January 2024 through April 2024 bowel record showed resident had no bowel movements (BM) on the following days: 01/01/2024 through 01/05/2024 (5 days with no BM) 01/07/2024 through 01/12/2024 (6 days with no BM) 01/16/2024 through 01/20/2024 (5 days with no BM) 01/29/2024 through 02/02/2024 (4 days with no BM) 02/04/2024 through 02/10/2024 (7 days with no BM) 02/12/2024 through 02/16/2024 (5 days with no BM) 02/18/2024 through 02/21/2024 (4 days with no BM) 02/23/2024 through 02/26/2024 (4 days with no BM) 02/28/2024 through 03/04/2024 (6 days with no BM) 03/20/2024 through 03/23/2024 (4 days with no BM) 03/26/2024 through 03/29/2024 (4 days with no BM) Review of Resident 26's January 2024 through April 2024 Medication Administration Record (MAR) showed bowel medications were not administered when needed for constipation, as ordered. Review of the facilities paper bowel program flow sheet tool January 2024 through March 2024 showed no documentation of bowel interventions for Resident 26. In an interview on 04/12/2024 at 4:28 PM, Staff K, Registered Nurse reviewed Resident 26's bowel pattern and stated the resident should have been given the as needed bowel medications to assist with their constipation. In an interview on 04/12/2024 at 4:30 PM, Staff P, Regional Nurse, stated the expectation was for nursing staff to administer the bowel medications as indicated to prevent impaction. 47328 <Resident 31> Bowel Management According to the 02/07/2024 admission assessment, Resident 31 required moderate up to maximal assistance for most activities of daily living including dressing, transfers, and toileting. Resident 31 was frequently incontinent of bowel and bladder. The assessment further showed Resident 31 had moderate cognitive impairment and was able to make their needs known. Review of the 02/05/2024 bowel and bladder care plan showed interventions for Resident 31 to have an unobstructed path to the bathroom and have a bowel/bladder evaluation completed upon admission and quarterly. The care plan instructed staff to monitor, document, and report possible causes of incontinence such as constipation, as needed. The 02/05/2024 fluid maintenance care plan instructed staff to administer medications as ordered, monitor and document bowel sounds and frequency of BM. Review of Resident 31's medical record showed no bowel evaluation had been completed. Review of Resident 31's provider orders showed active orders for: - 01/24/2024 Prune juice to be given twice daily as needed for bowel care - 01/24/2024 Miralax (powder laxative mixed with water) to be given twice daily as needed for constipation - 01/24/2024 Bisacodyl (stimulant laxative) tablet to be given twice daily as needed for constipation - 01/24/2024 MOM (liquid laxative) to be given as needed on day four if the resident did not have a bowel movement for three days - 01/24/2024 Bisacodyl suppository to be given as needed the following shift, during waking hours only, if there were no results from MOM - 01/24/2024 Fleet enema (liquid laxative inserted rectally) to be given as needed the following shift, during waking hours only, if there were no results from the suppository. Notify provider if no results from enema. Review of Resident 31's February 2024 through April 2024 bowel record showed no BM on the following days: 02/09/2024 through 02/11/2024 (3 days with no BM) 02/13/2024 through 02/18/2024 (6 days with no BM) 02/22/2024 through 03/03/2024 (11 days with no BM) 03/05/2024 through 03/07/2024 (3 days with no BM) 03/16/2024 through 03/21/2024 (6 days with no BM) 04/05/2024 through 04/08/2024 (4 days with no BM) Review of Resident 31's February 2024 through April 2024 Medication Administration Record (MAR) showed bowel medications were not administered when needed for constipation, as ordered. Review of the facilities paper bowel program flow sheet tool December 2023 through March 2024 showed no documentation of bowel interventions for Resident 31. In an interview on 04/11/2024 at 12:04 PM, Staff B, Director of Nursing, reviewed Resident 31's medical record. Staff B acknowledged Resident 31 went from 02/21/2024 until 03/04/2024, 12 days without a BM. Staff B further stated staff should have implemented the bowel protocol but did not. Edema Management Review of the 01/24/2024 admission nursing evaluation showed Resident 31 had 3+ (on a scale of 1 to 4 with 4 being the most severe) pitting (indentation to skin after pressure is applied) edema to bilateral lower extremities. Review of January 2024 though April 2024 progress notes documented a single note dated 01/24/2024, that identified Resident 31 had some edema to bilateral feet. No further description, assessment, monitoring, or intervention documentation was found. Review of Staff D, Medical Doctor, provider note dated 01/25/2024, documented