Every finding on record at Canterbury House

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of safety for 1 of 1 facility kitchens reviewed. The failure to ensure the kitchen's range vent hood and freezer were kept clean and free of dust, debris, and/or dirt build-up placed residents at risk for ingesting contaminated food and the development of foodborne illness. Findings included <Facility Policy>The facility policy titled, Sanitary Conditions: Equipment and Utensil Cleaning and Sanitization, published 01/2008, showed a potential cause of foodborne outbreaks was improper cleaning of contaminated equipment. The policy showed protecting equipment from contamination including dust and grease was indicated.The facility policy titled, Food Storage, updated 10/2017, showed the facility would ensure food storage areas/environment were kept clean, safe, and sanitary at all times. <Range Vent Hood>Observation on 01/12/2026 at 8:39 AM showed the kitchen's range vent hood had a visible buildup of dust and dirt. There were spider webs floating along the stainless vent hood baffle filter. The dirty range vent hood was situated adjacent to the food preparation area where steam tables were placed, and resident trays were prepared for meal service. In an interview on 01/12/2026 at 8:43 AM, Staff S (Dietary Supervisor) confirmed the range vent hood had an accumulation of dust and dirt built-up. Staff S stated it needed to be cleaned to ensure the food prepared and served to the residents during meal service remained free from any form of contamination. <Walk-In Freezer>Observation on 01/12/2026 at 9:09 AM showed the kitchen's walk-in freezer was dimly lit, with several boxes and packages stocked up all the way to the ceiling and almost touching the sprinkler head. The freezer's bulkhead had a notable amount of grayish-black dirt buildup which appeared in round patches and was mostly concentrated in areas of condensation (water vapor turned into a liquid form that could cause issues like molds). Review of the November 2025 and December 2025 Daily Cleaning Schedule- Landscape showed the dietary aide was responsible for cleaning the two refrigerators in the kitchen. In an interview on 01/12/2026 at 9:14 AM, Staff S confirmed the walk-in freezer's bulkhead had accumulated moist, dirt buildup and needed to be cleaned. Staff S stated they were unsure if cleaning the freezer's bulkhead was part of their daily cleaning schedule. Staff S stated it was important to ensure food was stored in sanitary conditions to prevent contamination that could result in foodborne illnesses. REFERENCE: WAC 388-97-1100 (3), -2980

Based on observation, interview, and record review, the facility failed to ensure essential equipment (a dishwasher) was kept in safe operating condition for 1 of 1 facility kitchens reviewed. These failures placed the residents at risk for infection from using improperly sanitized dishes and utensils during meals and the development of foodborne illness. Findings included.<Facility Policy>The facility policy titled, Sanitary Conditions: Equipment and Utensil Cleaning and Sanitization, published 01/2008, showed dishwashing machines were operated according to the manufacturer specifications. The policy showed, for Low Temperature Dishwashers, chemical sanitization included a wash cycle at 120 degrees Fahrenheit (F) and a final rinse with 50 parts per million (PPM) Chlorine (the chemical component used to test for proper sanitation) concentration on the dish surface.< Manufacturer's Instructions - Dishwasher> According to the 12/17/2010 Ecolab Installation and Operation manual provided by the facility, the safe operating temperature specified for this dishwasher was 120F (minimum) for both the wash and rinse cycle and the sanitizing rinse solution should be 50 PPM Chlorine (minimum). <Kitchen Dishwasher> Review of the January 2025 Kitchen Dishwashing Temperature Log showed the morning monitoring of the dishwasher was completed on 01/12/2026 and the dishwasher was within safe operating temperatures and chemical sanitation. Observation and interview on 01/12/2025 at 8:57 AM with Staff S (Dietary Supervisor) showed the dishwasher's chemical sanitation using the Chlorine test strip after a complete wash/rinse cycle did not meet the criteria of 50 PPM during testing as specified in the manufacturer's instruction manual. Staff S repeated the wash/rinse cycle, and the test strip yielded the same results. Staff S asked Staff T (Dietary Aide) to change the chemical solution bucket connected to the dishwasher and they ran the wash/rinse cycle again; the chemical testing still did not meet the criteria of 50 PPM. Staff S stated they would call the service maintenance provider to check the dishwasher immediately and would utilize the three-compartment sink (a manual dishwashing method) for the time being to ensure sanitation in washing the dishes. In an interview on 01/12/2025 at 10:37 AM, Staff S stated it was important to ensure the dishwasher was functioning according to the manufacturer's specifications, .so the residents would not get sick from eating off of dirty and unsanitized dishes and utensils. Staff S stated the monitoring of essential kitchen equipment for proper functioning was necessary for resident safety in preventing foodborne illnesses. REFERENCE: WAC 388-97-2100.

Based on observation, interview, record review the facility failed to ensure 3 of 5 residents (Residents 5, 9, & 74) reviewed for Restorative Nursing Program (RNP) services received the care and services they were assessed to require. The failure to provide hand splinting (Resident 5), Range of Motion (ROM) exercises (Resident 9), and grooming/dressing program (Resident 74) placed residents at risk for pain, contractures (the permanent or severe tightening of muscles resulting to immovable joints), decline in mobility, increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy>The facility's undated policy titled, Contracture Management, an addendum to ROM from the Restorative Nursing Aide (RNA) Training Program, showed the nursing team screened, assessed, and tracked in regular intervals changes in joint mobility in all residents with evidence of limited ROM, and plan a RNP as needed. The policy showed RNAs had an active role in screening and monitoring residents for changes in their joint mobility as they were involved with the residents' everyday living and had a better chance in observing ROM changes. The policy showed staff were expected to provide ROM programs initiated for residents and to follow a resident's splinting schedule if any. <Resident 5> According to a 11/30/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had limited ROM to both arms and legs. Resident 5 required total assistance from staff with personal hygiene, bed mobility, transfers, dressing, and toileting. The MDS showed Resident 5 had no rejection of care during the assessment period. Review of Resident 5's revised 03/23/2022 Impaired Mobility related to Muscle Weakness Care Plan (CP) RNAs were to provide Resident 5 a splint to their left hand seven days a week, wash and dry their hand, and apply a palm guard six-to-eight hours per day. Observation on 01/14/2026 at 10:54 AM, showed Resident 5 with no palm guard on their left hand. Review of the December 2025 and January 2026 Treatment Administration Records (TARs) showed Resident 5 did not receive their RNP on Sundays in December 2025 and January 2026. In an observation and interview on 01/16/2026 at 11:56 AM, Staff FF (Licensed Practical Nurse, MDS) reviewed Resident 5's December 2025 and January 2026 STARs and stated the lack of staff initials meant restorative services were not completed. Staff FF stated restorative services should be provided as ordered for the resident's care and should have been provided seven days per week but were not. <Resident 9> According to the 10/19/2025 admission MDS, Resident 9 could not communicate using words, had severely impaired cognitive and functional abilities due to an early onset progressive neurological condition, and was dependent on staff for all daily cares. The MDS showed Resident 9 had limited ROM to both their arms/hands and legs. A 01/03/2026 Discharge MDS showed Resident 9 was discharged to the hospital and a 01/08/2026 Entry Tracking showed the resident readmitted back to the facility. Review of Resident 9's 11/14/2025 Impaired Mobility CP showed the resident had decreased ROM and mobility due to their medical diagnosis of functional quadriplegia (the partial or total loss of sensation and motor function in all four limbs) resulting from their progressive neurological disorder. The CP showed a ROM program was put in place as a restorative nursing intervention. According to a 11/11/2025 Restorative Program Referral Form, the physical therapist recommended passive ROM (PROM) to Resident 9's bilateral upper and lower extremities. This referral form showed to provide all tolerated ROM and positional changes to prevent contractures and wounds/pressure injuries. Observation on 01/13/2026 at 11:58 AM showed Resident 9's wrists curled inwards; their hands and fingers were stiff and rigid. There were no purposeful movements observed on Resident 9's bilateral legs/feet. Review of the January 2026 TAR showed Resident 9 was not provided PROM from 01/04/2026 to 01/15/2026. In an interview on 01/15/2026 at 10:20 AM, Staff GG (RNA) stated Resident 9's PROM was discontinued. In an interview on 01/15/2026 at 10:43 AM, Staff FF stated they were part of the RNP staff as the licensed nurse responsible for the initiation, quarterly evaluation, and discontinuation of RNPs when they were no longer beneficial or applicable for the resident. Staff FF stated when Resident 9 discharged to the hospital, their PROM RNP was automatically discontinued from their software system. Staff FF stated, based on their assessment, Resident 9 continued to benefit from their PROM RNP which should have been re-initiated when the resident came back to the facility on [DATE] but was not. <Resident 74> According to the 12/30/2025 Quarterly MDS, Resident 74 had clear speech, intact memory and medical conditions including a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements. The MDS showed Resident 74 had limited ROM to both their arms/hands and legs; Resident 74 was assessed to be dependent on staff for dressing and required substantial/maximal assistance with their personal hygiene. Review of Resident 74's revised 10/20/2025 Impaired Mobility CP showed the resident had decreased ROM and an intervention was in place for a dressing/grooming RNP to help the resident attain and/or maintain their highest practicable function and wellbeing. The RNP was to be provided to Resident 74 two-to-four times a week. Review of Resident 74's 01/11/2026 Quarterly RNP evaluation completed by Staff FF showed the grooming program remained appropriate and beneficial for the resident at the time of the assessment. The ongoing goal for Resident 74's RNP was to maintain their current functional abilities in performing personal hygiene/grooming tasks and for their quality of life. In an observation and interview on 01/13/2026 at 8:38 AM, Resident 74 was observed in bed eating their breakfast with noticeable tremors to both their hands. Resident 74 stated they had limited ROM and experienced issues with raising both their arms. The resident was observed unable to fully extend their arms. Resident 74 stated they were provided RNP once in a while when the staff were able to get to it. Review of the December 2025 TAR showed Resident 74 was not consistently provided their grooming RNP as care planned: On the week of 12/07/2025 – 12/13/2025, it was provided once on 12/12/2025; and on the week of 12/14/2025 – 12/20/2025, none was provided. Review of the January 2026 TAR showed Resident 74 was not consistently provided their grooming RNP as care planned: On the week of 01/04/2026 – 01/10/2026, it was provided once on 01/09/2026. In an interview on 01/16/2026 at 10:21 AM, Staff GG stated they were one of two RNAs working in the facility and the two of them had alternate working days providing RNPs and working as a Certified Nursing Assistant (CNA) on the nursing units. Staff GG stated they had trouble meeting the RNP needs of residents, .it [RNPs] was too much for one restorative aide to provide all the RNPs for the day.[we] cannot possibly cover the RNP's recommended frequency and have not been able to do so. In an interview on 01/16/2026 at 10:43 AM, Staff FF reviewed Resident 74's grooming RNP and confirmed it was not consistently provided to the resident as care planned. Staff FF stated they were aware both restorative aides had difficulty providing RNPs to all the residents who were assessed to require them, especially if/when the restorative aide worked alone. Staff FF stated they informed Staff B (Director of Nursing) regarding this hardship. In an interview on 01/16/2026 at 11:19 AM, Staff HH (RNA) confirmed their work schedule as outlined by Staff GG. Staff HH stated they worked as a CNA at this time while Staff GG provided RNPs to residents. Staff HH stated they knew RNPs were important to provide to residents to prevent their functional decline, but it was not achievable with only one person doing it all. In an interview on 01/16/2026 at 2:35 PM, Staff B stated they expected the RNP staff to provide restorative care and services according to the resident's assessed needs/benefits and according to the resident's individualized CP. Staff B stated they expected the RNP staff to notify them if they had difficulty providing RNPs. Staff B stated it was important to provide RNPs to residents in order to maintain function and mobility, which were important aspects of a resident's quality of life. REFERENCE: WAC 388-97-1060(3)(d)(j)(ix).

Based on interview and record review, the facility: (1) failed to provide the resident and/or the representative a written notice of the facility's bed hold (a process to reserve a resident's current bed when was temporarily absent) policy, at the time of transfer/discharge or within 24 hours, and document in the resident's records for 3 of 4 residents (Residents 9, 27, & 82); and (2) failed to ensure appropriate information was communicated to the receiving health care institution or provider and document in the resident's records for 2 of 4 residents (Residents 9 & 27) reviewed for hospitalizations. These failures placed residents and their representatives at risk of not being informed of their right to, or the cost of ensuring their bed was held for them while hospitalized and unsafe and ineffective transition of care. Findings included . <Policy>The facility policy titled, Bed Hold, updated 05/2025, showed the resident and/or resident representative should be informed of the facility's bed hold policy in writing upon admission, transfer, or leave of absence. The policy showed if the facility was unable to provide the bed hold policy at the time of transfer, the policy must be provided within 24 hours. The policy showed if nursing was unable to provide notification at the time of transfer or discharge, the Social Services Director or designee would contact the resident and/or their representative to notify them of the bed hold policy, obtain a decision whether or not the resident or responsible party chose to secure a bed hold, and document the notification and decision in the Bed Hold Agreement form.<Resident 9> According to the 10/19/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 9 did not have the ability to communicate words, had severely impaired cognitive ability due to a neurological developmental disability, and was dependent on their representative for decision-making. A 01/03/2026 Discharge MDS showed Resident 9 was discharged to the hospital. Review of Resident 9's progress notes from 01/03/2026 until 01/08/2026 did not show the resident's transfer/discharge to the hospital was coordinated with the receiving institution or provider for safety as required. Review of Resident 9's medical records showed there was no documentation to support a bed hold was offered to the resident's representative or that the receiving hospital was provided with all the necessary personal and health information required for a safe and effective transition of care during the transfer/discharge. The facility was asked for any documentation regarding offering Resident 9's representative a bed hold and for any hospital transfer communication, but none was provided. In an interview on 01/16/2026 at 12:52 PM, Staff B (Director of Nursing) reviewed Resident 9's medical records and confirmed there was no documentation a bed hold was offered to the resident's representative or that staff documented their coordination with the receiving hospital. Staff B stated they expected staff to offer residents and/or their representatives a bed hold when they were transferred/discharged from the facility because it was a resident's right to be informed for appropriate decision-making. Staff B stated they expected the nursing staff to complete the required hospital transfer protocol and to document what was done in the resident's medical records. <Resident 82> According to the 11/14/2025 admission MDS, Resident 82 was alert, oriented, and was their own decision-maker. A 12/19/2025 Discharge MDS showed Resident 82 was discharged to the hospital. Review of Resident 82's medical records showed there was no documentation to support a bed hold was offered to the resident during or 24 hours after they were transferred/discharged to the hospital. The facility was asked for any documentation regarding offering Resident 82 a bed hold, but none was provided. In an interview on 01/16/2026 at 12:50 PM, Staff B reviewed Resident 82's medical records and stated there was no documentation found to support a bed hold was offered to the resident. <Resident 27> According to a 01/05/2026 Discharge Return Anticipated Minimum Data Set (MDS – an assessment tool), Resident 27 transferred to an acute care hospital on [DATE] with their return to facility anticipated. Review of Resident 27's medical record showed no documentation that the facility provided a medical report to the hospital, and no documentation that a bed hold was offered to Resident 27 for their 01/05/2026 transfer to the hospital. In an interview on 01/15/2026 at 10:56 AM, Staff K (RN Unit Manager) said the bed hold policy was included in pre-assembled hospital transfer packets that were sent with residents when they transferred to the hospital. Staff K said they believed Admissions staff followed up with hospitalized residents to offer the bed hold. Staff K looked for but could not find any hospital transfer packets at the nurse's station. In an interview on 01/16/2026 at 8:59 AM, Staff K said no hospital transfer packets were currently assembled. Staff K said they expected staff to document when they called a medical report to the hospital. Staff K confirmed staff did not document that a medical report was called to the hospital for Resident 27's transfer on 01/05/2026. In an interview on 01/16/2026 at 9:48 AM, Staff Z (Admissions Director) said their process when a resident transferred to the hospital was to call the patient at the hospital or their representative, offer the bed hold over the phone, and document in a progress note. Staff Z said when Resident 27 transferred to the hospital on [DATE], they called them on their cell phone and left a voicemail to offer the bed hold. Staff Z said they did not document the call but should have. In an interview on 01/16/2026 at 11:53 AM, Staff B (Director of Nursing) said when residents were transferred to the hospital, it was their expectation that staff document bed hold offered and that a medical report was called to the hospital. REFERENCE: WAC 388-97- 0120(4), -0140(1)(a)-(c)(i)-(iii). .