Resident 31 had edema to the top of their feet that extended to their shins. Review of Resident 31's provider orders found no provider orders for edema management. Review of the 02/05/2024 care plan showed no documentation of interventions for edema management. Review of Staff E, Physician Assistant, provider note dated 02/06/2024, showed Resident 31's edema was unchanged from 01/25/2024. On 04/08/2024 at 11:03 AM, Resident 31 was observed sitting up in their wheelchair with 3+ edema to both legs that extended from their feet up to middle thighs, both legs were in a dependent position, and no compression stockings were being worn. Similar observations were made on 04/08/2024 at 2:30 PM, 04/09/2024 at 8:57 AM and 1:56 PM, 04/10/2024 at 3:04 PM, 04/11/2024 at 11:18 AM. On 04/11/2024 at 2:45 PM, Resident 31 was observed sitting up in their wheelchair with 4+ edema to both legs that extended from their feet up to middle thighs, both legs were in a dependent position, shiny, and again no compression stockings were being worn. In an interview on 04/11/2024 at 9:45 AM, Staff A, Administrator, stated the facility had no edema management policy but edema management fell under their weight management policy. The weight management policy was requested on 04/11/2024 at 9:45 AM and by 2:25 PM, no policy had been provided. In an interview on 04/11/2024 at 11:38 AM, Staff C, Licensed Practical Nurse, stated edema was monitored by nursing staff and should be documented in the progress notes. Staff C further stated typical edema interventions consisted of compression stockings and elevation of the legs. Staff C acknowledged Resident 31 had edema for some time that was increasing and was unsure if there were interventions in place. In an interview on 04/11/2024 at 11:58 AM, Staff B, Director of Nursing, stated if a resident had significant edema they would be placed on alert for further monitoring. Staff B stated typical edema interventions consisted of elevation of the legs, diuretic medication (medication that helps the body get rid of excess fluid), and compression stockings. Staff B reviewed Resident 31's medical record and acknowledged Resident 31 had edema and no edema interventions had been implemented. Reference WAC 388-97- 1060 (1)

Based on observation, interview, and record review the facility failed to ensure staff followed enhanced barrier precautions, cleaned mechanical lifts after usage, and performed hand hygiene when indicated during the meal service and wound care. These failures placed residents at risk of transmission of communicable diseases and/or healthcare associated diseases, and diminished quality of life. Findings included . Review of the facility policy titled, Handwashing/Hand Hygiene revised 03/2018, showed hand hygiene was the facilities primary means to prevent the spread of infections. The policy instructed staff to perform hand hygiene with alcohol-based hand rub or soap and water before and after direct contact with residents; before performing any non-surgical invasive procedure; before and after handling an invasive device; before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care; after contact with object in the immediate vicinity of a resident; before and after handling food; before and after assisting a resident with meals; and after glove removal. The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention- with regard to hand hygiene showed, healthcare personnel should use alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, before performing an aseptic (free from living viruses, bacteria, and other germs that may cause disease) task, before moving from a soiled boy site to a clean body site on the same patient, after touching a patient or the patient's immediate environment and immediately after glove removal. When washing hands with soap and water rub hands together for at least 15 seconds. When using handrubs rub hands together covering all surfaces until dry. Unless hands are visibly soiled alcohol-based hand rub is preferred over soap and water in most situations due to evidence of better compliance compared to soap and water. <Enhanced barrier precautions> <Resident 10> Review of Resident 10's record, documented the resident was on enhanced precautions (an infection control intervention to reduce transmission of multidrug resisitant organisms) related to the placement of a urinay catheter. Enhanced precautions required staff to wear PPE (personal protective equipment, such as gowns and gloves) when providing cares such as transfers, toileting and dressing for the resident. On the door going into the resident's room, an enhanced barrier precaution sign was present that instructed staff what PPE was required. During an observation on 04/10/2024 at 2:27 PM, Staff U and Staff V, Nursing