Based on observation, interview, and record review the facility failed to ensure: physician orders were followed for 4 of 18 sampled residents (Residents 55, 1, 9, & 27), failed to notify the physician for refusals of medications for 1 of 5 residents (Resident 27) whose medication regimens were reviewed. These failures left residents at risk for unmet care needs and other negative health outcomes.Findings included .Facility PolicyAccording to the facility's 2007 Non-Controlled Medication Orders policy, staff were to administer medications in accordance with prescribers' written orders and, if necessary, staff would contact the prescriber for clarification. Staff were to document all interactions and the resulting order clarification in the nursing progress notes and elsewhere in the medical record.<Following Orders> <Resident 55> According to the 11/06/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 55 admitted on [DATE] with diagnoses including orthopedic (bone/muscle) conditions. The MDS showed Resident 55 required their nutrition to be delivered through tubing intravenously (directly to the blood). Review of the 11/10/2025 Care Area Assessment (CAA - care planning assessment using MDS data) showed Resident 58 received intravenous nutrition and staff were to care for the resident's Peripherally Inserted Central Catheter (PICC - the tubing providing Resident 55's nutrition to their blood) per the protocol. Record review showed a physician order for staff to remove liquid nutrition bag and tubing set from the infusion pump at 12:00 PM each day and discard, and an 11/22/2025 order for staff to perform a dressing change for Resident 55's PICC site every seven days on Saturdays and as needed. Record review showed nursing staff documented the dressing change on 01/10/2026 at 05:00 PM was not administered. Review of 01/10/2026 at 6:15 PM nursing progress note showed Resident 55 was out of the facility with their family. Observations on 01/12/2026 at 2:32 PM showed Resident 55's liquid nutrition bag and tubing set were connected to the infusion pump and Resident 55's PICC site, over two hours after the time the order stated to disconnect them. Resident 55's PICC site dressing was not dated, and the edges of the dressing were detaching from their skin. In an observation and interview on 01/12/2026 at 2:36 PM, Staff F (Registered Nurse - RN) stated Resident 55's PICC site dressing should be dated and changed based on its appearance but was not. Staff F stated the liquid nutrition bag and tubing should be disconnected and discarded at the ordered time but was not. In an interview on 01/16/2026 at 1:30 PM, Staff B (Director of Nursing) stated they expected staff to follow facility policy to label dressings with the date they were placed and follow physician orders. <Resident 1> According to the 12/26/2025 5-day MDS, Resident 1 had medically complex conditions including diabetes (difficulty controlling blood sugar), respiratory failure, and memory impairment. Review of the January 2026 Medication Administration Record (MAR) showed an 01/16/2025 order for a steroid inhaler, take one inhalation every morning and at bedtime and rinse the resident's mouth out after each use to avoid oral thrush (a yeast infection in the mouth which could be caused by steroid use). Review of the January 2026 MAR showed a 12/19/2024 order for a long-acting inhaler daily to treat Resident 1's chronic respiratory condition. Observation on 01/15/2026 at 8:21 AM Staff W (Licensed Practical Nurse - LPN), administered the steroid inhaler to Resident 1. After administering the steroid inhaler, Staff W provided Resident 1 their other long-acting inhaler medication without first rinsing Resident 1's mouth after using the steroid inhaler. Staff W did not wait in between administering both inhaler medications. In an interview on 01/15/2026 at 8:32 AM, Staff W stated they should have waited between inhalers for better effectiveness and rinsed Resident 1's medication after use of the steroid inhaler but did not. In an interview on 01/16/2026 at 12:00 PM, Staff K (RN unit manager) stated the nurses should follow orders as written. Staff K stated if the order stated to swish and rinse after use, the nurses should follow written orders. Staff K stated nurses should also wait between administering two different inhalers to avoid mixing the medications for better effectiveness of the medications. <Resident 9> According to the 10/19/2025 admission MDS, Resident 9 did not have the ability to communicate words, had short-term and long-term memory deficits, and medical conditions including an early-onset, progressive neurological condition that affected their bladder function. The MDS showed during the assessment period, Resident 9 had a suprapubic indwelling urinary catheter (tubing that entered their body through the abdomen to help drain their urine). According to a 01/03/2026 Discharge MDS, Resident 9 was discharged to the hospital. According to a 01/08/2026 Entry Tracking, Resident 9 returned to the facility. Review of the 01/08/2026 hospital discharge summary showed Resident 9 was diagnosed with a systemic infection because of their indwelling urinary catheter. The summary showed the discharging physician ordered two oral antibiotics for Resident 9; one of which was a double-strength antibiotic. Review of the January 2026 MAR showed, on 01/08/2026, Resident 9 was administered a single-strength dose of the antibiotic for which they required a double dose. The MAR showed, on 01/09/2026, the physician order was changed to the double-strength dose but incorrectly listed pneumonitis (a respiratory infection due to inhalation of food and vomit) as the indication for its use, instead of a urinary infection. On 01/13/2026 at 11:47 AM, Resident 9 was observed with an indwelling urinary catheter in place; it was draining clear, yellow urine into the collection bag. Resident 9 was observed without any breathing issues or respiratory discomfort. In an interview on 01/16/2026 at 1:15 PM, Staff DD (Advanced Registered Nurse Practitioner) stated both antibiotics prescribed for Resident 9 during their hospital discharge were for the treatment of their systemic urinary infection. In an interview on 01/16/2026 at 1:08 PM, Staff B reviewed Resident 9's January 2026 MAR and confirmed the resident was incorrectly administered a single-strength dose of antibiotic on 01/08/2026. Staff B stated they expected the nurses to follow physician orders as prescribed for resident safety. Staff B stated the nurse should have clarified the indication for Resident 9's antibiotic use to ensure the resident's medical records were accurate but did not. <Resident 27 - Oxygen> According to a 12/19/2025 Quarterly MDS, Resident 27 had multiple medically complex diagnoses including Chronic Obstructive Pulmonary Disease (COPD – a progressive lung disease that makes breathing difficult) and received oxygen therapy. Review of a 09/16/2025 physician's order showed Resident 27 was to receive oxygen through a nasal cannula (tubing with two prongs to deliver supplemental oxygen through the nose) at the rate of two Liters per Minute (L/Min) to keep oxygen saturation (oxygen sats – the level of oxygenation of the blood) between 88% - 92%. Observation on 01/13/2026 at 12:32 PM showed Resident 27 lying in their bed and received oxygen through a nasal cannula connected to an oxygen concentrator (a medical device that provides concentrated oxygen through a nasal cannula or mask). The concentrator was set to deliver oxygen at a rate of 0.5 L/Min. Resident 27 stated someone had been messing with the settings, and it should be set at least at 1 L/Min. Resident 27 said they felt they were getting enough oxygen. Resident 27 used a pulse oximeter (a device placed on a finger to measure oxygen sats) and showed his oxygen sats were currently 98%. Observations on 01/14/2026 at 08:54 AM and on 01/14/2026 at 10:08 AM showed Resident 27 received oxygen at a rate of 0.5 L/Min. In an observation and interview on 01/14/2026 at 10:26 AM, Staff L (RN) confirmed the oxygen concentrator was currently set at 0.5 L/min. Staff L said Resident 27 was to receive oxygen at 2 L/Min continuously and someone must have changed the rate. Staff L adjusted the concentrator rate to 2 L/min. Review of a January 2026 Treatment Administration Record (TAR) showed staff documented Resident 27's oxygen sats and administration of oxygen every shift (day, evening, and night) each day. For 34 shifts between 01/01/2026 and 01/14/2026, staff documented oxygen sats that ranged from 94% to 99%. No documented oxygen sats were within the oxygen parameters of 88% - 92%. Review of a December 2025 TAR showed staff documented oxygen sats for 92 shifts that ranged from 94% to 99%. No documented oxygen sats were within the oxygen parameters of 88% - 92%. Review of September 2025, October 2025, and November 2025 TARs showed similar results. All documented oxygen sats since the order date of 09/16/2025 ranged from 93% to 100%, with no results within the oxygen parameters of 88% - 92%. In an interview on 01/14/2026 at 2:06 PM, Staff K stated they thought there was an order to verify the oxygen concentrator settings, but there was not. Staff K stated they expected staff to follow ordered parameters to keep oxygen sats between 88% - 92% and confirmed they did not. In an interview on 01/15/2026 at 2:53 PM, Staff B said they expected staff to follow ordered parameters. <Notifying the Provider> <Resident 22> According to the 12/18/2025 Quarterly MDS, Resident 22 had multiple complex conditions including diabetes, depression, anxiety, and a chronic heart condition. Review of the revised 10/16/2025 impaired psychosocial well-being related to depression and anxiety Care Plan (CP) showed Resident 22's target behaviors included refusals of their medications. Review of the January 2026 MAR showed Resident 22 refused their oral diabetes medication daily from 01/01/2026 through 01/13/2026; refused their anxiety/depression medication daily from 01/01/2026 through 01/07/2026; refused their water pill to treat their chronic heart condition from 01/01/2026 through 01/09/2026; and refused their injectable diabetes medication on 01/01/2026, 01/02/2026, 01/03/2026, 01/06/202601/07/2026, 01/08/2026, 01/09/2026, 01/10/2026 and on 01/11/2026. Review of the January 2026 medical record did not show Resident 22's provider was notified every time Resident 22's refused their medications. In an interview on 01/15/2026 at 9:34 AM Staff W stated Resident 22 refused their medications all the time, and they should document each refusal and notified the provider about the refusals but did not. In an interview on 01/15/2026 at 8:41 AM Staff K stated they expected the nurses to notify the provider every time Resident 22 refused their medications. Staff K stated the nurses were expected to follow the directions provided, document interventions, and notify leadership and family, but did not. In an interview on 01/16/2026 at 10:56 AM Staff B stated the nurses should have reapproached the resident and determined the reason for the medication refusals and notified the provider for further instructions. <Resident 27> Review of a 07/11/2025 physician order showed staff were to administer a nasal spray (used to relieve allergy symptoms) with one spray in both nostrils each morning. Observation of a medication administration pass on 01/14/2026 at 8:54 AM showed Staff L administered multiple medications to Resident 27. Staff L did not offer or administer the ordered nasal spray. In an interview on 01/14/2026 at 10:22 AM, Staff L said they did not give the nasal spray and documented it was refused, because Resident 27 refused it every time. Staff L said Resident 27 did not want nurses to offer it anymore, so they did not offer and documented refused. Staff L said that other nurses and the doctor were aware of the refusals. In an interview on 01/14/2026 at 10:24 AM, Resident 27 said they did not like the nasal spray because it dried up their nose. Record review of November 2025, December 2025, and January 2026 MARs showed Resident 27 accepted the nasal spray 27 times and refused 43 times since 11/01/2025. In an interview on 01/14/2026 at 2:06 PM, Staff K said Resident 27 always refused the nasal spray. Staff K said staff should notify the doctor of refusals and ask for an order to discontinue it, and possibly an order for an alternative that Resident 27 would accept. Staff K said they would check to see if that was done. In an interview on 01/16/2026 at 8:59 AM, Staff K said staff notified Resident 27's doctor in December 2025 of refusals of the nasal spray. Staff K said the doctor wanted staff to continue to try to administer, but Resident 27 continued to refuse. No requested documentation to show communication with the doctor regarding nasal spray refusals was provided. In an interview on 01/15/2026 at 2:53 PM, Staff B said they expected staff to offer the medication each time it was due until the medication was discontinued. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview, and record review the facility failed to ensure effective coordination of care between the facility and hospice staff and failed to implement and develop a coordinated Care Plan (CP) for 2 of 2 residents (Resident 5 & 3) reviewed for hospice services. The failure to implement a system by which consistent communication between the facility and hospice staff occurred placed residents at risk for not receiving necessary care and services, avoidable discomfort, and other negative health outcomes. Findings included . <Facility Policy>According to the facility's updated September 2017 Hospice Provision of Care Policy, the facility would collaborate with outside providers to coordinate the provision of hospice care as directed by each residents' physician. The hospice and facility would agree upon a coordinated Care Plan (CP) to include directives and services hospice care which the facility would be responsible for. The CP was to be updated quarterly and as needed and would indicate each party's responsibilities. The unit manager would coordinate care services with the hospice team, and the hospice team would notify the facility of the care to be rendered. <Resident 5> According to a 11/30/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 was unable to be understood, had a traumatic brain dysfunction and received hospice (end of life) care services. Record review showed the revised 07/31/2025 Terminal Condition CP directed staff to work collaboratively with the external hospice team to ensure Resident 5's spiritual, emotional, intellectual, physical, and social needs were met to include working with the facility nursing staff to provide maximum comfort for Resident 5. The CP did not indicate what services the hospice team provided or how often services were provided to Resident 5. Record review of Resident 5's January 2026 Kardex (nursing aides' instruction sheet) showed staff were to provide a shower or bed bath twice weekly. The Kardex did not show what care services were provided by hospice services. Review of Resident 5's medical record showed documented hospice visits on 10/01/25 and 11/27/2025 and no hospice visits documented in the month of January 2026. In an interview on 01/15/2026 at 9:51 AM, Staff V (Certified Nursing Aide) stated they thought the hospice team provided showers to Resident 5 but was not sure. In an interview on 01/16/2026 at 9:04 AM Staff Y (Licensed Practical Nurse) stated hospice visit notes should be sent to the Director of Nursing (DON)after each visit and incorporated into the medical record. In an interview on 01/16/2026 10:32 AM Staff K (Registered Nurse, Unit Manager) stated hospice visit notes should be sent to the DON and then scanned into the medical record. Staff X stated they were unable to locate additional visit notes other than what was already noted in Resident 5's medical record. Staff K stated they knew the hospice nurse recently visited Resident 5 but was unsure what services were provided to coordinate care. Staff K stated hospice visit notes were important for the coordination of care and provided residents with continuity of care between the facility and hospice services. In an interview on 01/16/2026 at 10:53 AM Staff B (Director of Nursing) stated they expected the hospice team to provide notes when they visited to coordinate and provide continuity of care. Staff B stated they could not locate recent hospice visit notes in the medical record but they should be there. <Resident 3> According to a Modified 06/15/2025 Significant Change Assessment MDS, Resident 3 was able to be understood, had multiple diagnoses including heart conditions, respiratory conditions, wounds, and pain issues, and received hospice care services. Review of the revised 09/19/2025 hospice services CP showed staff would work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met, including working with nursing staff to provide maximum comfort for Resident 3. The CP did not show what services the hospice team provided or how often the service was provided to Resident 3. Observation and interview on 01/14/2026 at 8:25 AM showed Resident 3 lying in bed on their back. Resident 3 stated they had some pain. Resident 3 said they required hospice services and a hospice nurse visited them. In an interview on 01/14/2026 at 10:12 AM, the visiting hospice nurse stated they visited Resident 3 that day, and visited about once every three days for the last few months. The hospice nurse stated they monitored Resident 3's wound, provided medication management, and addressed other health and comfort issues. Review of Resident 3's medical record showed Resident 3 admitted to hospice services on 06/09/2025, and hospice visit notes were documented on 06/09/2025, 07/10/2025, 07/14/2025, 07/16/2025, 08/27/2025, and 10/02/2025. No hospice visits were documented for the month of September 2025, November 2025, December 2025 or January 2026. In an interview on 01/15/2026 at 11:28 AM, Staff K stated hospice staff were able to write visit notes to leave in Resident 3's hospice binder at the nursing station. Staff K stated normally hospice staff sent them an email for any order changes, and medical records staff would notify nursing staff, and upload orders to the EHR. Staff K was unable to locate Resident 3's hospice binder at that time and stated they would look for it. In an interview on 01/16/2026 at 8:59 AM, Staff K said they did not locate Resident 3's hospice binder. Staff K said they were unable to find any emails from hospice regarding Resident 3. Staff K stated they frequently coordinated verbally with hospice staff and stated such communication should be documented in the medical record. In an interview on 01/16/2026 at 11:53 AM, Staff B stated there should be consistent documentation of coordination of Resident 3's care with hospice staff. REFERENCE: WAC 388-97 -1620(1)(2)(b)(i)(ii), -0220.

Based on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves and gowns used to prevent exposure to infectious materials) for 1 supplemental resident (Resident 55) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); ensure staff followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 supplemental resident (Resident 88) reviewed for TBP; and ensure respiratory equipment was free from visible debris for 1 of 1 sampled residents (Resident 27) reviewed for respiratory care. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included .<Facility Policy>According to the facility's March 2025 TBP policy, the facility used different types of precautions to protect residents and staff from different kinds of communicable diseases. The facility would place appropriate signage at the entrance door of resident rooms to alert staff and visitors of necessary measures. The policy showed staff would use personal protective equipment (PPE) as indicated by the identified precaution.According to the facility's 03/26/2024 Cleaning and Disinfecting Environmental Surfaces policy, the facility would clean and disinfect semi-critical items, including respiratory therapy equipment, according to current CDC recommendations for disinfection of healthcare facilities.According to the facility's May 2015 Respiratory Equipment policy, updated May 2015, hand-held nebulizers (a machine that turns liquid medicine into a fine, inhalable mist for a 5-10 minute treatment, used for respiratory conditions), masks, and tubing were to be cleaned after each use and stored in a mesh bag, paper sack, or the compartment within the nebulizer machine<Precautions> <Resident 55>According to the 11/06/2025 admission Minimum data Set (MDS - an assessment tool), Resident 55 had received their nutrition intravenously (IV - through the blood). Record review of the 11/10/2025 Care Area Assessment (CAA - areas triggered by the MDS that required care planning) showed Resident 55 was at risk for infection related to their IV site. Observation on 01/14/2026 at 8:50 AM showed an EBP sign placed outside Resident 55's door, with instructions to staff to wear an isolation gown and gloves during high contact patient care activities. At this time, Staff E (Licensed Practical Nurse) was observed leaning over Resident 55 to administer an insulin injection. Staff E did not wear a gown. In an interview on 01/14/2026 at 8:54 AM, Staff E stated they did not consider insulin injections a high contact activity requiring a gown. In an interview on 01/16/2026 at 1:30 PM, Staff B (Director of Nursing) stated the administration of insulin was a high contact patient care activity. Staff B stated they expected staff to follow the facility infection control policy, but they did not. <Resident 88> Observation on 01/14/2026 at 10:35 AM showed Resident 88's door had a Contact Precaution sign posted and instructed all staff and visitors to put on a gown and gloves before entering the resident's room. Observation showed Staff G (Certified Nursing Assistant) repositioning Resident 88 in bed without wearing an isolation gown. At that time Staff C (Infection Preventionist) observed Staff G providing care for Resident 88 without wearing an isolation gown. Staff C stated they expected Staff G to follow the instructions on the sign and put on a gown and gloves prior to entering Resident 88's room, but they did not. In an interview on 01/16/2026 at 1:30 PM, Staff B stated they expected staff to follow instructions on posted precaution signs and follow the facility's infection control policy. <Respiratory Equipment> <Resident 27> According to the 12/19/2025 Quarterly MDS, Resident 27 re-admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory conditions. The MDS showed Resident 27 received oxygen therapy. Review of a Hospital After Visit Summary, dated 01/08/2026, showed Resident 27 was hospitalized from [DATE] through 01/08/2026 for exacerbation of a respiratory condition. Review of Resident 27's January 2026 Medication Administration Record showed Resident 27 received respiratory medication via a nebulizer four times daily. In an interview on 01/12/2026 at 10:02 AM, Resident 27 stated they frequently got pneumonia (a lung infection), and just returned from a hospital stay due to difficulty breathing. Observation on 01/12/2026 at 10:02 AM showed a nebulizer machine on Resident 27's overbed table. The machine had yellowish debris on the upper surface near the oxygen tubing port, and the air filter port was stained brown. The connected tubing and mouthpiece (a hand-held nebulizer delivery device the resident holds in their mouth to inhale the medicated mist) was stored directly on top of the nebulizer machine. The machine's tubing storage compartment contained a bottle of saline nasal spray and numerous sugar packets. Observations on 01/13/2026 at 12:32 PM, 01/14/2026 at 8:07 AM, and 01/14/2026 at 12:25 PM showed similar findings. In an interview on 01/13/2026 at 12:32 PM, Resident 27 stated staff cleaned the tubing and mouthpiece, but they did not clean the nebulizer machine itself. In an interview on 01/14/2026 at 12:25 PM, Staff L (Registered Nurse) stated the nebulizer machine was dirty and should be cleaned. Staff L stated the mouthpiece storage compartment should be emptied of personal items. In an interview on 01/14/2026 at 2:06 PM, Staff K (Unit Manager) stated the nebulizer machine should be clean. In an interview on 01/16/2026 at 11:45 AM, Staff B stated they expected respiratory tubing and equipment to be free from visible debris for resident safety and infection control. REFERENCE: WAC 388-97-1320(1)(a)(2)(a)(b).

Based on interview and record review, the facility failed to implement a system to ensure 2 of 5 Certified Nursing Assistants (CNAs) reviewed for training (Staff H,CNA & Staff I, CNA), received the required in-service training of no less than 12 hours per year. This failure placed residents at risk of receiving care from unqualified staff.Findings included.In an interview on 01/14/2026 at 12:44 PM, Staff J (Licensed Practical Nurse, Minimum Data Set) said CNAs should complete 12 hours of in-service training each year by the anniversary of their date of hire.<Staff H>Review of staff listing provided on 01/12/2026 showed the facility hired Staff H on 11/07/2019.Review of the training records provided for Staff H's last completed year of employment from 11/07/2024 through 11/07/2025 showed Staff H completed 15 minutes of in-service training.<Staff I>Review of the staff listing showed the facility hired Staff I on 10/16/2024.Review of records provided for training completed since 10/16/2024 showed Staff I had 38 in-service trainings assigned to them and none were completed.In an interview on 01/14/2026 at 12:42 PM, Staff C (Infection Preventionist/Staff Development) confirmed there was no system in place to track CNA's annual in-service hours. Staff C said it was important to ensure CNAs completed the required 12 hours of in-services annually to ensure they kept up with skills and knowledge to ensure the safety and care of residents, and to meet the requirement needed to renew their CNA license.In an interview on 01/16/2026 at 10:10 AM, Staff C confirmed Staff H and Staff I did not complete 12 hours of annual in-service training as required.In an interview on 01/16/2026 at 11:53 AM, Staff B (Director of Nursing) said they expected CNAs to complete 12 hours of in-service training annually.REFERENCE: WAC 388-97-1680 (2)(a-c).