Assistants, were in Resident 10's room transferring them from the wheelchair to the bed using a Hoyer (a mechanical lift used to transfer residents). Neither Staff U or Staff V were wearing the required PPE as instructed on the sign. During an interview on 04/10/2024 at 2:27 PM, Staff W, Licensed Practical Nurse read the enhanced barrier precautions sign and stated Staff U and V should have worn PPE During an interview on 04/10/2024 at 2:37 PM, Staff U stated they should have been wearing PPE prior to the resident being transferred because they had a catheter. The hoyer was placed in the hall at 2:43 PM and was not sanitized after being used for Resident 10. During an observation on 04/11/2024 at 6:17 AM, Staff X, Nursing Assistant, had used the hoyer to get a resident out of bed and placed the machine in the hallway. Staff X did not sanitize the machine after it's use. During an observation on 04/11/2024 at 6:18 AM, Staff X and Staff Y Nursing Assistants, entered room [ROOM NUMBER] to assist the resident to the toilet, neither of them were wearing PPE and an enhanced barrier precaution sign was present on the resident's door. During an observation on 04/11/2024 the hoyer was placed in the hall at 10:17 AM and was not sanitized after being used for Resident 10. <Resident 8> Resident 8 was on enhanced barrier precautions related to wounds on their toes. Staff K, Licensed Practical Nurse, entered Resident 8's room and performed a dressing change without a gown as required. During an interview on 04/11/12024 at 9:18 AM, Staff K stated they knew the resident's roommate was on precautions but did not know Resident 8 was also on precautions. Staff K stated they should have worn a gown to protect themselves from bacteria. <Catheter> According to the 02/14/2024 annual assessment, Resident 4 had diagnoses which included benign prostatic hyperplasia (prostate gland enlargement that can cause difficulty with urination), and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow) and was moderately cognitively impaired but able to direct their care. The resident required substantial to maximal assistance for activities of daily living such as toileting and had a urinary catheter. During observations on 04/09/2024 at 9:36 AM and 04/11/2024 at 6:14 AM, Resident 4 was observed lying back in their recliner asleep, and their urninary catheter collection bag was lying on the floor without a cover over it. Review of Resident 4's record documented on 02/28/2024 the resident had a urninary tract infection and was treated with an antibiotic for seven days. During an interview on 04/11/2024 at 10:21 AM, Staff H, Nursing Assistant, stated a catheter needed to be stored in a privacy bag, and up off the floor because bacteria can travel up the catheter tubing. During an interview on 04/11/2024 at 11:07 AM, Staff B, Director of Nursing, stated a catheter needed to be placed in a privacy bag, not touching the floor as this could have an increased risk for an infection. <Wound care> <Resident 10> On 04/10/2024 at 2:56 PM, during an observation of Resident 10's wound on their buttocks , Staff Y, Licensed Practical Nurse, unhooked the resident's urinary catheter from the bed, and witth the assistance of Staff X, Nursing Assistant, they repositioned the resident onto their side.Staff Y then removed their gloves, and without performing hand hygiene, put on new gloves and removed the resident's soiled buttock dressing. After removing the dressing, Staff Y changed their gloves, cleansed the wound, and while wearing the same gloves, grabbed more gauze out of the package, and then wiped the wound. No hand hygiene was performed between removing the soiled gloves and putting on clean gloves. After wiping the wound, Staff Y then changed gloves, measured the wound and applied ointment to the wound. Still wearing the same soiled gloves, Staff Y removed Resident 4's compression socks, and then proceeded to assist Staff X, to change the soiled incontinence brief Staff Y then discarded the soiled brief into the garbage, and without performing hand hygiene and putting on new gloves, touched the resident's legs. Staff X removed their gloves, and without performing hand hygiene, put on new gloves and assisted the resident with repositioning. During an interview on 04/10/2024 at 3:21 PM, Staff Y stated they should have used hand sanitizer after the wound was cleansed, after incontinence care was provided and the aide should have done so also. <Resident 28> During an observation of Resident 28's buttock wound on 04/12/2024 at 8:45 AM, Staff L, Nursing Assistant, performed incontinence cares, and without performing hand hygiene or changing gloves, touched the resident's leg and removed the dressing from the resident's right upper buttock. Staff K cleansed the wound, and without