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on facility staff for assistance with Activities of Daily Living (ADLs) received the assistance they were assessed to require for 2 of 3 sampled residents (Residents 1 & 29) reviewed for ADLs. The failure to provide bathing and grooming assistance for (Residents 29) and nail care for (Resident 1) left residents at risk for body odors, unmet care needs, and a decreased self-worth and/or quality of life. Findings included <Facility Policy>The facility policy titled, Bath or Shower Assistance, updated 11/2016, showed the facility provided ADL assistance according to the resident's Care Plan (CP) and the resident's need for assistance.<Resident 1> According to the 12/26/2025 5-day Minimum Data Set (MDS - an assessment tool) Resident 1 had medically complex conditions including diabetes (a condition making it more difficult to control blood sugar), respiratory failure, and muscle weakness. The MDS showed Resident 1 required substantial assistance from staff for bathing and lower body dressing. According to the 06/23/2025 Diabetes CP, staff were to notify the nurses when Resident 1 had long toenails. The CP showed the facility nurses were to trim Resident 1's nails or refer Resident 1 to the podiatrist for foot care because of the resident's diabetes diagnosis. Review of the January 2026 caregiver task sheets and the nurses' January 2026 Treatment Administration Record (TAR) did not show toenail care scheduled for Resident 1. Observations on 01/12/2026 at 9:33 AM and on 01/14/2026 at 10:16 AM showed Resident 1 had long toenails that were half an inch past the nail bed. In an interview on 01/12/226 at 9:41 AM, Resident 1 stated they would like their toenails trimmed as they caused discomfort. In an observation and interview on 01/15/2026 at 8:37 AM, Staff W (Licensed Practical Nurse) observed Resident 1's toenails and stated Resident 1's toenails should be trimmed for comfort and to prevent curling but were not. In an interview on 01/14/2026 at 10:16 AM Staff L (Registered Nurse) stated nurses should cut diabetic resident's toenails unless the nails were too hard to cut. Staff L stated staff should check residents' toenails on bath days and report to the nurses when toenails needed to be cut. In an interview on 01/15/2026 at 8:33 AM Staff K (Unit Manager) stated the nursing aides should tell the nurses when residents' toenails needed to be cut. Staff K stated toenail care task should be on the Resident 1's TAR but was not. In an interview on 01/16/2026 at 11:03 AM Staff AA (Regional Director of Clinical Operations) stated there was a standard of care for ADLs and providing ADL assistance was important to promote healing and independence and to retain functional ability. <Resident 29> According to the 01/07/2026 admission MDS, Resident 29 had clear speech, intact memory, and diagnoses including heart and kidney failure, unstable blood sugar levels, severe obesity, and muscle weakness and had difficulty in walking. The MDS showed Resident 29 was assessed to be dependent on two staff for assistance with their shower/bathing and toileting hygiene. Review of the revised 01/12/2026 ADL CP showed Resident 29 needed substantial/maximal assistance with showers, grooming, and hygiene, and their bathing schedule was twice a week on Mondays and Thursdays during day shift. The CP showed Resident 29 was unable to perform ADLs independently due to their limited mobility and medical conditions. In an observation and interview on 01/13/2026 at 8:49 AM, Resident 29 was observed with facial hair/stubbles and long, unkempt, matted hair; a pungent smell was noticeably coming from the resident's breath and lower body. There were white flakes covering both the shoulders and upper chest portion of the resident's gown. Resident 29 stated they did not have a shower/bath in almost two weeks since they admitted to the facility on [DATE]. Resident 29 stated a caregiver came and offered them a shower once, only to come back and tell them the facility ran out of towels so the shower/bath was not provided. Resident 29 stated they did not brush their teeth since they were admitted and pointed to a facility-provided toiletries bag sitting on top of their nightstand and stated all items inside it were still unopened. Resident 29 stated they told staff they wanted to shave their facial hair and needed help but was told they Need to walk first. Review of Resident 29's January 2025 shower log showed the resident was provided a bed bath on 01/03/2026, 01/05/2025, and 01/08/2026 by Staff N (Licensed Practical Nurse, Care Coordinator). The log showed Resident 29 was not given a shower/bath on 01/12/2026 as care planned. In an interview on 01/14/2026 at 9:15 AM, Staff BB (Certified Nursing Assistant - CNA) stated the facility did not have a delegated shower aide and the CNAs were responsible for giving residents their shower/bath. Staff BB stated they refer to the CP to determine the resident's bathing preference and what day(s) in the week to provide it. In an observation and interview on 01/14/2026 at 11:16 AM, Staff CC (CNA) stated they were the staff assigned to Resident 29 for that day. Staff CC went inside Resident 29's room, confirmed the resident needed grooming and hygiene assistance, and stated they would help the resident. Resident 29 was observed telling Staff CC they did not have a shower/bath or received assistance to brush their teeth since they admitted to the facility. Resident 29 was observed directing Staff CC to look into the bag of toiletries. Staff CC did and found all items inside the bag were sealed/unopened including the toothpaste and mouthwash; the toothbrush was still inside the intact plastic wrapper. In an interview on 01/14/2026 at 12:42 PM, Staff DD (Registered Nurse, Unit Manager) reviewed Resident 29's medical records and stated the resident should have but did not receive a shower/bath on 01/12/2026. Staff DD stated it was important to provide ADL assistance to dependent residents, especially with bathing and grooming, for their quality of life and dignity, .so [residents] feel clean, loved, and respected. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review, the facility failed to maintain safe water temperatures for 2 of 14 resident room sinks (Rooms 215 & 301) reviewed for water temperatures; and failed to secure potentially hazardous items in 1 of 2 clean utility rooms (West Nursing Station clean utility room) reviewed for accident hazards. These failures placed residents at risk for accidents, injury, and a diminished quality of life.Findings included.<Policy>According to the facility's July 2008 Washington State Water Temperature Regulations policy, the facility must ensure the hot water system maintained water temperatures at 110 degrees Fahrenheit (F), plus or minus 10 F, for fixtures used by residents and staff.<Water temperatures> <room [ROOM NUMBER]> Observation on 01/13/2026 at 10:33 AM showed the hot water temperature of the sink in room [ROOM NUMBER]'s bathroom was 123 F. No residents were present. Observation on 01/13/2026 at 11:32 AM showed Resident 46 independently using the sink in room [ROOM NUMBER]'s bathroom. Resident 46 stated the water was hot, but they were able to adjust the temperature with cold water. In an interview on 01/14/2026 at 1:19 PM, Staff M (Maintenance Director) stated they tested and documented water temperatures in sampled resident rooms weekly. Staff M stated the highest water temperature should be 120 F for safety. Observation with Staff M on 01/14/2026 at 1:22 PM showed the hot water temperature of room [ROOM NUMBER]'s bathroom sink using a facility thermometer reached 125.1 F before settling at 120 F. Staff M stated they would document a temperature of 120 F as the result. <room [ROOM NUMBER]> Observation on 01/13/2026 at 10:21 AM showed the water temperature of the room sink in room [ROOM NUMBER] was 121.5 F. Residents 58 & 77 (the room's occupants) stated they used the sink and adjusted the water when it was too hot with the cold water. Observation with Staff M on 01/14/2026 at 1:26 PM showed the hot water temperature of room [ROOM NUMBER]'s room sink reached 122.7 F before settling at 116 F. Staff M stated they would document a temperature of 116 F as the result. In an interview on 01/14/2026 at 2:02 PM, Staff A (Administrator) stated they expected hot water temperatures in resident rooms to always be within the safe range. Staff A stated there could be a short burst of hot water coming through the lines from the hot water heater when water was first turned on and agreed it would be hazardous to residents using the sink during that time. Staff A confirmed the temperatures went above the safe range, and the facility needed to adjust the hot water temperature. <Clean Utility Room> Observation on 01/12/2026 at 8:33 AM showed the clean utility room across from the [NAME] Nursing Station had a keypad lock on the door. The door opened easily without entering a code on the keypad. Observation inside the clean utility room showed supplies stored included a bin of disposable razors. In an interview on 01/12/2026, Staff E (Licensed Practical Nurse) stated the door should be locked because there were hazardous items stored in the room but was not. Observations on 01/12/2026 at 12:14 PM, 01/13/2026 at 12:29 PM, and 01/14/2026 at 11:06 AM showed the door opened easily without using the keypad. In an interview on 01/14/2026 at 11:07 AM, Staff A stated the door was supposed to be locked, but it did not latch correctly and needed to be fixed. Staff A stated the razors in the room were hazardous and should be secured for resident safety. Reference WAC 388-97-1061 (3)(g), -3320

Based on observation, interview, and record review the facility failed to ensure residents' Care Plans (CPs) were comprehensive and implemented for 1 of 18 (Resident 22) sample residents whose CPs were reviewed. This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Facility Policy>The facility was unable to provide a policy describing their CP development and implementation standards and expectations. <Resident 22> According to the 12/18/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 had multiple complex conditions including diabetes, depression, anxiety and a chronic heart condition. Review of the revised 10/16/2025 Impaired psychosocial well-being related to depression and anxiety CP showed Resident 22's target behaviors included refusing their medications. This CP included no directions to staff showing what to do when Resident 22 refused their medications. No other CP was developed to address Resident 22's needs related to refusing medications. Review of the January 2026 Medication Administration Record showed Resident 22 refused their oral diabetes medication daily from 01/01/2026 through 01/13/2026; refused their anxiety/depression medication daily from 01/01/2026 through 01/07/2026; refused their water pill to treat their chronic heart condition from 01/01/2026 through 01/09/2026; and refused injectable diabetes medication on 01/01/2026, 01/02/2026, 01/03/2026, 01/06/202601/07/2026, 01/08/2026, 01/09/2026, 01/10/2026 and on 01/11/2026. Review of the medical record did not show Resident 22's provider was notified every time Resident 22's refused their medications in January 2026. In an interview on 01/15/2026 at 9:28 AM, Resident 22 stated they did not want to talk about their refusal of medications and became frustrated. In an interview on 01/15/2026 at 9:34 AM, Staff W (Licensed Practical Nurse) stated Resident 22 refused their medications all the time and they should have documented each refusal and notified the provider about the refusals but did not. In an interview on 01/15/2026 at 8:41 AM Staff K (Registered Nurse, Unit Manager) stated they expected the nurses to notify the provider every time Resident 22 refused their medications. Staff K stated the nurses were expected to follow the directions provided, document the interventions attempted, notify behavior support services, and notify leadership and family but did not. Staff K stated refusal of medications should be addressed in Resident 22's CP with instructions for staff to follow when Resident 22 refused their medications. In an interview on 01/16/2026 at 10:56 AM Staff B (Director of Nursing) stated the nurses should have reapproached the resident and determined the reason for the medication refusals and notified the provider. Staff B stated Resident 22's CP should include interventions showing staff what to do when Resident 22 refused their medications but did not. Refer to: F658 - Services Provided Meet Professional Standards REFERENCE: WAC 388-97-1020(1), (2)(a-b).

Based on interview and record review, the facility failed to 1) review resident rights and the grievance policy in accordance with their process and 2) initiate, investigate and document resolutions for grievances raised during 3 of 3 Resident Council (RC) meetings (11/03/2025, 12/10/2025, and 01/08/2025) reviewed. This failure placed residents at risk of increased feelings of powerlessness, frustration, and decreased quality of life.Findings included .<Facility Policy>According to the facility's January 2017 Resident Council policy, the facility was responsible for providing staff support for monthly RC meetings to gather and discuss thoughts, ideas, or issues related to the residents' care and treatment. Staff would review old and new business to ensure members had an opportunity to express their concerns. Staff would ensure resident concerns were resolved via the facility's grievance policy and provide updates on each concern by the next RC meeting.Review of the November 2016 Grievance Procedure policy showed staff would resolve grievances immediately, if possible, or complete a Grievance Form and give it to the Grievance Official within 24 hours.Review of the March 2025 Grievance Procedure Policy Posting showed the Grievance Official would give the Grievance Form to the appropriate department manager, who would review the concern, respond within five business days, and return the form to the Grievance Official. If unable to resolve the grievance in five days, the Administrator would review during the daily manager meetings until a resolution was obtained. The residents would receive a written decision regarding their grievances.<Resident Council> Review of the 11/03/2025 RC Minutes showed RC sample members (Resident 24, Resident 14, Resident 47, and Resident 60) attended. The old business section was labelled Yes and no additional information was documented. The new business section instructed staff to review resident rights and the grievance policy, but no additional information was documented. residents not knowing their shower schedule times, wanting fresh ice water at the beginning of each shift, ensuring soiled linens were removed after each resident care, and experiencing long call light wait times. A Dietary concern was expressed regarding wanting taco salads returned to the menu. Review of the 12/10/2025 RC Minutes showed RC sample members attended. The old business section was labelled Yes and no additional information documented. The new business section included concerns regarding nursing staff not wearing their name tags and trash not being removed after resident care. Residents raised housekeeping concerns with bathroom cleanliness. No additional information was documented regarding staff reviewing resident rights or the grievance policy. Review of the 01/08/2026 RC Minutes showed RC sample members attended. The old business section was labelled Yes and no additional information documented. The new business section included the same housekeeping concern from the previous meeting regarding bathroom cleanliness. No additional information was documented regarding staff reviewing resident rights or the grievance policy. In an interview on 01/14/2026 at 1:19 PM, RC members stated they were unaware they had the right to receive a written response regarding their grievances and had not received a response for the issues raised during RC meetings. Resident 24 stated they were unaware of the status of concerns verbalized during the past 3 monthly RC meetings, did not think Grievance Forms were completed for each concern, and did not feel their concerns were resolved. RC members stated they did not feel they could rely on nursing staff to file Grievance Forms on their behalf and did not feel the current grievance process offered enough privacy. In an interview on 01/15/2026 at 12:02 PM, Staff D (Activities Director) stated they conducted all RC meetings but did not complete Grievance Forms when residents verbalized concerns during the meetings. Staff D stated they discussed the residents' concerns with Staff A (Administrator) after each RC meeting. Staff D stated they did not review resident rights and the grievance policy with residents as instructed on the RC Minutes form. In an interview and record review on 01/15/2026 at 12:36 PM, Staff A stated they expected staff to follow the facility policies and procedures when conducting RC meetings, but they did not. Staff A stated the facility should have initiated the grievance process (including starting a Grievance Form and adding the grievance to the log) to address each of the residents' concerns discussed during the 11/03/2025 and 12/10/2025 RC meetings, but they did not. Staff A stated it was important to resolve grievances timely, so the residents felt the facility was a safe and homelike environment. REFERENCE WAC 388-97-0920 (1-6)

Based on interview and record review, the facility failed to complete resident assessments within the regulatory timeframes for 2 of 12 sampled residents (Resident 2 & 5) reviewed for assessment completion and timing. The failure to ensure comprehensive admission Minimum Data Set (MDS - an assessment tool) and Quarterly MDS assessments were completed timely delayed the residents' care planning process, hindered necessary Care Plan (CP) revisions, and placed residents at risk for delayed services, unidentified status change and care needs, and a decreased quality of life. Findings included <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual>The October 2023 RAI Manual outlined the admission MDS as a comprehensive assessment for a new resident and, under some circumstances, a returning resident, used to promptly assess the resident, develop their CP, and provide the appropriate care necessary to attain and/or maintain the resident's highest practicable well-being; a Quarterly MDS was a non-comprehensive assessment for a resident completed at least every 92 days to track a resident's status between comprehensive assessments that ensured critical indicators of gradual change in a resident's status were monitored. The manual showed the admission MDS must be completed by the end of day 14 of the resident's stay; with day 1 as the admission date to the facility and the Quarterly MDS must be completed no later than 14 days after the Assessment Reference Date (ARD). <Resident 2>According to the 12/08/2023 admission MDS, Resident 2 admitted to the facility on [DATE]. This MDS was dated as complete by the Registered Nurse (RN) Coordinator on 12/23/2025, eight days past the required regulatory timeframe. <Resident 5>Review of Resident 5's 11/30/2025 Quarterly MDS showed the RN Coordinator completed the assessment on 12/15/2025, one day past the required regulatory timeframe. In an interview on 01/14/2026 at 9:36 AM, Staff U (Licensed Practical Nurse, MDS) stated they referred to the RAI manual for guidance in completing MDS assessments. Staff U stated it was important to ensure MDS assessments were completed timely because it was what drove the CP, .so there would not be a delay in the resident's care planning process, and the staff would be able to provide safe and appropriate care. Staff U reviewed Resident 2 and 5's MDS assessments and stated they were both completed late. REFERENCE: WAC 388-97-1000(b)(c)(ii), (3)(a)

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status of 3 of 16 sample residents (Residents 67, 3, & 10) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included . <Facility Policy>According to the facility's March 2019 updated Resident Assessment Instrument (RAI) Policy, the facility would complete MDS assessments per the RAI Manual.<Resident 67> According to the 12/27/2025 Annual Minimum Data Set (MDS – an assessment tool), Resident 67 had multiple medical conditions including anxiety and bipolar disorder (a serious mental illness causing extreme shifts in mood, energy, and activity, from intense highs characterized by mania to deep lows characterized by depression, that disrupts daily functioning, sleep, and concentration). The MDS showed Resident 67 was given antipsychotic, antianxiety, and antidepressant medications during the assessment period. The MDS showed Resident 67's was not currently considered by the state Preadmission Screening and Resident Review (PASRR) process to have serious mental illness. Review of Resident 67's medical records showed the resident was referred to the State Agency for a Level II PASSR evaluation on 03/05/2025. The initial psychiatric evaluation was completed on 09/16/2025 and the evaluator provided recommendations regarding Resident 67's mental health care. Review of Resident 67's 11/13/2025 Level II PASSR Care Plan (CP) showed the interventions put in place to care for and support the resident's mental health needs included routine monitoring of their target behaviors (behaviors requiring treatment), medication side effects, and the provision of non-pharmacological interventions such as breathing exercises and diversion activities. On 01/12/2026 at 10:12 AM, Resident 67 was observed lying in bed and watching television; their room was dark as there were no lights on and the window blinds were closed shut. Resident 67 stated they prefer their room as such because they did not want too much stimulation. Resident 67 was observed to be hesitant about responding to the questions being asked and avoided eye contact but was pleasant during the conversation. In an interview on 01/14/2026 at 9:28 AM, Staff U (Licensed Practical Nurse, MDS) stated it was important to ensure MDS assessments were completed accurately because it involved the direct care of residents, [we] want to make sure the care needs identified during the assessment was captured in the CP for resident safety. Staff U reviewed Resident 67's Annual MDS and stated the resident's Level II PASSR status should have been captured in the assessment, but was not. <Resident 3> According to the 12/11/2025 Quarterly MDS showed Resident 3 not receive hospice services. According to a 07/21/2025 physician's order, Resident 3 admitted to hospice services on 06/09/2025. In an interview on 01/14/2026 at 10:12 AM, the visiting Hospice Nurse stated they visited Resident 3 about every three days for the last few months and provided services including medication management and wound monitoring. In an interview on 01/15/2026 at 2:18 PM, Staff U confirmed the MDS was incorrect. Staff U stated they should have coded that Resident 3 received hospice services but did not. <Resident 10> According to the 08/14/2025 admission MDS, Resident 10 had no dental issues. Review of a 07/31/2025 hospital speech therapy swallow assessment showed Resident 10 had upper and lower dentures. Observation on 01/14/2026 at 10:56 AM showed Resident 10 had one upper denture in place and no lower teeth present. At that time, Resident 10 stated plans were in place to get them new lower dentures at that time. In an interview on 01/15/2026 at 2:18 PM, Staff U stated Resident 10 had both upper and lower dentures when they assessed them. Staff U stated they should have coded Resident 10 had no natural teeth or tooth fragments, but did not. REFERENCE: WAC 388-97-1000(1)(a)(b)(4)(a). .