performing hand hygiene, changed gloves, applied ointment and a new dressing to the wound. After the buttock wound care was completed. Staff K applied a new pair of gloves, cleansed the resident's left leg wound, removed their gloves, applied new gloves and put a treatment on the wound, without hand hygiene being performed. Staff L using the same gloves that was worn during incontinence care placed a brief onto the resident and pulled up their pants. During an interview on 04/12/2024 at 8:57 AM, Staff K stated hand hygiene should have been performed before the dressing change, and every time gloves were changed during the dressing change. Staff K stated you could have encountered bacteria that could be passed on to yourself and other residents. During an interview on 04/12/2024 at 8:59 AM, Staff L stated gloves needed to be changed once they have been soiled. Staff L stated they should have performed hand hygiene and placed new gloves on prior to having touched the resident's leg and the dressing being removed because that can cause cross contamination. During an interview on 04/12/2024 at 4:46 PM, Staff B, Director of Nursing, stated the expectation was for staff to have worn gowns and gloves for residents on enhanced barrier precautions. Staff B stated staff were to have performed hand hygiene when going from dirty to clean areas and when their gloves were changed. Staff B added the mechanical lifts should have been wiped down after each use to prevent infections. Reference: WAC 388-97-1320 (2)(a) 47328 <Dining Room> During continuous observation of meal service on 04/08/2024 from 12:32 PM until 12:52 PM, Staff L, Nursing Assistant, passed out desserts to 11 different residents without performing hand hygiene before, in between residents, or after. Staff L then poured water into a cup, opened two straws while touching the mouthpiece, and gave a resident a sip of water. Staff L washed their hands with soap and water at the sink in the back of the dining room. Staff L then started assisting two different residents to eat their lunch, used their walkie talkie, adjusted the chair they were sitting on, and continued to assist the two residents to eat their lunch without performing hand hygiene after touching objects in the immediate vicinity of a resident or in between assisting the two different residents. Reference WAC 388-97-1320 (1)(c )

Based on observation, interview and record review, the facility failed to provide assistive cups as care planned for 1 of 3 sampled residents (Resident 17) reviewed for activities of daily living (ADL's). This failure placed the resident at risk for continued swallowing difficulties and decreased fluid intake. Findings included . A review of the 03/04/2024 comprehensive admission assessment documented Resident 17 had diagnoses which included kidney stones and an enlarged prostate. The resident had moderate cognitive impairment and required set-up/clean-up assistance for eating. Resident 17 had loss of food from their mouth when eating and held food in their mouth or cheeks after eating. The baseline care plan dated 02/27/2024 showed Resident 17 required set-up/clean-up assistance for eating and was to use a sippy cup (has a spout and two handles to aid drinking and prevent spillage) for all liquids and could also use a straw. The nutritional care plan documented Resident 17 was to have aspiration precautions (interventions that prevented inhaling foods and drinks when eating such as sitting upright for example.) Resident 17's current Individual Service Plan (ISP, staff instructions for providing the resident's care) active at the time of the survey documented the resident was to use sippy cups for all fluids. On 04/10/2024 at 12:22 PM, Resident 17 was observed in the dining room seated in their wheelchair. At this time, the resident was provided water in a light green clear plastic juice-size glass. At 12:26 PM, tomato juice was provided in the same type of juice glass. The juice glasses did not have lids, handles, or a straw. Resident 17 drank from them without coughing. On 04/11/2024 at 7:44 AM, Resident 17 was seated in the dining room for breakfast. The resident had water in a sippy cup, and coffee in a coffee mug that had a lid and straw. Resident 17 stated they used both hands to eat because food slid off their silverware. They did not like larger silverware but liked the cups with handles because they were able to drink from them easier. On 04/11/2024 at 12:11 PM, Resident 17 was provided water in a plastic juice glass, and coffee in a mug with a lid and straw during lunch. At 12:17 PM, the resident was provided cranberry juice and milk in sippy cups. The resident alternated drinking from the water, juice, milk and coffee during their lunch. At 1:02 PM, Resident 17 took a drink of milk, then started to cough. The cough was very quiet, and staff in the dining room did not hear it. At 1:10 PM, Resident 17 was no longer coughing and scooted in their wheelchair out of the dining room. When interviewed on 04/11/2024 at 1:10 PM, Staff F, Nursing Assistant, stated they guessed Resident 17 was able to use either type of drinkware-a plastic juice glass or a sippy cup. Staff F stated Resident 17 used the regular juice glasses when they were in their room. Staff F was unsure why the resident needed the sippy cup and who determined what assistive devices a resident was to use. Staff F stated they looked on a resident's meal ticket when they were unsure what assistive devices a resident needed. On 04/12/2024 at 8:23 AM, a plastic juice glass half full of water was observed on Resident 17's overbed table in their room. When interviewed on 04/12/2024 at 12:25 PM, Staff G, Speech Therapist, stated they had worked with Resident 17 regarding their ability to swallow when the resident was first admitted . Staff G stated a recommendation was made for Resident 17 to use a sippy cup because the resident spilled fluids from their mouth when they drank; the cup was easier for the resident to hold, and there was less spillage. When interviewed on 04/12/2024 at 01:12 PM, Staff H, Nursing Assistant Registrant, stated a resident's meal ticket usually showed what assistive devices a resident used. They were unsure if that information was on the care plan. Resident 17's meal ticket was observed at this time and did not instruct staff to use sippy cups for the resident. When interviewed on 04/12/2024 at 04:51 PM, Staff B, Director of Nursing, stated they included speech therapy recommendations when they entered in a resident's diet order and this information was also on a resident's ISP. Staff B stated they expected staff to follow the residents care plans; not doing so might put a resident at risk of aspiration or other complications. Reference: WAC 388-97-0860(2)

Based on observation, interview, and record review the facility failed to assess and care plan for safe self-medication administration for 1of 1 sampled residents (Resident 28), reviewed for medication administration. This failure placed residents at risk of medication errors, adverse side effects, and diminished quality of life. Findings included . Review of the facility policy titled, Self-Administration of Medication revised 09/2017, documented if a resident desired to self-administer medications the facility would complete a self-medication evaluation before the resident was able to self-administer medications. The assessment would be reviewed quarterly or upon a change of condition. The policy instructed nursing staff to obtain a provider order for self-administration for the specific medications, initiate a self-medication administration care plan, initiate a bedside self-medication administration record, determine whether medication would be stored at the nursing station or at bedside, and obtain and initiate proper safety mechanisms if medications were to be stored at the resident's bedside. According to the 01/29/2024 admission assessment, Resident 28 had diagnose which included hyponatremia (low sodium levels), and Transient Ischemic Attack (TIA- temporary stroke like symptoms). Resident 28 was cognitively intact and able to make their needs known. On 04/08/2024 at 10:48 AM, Resident 28 was observed to have a large semi translucent bottle half full of colorful TUMS (an over-the-counter antacid) on their nightstand next to their bed with 7 TUMS tablets sitting outside of the bottle on the nightstand. Similar observations were made on 04/08/2024 at 3:29 PM, 04/09/2024 at 9:00 AM and 1:53 PM, 04/10/2024 at 8:43 AM, and 04/11/2024 at 6:19 AM. Review of providers orders showed no documentation Resident 28 self-administered medications and/or stored them at their bedside. Resident 28 had an order dated 01/17/2024 for TUMS 500mg every 4 hours as needed for indigestion. Review of Resident 28's medical record showed no documentation a self-medication evaluation had been completed. Review of the 01/18/2024 care plan showed no documentation Resident 28 self-administered medications and/or stored them at their bedside. In an interview on 04/11/2024 at 6:19 AM, Resident 28 was asked about the bottle of TUMS that was on their nightstand. Resident 28 stated they took the TUMS as needed for indigestion. Resident 28 stated staff had not spoken with them about the antacids. Resident 28 acknowledged they did not inform staff when they self-administered the TUMS. During observation and interview on 04/11/2024 at 6:30 AM, Staff C, Licensed Practical Nurse, stated they were unsure why Resident 28 had a bottle of TUMS at their bedside. Staff C removed the bottle from the bedside and noted the bottle was labeled