Based on interview and record review, the facility failed to ensure 5 of 6 residents (Resident 1, 3, 12, 14, 15 ) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to document identified target behaviors, monitor all target behaviors, document when behaviors occurred, implement and document behavioral interventions before administering medications, assess the effectiveness of the interventions before increasing medications, and to have as needed psychotropic medication (affects behavior, mood, thoughts, or perception) orders with stop dates and physician reassessment for extended use. These failures left residents at risk for unnecessary medications, adverse side effects, unmet needs, and diminished quality of life Findings included . Review of the facility policy titled, Psychotropic Drugs, updated 10/2022, showed the facility would evaluate and implement interventions for residents on psychotropic medications. Treatment would include the use of environmental and/or behavioral interventions prior to initiating psychotropic medications. Prior to initiating any psychotropic medication the Interdisciplinary Team (IDT) would review the resident's medical record, including behavior monitoring, investigate the causal factors triggering the behavior symptoms, and evaluate the resident's medication regime to validate the resident was not receiving duplicate drug therapy. The policy shoed the IDT would hold at a minimum a monthly psychotropic review to ensure residents had appropriate diagnosis, consent, and supporting documentation for resident's taking psychotropics. As needed psychotropic drugs were limited to fourteen days except when the physician believed it was appropriate to extend treatment. The physician would document their rationale in the resident's medical record. The policy showed the physician would be onsite to reevaluate the resident for the continued use and did not include just replacement of the current order <Resident 1> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 10/23/2024, showed Resident 1 admitted to the facility on [DATE], had severe impairments to their decision making, was rarely or never understood, and had a Collateral Contact (CC) for decision making. The MDS showed Resident 1 had verbal behavioral symptoms directed at others that occurred one to three days during the seven day look back period that significantly disrupted care and the living environment. The MDS showed Resident 1 had no physical behaviors directed towards others and did not refuse care. The MDS showed Resident 1 had medically complex conditions, including, a brain dysfunction that caused confusion and memory loss, anxiety, and depression. Review of section N, medications of the MDS, showed Resident 1 used an antipsychotic, antianxiety, and antidepressant medications, kicking and hitting Review of Resident 1's medical record, dated 07/17/2024 through 12/06/2024, showed six Care Plans (CP) for antipsychotic, antianxiety, and antidepressant medication use and three behavior CP's. Resident 1's CP for antipsychotic use showed Resident 1 used an antipsychotic for behavior management. The CP's directed staff to monitor and record the number of occurrences of target behaviors that included screaming, throwing items, disrobing, inappropriate response to verbal communication, violence or aggression towards staff, anxiousness/agitation, restlessness, impulsivity, and poor safety awareness, yelling, crawling out of bed, refusing care, showers, and medications. The CP directed staff to administer medications as ordered and monitor the effectiveness of the medications, monitor the behavior episodes, attempt to determine the underlying cause, and consider the location, time of day, persons involved, and the situation. Review of Resident 1's physician orders showed Resident 1 was prescribed seven psychotropic medications including an antipsychotic medication twice daily, an antidepressant to treat depression, another antidepressant to treat insomnia, and an antianxiety medication to treat anxiety as needed. Review of Resident 1's as needed antianxiety medication, dated 11/14/2024, showed Resident 1 was prescribed an antianxiety medication 2 milligrams (mg) as needed for agitation, restlessness related to anxiety, every six hours for fourteen days. The antianxiety medication was re-ordered on 11/29/2024 for an additional fourteen days and on 12/04/2024 was changed to as need every four hours and routinely twice daily. Review of a physician progress notes, dated 11/12/2024, showed the physician discontinued the as needed antianxiety medication for Resident 1. No additional progress notes were observed to indicate why Resident 1's as needed anti-anxiety medication was re-started on 11/14/2024. Review of a 12/04/2024 nursing progress note showed the physician was called because Resident 1 was screaming, kicking and hitting, attempts to re-direct the resident were unsuccessful, and the physician ordered a one time dose of antipsychotic medication and to increase the antianxiety medication from every six hours to every four hours as needed for anxiety. Review of Resident 1's Medication Administration (MAR), dated November 2024 showed two behavior monitors that directed staff to monitor behaviors of crying, withdrawn, refusing care or medications, yelling, and anxious/agitated. The behavior monitoring directed staff to implement interventions of providing a calm space, encourage family visits, one on one socialization, sensory stimulation/activities, and counseling/therapy. The MAR showed on 11/14/2024 at 6:32 PM, 11/15/2024 at 6:00 PM, 11/19/2024 at 4:45 PM, 11/21/2024 at 8:05 AM, 11/26/2024 at 3:31 PM, 11/27/2024 at 3:31 PM, 11/28/2024 at 3:46 PM , 12/02/2024 at 3:24 PM, and 12/05/2024 at 1:05 PM, facility staff administered Resident 's as needed antianxiety medication without documenting behaviors or when staff did document behaviors, did not document non-medicinal interventions attempted, or their effectiveness before medicating Resident 1. During an interview on 12/12/2024 at 4:25 PM, Staff B (Director of Nursing) stated Resident 1 had behaviors of crying, withdrawn, refusing medications, refusing care, yelling, and crawling. Staff B reviewed Resident 1's CP and stated staff were not but should be monitoring all of Resident 1's identified behaviors. Staff B stated they would have to look into because they were not sure if there was a transcription error with the as needed antianxiety medication when reviewing the MAR, the medication showed as needed every fours and to be given twice daily. Staff documentation showed the antianxiety medication was increased to every fours as needed, and did not mention that it was to be given twice daily. Staff B stated there should be documentation to support why the medication was reordered on 11/14/2024, two days after another physician discontinued it. <Resident 3> Review of the quarterly MDS, dated [DATE], showed Resident 3 was able to make needs known, made their own decisions, spoke a different primary language, and could understand and be understood by others. The MDS showed Resident 3 had no behaviors, and had medically complex conditions including' end stage renal disease, diabetes, and high blood pressure. The MDS showed Resident 3 was dependent on staff for toileting and lower extremity dressing, and maximum assist for personal hygiene, and bed mobility. Review of a physician's order, dated 11/15/2024, showed Resident 3 was prescribed an antianxiety medication as needed every six hours for adjustment disorder with anxiety. The as needed antianxiety physician's order had no stop date. Review of Resident 3's MAR, dated November 2024, showed Resident 3 received the antianxiety medication five times from 11/15-11/25/2024. The MAR showed no medication side effect monitoring or behavior monitoring for Resident 3's anxiety. Review of Resident 3's medical record, dated 11/15/2024-11/25/2024, showed no consent was obtained from Resident 3 for the antianxiety medication. In an interview on 12/12/2024 at 1:30 PM, Staff P (Certified Nursing Assistant) sated Resident 3 cried all the time, usually from pain from a medical issue. Staff P stated they worked with the resident often because they spoke the same language. During an interview on 12/12/2024 at 4:27 PM, Staff B stated Resident 3 had behaviors of crying and heightened emotions. Staff B stated, staff were not but should be monitoring Resident 3's behaviors and interventions to ensure the medication was effective. Staff B stated they would expect the as needed antianxiety medication to have a stop date of 14 days, and physician documentation for any extended use in the resident's record. <Resident 12> Review of the significant change MDS, dated [DATE] showed Resident 12 was not able to make needs known, had no speech, rarely made self understood, and rarely understands. The MDS showed Resident 12 had impairments to all extremities and was dependent on staff for toileting, personal hygiene, bathing, dressing, and bed mobility. The MDS showed Resident 12 had medically complex conditions including; soft tissue disorder, paraplegia (no feeling or use of lower extremities), dementia, anxiety, and depression. Review of Resident 12's MAR, dated December 2024, showed Resident 12 had an order for an as need antianxiety medication every two hours as needed for agitation. Review of the MAR showed Resident 12 was administered the medication three times. The MAR showed no stop date for the as needed antianxiety medication, no behavior monitoring, or interventions developed for staff to implement before medicating Resident 12. In an interview on 12/12/2024 at 4:28 PM, Staff B stated they would expect the as needed antianxiety medication to have a stop date of 14 days. Staff B stated staff were not but should be monitoring behaviors, attempting interventions before administering medications, and documentation in the resident's medical record. <Resident 14> Review of a quarterly MDS, dated [DATE], showed Resident 14 was able to make needs known, own decisions, had no behaviors, clear speech, made self understood, and was able to understand others. The MDS showed Resident 2 needed moderate assistance with toileting and dressing, and was independent with transfers. The MDS showed Resident 14 had medically complex conditions that included; cancer, high blood pressure, anxiety, and depression. Review of Resident 14's MAR, dated November 2024 and December 2024, showed Resident 14 was started on an as needed antianxiety medication on 10/11/2024 for 14 days. Review of the MAR showed the as needed antianxiety medication was re-ordered on 10/25/2024, 10/29/2024, 11/15/2024, and 12/01/2024, to be extended an additional 14 days. The MAR's showed Resident 14 received the antianxiety medication almost daily or twice a day. Review of the behavior monitoring, dated November 2024, showed staff were directed to monitor the resident for anxiety and staff documented Resident 14 had no behaviors in the month of November. Review of the behavior monitoring, dated December 1st through the 6th 2024, showed Resident 14 had no behaviors during that time. Review of Resident 12's medical record, dated 10/25/2024 through 12/06/2024, showed one note from the physician, dated 11/26/2024, that Resident 14 was on chronic antianxiety medications, facility staff were monitoring the resident for target symptoms including restlessness, hitting staff or others, verbal aggression with staff, cussing, using racial slurs, delirium, and refusal if care. The physician progress note showed to continue the antianxiety medication as needed for anxiety but did not give a rationale for extended use. No other physician notes were observed in Resident 12's record for the extended use of the antianxiety medication that was reordered four times. During an interview on 12/12/2024 at 4:29 PM, Staff B stated they would expect staff to be monitoring the identified target behaviors, implementing interventions, and documenting before the medication was administered. Staff B stated the as needed medication should only be renewed when the physician did an onsite visit and documented their rationale for continued use in the resident's record. <Resident 15> Review of an admission MDS, dated [DATE], showed Resident 15 discharged from the facility on 12/07/2024. No additional information from the MDS was observed. Review of Resident 15's record showed they had diagnoses including; liver failure, kidney failure, and a recent skin surgery/ Review of Resident 15's physician's orders, dated 11/30/2024, showed an order for an as needed antianxiety medication, with no stop date. Review of the physician's orders showed no behavior monitoring. During an interview on 12/12/2024 at 4:30 PM, Staff B stated they would expect the as needed medication to have a stop date of 14 days, and staff were not but should have monitored behaviors, implemented intervention, and document before the as needed antianxiety medication was administered. In an interview on 12/12/2024 at 4:32 PM, Staff B stated resident's on psychotropics should be monitored for medication side effects, effectiveness of medication, and behavior monitoring. Staff B stated behavior monitoring should include all behaviors observed and identified by staff, and when a resident had behaviors they would expect staff to document behaviors, attempt interventions, if interventions were not effective, try something different, and document. Staff B stated they would expect staff to attempt interventions before medicating the resident. Staff B stated as needed psychotropic medications are only valid for fourteen days, after fourteen days the physician should review the resident's record and make a decision to discontinue or extend the medication and document the reason in the resident's record. WAC: REFERENCE 388-97-1060(3)(k)(i). Refer to F-552