as Ultra Strength 1000mg tablets. Staff C reviewed Resident 28's provider orders and acknowledged Resident 28's TUMS order was for 500mg not the ultra-strength 1000mg tablets. Staff C stated the facility did not allow for self-medication administration and medications were typically locked up in the medication cart. In an interview on 04/11/2024 at 1:04 PM, Staff B, Director of Nursing, stated if a resident chose to self-administer medications an assessment would be done, and it would need to be care planned. Staff B further stated if medications were kept at the resident's bedside, they needed to be locked up for safety to ensure all other residents did not have access to them. Reference WAC: 388-97-0440, 1060 (3)(I)

Based on observation, interview, and record review, it was determined the facility failed to develop and implement nutritional interventions in a timely manner for 1 of 4 residents (#19) reviewed for weight loss in a sample of 26. This resulted in harm to the resident when he experienced a weight loss of 23.2% body weight in 4 months. Findings include: Resident #19 had [DIAGNOSES REDACTED]. Per record review, the resident was extensive assist with most activities of daily living (ADL's) which included eating. Per review of the resident's most recent plan of care, there was no care plan related to weight loss. Per record review, a nutritional assessment dated [DATE] identified the resident's Ideal Body Weight (IBW) was between 133-163 pounds. The resident's admission weight was 189 pounds and it was noted he had some [MEDICAL CONDITION] (fluid retention). At that time, the resident was eating 80-100% of his meals. Per record review, the resident had experienced a weight gain on 1/1/14 to 194 pounds and was placed on a diuretic (medication that reduces fluid) on 1/6/14. On 1/20/14 the resident weighed 201. By 1/23/14 the resident was back down to admission weight of 189. On 2/17/14 the resident's weight was documented at 175 pounds (a loss of 14 pounds or 7.4% of body weight) in 2 months. The resident was evaluated by the facility and it was noted the resident's [MEDICAL CONDITION] had improved greatly and the plan was to consider adding a nutritional shake related to a decrease in his protein levels. This intervention was not put in place. On 3/10/14 the resident's weight was documented at 166 (a loss of 23 pounds or 12.2% of body weight in less than 3 months). The resident was evaluated by the facility and the resident was noted to eat well with meals, his [MEDICAL CONDITION] had resolved, and the plan was to monitor weights 1 more month and consider adding a nutritional supplement. No further interventions were put into place, despite the fact the resident continued to lose weight. A dietician note dated 3/25/14 documented the resident weighed 163 pounds, a loss of 25 pounds since his admission to the facility 3 months prior. The note documented the resident had [MEDICAL CONDITION] which had resolved, and his weights were within the desirable limits. The plan was to add a snack between meals and watch the weights. On 4/10/14 the resident's weight was 145 pounds, a significant weight loss of 44 pounds or 23.2% in under 4 months. A facility review was completed on 4/14/14, and it noted the resident had been on a large dose of a diuretic previously and was now not eating well. The diuretic was discontinued and the resident had been started on a nutritional supplement on 4/7/14. Per record review, there was no indication facility staff were monitoring the resident's intake, or had done a recent review of the resident's food preferences (in order to provide favorite foods so he might eat better). The May 2014 treatment record documented the resident had developed a pressure ulcer on his lower right buttocks on 5/30/14 (people with poor nutrition are at increased risk for skin alterations). Per observation on 7/21/14 at 12:20 p.m., the resident was in the dining room feeding himself lunch. He had eaten 1/2 of his meal and consumed about 1/2 of his nutritional supplement. In an interview on 7/24/14 12:55 p.m., Staff #A said the resident had gained some weight the first month of his admission to the facility because of [MEDICAL CONDITION], so was put on a diuretic. She felt the resident's weight went down from 166 pounds to 145 pounds because of the [MEDICAL CONDITION]. Staff #A also said the resident's appetite and food intake had declined prior to his pressure ulcer getting worse. She stated meal monitors were not normally done for residents, but if there was an issue with weight loss then they would be placed in restorative dining for staff to assist and monitor food and fluid intake. She confirmed the resident's intake wasn't monitored after losing weight and the resident had not been placed in the restorative dining.