Based on observation, interview, and record review the facility failed to implement their abuse and neglect policies and procedures regarding identification, investigation, protecting, and reporting of abuse and neglect incidents. The facility failed to thoroughly investigate incidents and allegations of abuse, sexual abuse, and neglect for 7 of 9 residents (Resident 2, 1, 4, 3, 5, 6, 7) reviewed for incidents, failed to identify and report incidents as potential for abuse or neglect related to falls and bruises for 2 of 2 residents (Resident 2, 8), and failed to ensure facility staff implemented abuse policies and procedures and protected residents from further abuse by staff for 1 (Staff D) of 6 staff involved in incidents, when Staff D went back to Resident 4 and Resident 5's room despite an allegation of verbal abuse, and failed to timely report allegations of sexual abuse to local authorities as required for 1 of 2 residents ( Resident 2) reviewed for sexual abuse allegations. These failures placed the residents at risk for abuse by caregivers, and placed all residents at risk for for unidentified and on-going abuse/neglect, and a diminished quality of life. Findings included . Review of the facility policy, Abuse Investigations, dated 10/2022, showed the facility would conduct a thorough investigation of potential or suspected allegations of abuse and neglect in accordance with state and federal rules. The policy showed staff would identify and interview all persons involved, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The facility would protect the alleged victim during the investigation, determine if abuse or neglect occurred and maintain complete and thorough documentation of the investigation. Review of the facility policy, Investigations of Alleged Sexual Abuse, dated 10/2022, showed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy directed staff to immediately protect the resident, report to the facility administrator, supervisor, state survey agency, and the local police department. The policy showed the facility would conduct a thorough abuse investigation to determine if sexual abuse occurred by conducting a physical exam for potential injuries of sexual abuse. The policy showed the facility would provide additional medical follow-up including sending the resident to the hospital emergency room for a rape kit as indicated. <Resident 2> Review of Resident 2's quarterly Minimum Data Set (MDS, an assessment tool), dated 10/14/2024, showed Resident 2 had impairments to their thought process, had adequate hearing, vision, clear speech, and was able to make themselves understood, and able to understand others. The MDS showed Resident 2 had no behaviors, had no impairments to their extremities, and was dependent on facility staff for toileting, bathing, dressing, personal hygiene, and bed mobility. The MDS showed Resident 2 had medically complex conditions, including; anxiety, schizophrenia, and adult failure to thrive. Review of an Activities of Daily Living (ADL) Care Plan (CP), dated 10/30/2024, showed Resident 2 was dependent on two staff members to turn, reposition, and provide incontinence care. Review of an at risk for trauma/re-traumatization CP, dated 09/12/2024, showed Resident 2 was at risk for re-traumatization due to past and current trauma the resident experienced. The CP directed staff to listen to resident concerns and notify the Licensed Nurse (LN) or Social Worker (SW) when the resident reported feelings of re-traumatization or displayed changes in behavior or mood. The CP did not indicate what type of trauma Resident 2 experienced and did not identify what triggered the resident for potential re-traumatization. Review of a facility investigation, dated 11/11/2024, showed Resident 2 told a caregiver (Staff E, Certified Nursing Assistant, CNA/Restorative Nursing Aide) they were raped. Staff F (Licensed Practical Nurse, LPN) interviewed Resident 2 who stated an old man raped them the other day. Resident 2 stated the old man took off my brief that was full of poop and smelled it. Staff F asked Resident 2 if they were touched inappropriately and Resident 2, replied yeah they were wiping down there but denied anything being inserted vaginally. The investigation showed the facility administrator, director of nursing, and Resident 2's collateral contact was notified of Resident 2's allegation of sexual abuse. The investigation showed the facility identified one staff member (Staff G, CNA) that worked with Resident 2. Staff G denied providing bowel incontinence care during that time. The investigation showed local police were notified on 11/14/2024, three days after Resident 2 alleged rape and the Interdisciplinary Team (IDT) concluded that Resident 2 described routine incontinence care, denied anything inserted vaginally or rectally, and it was reasonable to believe the allegation resulted from Resident 2's medical diagnoses and a recent medication change. Review of a late entry Nursing Progress Note (NPN), dated 11/11/2024 and entered on 11/13/2024, showed Staff F documented that Resident 1 stated they were raped by an old man the other day, when Staff F asked Resident 2 what they looked like, Resident replied an old man. The progress note showed Staff F informed the administrator, director of nursing, and Resident 2's collateral contact. Review of Staff E's investigation interview, dated 11/15/2024, showed Staff H (Social Services Assistant, CNA) interviewed Staff F to see if they heard or observed any inappropriate behavior with staff and residents, Staff E stated no. Review of the nursing staff schedule from 11/04/2024-11/11/2024, showed eight other male staff members worked with Resident 2 during the time the allegation was made. The scheduled showed on 11/09/2024, Staff I (LPN) was Resident 2's nurse the night the facility determined Staff G was assigned to Resident 2. In an interview and observation on 11/20/2024 at 10:45 AM, Resident 2 was observed in bed and stated, when I was asleep an old man came into the room, removed their brief and smelled it. Resident 2 stated this made them mad and the old man left. During an observation and interview on 12/12/2024 at 1:36 PM, Resident 2 stated the old man was average height, Caucasian with black hair that walked in the room with no devices. Resident 2 stated they had never seen this old man before and has not seen them since the incident. Resident 2 stated the old man did not say anything during the incident and repeated the same encounter as the previous interview. Resident 2 stated they had trauma in their past and did not want to discuss their trauma. In an interview on 12/12/2024 at 1:50 PM, Staff A (Administrator) stated when a resident alleged sexual abuse they would expect staff to report to the state hotline, the resident's provider, resident representative, and police. The staff should perform a physical assessment, suspend the alleged perpetrator, and monitor the resident for psychological harm. Staff A stated the police should have been notified immediately after the allegation was made and acknowledged the facility waited four days to report to the police. Staff A stated Resident 2's provider was notified the next day (11/12/2024) of the allegation, would expect staff to notify the provider immediately after the allegation, and would expect staff to document the notifications in the investigation. Staff A stated they determined Staff G as the perpetrator because he was the only male assigned to Resident 2 a few days prior that could fit the description of an old man. Staff A stated the investigation was not thorough, should have but did not include the possibility of a resident in the facility or other male staff that cared for Resident 2. Staff A was not sure if Resident 2's collateral contact was asked if they would like Resident 2 to be evaluated further at the emergency room and would expect staff to document thoroughly on the investigation. Staff A stated they were not sure who the other aides were when Staff G was providing incontinence care to Resident 2 as they required two staff members for bed mobility and incontinence care. Staff A stated they would expect staff to follow the CP if the resident required two aides they would expect two aides for bed mobility and incontinence care. Staff A would expect the other aides to be identified in the investigation and interviewed about the incident. Staff A stated Staff H helped with interviews, asked very broad questions, and did not seek further information or details specific to the event. <Resident 1> Review of Resident 1's quarterly MDS, dated [DATE], showed Resident 1 had impairments to their decision making ability and thought process, was rarely understood by others, had adequate hearing, vision, and clear speech. The MDS showed Resident 1 had no physical behaviors directed towards others, had verbal behaviors directed at others occurring one to three days of the seven day look back period, and had no other behavioral symptoms, such as disrobing, screaming, rejecting care or throwing food. The MDS showed the behaviors did not put the resident at significant risk of injury, did not interfere with their care or with the resident's participation in activities, and the behaviors significantly disrupted the living environment. The MDS showed Resident 1 required maximum assistance from staff with toileting, personal hygiene, bed mobility, and transfers. The MDS showed Resident 1 had medically complex conditions including a brain dysfunction that caused confusion and memory loss, anxiety, and depression that required treatment with antipsychotic, antianxiety, antidepressant, and pain medications. Review of facility fall assessment, dated 11/05/2024, showed Resident 1 was assessed as a high fall risk due to severe impairments to their decision making, poor safety awareness, and balance problems. Review of a facility fall CP, revised 11/05/2024, showed Resident 1 had a history of crawling on the floor. The CP showed Resident 1 had a bed and wheelchair alarm to alert staff of Resident 1 rising from the bed or chair. The CP directed staff to keep Resident 1 in high visible areas when awake, provide activities that promote exercise, and when a fall occurred monitor, document, and report the fall to the provider. Review of a NPN, dated 11/30/2024, showed Staff J (Registered Nurse, RN) documented Resident 1 was trying to get out of their wheelchair during the day shift, Resident 2 wanted to be laid down, and was put into bed. Staff J documented at 2:35 PM Resident 2 crawled out of bed and almost by the door when another resident called and reported Resident 2 was crawling on the floor. Staff J documented Resident 2 was placed in the wheelchair by the nurse station so they could be closely monitored. The NPN showed no indication the provider, Resident 1's collateral contact, administrator or Director of Nursing (DON) were notified Resident 2 was found crawling on the floor into the hallway. The NPN note showed no indication Resident 1 was assessed for an injury after they were found crawling in the hallway. Review of a NPN, dated 12/4/2024, showed Staff J documented Resident 1 was yelling and trying to jump out of their wheelchair and was laid down at 1:00 PM. Staff J documented Resident 1 crawled out of bed to the doorway, into the hallway, and was transferred into the wheelchair in the middle of the hallway. The NPN showed no indication Resident 1 was assessed for an injury or Resident 1's CC was notified of Resident 1 crawling out of bed into the hallway. Review of a NPN, dated 12/8/2024, showed Staff J documented Resident 1 was given medications at 7:00 PM, by 7:30 PM crawled out of bed to the room doorway an started screaming. The NPN showed no indication the provider, Resident 1's collateral contact, administrator or Director of Nursing (DON) was notified of Resident 2 found crawling on the floor into the hallway. The NPN note showed no indication Resident 1 was assessed for an injury after found crawling in the hallway. Review of the facility abuse log, dated November 2024 and December 2024, showed Resident 1's crawls out of bed were not observed on the log. During an interview on 12/12/2024 at 10:45 AM, Resident 1's CC stated on 12/11/2024 Resident 1 crawled into the bathroom and then out into the hallway where they had a bowel movement. The CC stated they were aware that a bed and chair alarm was used with Resident 1. The CC suspected the bed alarm was turned off if the staff didn't realize the resident was out of the bed and already in the hallway. During an observation and interview on 12/12/2024 at 1:39 PM, Resident 1 was observed sleeping in bed with their eyes closed. Observations showed no bed alarm or chair alarm. Staff J was asked where the bed and chair were located, looked under Resident 1 in the bed, and no bed alarm was observed under Resident 1. Staff J did not find the chair alarm for Resident 1. Staff A and Staff B (DON) confirmed no bed or chair alarm was observed in the room or being used on Resident 1 as ordered by the provider. Staff A stated they would expect Resident 1's bed and chair alarms to be in use and functioning. During an interview on 12/12/2024 at 2:35 PM, Staff A stated Resident 1 had behaviors of crawling out of bed, they were not able to tell the staff if they fell , and this behavior should be treated as a fall to rule out injury. Staff A stated all falls should be on abuse log, reported to provider and resident's responsible party, and investigated. Staff B stated they would expect staff to assess the resident for injury after found crawling on the ground. Staff A acknowledged Resident 1's crawls out of bed on 11/30/2024, 12/04/2024, and 12/08/2024, were not logged, investigated or reported to the provider or CC as they would expect. <Resident 4> Review of Resident 4's admission MDS, dated [DATE], showed Resident 4 was able to make their needs known, own decisions, could understand, and be understood by others. The MDS showed Resident 4 had diagnoses including; chronic respiratory failure, difficulty walking, and chronic lung disease. The MDS showed Resident 4 required maximum staff assistance with dressing toileting, and personal hygiene. Review of a facility investigation documents, dated 11/21/2024, showed Resident 4 reported a few nights ago that Staff D (CNA) yelled at them stating you are going to get my mom (Staff K, CNA) fired. Resident 4 denied reporting Staff D or Staff K. Review of the incident report showed blank areas for mental status, predisposing situation factors, and statements. The incident report did not indicate the provider was notified of the incident and the investigation did not rule out abuse and neglect. Per the investigation, no other residents had concerns about Staff D or Staff K, Resident 4 did not express psychosocial harm during monitoring, and both alleged staff members would not be allowed to work with the resident. Review of a resident interview, dated 11/21/2024, showed Resident 9 had concerns about Staff K stating they made excuses or said they were busy when Resident 9 needed help. Review of a typed note from Staff L (Social Services Director) showed when they revisited Resident 4, the resident reported that Staff D came back into their room with another CNA to make the bed while they were in the bathroom. Review of Resident 4's NPN's showed no documentation of the incident, no psychological monitoring, and no follow up or monitoring for Staff D returning to Resident 4's room after the incident. In an interview and observation on 12/04/2024 at 3:00 PM, Resident 4 was observed in the room, sitting on the bed with their phone. Resident 4 stated they had concerns about Staff D and Staff K. Resident 4 said Staff D yelled at them about going to get their mom fired and was not sure why Staff D was yelling at them because they did not report anything to staff. Resident 4 stated Staff D and Staff K have not provided care after the incident but Staff D came into the room to talk to the CNA that was making their bed. Resident 4 stated Staff D didn't say anything to them but they felt uncomfortable and went into the bathroom. Resident 4 stated they were told that Staff D would not be allowed back in my room. During an interview on 12/12/2024 at 2:45 PM, Staff A stated both Resident 4 and their roommate (Resident 5) had issues with Staff D, and Resident 4 was targeting Staff D. Staff A stated there was no documentation about the incident, that the provider was notified, and no monitoring for psychological harm to support the investigation conclusion of no psychological harm during monitoring. Staff A stated Staff D went into Resident 4's room because Resident 4 was care in pairs (two staff at all times with care) and they were the second caregiver. Staff A stated Staff D should not have gone back in the room, there was no staff follow-up after Staff L was informed that Staff D returned to the room, and no staff followed up on Resident 9's concerns about Staff K. Staff A stated the investigation should rule out abuse and neglect and acknowledged the investigation did not rule out abuse or neglect. <Resident 5> Review of the admission MDS, dated [DATE], showed Resident 4 was able to make needs known own decisions, and had no behaviors. The MDS showed Resident 5 had medically complex conditions including depression, renal insufficiency, and lymphedema (swelling in an extremity). The MDS showed Resident 5 was dependent on staff for toileting, and required max assistance with upper extremity dressing. Review of a facility investigation, dated 11/21/2024, showed Resident 5 requested help with changing their gown when Staff D tossed the gown to the resident and told Resident 4 to figure out themselves how to put it on. The incident report documents provided, did not include all pages, blank areas for mental status and predisposing environmental, physiological, and situation factors. The investigation documents did not show indication the provider was notified of the incident and showed Staff D denied tossing a gown at the resident and assisted them to put on the gown. Review of the investigation documents showed Staff D would no longer work with the resident, the resident had no psychological harm, and discharged the day after the incident. The investigation did not rule out abuse and neglect. In an interview and observation on 12/04/2024 at 3:42 PM, Resident 5 was observed in their bed, and stated they had concerns with Staff D, they did not like how they talked on their phone in a different language while providing care. Resident 5 stated they were told Staff D would not come to their room after the incident and Staff D came back in the room with another CNA who was changing the bed. Resident 5 stated their roommate Resident 4 went into the bathroom. In an interview on 12/12/2024 at 2:50 PM Staff A stated Resident 5 had issues with Staff D, the provider should have been notified of the incident, and the investigation should rule out abuse and neglect. Staff A stated Staff D went into Resident 5's room because Resident 4 was care in pairs (two staff at all times with care) and they were the second caregiver. Staff A stated Staff D should not have gone back into Resident 5's room. <Resident 6> Review of a admission MDS, dated [DATE], showed Resident 6 was able to make needs known, own decisions, and had no behaviors. The MDS showed Resident 6 had diagnoses including orthopedic after care, osteoporosis, anxiety, and diabetes. The MDS showed Resident 6 was dependent on staff for toileting and required max assistance with bed mobility. Review of a facility investigation, dated 11/22/2024, showed Resident 6 reported a staff member put three briefs on them during the night and told Resident 6 they would be changed when the third brief was wet. The investigation showed Staff M (CNA) was identified as the staff providing this care. Staff M denied putting three briefs on Resident 6. The investigation showed that Staff N (CNA) did not observe multiple briefs on Resident 6 although their statement showed they only helped reposition the resident. The investigation showed other residents were interviewed and had no concerns for their care. The investigation concluded that Staff M would no longer work with Resident 6 and did not rule out abuse or neglect. Review of the resident interview questions for the investigation, undated showed two residents (Resident 7 and Resident 10) had concerns for staff not changing their brief when needed and when Resident 7 requested help they were told everyone was gone. Resident 10's CC had concerns with how long Resident 10 was up in the wheelchair, staff didn't know how to use the mechanical lift, and it took an hour for staff to help the resident. Review of resident interviews, dated 11/22/2024, showed residents were asked if they had any issues with their care on night shift. During an interview on 12/04/2024 at 3:42 PM, Resident 5 stated staff used multiple briefs on the resident before. Resident 5 stated it happened more often in the evening and during the night shift and staff would double the briefs to make it look like one brief. Resident 6 was not available for an interview. In an interview on 12/12/2024, at 3:00 PM, Staff A stated the incident report should be thorough, when asked if residents were asked about staff applying multiple briefs, they were not sure. Staff A stated the resident interview questions should be more specific to the allegation, Staff N should have additional follow up questions to determine if they provided care or changed Resident 6's brief. Staff A stated the investigation did not but should have ruled out abuse and neglect. Staff A stated an investigation was started for Resident 7's concern but would have to look into Resident 10's concerns. <Resident 3> Review of the quarterly MDS, dated [DATE], showed Resident 3 was able to make needs known, own decisions, spoke a different primary language, and could understand and be understood by others. The MDS showed Resident 3 had no behaviors, and medically complex conditions including' end stage renal disease, diabetes, and high blood pressure. The MDS showed Resident 3 was dependent on staff for toileting and lower extremity dressing, and maximum assist for personal hygiene, and bed mobility. Review of a facility investigation, dated 11/22/2034 showed Resident 3 reported that Staff N (CNA) pushed them, they started to fall, and Staff N refused to help prevent Resident 3 from falling. Resident 3 reported Staff N pulled them up by the waist and put them back in bed. The investigation showed Staff N stated they found Resident 3 crying, wanted help to be pulled up in bed but was a two person assist and Staff N needed to get help. Staff N stated Resident 3 started to pull themselves up in bed and Resident 3's legs started to fall off the bed and slid to the point that Staff N had to stop the resident and put their feet back in bed. Staff L followed up with Resident 3 who was uncomfortable stating Staff N was rough, did not listen to them, and was scared. The investigation showed Staff N would not provide care to Resident 3, no other resident interviews showed concerns with care, and the investigation did not rule out abuse or neglect. Review of investigation resident interviews, dated 11/22/2024, showed Resident 11 answered, no staff did not treat them with respect or dignity. In an observation and interview on 12/12/2024 at 1:18 PM, Resident 3 was observed in bed and stated Staff N passed by their room and looked upset and annoyed that they needed to be changed after a bowel movement. Resident 3 stated Staff N started to change them, and pushed them as they were turning, causing their legs to fall out of bed. Resident 3 said their knees were on the ground with their belly and upper body on the bed. Resident 3 stated they asked why they pushed them and Staff N was quiet and quickly put them in the bed. Once in the bed Resident 3 stated Staff N got really close to their face and was aggressive. Resident 3 stated they told Staff N they would report them and Staff N replied, do it. Resident 3 stated they felt insulted, discriminated against, and didn't understand what they did to make Staff N mad. Review of a social services progress note, dated 11/26/2024, showed Staff L documented they followed up with Resident 3 who stated they had psych harm related to the care received at the facility and did not want to receive care from Staff N. Staff L documented Resident 3 was offered behavioral health services but declined. Review of progress notes showed no staff follow up on Resident 3's psych harm statements. In an interview on 12/12/2024 at 2:55 PM, Staff A stated the investigation should have documentation that abuse and neglect was ruled out. Staff A stated they believed Resident 3 had prior issues with Staff N and did not like them. Staff A stated they think a grievance was made for Resident 11's CC's concern and would have to look. Staff A stated facility staff should have but didn't follow up with Resident 3's statement of experiencing psych harm. <Resident 7> Review of quarterly MDS, dated [DATE], showed Resident 7 was able to make needs known, own decisions, and no behaviors. The MDS showed Resident 7 had diagnoses including chronic obstructive pulmonary disease, diabetes, anxiety, and depression. The MDS showed Resident 7 was dependent on staff for toileting, dressing, bed mobility, and transfers. Review of a facility investigation, dated 11/25/2024, showed Resident 7 complained that on two separate occasions they waited three hours to be changed by facility staff. The facility conducted an investigation that showed abuse and neglect was ruled out. The investigation documents showed five residents were asked if they experienced long call light wait times, all five of five residents replied yes. Two out of five residents stated they were not able to be toileted when they asked facility staff. In an observation and interview on 12/04/2024 at 2:49 PM, Resident 7 was observed in bed and stated the staff the facility identified in the investigation were not the staff involved. When asked who staff were, Resident 7 replied name tags are not always visible and stated they didn't want to go there. When asked about the staff the facility identified, Resident 7 stated they had not seen them since the incident. During an interview on 12/12/2024 at 3:10 PM Staff A stated the investigation information should be reviewed for further concerns. Staff A stated they would expect staff to follow up on the resident interviews gathered during the investigation to get more details about concerns with toileting and call light response. <Resident 8> Review of a quarterly MDS, dated [DATE], showed Resident 8 was not able to make their needs known, not able to make own decisions, was non-verbal with severely impaired vision and hearing. The MDS showed Resident 8 had medically complex conditions including dementia, schizophrenia, and diabetes. The MDS showed Resident 8 self propelled in a wheelchair for mobility, was dependent on staff for toileting, dressing, personal hygiene, bed mobility, and transfers. In an observation on 12/04/2024 at 2:27 PM Resident 8 was observed sitting in their wheelchair in the hallway, a large dark purple area was observed on their forehead near the hairline. During an interview on 12/04/2024 at 2:33 PM Staff J stated they did not know about a bruise on Resident 8's forehead and stated the bruise was not there earlier when Staff J gave Resident 8 their medications. Review of the facility December 2024 abuse log, showed the facility logged Resident 8's bruise as a bruise of deep color and depth. The facility did not report to the state hotline as the bruise was in an area not generally vulnerable to trauma, such as the face or neck. In an interview on 12/12/2024 at 4:00 PM, Staff A stated Resident 8 is very vulnerable because they prefer to self propel around the facility with impaired vision. Staff A stated the facility had tried a helmet with Resident 8 but they refused to wear it. Staff A stated the facility should have but didn't report the bruise to Resident 8's forehead. WAC: REFERENCE 388-97-0640(2)(b)(5)(6)(a)(b)(7)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure 3 (Resident 1, 12, 3) of 6 residents or resident representatives reviewed were fully informed orally and in writing of the potential risks associated with the use of psychotropic medications (medications that alter the thought process). In addition, based on interview and record review the facility failed to obtain informed consent for devices used for 1 (Resident 1) of 4 residents reviewed for devices. These failures prevented residents and/or legal representatives from making informed decisions about the use of multiple antidepressant medications, and precluded them from exercising their right to refuse/decline the proposed medications. Findings included . Review of the facility policy titled, Informed Consent for Psychotropic Drugs, updated 09/2017, showed the facility would obtain informed consent form the resident or resident representative before the drug prescribed is administered. The licensed nurse would review the drug, dosage and frequency, discuss the rationale/benefits for the order and discuss the potential risk factors of taking the prescribed drug with the resident or resident representative, and obtain their signature if they agree to take the prescribed drug. The policy showed the psychotropic drug consent would be signed and placed in the resident's medical record. Review of a facility policy, titled, Devices, updated 09/2017, showed devices were implemented after consent was obtained addressing the risks and benefits with the resident or the resident representative. The policy showed an individual consent would be obtained for each device. <Resident 1> <Psychotropic Medications> Review of a quarterly Minimum Data Set (MDS, an assessment tool), dated 10/23/2024, showed Resident 1 admitted to the facility on [DATE], had severe impairments to their decision making, was rarely or never understood, and had a Collateral Contact (CC) for decision making. The MDS showed Resident 1 had verbal behavioral symptoms directed at others that occurred 1 to 3 days of the 7 day look back period that significantly disrupted care and the living environment. The MDS showed Resident 1 had no physical behaviors directed towards others and did not refuse care. The MDS showed Resident 1 had medically complex conditions, including, a brain dysfunction that caused confusion and memory loss, anxiety, and depression. Review of section N, medications of the MDS, showed Resident 1 used an antipsychotic, antianxiety, and antidepressant medications. Review of an antipsychotic Care Plan, (CP), revised 11/09/2024, showed Resident 1 used an antipsychotic for behavior management and directed staff to monitor the effectiveness of the medication. The CP directed staff to discuss with the physician and the family the need for on-going use of the medication and review behaviors, interventions, and alternate therapies attempted to determine the effectiveness. Review of a Nursing Progress Note (NPN), dated 12/04/2024 at 10:54 AM, showed Staff F (Licensed Practical Nurse, LPN) documented Resident 1 was screaming at the top of their lungs, kicking, swinging arms and legs. Staff F documented multiple attempts to redirect were unsuccessful, a call was placed to the behavioral health support, and a new physician order was received for a one time dose of an antipsychotic and to increase Resident 1's an antidepressant (a class of depressant drugs used to treat anxiety, insomnia, and seizures) medication from every six hours to every four hours as needed for an anxiety. The NPN showed Staff F left a message with Resident 1's CC to call the facility. Review of Resident 1's December 2024 Medication Administration Record (MAR), showed Staff J (Registered Nurse, RN) administered the one time dose of the antipsychotic medication at 11:00 AM. Review of Resident 1's record showed no documentation of informed consent was obtained from Resident 1's CC before facility staff administered the one time dose of antipsychotic medication and increased the frequency of Resident 1's antidepressant medication. In an interview on 12/12/2024 at 10:45 AM, Resident 1's CC stated they received a call from the facility on 12/04/2024 that Resident 1 had crawled out of bed and stated no one discussed medications with them at this time. During an interview on 12/12/2024 at 4:18 PM, Staff B (Director of Nursing) stated medications that require informed consent should not be given before consent obtained so the resident or resident representative can make an informed decision about the medication. Staff B stated no documentation could be found that showed Resident 1's CC was informed and consented to the medications before given by staff. <Devices> Review of Resident 1's fall CP, revised 11/05/2024, showed Resident 1 had seven devices including; a bed alarm, a chair alarm, tilt-n-space (a wheelchair that reclines) wheelchair, a perimeter mattress, bed in lowest position, fall mat, and bed against the wall. Review of Resident 1's record from admission, dated 07-24-2024-12/09/2024, showed no consent was obtained from resident 1's CC for the use of a fall mat at the bedside, bed against the wall, or perimeter mattress. In an interview on 12/12/2024 at 4:20 PM, Staff B stated all devices should have informed consent before being implemented. <Resident 12> Review of a significant change MDS, dated [DATE], showed Resident 12 was not able to make their needs known, not able to make own decisions, rarely made themselves understood, and rarely understood others. The MDS showed Resident 12 had no behaviors, and medically complex conditions that included dementia, anxiety, depression, and paraplegia (an impairment in motor or sensory function of the lower extremities). The MDS showed Resident 12 was dependent on staff for all care, including toileting, dressing, eating, and transfers. Review of hospital transfer orders and documents, dated 12/03/2024, showed Resident 12 was being treated under hospice care with comfort as the goal. A physician's order, dated 12/03/2024, showed Resident 12 was prescribed an antipsychotic medication to be given every two hours as needed. Review of Resident 12's December 2024 MAR, showed on 12/05/2024 at 1:15 PM and 9:30 PM, and on 12/06/2024 at 9:28 AM, Resident 12 received the antipsychotic medication. Review of Resident 12's medical record from readmission on 12/04/2024 to 12/06/2024, showed no consent was obtained from Resident 12's CC before staff administered the antipsychotic medication. During an interview on 12/12/2024 at 4:25 PM, Staff B stated all antipsychotic medications should have informed consent before medication was administered. <Resident 3> Review of the quarterly MDS, dated [DATE], showed Resident 3 was able to make needs known, own decisions, spoke a different primary language, and could understand and be understood by others. The MDS showed Resident 3 had no behaviors, and medically complex conditions including' end stage renal disease, diabetes, and high blood pressure. The MDS showed Resident 3 was dependent on staff for toileting and lower extremity dressing, and maximum assist for personal hygiene, and bed mobility. Review of a physicians order, dated 11/15/2024, showed Resident 3 was prescribed an antianxiety medication as needed every six hours for adjustment disorder with anxiety. Review of Resident 3's MAR, dated November 2024, showed Resident 3 received the antianxiety medication five times from 11/15-11/25/2024. Review of Resident 3's medical record, dated 11/15/2024-12/12/2024, showed no documentation consent was obtained for Resident 3's antianxiety medication before staff administered the medication. In an interview on 12/12/2024 at 4:27 PM, Staff B stated they would expect staff to obtain consent and document before administering the antianxiety medication. WAC: REFERENCE 388-97-0260

Based on observation, interview, and record review the facility failed to consistently assess and monitor change in condition and implement provider orders timely for 1 of 1 resident (Resident 16) reviewed for significant injury of unknown origin. Resident 16 experienced harm when there was a delay in assessment and treatment by a medical professional and the resident required surgical intervention for a large, expanding hematoma to their right calf, and a blood transfusion for a critically low blood count. These failures placed all residents at risk for delay in treatment, worsening of condition, unmet care needs, and decreased quality of life. Findings included . <Facility Policy> According to a facility policy titled, Skin Integrity, revised October 2022, nursing staff would complete a full body skin assessment weekly. The policy showed when a skin impairment was identified after admission, the facility would place the resident on alert charting for the skin impairment. The policy showed staff would document the notification of the skin impairment to the physician and the resident representative in the resident's records. The policy showed the facility would implement new interventions and document on the resident's care plan. The policy showed the staff would notify the Director of Nursing (DON) of skin impairments that indicated a potential significant change in condition such as a hematoma. The policy showed the DON would document their assessment of the skin impairment in the resident's records in a nursing note. The policy showed the significant bruising would be evaluated and documented weekly by nursing staff in the resident's records. Review of the facility policy titled, Abuse Protection, revised October 2022, showed the facility would respond immediately to suspicion/allegations of abuse/neglect. The policy showed the facility would examine the alleged victim for signs of injury which included a physical examination and/or a psychological examination. The policy showed the facility would provide medical treatment as needed. <Resident 16> Review of Resident 16's records showed an 08/01/2024 skin assessment upon admission that only showed no new skin impairments were identified but did not have an assessment of the three pressure ulcers Resident 16 admitted with. There were no other weekly skin assessments in Resident 16's records. According to the 08/07/2024 Admission MDS, Resident 16 admitted to the facility on [DATE] and was severely cognitively impaired. Resident 16 had diagnoses of three active pressure ulcers, paraplegia, non-Alzheimer's dementia, and chronic pain syndrome. The assessment showed Resident 16 was taking blood thinner medications during the assessment period. The MDS showed no hematomas or other non-pressure skin concerns were identified at time of the assessment. Review of Resident 16's records showed an order was placed by the facility Physician Assistant (PA) on 08/13/2024 to obtain an ultrasound STAT (immediately) of the right leg. Resident 16's records showed an 08/15/2024 progress note from the contracted wound PA that instructed staff to send Resident 16 to the hospital for the right calf hematoma. Resident 16's records showed no nursing skin assessments of the hematoma, no pain assessments were completed, no ultrasound was obtained, and no monitoring of the right calf hematoma. According to the 08/15/2024 Modified Discharge Return Anticipated MDS, Resident 16 was discharged to an acute care hospital on 08/15/2024 and had a diagnosis of unspecified soft tissue disorder related to use/pressure of their right lower leg. Review of the 08/23/2024 hospital summary report showed Resident 16's primary diagnosis was an expanding right calf hematoma that required surgical evacuation and a critically low blood count which required a blood transfusion. In an interview on 09/29/2024 at 6:56 PM, the Resident Representative (RR) for Resident 16 stated they found and reported to nursing staff, a large hematoma on Resident 16's right calf on 08/10/2024. Resident 16's RR stated the nursing staff told them the hematoma would not be assessed until the contracted wound team came in on 08/15/2024. The RR for Resident 16 stated they were concerned about waiting because the hematoma was getting larger, the right lower leg was swollen, red and warm to the touch, and the dressing had been saturated with blood, so they called and reported to Staff B (Director of Nursing) on 08/13/2024. In an interview on 10/02/2024 at 1:47 PM Staff B provided a paper copy of a communication form, dated 08/10/2024, to the Medical Director (MD) that showed nursing informing the MD on 08/10/2024 of the hematoma to Resident 16's right calf. Staff B stated the RR reported the hematoma to them on 08/13/2024 with the suggestion the hematoma may have happened during a transfer for a shower on 08/09/2024. The MD communication form showed orders for an ultrasound written on 08/12/2024 from the facility PA. Staff B stated they did not send the STAT ultrasound to the contracted company until 08/14/2024 and the ultrasound did not get done because Resident 16 discharged to the hospital on 08/15/2024. Staff B stated they did not document an assessment of the hematoma, complete a pain assessment, or complete a skin check. In an interview on 10/03/2024 at 10:38 AM Staff B provided a copy of an undated witness interview with the bath aide regarding what the bath aide observed during the bed bath they provided on 08/09/2024. The bath aide witness statement showed Resident 16 had no swelling to right foot/leg on that day (08/09/2024), no skin issues, and no bruising. In an interview on 10/04/2024 at 10:33 AM Staff A stated they should have reported Resident 16's significant injury of unknown origin to the state agency within two hours, ordered the ultrasound the same day the facility PA ordered it, and started the investigation immediately to rule out abuse and neglect, but they did not. Staff A stated they expected a STAT order to be done the same day it was placed. Refer to F609 - Timeframe: Abuse reported to Administration/State Agency, Timeframe: Investigate Abuse. Refer to F610 - Investigate Abuse. REFERENCE: WAC 388-97-1060(1). 44296

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 3 of 7 (Residents 22, 57, & 13) residents and 2 supplemental residents (Resident 185 & 53) reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 22> According to the 08/12/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 22 had diagnoses including depression, bipolar disorder, and Post Traumatic Stress Disorder (PTSD). The MDS showed Resident 22 took antidepressant medications. This MDS showed Resident 22 admitted on [DATE]. According to the September 2024 Medication Administration Record (MAR), Resident 22 took two antidepressant medications (one first prescribed on 07/30/2022 and the second first prescribed on 05/10/2023), a medication to treat PTSD first prescribed on 05/24/2024, and an antianxiety medication first prescribed on 09/25/2024. Record review showed an 08/02/2022 Level I PASRR for Resident 22. This PASRR listed only a diagnosis of depression under the Serious Mental Illness [SMI] Indicators section. It did not include Resident 22's PTSD or bipolar diagnoses. A new Level I PASRR was completed by facility staff on 09/23/2024. This Level I PASRR had an admitted [DATE]. In an interview on 10/04/2024 at 2:40 PM Staff U (Divisional Director of Social Services) stated it was important for PASRR forms to be accurate and updated with changes. Staff U reviewed Resident 22's chart and stated their PASRR should be updated when new SMI indicators were identified but was not. <Resident 57> According to the 09/03/2024 Significant Change MDS, Resident 57 had severely impaired memory, received hospice services, and had medically complex diagnoses including anxiety, bipolar disorder, and schizophrenia. The MDS showed Resident 57 received antipsychotic and antianxiety medications. Review of the physician's orders showed a 03/10/2024 order for an antipsychotic medication, a 07/25/2024 order for a second antipsychotic medication, and a 07/10/2024 order for a medication to treat anxiety. Record review showed a 10/24/2023 Level I PASRR form. This PASRR showed Resident 57 had anxiety, bipolar, and schizophrenia diagnoses, and dementia. The Level I PASRR showed Resident 57 did not require a Level II Evaluation. In an interview on 10/04/2024 at 2:40 PM Staff U stated it was important for Level I PASRRs to be accurate. Staff U stated Level I PASRRs should be updated when necessary, including when a significant change was identified. 46479 <Resident 13> According to the 09/02/2024 Quarterly MDS, Resident 13 had diagnoses of anxiety, PTSD, bipolar disorder, and schizophrenia. The assessment showed Resident 13 was taking antipsychotic, antianxiety, and antidepressant medications. The MDS showed Resident 13's most recent admission to the facility was 09/13/2023. Review of Resident 13's 09/30/2024 physician orders showed the resident was receiving two different medications for anxiety, an antidepressant medication, one medication to treat bipolar disorder, and two different medications to treat their schizophrenia disorder. Review of Resident 13's 09/07/2023 Level I PASRR showed the evaluator marked no, indicating the resident did not have a SMI. The PASRR did not indicate Resident 13 had schizophrenia, mood, or anxiety disorders. The PASRR did not show whether Resident 13 had evidence of a SMI. In an interview on 10/02/2024 at 12:17 PM, Staff D (Social Services Director) reviewed Resident 13's PASRR and confirmed the form was incomplete. Staff D stated if Resident 13's Level I PASRR was completed, the resident would have a PASRR Level II assessment. 43642 <Resident 185> According to a 09/24/2024 Admission MDS, Resident 185 admitted to the facility on [DATE]. This MDS showed Resident 185 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication during the assessment period. Review of Resident 185's September 2024 MAR showed the resident was receiving three different medications for depression. Review of a 09/18/2024 PASRR Level 1 showed Resident 185 had no SMI indicators. Staff did not identify the PASRR Level 1 was inaccurate on admission and did not include Resident 185's diagnosis of depression. In an interview on 10/02/2024 at 1:30 PM, Staff D stated an accurate PASRR Level 1 was important so a resident would get the services they required. Staff D stated their expectation was for a PASRR Level 1 to be accurate. Staff D reviewed Resident 185's PASRR Level 1 and stated it was inaccurate and needed to be revised. <Resident 53> According to a 09/02/2024 Admission MDS, Resident 53 admitted to the facility on [DATE]. This MDS showed Resident 53 had multiple medically complex diagnoses including depression and an anxiety disorder and required the use of antidepressant medications during the assessment period. Review of Resident 53's September 2024 MAR showed the resident was receiving an antidepressant medication for depression. Review of a 08/25/2024 PASRR Level 1 showed Resident 53 was identified with SMI indicators of a mood disorder, which included depression, and an anxiety disorder. Section four on the PASRR Level 1 was marked Resident 53 did not show indicators of SMI and no Level II evaluation was indicated. Staff did not correct section four of the 08/25/2024 PASRR Level 1 and refer Resident 53 for a PASRR Level II as required. In an interview on 10/04/2024 at 2:40 PM, Staff U reviewed Resident 53's records and stated staff should have, but did not correct the residents PASRR Level 1 and refer Resident 53 for a Level II evaluation. REFERENCE: WAC 388-97-1915(1)(2)(a-c). .

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained, and/or implemented, and incorporated into the Care Plan (CP) for 1 of 7 (Resident 23) residents reviewed for PASRR Level II. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Facility Policy> According to the facility's July 2015 Mental Health Rehabilitation Services policy, residents diagnosed with a mental illness or developmental disability would be prescreened through the PASRR process and receive the treatment they were assessed to require from the evaluation. The policy showed the social services department was responsible for reviewing all residents receiving a Level II PASRR screening. <Resident 23> According to the 09/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 23 had medically complex diagnoses including a history of stroke, alcohol dependence, and a psychotic disorder. The MDS showed Resident 23 took antipsychotic medication. Record review showed Resident 23 had a 10/04/2024 physician's order for an antipsychotic medication, give 100 milligrams two times a day. Record review showed a 01/19/2023 PASRR Notification of Determination form that showed Resident 23 was assessed to have a significant change in their behavioral health. The form showed Resident 23 met the requirements for Level II services. Record review showed no Level II referral was completed for Resident 23 and no recommendations. In an in interview on 10/03/2024 at 9:34 AM Staff U (Divisional Director of Social Services) stated, after reviewing the record, they could not find a PASRR Level II for Resident 23. Staff U stated they would expect a referral and evaluation to be completed after the 01/29/2023 Notification of Determination. REFERENCE: WAC 388-97-1915 (4).

Based on observation, interview, and record review the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra (an opening that allows urine to leave the body) that drains urine into a bag) were provided catheter care consistent with standards of practice for indwelling catheters, consistent documentation of catheter procedures and resident response, and coordinated referrals to a urologist for evaluation as ordered by a physician for 5 of 5 residents (Resident 3, 2, 1, 4 & 5) reviewed for indwelling urinary catheters. Resident 3 experienced harm when they had redness, swelling, and skin breakdown around the urethra due to catheter friction wear that required a surgical procedure to facilitate urinary function through a tube inserted in the lower abdomen. This placed all residents with urinary catheters at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues. Findings included . Review of the facility Evaluation for Indwelling Catheters policy, dated 02/2018, showed residents admitted to the facility without an indwelling catheter are not catheterized unless a medical condition dictates that catheterization is necessary. <Resident 3> According to the 12/07/2023 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 3 admitted to the facility on [DATE] and was able to make their own decisions and needs known. The MDS showed Resident 3 had medically complex conditions including osteomyelitis (infection of the bone) of the sacral (tailbone) region, enlarged prostate (causes blockage of flow of urine out of the bladder), obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urine flow), sepsis (blood infection), and diabetes. The MDS showed Resident 3 had an indwelling urinary catheter, a surgical wound, and required antibiotics to treat the bone infection. Review of a hospital history and physical, dated 11/24/2023, showed Resident 3 had imaging of their bladder that showed the resident had chronic obstructions to their bladder outlet (the area of the bladder near where urine should exit) and multiple bladder stones (hard masses of minerals in the bladder) with no obstruction of the urethra. Review of a facility admission assessment, dated 12/01/2023, showed Resident 3's urine assessment was documented as yellow urine draining without difficulties from a urinary catheter. Review of Resident 3's Physicians Orders (PO) showed a 12/04/2023 PO for a 16 French (fr.-size of catheter) urinary catheter with a 10 cubic centimeter (cc) filled balloon and a drainage bag. Review of a PO, dated 12/05/2023, instructed staff to remove the urinary catheter. Review of a PO, dated 12/06/2023, instructed staff to straight catheter Resident 3 three times and if Resident 3 was not able to urinate a foley catheter should be replaced. Review of a paper copy PO dated 12/13/2023, that was not in Resident 3's medical record and stored in Staff C's office, showed a PO for a 16 fr. foley catheter with a 10 cc balloon. The PO showed Resident 3 failed a voiding trial on 12/06/2023 and instructed staff to change the indwelling catheter and drainage bag as needed for blockage, excessive soiling, and dysfunction. Review of Resident 3's POs from 12/04/2023- 12/26/2023, showed no POs that instructed staff to provide catheter care, for a securement device for the urinary catheter, and to change the urinary catheter as needed for blockage, excessive soiling, or dysfunction. Review of a Nursing Progress Note (NPN) dated 12/05/2023 showed Resident 3 had their urinary catheter removed, urine was pink tinged, and Resident 3 was instructed to report to staff any difficulties with urinating. A NPN, dated 12/05/2023, showed Resident 3 was urinating without difficulty. Review of resident 3's NPN's, dated 12/06/2023, showed no documentation that Resident 3 had urinating difficulties, was not able to void, and if the foley catheter replaced. Review of an indwelling foley catheter Care Plan (CP), dated 12/08/2023, showed Resident 3 had an indwelling catheter due to an enlarged prostate. The CP directed staff to check for a catheter leg strap to secure the catheter in place, monitor and document any pain or discomfort due to the catheter, and monitor and report any signs to the physician of pain, burning, or blood-tinged urine. Review of a NPN, dated 12/13/2023, documented by Staff C (Infection Preventionist, Licensed Practical Nurse, LPN) showed that Resident 3 had failed a voiding trial (urinary catheter removed and not able to urinate), recommended to attempt another voiding trial, and provider was informed. Review of NPN's from 12/13/2023-12/24/2023 did not include documentation if or when the foley catheter was replaced and no documentation about Resident 3's urinary catheter until 12/25/2023. A NPN, dated 12/25/2023, showed Staff E (LPN) was informed by the shower aide that Resident 3 had redness and swelling to their penis and scrotum. Staff E documented that Resident 3 had urethral wear (deterioration of the skin due to catheter placement, tugging, or friction) related to the catheter. The NPN showed Staff E filled out a SBAR (Scenario, Background, Assessment, and Recommendations, a structured communication form between facility staff and physicians) form for the physician to review. Review of Resident 3's medical record showed no documentation of an SBAR completed on 12/25/2023 for Resident 3. Review of a skin observation tool, dated 12/25/2023, showed Resident 3 had a new skin impairment to the urethra that measured three centimeters (cm) in length and one cm in width. The wound was described as linear and additional comments showed, appears as urethral wear due to urinary catheter placement. Review of a NPN, dated 12/26/2023, showed Resident 3 was noted with redness and swelling to their penis and an abscess (collection of pus built up within the tissue) with necrotic (dead tissue) tissue to the urethra. The NPN showed the physician was notified and gave PO to send Resident 3 to the hospital emergently for further assessment. In an interview on 01/05/2024 at 11:00 AM, Resident 3 stated they admitted to the facility with a urinary catheter, staff attempted to discontinue the urinary catheter but Resident 3 had difficulties urinating after the urinary catheter was removed. Resident 3 stated Staff E put in a new urinary catheter, could not recall the exact date but stated, it was rough and hurt so much, it felt like they bifurcated (divided into two different parts) my urethra, and I was in a lot of pain for a while. I noted a drip of pus from my penis and asked to see the physician. Resident 3 stated at the hospital they were informed their penis had the beginning stages of gangrene (death of tissue from loss of blood supply) and they discussed amputating their penis due to the infection. In an interview on 01/22/2024 at 2:40 PM Staff E stated certified nurse's assistants (CNA's) performed catheter care, a PO was necessary before inserting or removing a urinary catheter and did not recall if they inserted a urinary catheter into Resident 3 or if anything happened during that procedure. During an interview on 01/22/2024 at 3:15 PM, Staff C when asked to clarify their NPN on 12/13/2023, replied, I think they were voiding okay. When asked if the urinary catheter was replaced, Staff C stated they would have to review their notes that needed to be scanned into the resident's records. Staff C produced a paper copy of a PO for an indwelling catheter, dated 12/13/2023, and showed Staff C documented, failed voiding trial on 12/06/2023, discussion of a second voiding trial or a urology consult considering sacral wound. The PO directed staff to change the indwelling catheter and drainage bag as needed only and to change for blockage, excessive soiling, dysfunction, or with a PO for urinalysis (test on urine). Staff C stated they were not sure if Resident 3's urinary catheter was replaced on 12/06/2023 or 12/13/2023, which staff member replaced the urinary catheter, and if there had been any issues during the insertion of the urinary catheter. Staff C stated there was no PO for catheter care every shift, a current PO for the urinary catheter in Resident 3's medical record, a PO for a leg securement device, or a PO to change the urinary catheter and privacy bag as needed. Staff C stated they would expect the PO's to be in the resident's record. In an interview on 01/22/2024 at 3:00 PM Staff D (Registered Nurse, Resident Care Manager) stated when a resident had a urinary catheter, they would expect PO's to include; foley catheter care every shift, done by the CNA and under the supervision of the nurse, a privacy bag over the urine collection bag, the urinary collection bag to be below the bladder at all times, a securement device to prevent the catheter from tugging, and the size of the catheter and the size of the balloon. Staff D stated a PO was needed for staff to insert or remove a urinary catheter. During an interview on 02/02/2024 at 11:50 AM Resident 3 stated they did not recall facility staff providing catheter care daily or a securement device for their urinary catheter. Resident 3 stated they underwent a surgical procedure and now could urinate through a tube in their lower abdomen connected to a catheter bag, and luckily did not have to have their penis amputated. In an interview on 02/02/2024 at 1:20 PM, Staff B (Director of Nursing), stated they would expect a resident with an indwelling urinary catheter to have POs to include the foley catheter size, catheter care every shift, and a privacy bag. Staff B stated CNAs are responsible for providing catheter care every shift and as needed. Staff B stated they would expect to see documentation the foley catheter was replaced in the resident's record. <Resident 2> Review of the 11/05/2023 Quarterly MDS, showed Resident 2 admitted to the facility on [DATE], had an indwelling urinary catheter, and was not able to make their own decisions. The MDS showed Resident 2 had medically complex conditions including obstructive uropathy, enlarged prostate with lower urinary tract symptoms, and kidney failure. Review of an indwelling catheter CP, dated 09/05/2023, showed staff were to check for a catheter securement device, follow up with the urologist as ordered, provide catheter care every shift, and monitor and document any pain or discomfort related to the urinary catheter. Review of a hospital after visit summary, dated 10/30/2023, showed Resident 3 was instructed to follow up with a urologist for urinary retention (inability to fully empty the bladder) and to schedule an appointment as soon as possible. Review of a NPN, dated 10/30/2023, showed Resident 2 readmitted to the facility with a urinary catheter present for a sudden onset of bilateral (both) obstructive uropathy and staff were instructed to not remove the urinary catheter until Resident 2 was seen by a urologist. Review of Resident 2's POs showed a 10/30/2023 PO for a 16 fr. urinary catheter with 10 cc balloon. A 11/03/2023 PO showed staff were to remove the urinary catheter and start a voiding trial. A 11/04/2023 PO showed PO for a 16 fr. urinary catheter with 10 cc balloon. A 11/07/2023 PO directed staff to remove the urinary catheter. A 11/08/2023 PO showed a 16 fr. urinary catheter with 10 cc balloon. A 12/04/2023 PO directed staff to remove the urinary catheter. Review of Resident 2's POs showed the facility did not ensure Resident 2 had POs that instructed staff to provide catheter care, for a securement device for the urinary catheter, and to change the urinary catheter as needed for blockage or dysfunction. Review of a NPN, dated 11/03/2023, showed Resident 2's urinary catheter was removed without difficulties. An NPN, dated 11/04/2023 showed Resident 2 was not able to urinate and the urinary catheter had to be reinserted. Review of a NPN, dated 11/07/2023 showed Staff C documented Resident 2 had their catheter removed for a second time. The resident failed a voiding trial, and the urinary catheter was re-inserted. A 11/08/2023 NPN showed Resident 2's urinary catheter was removed for a third time and had to be reinserted as Resident 2 was not able to urinate. During an interview on 01/22/2024 at 3:45 PM, Staff C stated the physician makes the determination on when and how many times to initiate the urinary catheter removal and voiding trial. Staff C stated they did not remember knowing Resident 2 had orders to follow up with a urologist before removing the urinary catheter, and stated it looked like the facility was trying to get an appointment with the urologist. Staff C stated if Resident 2 had POs to follow up with a urologist before catheter removal, staff should have waited to remove the urinary catheter until the resident was seen by the urologist. In an interview on 02/02/2024 at 1:35 PM Staff A (Administrator), stated Resident 2 should have seen the urologist before urinary catheter removal. <Resident 1> Review of the 11/23/2023 Admission MDS, showed Resident 1 admitted to the facility on [DATE], had an indwelling urinary catheter, and was able to make their needs known. The MDS showed Resident 1 had diagnoses including femur fracture, and kidney failure. Review of a urinary catheter CP, revised 12/11/2023, directed staff to check for a catheter securement device and monitor and document pain and discomfort due to the catheter. Review of Resident 1's PO's, showed a PO, dated 11/18/2023, that directed staff to insert a urinary catheter for urinary retention. Review of a PO, dated 11/27/2023, directed staff to insert a urinary catheter, and a 11/28/2023 PO to change the indwelling catheter and drainage bag as needed. Additional PO's on 12/01/2023, 12/13/2023, and 12/17/2023 showed staff were to remove the urinary catheter. Review of a paper copy of a PO, dated 12/12/2023, showed a PO for an indwelling catheter, scanned into Resident 1's electronic medical record and showed that Resident 1 failed voiding trials on 11/18/2023 and 12/01/2023. The 12/12/2023, paper copy PO directed staff to discontinue the indwelling catheter and start post void residuals (PVR, the amount of urine retained in the bladder after urinating). Review of PO's after 12/12/2023, showed a 12/13/2023 PO to discontinue the urinary catheter, start voiding trial, monitor output, and complete a progress note about the effectiveness of the voiding trial and catheter removal. Review of Resident 1's POs from 11/08/2023-12/17/2023 showed the facility did not ensure Resident 1 had POs that instructed staff to provide catheter care and for a securement device for the urinary catheter. No POs were observed to start PVR's, as written on the paper 12/12/2023 PO for Resident 1. Review of a NPN, dated 11/18/2023, showed Resident 1 had a urinary catheter inserted due to urinary retention. Review of Resident 1's NPN, dated 11/19/2023-11/28/2023 showed no documentation if or when the catheter was removed or, if or when a new catheter was inserted. Review of a NPN, dated 12/01/2023, showed staff removed the urinary catheter. Review of NPN's, dated 12/02/2023-12/12/2023 showed no documentation if or when the catheter was removed or, if or when a new catheter was inserted. Review of a NPN, dated 12/13/2023, showed Resident 1 failed a voiding trial and orders were placed to attempt another voiding trial. Review of a NPN, dated 12/17/2023, showed no documentation on 12/17/2023 if the urinary catheter was replaced and how the resident responded to the procedure. In an interview on 01/22/2024 at 4:00 PM, Staff C stated they did not see catheter care orders in Resident 1's record and would expect them to be there. When asked what date the urinary catheter was re-inserted, Staff C stated they would have to look. No additional information was provided. <Resident 4> Review of a 01/15/2024 Admission MDS, Resident 4 admitted to the facility on [DATE]. The MDS showed Resident 4 was able to make their needs known, had an indwelling catheter and intermittent catheterization. Resident 4 had medically complex diagnoses including osteomyelitis (bone infection) and urine retention. Review of a NPN, dated 01/11/2024, showed Resident 4 complained of abdominal distention (bladder feels full) after urinating and staff straight cathed (an in and out catheter to drain urine) Resident 4. A 01/12/2024 NPN showed Resident 4 was not able to void for more than eight hours after the catheter was removed and the urinary catheter was reinserted. Review of a 01/11/2024 paper copy of a PO for indwelling catheter showed no medical justification documented for the catheter. Review of Resident 4's POs showed a 01/12/2024 PO for a 16 fr. urinary catheter with 30 cc balloon, and no diagnosis for the urinary catheter was documented. Review of an indwelling catheter CP, dated 01/16/2024, showed Resident 4 had an indwelling urinary catheter indicated for acute urinary retention confirmed by PVR. The CP directed staff to anchor catheter with a securement device, catheter care every shift, and to monitor the placement and positioning of the catheter to prevent obstructed flow. During an interview and observations on 01/22/2024 at 2:32 PM, Resident 4 stated they had no history of urinary retention, this was a new issue, and the hospital removed the urinary catheter before the resident admitted to the facility. Resident 4's urinary collection bag was observed in a privacy bag sitting on the resident's bed at the bladder level. When asked why the urinary collection bag was on the bed, Resident 4 replied they were not sure, and staff had recently been in the room. In an interview on 01/22/2024 at 2:28 PM Staff F (CNA) stated they were training a new employee who left the urinary catheter on the bed and would talk with them because the urinary catheter should be below the bladder, so the urine does not back up into the bladder. <Resident 5> Review of an Admission MDS, dated [DATE], showed Resident 5 admitted to the facility on [DATE]. The MDS showed Resident 5 was able to make their needs known and did not have a urinary catheter. Resident 5 had medically complex conditions that included osteomyelitis (infection of the bone) of the sacral (tailbone) region and neurogenic bladder (lacks bladder control due to brain, spinal cord or nerve damage). Review of a urinary catheter CP, dated 01/18/2024, showed Resident 5 required an indwelling urinary catheter for a deep wound located on their tailbone. The CP directed staff to anchor the catheter with a securement device to prevent urethral tears, erosion, or dislodgement. Review of PO's showed a 01/17/2024 PO to insert a 16 fr. with 10 cc balloon indwelling catheter. During an interview and observation on 01/22/2024 at 2:40 PM, Resident 5 was observed sleeping in bed, a wound vac (device used to pull drainage from a wound through suction) was in place, and a urinary catheter collection bag covered by a privacy bag was observed hanging on the side of the bed. Resident 5 was asked if there was a securement device to keep their catheter in place and looked at their right leg and stated, no there was not a securement device for their catheter. No securement device was observed to Resident 5's legs. REFERENCE: WAC 388-97-1060(3)(c)