Based on observation, interview, and record review, it was determined the facilty failed to conduct ongoing evaluation, assessments or implement timely interventions for residents at risk for pressure ulcers in order to prevent pressure ulcer development for 2 of 3 (#19, 43) residents in a sample of 26. This resulted in harm to Resident #19. Findings include. 1. Resident #19 had [DIAGNOSES REDACTED]. Per record review, the resident required extensive assist with most activities of daily living (ADL's) which included bed mobility and transfers. Per record review, a pressure risk assessment tool dated 4/5/14 indicated the resident was at moderate risk for developing pressure ulcers. The resident's initial plan of care for skin issues dated 1/3/14 directed staff to encourage the resident to elevate his legs while in bed, licensed staff was to do a quarterly pressure risk assessments and weekly skin checks, and a cushion was to be placed in the resident's wheel chair. A progress note dated 5/30/14 identified the resident had an open area on his right ischial tuberosity (bottom of the right buttock). The area measured 1.5 cm (centimeters) x 0.6 cm. On 6/3/14 a progress note indicated the measured 3.0 cm x 1.5 cm - an increase in size. On 6/12/14 the facility started a pressure sore identification and progress record - 9 days after the pressure ulcer had worsened. The measurement was 2.5 cm x 2.5 cm and non-stageable (meaning the depth could not be visualized). There was a small amount of drainage with 10% eschar (black dead tissue) and 30% slough (yellowish tissue on the surface of a wound). The resident's care plan was updated on 6/21/14 with interventions to place the resident on a turning schedule and place an air mattress on the bed. In addition, the resident was to be up last for meals and first down after meals. These interventions were put into place 23 days after the wound was first identified and had worsened. According to the June 2014 treatment record, a cream was being applied to the right buttocks open area. Additional record review revealed other treatments were attempted during June 2014, but there was not consistent documentation to reflect whether or not the treatments were done. A dietician note on 6/24/14 noted the resident had lost 36 pounds over the last 6 months and he now had skin breakdown. This assessment was done 26 days after the resident developed a pressure ulcer, which had worsened. Per record review, the pressure ulcer on 7/5/14 measured 2cm x 3cm x 1.2cm deep. There was a small amount of drainage noted and the wound bed had 60-70% slough. On 7/8/14 the physician evaluated the wound and recommended continuing the same treatment, and added a Waterpik and other debridement (removal of unhealthy tissue) methods. A culture of the wound was also ordered. On 7/13/14 the culture of the wound indicated an infection, and the resident was started on an antibiotic. The resident's dressing change was observed on 7/23/14 at 11:00 a.m. A wound nurse not associated with the facility was present to evaluate the resident's pressure ulcer. The wound measured 3.5 cm x 3.5 cm x 1.0 cm depth. The wound bed was covered with black eschar. The skin surrounding the wound was dark red, hard and warm and was non-blanching (when pressure is applied to the reddened area it turns white). Per interview on 7/24/14 at 11:55 a.m., Staff #A stated that wound care was done by the nurse in the evening. When a wound was identified, the staff was supposed to put it on the wound identification form right away. The wound nurse from the community was supposed to evaluate the pressure ulcer in May but didn't come until July. The facility failed to assess, and to put additional interventions in place in a timely manner, resulted in the pressure ulcer increasing in size. 2. Resident #43 had [DIAGNOSES REDACTED]. Per record review, the resident could make her needs known, required extensive assistance of one staff for transfers and bed mobility, and had occasional urinary incontinence. The resident had a history of [REDACTED]. The 4/30/14 care plan summary indicated the pressure ulcers were healed, and the resident was currently refusing the specialized wheelchair cushion and air mattress for prevention of pressure ulcers. The only medication and/or treatment the resident accepted was Tylenol for chronic pain. Review of a physician note on 7/10/14 revealed the resident had increased pain on the bottom of the right buttock with no skin breakdown. The physician ordered an anesthetic patch to deliver localized pain relief to the area. A 24 Hour Nursing Report of 7/19/14 (9 days later) documented the resident now had a small open area on the buttock. There was no evaluation of the open area and no treatment provided, including new interventions, to prevent pressure on the affected area. On 7/20/14 at 7:20 p.m., the resident was in bed on her left side and had activated her call light. She was rubbing her right buttock and said she had a sore and needed something for it. During observation of care with Staff #G at 7:25 p.m. the same day, the resident had a small open pressure ulcer on the bottom of the right buttock with a bloody wound bed and a red margin surrounding the ulcer. Staff #G stated the resident had ongoing problems with pain in the right buttock and had just developed the ulcer. Staff #G stated she cleaned the ulcer and applied an anesthetic cream. At that time, the resident's wheelchair was sitting near the bed. The wheelchair seat padding consisted of 2 pieces of thin foam and no specialized seat cushion (as per the plan of care). During hourly observations on 7/21/14 from 9:00-11:00 a.m., the resident sat in the wheelchair with the thin foam seat padding. It was unclear if staff had made attempts to use the specialized cushion after the developement of the pressure ulcer. In an interview on 7/21/14 at 11:00 a.m.,Staff #A stated the resident had no current pressure ulcers. When informed by the surveyor that the resident had a pressure ulcer as of 7/19/14, Staff #A stated she was unaware of a pressure ulcer. There was nothing documented on the resident's skin evaluation sheets so she was not informed. At 2:00 p.m., Staff #A confirmed the resident had a Stage II (partial skin thickness) ulcer that was not thoroughly evaluated until 7/21/14. The facility failed to monitor the progress of a pressure ulcer once it developed, and did not ensure additional preventative measures were put in place so it would heal.