Based on interview and record review the facility failed to assess resident devices to ensure resident safety for 3 (Resident 1, 2 & 3) of 3 residents reviewed for devices and accidents. The failure to thoroughly conduct a device risk assessment for an alternating air mattress and to assess and identify the risk of hazards and injury, evaluate those hazards, and implement interventions to reduce those hazards resulted in harm for Resident 1, who sustained a femur fracture after an unwitnessed fall. This failure placed all residents with an alternating air mattress (AAM-inflates and deflates to alternate pressure) at risk for significant injury, pain, and diminished quality of life. Findings included . According to the 09/2017 facility Device policy if a resident's medical condition or symptoms warrant the use of a physical device, a Device Evaluation (evaluates and identifies the type of device being used, what safety interventions are put in place to prevent injury and risk of injury related to the device) is completed, and a Device Evaluation Review (review of devices in use and for any changes noted from past reviews, continued use or plan to reduce usage) is completed by nursing on a quarterly basis or upon a residents change in condition. Resident 1 Review of the 12/29/2022 Quarterly Minimum Data Set (MDS-an assessment tool) showed Resident 1 had severe mental impairment with diagnoses including medically complex conditions, dementia, diabetes, stroke (brain bleed) with aphasia (inability to understand or express speech), and right sided hemiplegia (muscle weakness of one side of the body affecting arms and legs). The MDS showed Resident 1 required two-person extensive assistance for turning and repositioning in bed, toileting, and was dependent on staff for transfers. The assessment of Resident 1's skin showed no current pressure ulcers or skin issues present, and the resident did not require pressure ulcer care, a turning or repositioning program, or nutritional intervention to manage skin problems. A 04/07/2022 physicians order (PO) showed a PO for an AAM for pressure reduction. Review of Resident 1's 05/25/2022 revised Care Plan (CP) showed a potential for skin break down and an intervention added for a AAM on 08/21/2021. Review of a 01/06/2023 facility fall investigation showed Resident 1 was changed by Staff F (CNA- Certified Nursing Assistant) at 11:15 PM, was positioned slightly towards their right side with pillows placed under their back. Review of investigative documents showed only one CNA was interviewed regarding Resident 1's fall. The investigation concluded that the possibility of putting more weight towards the right side might have contributed to Resident 1 sliding down and off the right side of the bed. In an interview on 02/09/2023 at 5:20 PM Staff B (Interim Director of Nursing) stated Staff F would be re-educated on following the resident's CP for two staff present for bed mobility. A 01/07/2023 nursing progress note about the 01/06/2023 fall showed Resident 1 was heard yelling from the hallway. Staff G (Licensed Practical Nurse) found Resident 1 face down on the floor of the right side of their bed at 11:45 PM on 01/06/2023. The resident was assessed by facility staff and found to have pain and swelling to the right knee. Emergency personnel were called, and Resident 1 was sent to the hospital for further evaluation. Review of 01/07/2023 hospital history and physical note showed Resident 1 had a right femur (thigh bone) fracture that was displaced (bone breaks into two or more parts and ends do not line up) and comminuted (bone breaks in many pieces), with a right leg deformity and swelling. Review of a 02/01/2023 hospital follow up note showed Resident 1 underwent surgery to repair the femur fracture on 01/07/2023 and had complications following the surgery that included a deep skin and soft tissue infection (SSTI) that affected the skin, muscles, connective tissue and the surgical hardware. Resident 1 required an additional surgery on 01/25/2023 to clean the right femur surgical incision. The resident required IV (intravenous- in the vein) antibiotics to treat a multi-drug resistant organism (difficult to treat infections). Resident 1 required IV antibiotics twice daily and would continue the antibiotics for the next nine weeks to treat the SSTI. During an interview on 01/31/2023 at 12:49 PM Staff B stated Resident 1 had an AAM for a pressure ulcer (PU- injury to skin/tissue from prolonged pressure on the skin) to the left heel that healed. When asked if they resident had and current PU's, Staff B replied the left heel PU healed on 05/25/2022, over eight months ago. Review of Resident 1's 08/21/2021 device informed consent showed an AAM was indicated for use due to medical reasons of weakness, hemiplegia, and history of stroke. The consent did not indicate the air mattress was used for pressure reduction. Review of a 07/13/2022 Quarterly Nursing Review (QNR) showed under the section devices Staff D (Resident Care Manager (RCM)- Registered Nurse) marked no changes noted since the past review, continue with air mattress related to Resident 1's stroke, and did not include Resident 1's pressure ulcer healing two months prior. A 10/13/2022 QNR showed under section devices staff marked non-applicable/no devices in use and was signed by Staff E (RCM- licensed practical nurse) on 10/13/2022. This assessment showed it was modified on 01/09/2023 for incomplete documentation. This modification occurred 3 days after Resident 1 experienced the fall resulting in a fracture. Review of the modified 10/13/2022 form showed under devices staff documented no changes since past review and did not indicate what device was being reviewed Review of a 10/22/2022 QNR had similar findings and showed the devices reviewed were marked as no changes, the review did not address what device was being reviewed and did not include Resident 1's pressure ulcer that resolved five months prior. Review of a 01/02/2023 Annual Device Evaluation showed under Specialty Mattress staff answered three out of eight questions and did not address the resident's cognition (mental status), observe and evaluate the resident for bed mobility, observe and evaluate transfer status, evaluate the risk for injury related to this specialty mattress, what safety interventions were put in place to prevent injury related to the specialty mattress and had risk and benefits been discussed with the resident or family. These areas of the form were left blank. In an interview on 01/31/2023 at 12:49 PM with Staff A and Staff B, when asked if the 01/02/2023 Device Evaluation was thoroughly completed, Staff B stated all answers are not completed and they would expect the evaluation to be thoroughly completed with all sections answered. When asked how the facility assessed the risk of injury and Staff B replied to it should be done with the annual evaluation. When asked if the AAM was thoroughly assessed and if the evaluation addressed the change of Resident 1's pressure ulcer healing eight months prior could this have been prevented, Staff A stated they would need to look at the resident's record. During an interview on 02/03/2023 at 11:27 AM Staff A stated the left heel ulcer would have been an improvement in Resident 1's condition but did not significantly change the plan of care. Staff A stated the 01/02/2023 annual device evaluation did assess entrapment, but other sections that assessed the resident's cognition (mental status), observe and evaluate the resident for bed mobility, observe and evaluate transfer status, evaluate the risk for injury related to this specialty mattress, what safety interventions were put in place to prevent injury related to the specialty mattress and had risk and benefits been discussed with the resident or family. These areas of the form were not addressed and left blank. Resident 2 According to the 11/07/2022 Quarterly MDS, Resident 2 was cognitively intact, able to make their own decisions, and had diagnoses including medically complex conditions, kidney disease, and a stage 4 (deep ulcer reaching muscle, tendons, and bones) PU to their sacrum (located at base of spine). Resident 2 required two staff members for bed mobility and transfers. The MDS assessed Resident 2's skin with one stage 4 PU, requiring a pressure reducing device for the bed, PU care, and nutritional intervention to manage skin problems. Review of a 04/11/2022 PU CP showed Resident 2 required an AAM. A 04/07/2022 PO showed AAM for pressure reduction. Review of 10/06/2022 QNR showed staff documented under section devices non-applicable/no device in use. Similar findings were found for the 01/06/2023 QNR device evaluation. Resident 3 According to the 11/02/2022 Quarterly MDS, Resident 3 had moderately impaired cognition, and diagnoses including medically complex conditions, kidney failure, and muscle weakness. Resident 2 required two staff members for bed mobility and was dependent on staff for transfers. The MDS assessed Resident 3's skin with no PU's, at risk for PU's, and required a pressure reducing device for the bed. Review of 03/17/2022 skin integrity CP showed Resident 2 required an AAM for pressure reduction. Review of a 04/07/2022 PO showed AAM for pressure reduction. Review of a 10/07/2022 Device Evaluation showed under Specialty Mattress Evaluation Staff D answered three out of eight questions and did not address evaluating the resident's cognition, observe and evaluate the resident for bed mobility, observe and evaluate transfer status, evaluate the risk for injury related to this specialty mattress, what safety interventions were put in place to prevent injury related to the specialty mattress and had risk and benefits been discussed with the resident or family. These areas of the form were left blank. Review of a 01/07/2023 Device Evaluation showed similar findings and showed staff did not thoroughly assess the specialty mattress and left answers blank. In an interview on 02/07/2023 at 4:27 PM Staff B stated Resident 2's Device Evaluations did not reflect any devices were in use and staff need education on the device evaluation process to ensure it is completed thoroughly. Staff B acknowledged Resident 3's 10/07/2022 device evaluation was not thoroughly completed and not all questions were answered. Staff B would expect the device evaluations to be completed initially when the device is placed and reviewed on a quarterly basis. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 1) of 3 residents reviewed for conditions needing medical attention or follow-up, received the care they required in a timely manner. Resident 1 was transported to a Urology (the function and disorders of the urinary system) appointment, left unattended for at least six hours in the lobby, and not returned to the facility for approximately 11 hours. The resident missed their scheduled [CONDITION(S)] medication and a blood sugar check to determine whether there was a need to give medication. In addition, when the resident was finally seen by the practitioner, they had to have their bladder drained due to urine retention while waiting to be seen. Resident 1 was found to experience harm when they were left unattended for a long period of time and required additional insulin, increased blood sugar monitoring, and subsequent lab draws upon return to the facility. Findings included . A report received by a State Agency (SA) showed, Resident 1 was gone from the facility, for 6 hours before [the facility] had noticed. This report showed a clinic security staff found the resident. This report showed Resident 1 presented as, very demented and confused. This report showed Resident 1 thought they were at the clinic for days. The [resident's] head has been in their lap, [they have] no POA [Power of Attorney] or family to contact in [their] chart. Review of an 08/24/2022 modified Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE] with medically complex conditions, to include [CONDITION(S)] (when urine cannot drain through the urinary tract), diabetes, dementia, and [CONDITION(S)] disorder. This MDS showed staff assessed Resident 1 had a BIMS [Brief Interview for Mental Status, a cognitive examination] score of 11 out of 15, or moderately impaired cognition. This MDS showed Resident 1 required extensive assistance of 1 person to transfer in and out of their wheelchair, walking, locomotion on and off the unit, and toilet use. This MDS showed Resident 1 used a walker and wheelchair for mobility. Review of an 08/24/2022 Cognition Care Plan (CP) showed, The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia. This CP showed interventions of, Cue, reorient and supervise [the resident] as needed as much as possible to decrease confusion. Review of 08/18/2022 progress notes showed the staff identified Resident 1 was alert, oriented to person and place, and forgetful at times. An 08/23/2022 progress note timed at 9:52 PM showed, S/S [Signs and Symptoms] of Dementia noted this shift, as evidence by resident did not know where [they were] even after staff oriented [the] resident. After an hour, the resident was oriented. Safety maintained . Staff care and assist with ADLs [Activities of Daily Living] and meal tray rendered Review of an 08/23/2022 provider History and Physical note showed, Awake, alert, oriented to self and year only, not location or month. Review of an 08/23/2022 3:24 PM Late Entry Progress Note written on 08/24/2022 at 5:36 PM showed, Staff B (Director of Nursing), tried to call Trimed [a transport company] to set up transport for this resident for tomorrow's appointment urology [clinic] at 0830 H [8:30 AM] but Trimed said they do not have any available transport for early pick up at 0700H [7:00 AM]. Resorted to call yellow cab as last option for this appointment. A subsequent 08/23/2022 3:25 PM progress note showed the staff notified Resident 1 of the urology appointment that was out of town and county, to include the pick-up and return times. Another 08/23/2022 3:28 PM Late Entry Progress note written by Staff B on 08/24/2022 at 5:30 PM showed that staff gave instructions to Yellow Cab to take Resident 1 to, 3rd floor C320 for check in, in the urology clinic and pick up at the same clinic location. This note showed the agent at the Yellow Cab call center noted the transport details. An 08/24/2022 5:58 PM progress note showed the staff notified Staff B that Resident 1 failed to return from their out-of-town appointment at 9:30 AM, via yellow cab as transport was arranged. This note showed that after multiple failed attempts by the facility to reach the clinic to inquire of Resident 1's whereabouts and confirm if they were seen by the clinic doctor, the facility was able to speak with the receptionist who informed them that the resident was not checked-in for their appointment and, the driver just bring [sic] [the resident] to the lobby. On 09/08/2022 at 3:29 PM, the Urology Clinic Collateral Contact (CC) stated that check-in occurred on the third floor. The receptionist stated that on the right side of the 3rd floor was the orthopedic check-in, and on the left side was the urology check-in, all on the same floor area. The CC stated that Resident 1 was found in the orthopedics office side and, Nobody brought the resident to the receptionist desk. Whoever came in just placed [the resident] at the ortho [orthopedics] side. Nobody was aware of [the resident] until quite some time later on in the day. We got notified by security who was called to the ortho side because they had someone complain of [Resident 1] sitting there for a while. And then security came over to see if [Resident 1] was a patient of ours. The CC stated that they were able to identify who Resident 1 was when, Security found some paperwork on [the resident] and we saw [the resident] was a patient of ours who had an appointment at 8:30 in the morning but never checked in. Whoever brought [the resident] there, there's a wall that covers exactly where [the resident] was sitting, it blocks the view from that side of the lobby. The CC stated that Resident 1 never called out for help, Nope, we didn't hear anything. [The resident] sat there all day until some patient or someone complained about [them] sitting there for a while. Review of a facility event timeline showed the facility connected with the clinic at 2:00 PM. This timeline showed, the clinic receptionist confirmed Resident 1 was in the lobby in their wheel chair, just sitting in the lobby with the paperwork. This timeline showed the facility asked the clinic to provide food and drinks to Resident 1 and keep them in the clinic. The timeline showed the facility requested of Yellow Cab to pick up Resident 1 from the clinic again. At 3:00 PM, the facility notified the clinic that Yellow Cab was on their way to pick up Resident 1, and the clinic informed the facility that the doctor was seeing Resident 1 to complete the appointment. Review of 08/24/2022 progress notes showed that on Yellow Cab's second attempt to pick up Resident 1 from the urology clinic, the driver left because, the resident is not ready yet and that they cannot wait and the max [maximum] time they can wait is 20 mins [minutes] as per their protocol. Staff B told the clinic about Yellow Cab's departure and sent, our social services to drive the bus to pick up the resident. The facility staff arrived at the clinic at 5:30 PM. On 08/29/2022 at 3:17 PM, A Yellow Cab Collateral Contact (CC) confirmed the facility called them to set up a wheelchair van transport for Resident 1. The CC stated that the transport company provided physical assistance to and checked-in residents at appointments. Staff C stated that the instruction they received from the facility was to take Resident 1 to the appointment. The CC stated that review of 08/24/2022 10:23 AM driver notes showed, a driver returned to pick up Resident 1 from their appointment but left because Resident 1 was a no-show because [the driver] could not find the [resident] there. When asked to explain what location the driver referred to as there, the CC stated, I can't really tell you what happened. Our driver was in Tacoma and waited for 8 minutes and still no passenger. The CC stated the driver who went to pick up Resident 1 was not the same driver who had dropped them off to their 8:00 AM appointment. The CC stated they were given the instructions to pick up the resident at the 3rd floor C320. The CC stated the driver called Resident 1's identified telephone number unsuccessfully. Review of the Yellow Pages showed it was the facility's phone number and not the resident's that the driver called. The CC stated that they found no documentation to show the driver called the facility to let them know they were unable to locate Resident 1 and bring them back to the facility as scheduled. On 09/07/2022 at 2:36 PM, another Yellow Cab CC stated, If [a passenger has] impaired cognition then it's really advantageous to have the nursing home staff with them or family so they can get to the appointment safely. The CC was asked what the extent of their responsibility for a cognitively impaired resident was. The CC stated, That's a good question. The only thing we are responsible for is to pick up and drop off the resident at their location. Checking them in for an appointment would be dependent on the driver. Am not quite sure if everyone does that here. The CC was asked if they needed to know if a resident was oriented or not to what was happening around them. The CC stated, Yes, we need to know if they are oriented or not so [the driver] can be instructed to do what they need to do. When asked what the expectation was of a driver to check-in a cognitively impaired resident and ensure a complete and safe drop-off and pick-up to and from the appointment, the CC stated, [The driver's] not going to know that unless they are told. Unfortunately, there isn't any particular notes here, just to call the passenger upon arrival [at the facility] and drop them off at a specific suite in [a clinic in] Tacoma, and the number to contact the passenger. We transport everybody. As long as we have a notation here that they [the resident] require a check-in, we instruct the driver to do that. Unfortunately, we don't have that [notation] here for this trip. Review of 08/24/2022 progress notes showed Resident 1 returned to the facility at 6:15 PM, a period of 11 hours away from the facility. Review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A SS varies the dose of insulin based on the blood sugar level. The higher the blood sugar, the more insulin is administered. The August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's blood sugar values ran at a low of 129 to a high of 408 (normal is between 70 to 130 for a diabetic). Review of an 08/24/2022 progress note showed that when Resident 1 arrived at the facility, staff checked their blood sugar which measured 500. The nurse administered insulin and notified the doctor, who ordered for the blood sugar to be rechecked in 30 minutes. After dinner, Resident 1's blood sugar was 548 and the doctor ordered an additional 20 units of insulin to be administered. The doctor also ordered the staff to check Resident 1's blood sugar two hours later, then every four hours, and have blood drawn for labs the following morning. Resident 1's blood sugar at bedtime was 412 and no further orders were given by the doctor. Review of 08/24/2022 Urology Clinic notes showed Resident 1, was dropped off at lobby this morning, did not check in. Found in lobby 7 hours after [the resident] arrived. Pt [patient] is poor historian. This visit summary showed the clinic scanned the resident's bladder and found, > [greater than] 1L [liter of urine] today. One liter is approximately 33 ounces. The insertion of an indwelling urinary catheter was required to drain the one plus liter of urine out of Resident 1's bladder. This note showed the Medical Assistant signed the summary at 3:05 PM, 6.5 hours after the intended appointment of 8:30 AM. On 08/25/2022 at 9:50 AM, the day after the transport event, Resident 1 was observed in a dimly lit room in bed. Resident 1 answered, No, when asked if they had gone to any appointments recently. When asked to describe how their day went the day before (08/24/2022), Resident 1 could not recount the event of the day and stated that they did not go to any appointments on 08/24/2022. The above findings were shared with Staff A, Administrator, and Staff B, Staff Development Coordinator/Infection Preventionist, on 09/09/2022 at 11:42 AM. Staff A acknowledged the Yellow Cab driver was not the adequate supervision Resident 1 required during transport services and appointments. Staff A acknowledged the facility should but did not send an escort with Resident 1, who would be able to check-in Resident 1 properly at the clinic and return with the resident at the appropriate time to the facility. No further information was provided to show the facility communicated with the transport service and informed them of Resident 1's limitations, physical and cognitive, before setting up the transport.