Based on observation, interview, and record review, it was determined the facility failed to provide an ongoing program of activities for 2 of 6 cognitively impaired residents (#19, 25) in a sample of 26. Failure to assess and plan meaningful individualized activities placed the residents at risk for diminished quality of life. Findings include: 1. Resident #19 had [DIAGNOSES REDACTED]. The resident required extensive assist with most activities of daily living (ADL's). The resident had confusion but was able to make his needs known. Per review of the most recent activity note dated 4/14/14, it was documented the resident had declined in the last few months. He refused to go to activities although it stated he enjoyed them and they were important. He watched television and looked at magazines. He did attend bible story club and liked music. Per review of the resident's plan of care, the goal was for the resident to participate in activities of interest and the intervention was to ask the resident if he would like to attend scheduled activities. Per record review, the resident developed an unstageable pressure ulcer 5/30/14 and treatment was to place the resident on a turning schedule which allowed the resident to only be out of bed for 2 hours during meal times. Per review of the activity flow sheet for June 2014, the resident attended 7 activities which included good news club, coffee social and music. July 2014 the resident attended good news story 1 time and no further activities had been documented. Per an interview on 7/21/14 at 1:35 p.m., a family member stated that the resident did not participate in activities because he was kept in bed as much as possible due to a sore on his bottom. On 7/21/14 at 2:15 p.m., the resident was observed laying on his right side, his eyes were open and he was staring at the wall. The T.V. was on but was located behind the resident where he was unable to see it. Per observation on 7/22/14 at 10:45 a.m., the resident was observed on his right side facing the wall. The resident was awake staring at the wall. When asked about activities, the resident stated the television had been on all night but he hadn't really looked at it. During an interview on 7/24/14 at 9:45 a.m., Staff #F stated the resident's family wanted him to attend the good news story which his daughter taught. As far as other activities, he had to be in bed so they put the television on the older shows for him. On 7/24/14 at 11:25 a.m., Staff #E stated the resident didn't go to much. She stated she tried to get him out of his room but because of a pressure ulcer on his bottom he had to lay down a lot. She stated she did not re-evaluate the resident for individualized activities in his room because she assumed his pressure ulcer would heal quickly and he would be able to be up again. 2. Resident #25 had [DIAGNOSES REDACTED]. Per record review, the resident had memory impairment and was unable to make her needs known. She required extensive assist with most activities of daily living (ADL's). An activity note dated 5/2/14, documented the resident's dementia had progressed and she was unable to do anything independently. The resident was noted to have unintelligible conversation most of the time. The resident spent most of the day in the recliner in the common area and liked to watch people and occasionally make a few comments. The most recent plan of care identified the resident's goal would be to continue to socialize at meals and attend music activity weekly. Interventions included to encourage the resident to sit in the recliner at the nurses station, offer magazines to look through, music activity and walking outside with staff when weather allowed. During observation on 7/21/14 at 10:30 a.m., 1:22 p.m., and 2:22 p.m., Resident #25 was observed sitting in a recliner by the nurses station. The resident was observed sleeping off and on and no reading material was available. On 7/22/14 at 10:00 a.m., Resident #25 was interviewed. She was unable to answer questions in regards to activities she preferred. There was no reading material available to the resident. Per review of the activities flow sheet, the resident's only interventions were to encourage the resident to sit at nurses station and pet the dog, invite to music and invite to read together. For June 2014 the resident had 1 pet visit and July 2014 the resident had 1 music activity. Per interview on 7/24/14 at 11:30 a.m., Staff #E stated that the resident really didn't do much. She stated the resident used to like to pet the facility dog but the dog was no longer there. Staff #E stated the resident's dementia was bad. Sometimes the resident would talk but she was hard to understand. She stated she could give the resident a magazine but didn't think she would understand. The resident couldn't handle group activities because it was too much stimulation. She stated she didn't really have time during the week to do 1:1's or individual activities because she had her structured groups and encouraged the weekend activities staff to do that.