Based on observation, interview and record review, the facility failed to ensure 1 (Resident 1) of 3 residents reviewed for falls was safely positioned in a wheelchair. This failure caused Resident 1 to fall forward, out of the wheel chair, and experience a right forehead hematoma (localized swelling filled with blood) and bruising to both eyes. This failure placed other residents at risk for further falls and associated injuries. Findings included . Review of a 04/29/2022 Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE] with medically complex conditions. This MDS showed Resident 1's cognition was severely impaired, required 2 staff to assist with transfers, and used a wheel chair. The MDS showed Resident 1 was free from falls in the previous six months. Review of a 03/31/2021 Falls Care Plan (CP) showed Resident 1 was at a high risk for falls due to gait/balance problems, impulsiveness, lack of safety awareness, and impaired cognition. The Falls CP showed Resident 1 used a Tilt and [sic] Space wheel chair to maintain proper body positioning/alignment. A Tilt-in-Space wheelchair keeps the resident's posture the same, while the whole seat tilts backward. A 07/21/2022 Behavior CP showed the staff identified, on 04/03/2022, that Resident 1 had the behavior of taking off non-skid socks and gerisleeves (cloth sleeve) to [their] arm. Review of a 07/19/2022 facility Investigative Report (IR) showed that prior to Resident 1's transfer from the wheel chair to the bed, Staff B (Nursing Assistant Certified) and Staff C (Nursing Assistant - Registered) observed the resident bending over while sitting in the WC [wheelchair] touching [their socks and the floor]. This IR showed that when Staff B went to get a gait belt [used to support a resident when standing], in the same room to assist in the transfer of Resident 1, Staff C moved Resident 1's wheel chair towards the bed, while the resident leaned forward. The IR showed Resident 1, suddenly fell forward on [their] face to the floor. Review of the 07/19/2022 IR showed that Staff C, Honestly admitted that it was a misjudgment on [their] part to move the chair while [Resident 1 was bending over. Staff C confirmed that the resident was bending over in the wheel chair and fell towards the floor when Staff C moved the wheel chair. The 07/19/2022 IR concluded that Resident 1 fell due to, misjudgment of [Staff C] to move [the resident's] wheel chair while the resident was bending over. This IR showed the resident's impaired condition, lack of safety awareness, and a urinary tract infection ([CONDITION(S)]) were added contributors to the fall. Review of Resident 1's CP after the fall showed no interventions that instructed the staff on how to position Resident 1 in their Tilt-in-Space wheel chair, when staff observed Resident 1 lean or bend forward. A 07/20/2022 note written by Staff D, Nurse Practitioner, showed Resident 1 developed a right forehead hematoma and bruising to both eyes from the fall. This note showed x-rays were negative for hip or head fractures and no hospitalization was required. On 07/21/2022 at 1:15 PM, Staff D stated that the use of a blood thinner made Resident 1's facial bruising more pronounced. An observation on 07/21/2022 at 1:19 PM showed Resident 1 at the Nurses Station with Staff E, Registered Nurse. Resident 1 presented with dark purple bruising to both eyes and a raised hematoma to the right side of the forehead. Resident 1 was fidgeting with their geri-sleeves. Staff E confirmed Resident 1 was in the same wheel chair as when the fall occurred, and was seated approximately 1 to 1 1/2 feet from the ground in a slight tilt. Staff E stated that Resident 1 typically sat in their chair with no issues and did not stand. Staff E attributed Resident 1's behavior of leaning forward in their wheel chair to end stage dementia. Resident 1 was observed to remove their geri-sleeves quickly. On 08/02/2022 at 4:25 PM, Staff F, a CNA familiar with Resident 1, stated that they observed the resident remove their socks when sitting in the wheel chair throughout the day. Staff F stated that the resident would either bring their foot up to the knee level or lean forward and reach for their foot and remove the sock. Staff F stated that the frequency at which Resident 1 would lean over when sitting in their wheel chair and remove their socks would be pretty often. Staff F stated, I don't think [Resident 1] really likes socks. We put them back on. We tried to put like a little bit longer socks because it takes a little longer for the resident to take them off. Staff F stated that when they saw Resident 1 lean forward in their wheel chair, sometimes staff would assist the resident to bed, where the resident could have more space to move. Staff F stated that they knew Resident 1 fell , but did not know the circumstances surrounding the fall as they were off duty. On 08/02/2022 at 4:05 PM, Staff G, a Licensed Practical Nurse familiar with Resident 1, stated that just before the interview, the resident's socks were found on the floor. Staff G stated that Resident 1 presently was, sitting upright, slightly tilted but not tilted all the way back, in their wheel chair. Staff G stated that they never saw the resident actually remove their socks but saw them reach out for other things. Staff G stated that they had no idea how Resident 1 removed their socks and, I just see [the socks] on the floor. Staff G stated that Resident 1's safety was important, and was concerned about the resident's behavior of reaching out for things or bending over in their wheelchair. Staff G stated that they did not know how Resident 1 fell , but I know [the resident] had a fall. On 08/03/2022 at 1:05 PM, Staff H, Occupational Therapist, stated, Most people with dementia tend to lean forward because they think there's something on the floor. They want to pick up items on the floor. That is a potential risk for falls. Even if I have good trunk control, if I lean excessively forward, I have a potential to fall, regardless of what type of wheelchair is used. Unfortunately, most of our patients with dementia lose their sense of trunk control and then they lean forward and don't have the depth perception. Plus, a lot of them have visual deficits anyway, so they just keep leaning forward. In all honesty, [Resident 1's] wheelchair is almost to the ground, so [they] must have been really leaning forward when [they] fell . Staff H stated that staff should not have moved Resident 1's wheelchair when the resident was leaning forward and stated, It's a basic Newton's law of gravity. If the item is moving, no matter what the speed, there will be some consequences. If [staff] see the resident leaning forward like that, they have to stop, and reposition the resident. Staff H stated staff should use verbal then tactile cues, then tilt the wheelchair if necessary to address the excessive leaning. Staff H added, Even if it's a basket, it will fall down. The above findings were shared with Staff A, Director of Nursing, on 08/02/2022 at 11:25 AM. Staff A acknowledged Staff C should have ensured Resident 1 sat upright before moving the wheel chair. Staff A stated Resident 1's behavior of bending or moving forward is not an established behavior, contrary to staff interviews. Staff A stated that they expected the CP to show how to safely position Resident 1 when the staff observed Resident 1 leaning over in their wheel chair. Staff A acknowledged that the CP lacked interventions before or after the fall, to safely position Resident 1 in their Tilt-in-Space wheelchair when the staff observed Resident 1 leaning over the wheelchair, placing Resident 1 at risk for falls months prior to the traumatic fall of 07/19/2022. Staff A stated, I didn't make changes [to the CP]. Staff A acknowledged Resident 1's behavior of leaning over the wheelchair placed them at risk for falls. On 08/02/2022 after the interview with Staff A, the CP showed the intervention, Staff to make sure the resident when bending or touching [their] socks or floor, staff to redirect resident to sit back or tilt the wc backward for safety.

Based on observation, interview, and record review, the facility failed to implement a system which ensured residents nutrition and hydration status was assessed, monitored, and maintained within acceptable parameters, for 4 (Residents 44, 213, 42 & 21) of 11 residents reviewed. Facility staff failure to: accurately record and tabulate fluid intake for residents on fluid restrictions; consistently and accurately document meal intake; ensure dental issues affecting a resident's ability to chew and intake were timely addressed; consistently obtain and evaluate resident weights; ensure residents with significant or trending weight loss were assessed weekly by the interdisciplinary nutrition committee until stable; and validate nutritional interventions were implemented and effective. These failures placed residents at risk for unidentified weight loss, delay in treatment and decreased quality of life, and resulted in harm to Resident 44 who experienced severe unplanned weight loss, losing 39% of their body weight in 7 months. Findings included . According to the facility's Weights policy, revised 06/10/2021, weights are used as one component of data collection needed to evaluate the resident's nutritional status, fluid retention, or diuresis (excessive urine production). This policy provides a guideline for staff to weigh residents weekly for the following: food intake has declined and persisted; slow trending of weight loss/ gain; and for significant weight loss/ gain which is identified as 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. This policy directs staff to re-weigh within 24 hours any weight with a five-pound (lbs.) variance and if a significant variance is actual after re-weight, staff are to document in medical record, revise Care Plan (CP), refer to Nutritional Hydration Skin Committee (NHSC), and notify the physician. According to this policy these notifications are to be recorded in the nursing progress notes of the medical chart. Resident 44 According to the 01/31/2022 Medicare 5 Day Minimum Data Set (MDS - an assessment tool), Resident 44 admitted to the facility on [DATE], was sent to a local hospital on 01/14/2022 and readmitted on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS showed Resident 44 was on a therapeutic altered texture diet, did not have signs and symptoms of a swallowing disorder, and had unknown or no weight loss of 5% or more in the last month. Review of a 06/28/2021 Nutrition CP showed the resident was at risk for nutrition changes related to being on a therapeutic diet, altered dental status (Resident 44 used upper dentures), poor intake by mouth, significant weight loss, modified diet texture, dysphasia (difficulty swallowing), and possible comorbidities (medical diagnoses). A 06/15/2021 Physicians Order (PO) showed Resident 44 admitted on a CCHO (Controlled Carbohydrate) diet with regular texture. Review of the resident's weights showed the resident weighed 213 lbs. on 06/15/2021. On 06/22/2021 the resident weighed 192.6 lbs., a 20 lb. weight loss in one week. The resident was re-weighed on 06/23/2021 and weighed 189.8 lbs., an additional 2.8 lbs. loss. The resident had a total weight loss of 22.8 lbs. or a 10.89% weight loss in eight days. A 06/28/2021 Nutritional Evaluation showed the Registered Dietician (RD) recommended adding large protein portions and nutritionally enhanced (increased fats, more butter, milk) meals for the resident's significant weight loss. A 06/30/2021 NHSC review form showed the resident was assessed for weight loss. The review form included a section of factors potentially affecting the resident's nutritional status, no factors were marked. The committee's plan was to add weekly weights and only use a mechanical lift to weigh the resident, to eliminate the possibility of significant weight differences related to different methods of weighing. Review of the resident's weights showed no weight recorded for 6/30/2021. On 07/08/2021 the resident weighed 176.2 lbs. A weight loss of 13.6 lbs. in 2 weeks. On 07/14/2021 the NHSC met to discuss the resident's weight loss, eight days after it was identified. The committee's plan was to add a no sugar added house shake three times a day with meals. On 07/14/2021 the resident weighed 168.4 lbs. The resident was reweighed on 07/15/2021 and weighed 168.8 lbs. A weight loss of 7.4 lbs. in one week. A 07/16/2021 Nursing progress note showed the resident was started on [MEDICATION(S)] (an anti-depressant) as an appetite stimulant. A 07/16/2021 Provider encounter note showed the resident informed the provider they lost their upper dentures a couple of weeks prior while in the facility and the RCM (Resident Care Manager) was aware and would work on locating them or replacing them. Review of a 06/14/2021 Personal Belonging Inventory List showed the resident admitted with upper dentures. Review of weight records showed the resident continued to lose weight. On 08/18/2021 the resident weighed 153 lbs. and on 09/22/2021 the resident weighed 142 lbs. On 09/22/2021, the resident was reviewed at the NHSC meeting for significant weight loss of 33.3% weight loss in 3 months. The review form showed a section of factors potentially affecting the resident's nutritional status, no factors were marked. The committee's plan was to change the no sugar added supplement to a regular house supplement, remove the CCHO from the resident's diet and complete a new food preference worksheet. A 09/22/2021 Food Preference showed the resident disliked cottage cheese, milk, raw vegetables and spicy food. The resident liked sandwiches, soup, and macaroni and cheese. Review of weights showed the resident had 2 weeks with weight gains during October 2021. On 10/27/2021 the resident weighed 146.6 lbs. The resident weight record showed one weight for the month of November on the 30th at 149 lbs. There was no indication the facility obtained or documented weekly weights for 3 weeks in November. The next weight documented was 12/31/2021, four weeks since the resident's last weight, and the resident weighed 132 lbs. A difference of 17 lbs. over 4 weeks. On 01/05/2022 the resident was reviewed at the NHSC meeting for significant weight loss of 10.5% in one month, 8.3% in three months, and 24.3% in six months. The committee recommended the resident be re-evaluated by the Psychiatrist. A 01/07/2022 Psychiatry note showed the resident told the provider they had difficulty getting the sleep they needed due to bedtime anxiety. The provider started the resident on a 14-day trial of [MEDICATION(S)] (an anti-anxiety medication) as needed for increased anxiety and recommended to encourage oral intake with favorite beverages or meals. Review of the resident's PO's showed a 01/14/2022 PO for [MEDICATION(S)] twice a day for anxiety. The medication was ordered a week after the recommendations were made and transcribed as twice a day, not twice a day as needed per the Psychiatrist note on 01/07/2022. A 01/07/2022 Nursing progress note showed the resident was informed of their significant weight loss and food preferences were updated. Review of the resident's clinical record showed no indication the facility actually updated the food preference worksheet. Review of the resident's weight record showed no weight obtained for the first week of January 2022. On 01/14/2022 Resident 44 was sent to a local hospital for respiratory distress related to COVID 19. The resident returned on 01/24/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a new diet order of Regular diet, pureed texture related to dysphasia, and to follow up with a GI specialist. Review of a 01/19/2022 Speech Pathology Treatment record from the hospital, showed the resident had a modified [MEDICATION(S)] swallow study (assess the swallow reflex) on 01/18/2022 that showed the resident had pharyngeal (throat) residue with solid foods. The speech language pathologist (SLP) recommended the resident swallow two times after a bite of food and/or alternate food with a drink. Additionally, the SLP stated the resident would be able to upgrade to a mechanically altered solid diet, if they desired and had their dentures. The SLP stated the resident would not be appropriate for dysphasia advanced (altered texture diet) or regular solids due to lack of dentition (no upper dentures). Review of the resident's clinical record showed a 01/25/2022 Resident Refusal of Diet and Fluids Informed Consent that was signed by the resident who refused the recommendations of a regular, CCHO, pureed texture diet. Per the consent, it showed the resident chose a regular textured diet because it was their preference, especially to have graham crackers. A 01/25/2022 Nursing Progress note showed the hospital informed the facility of the resident's GI biopsy that was positive for h. pylori (Helicobacter Pylori-a type of bacteria that infects the stomach tissue) and the resident was started on an antibiotic to treat the infection on 01/26/2022. Review of the resident's weight record showed the resident weighed 142.2 lbs. on 01/26/2022. A weight on 02/01/2022 showed the resident weighed 135.6 lbs., a 6.6 lb. weight loss in less than one week. A 02/03/2022 Community wound provider note showed the resident was seen for a suspected deep tissue injury (SDTI) to their sacrum that was present upon readmission from the hospital (a condition that can occur because of poor nutrition). During an interview and observation on 02/02/2022 at 10:26 AM Resident 44 was lying in bed, their breakfast tray consisting of pureed food and beverages remained untouched on the over bed table, despite the resident's documented preference for solid food. Resident 44 restated they lost their dentures after the first week of being at the facility in June 2021, and they still had not heard anything back about their missing upper dentures. Additionally, the resident stated they didn't eat their breakfast because the food doesn't taste good. In an interview on 02/04/2022 at 1:13 PM Staff X (Certified Nursing Assistant- CNA) stated Resident 44 ate nothing for lunch. The resident's lunch meal was observed untouched, and no food consumed. Staff X stated this has been going on for 2 months and the resident just doesn't want to eat. In an interview on 02/07/2022 at 1:02 PM Resident 44 stated they asked facility staff for chicken and some tomato soup. At 1:13 PM Staff Y (CNA) stated the resident requested chicken soup and they are going to the kitchen to see if they have any. At 1:31 PM Staff Y returned, and Resident 44 stated they did not want the pureed soup or the pureed tuna, they wanted a tuna sandwich and hot chocolate. Staff Y stated the dietary manager told them they can't have chicken soup because the resident is on a pureed diet. In an interview on 02/07/2022 at 1:41 PM Staff J (Resident Care Manager- RCM) stated the resident had signed a risk and benefits informed consent for regular texture food and could have a regular diet if they are refusing the pureed food. Staff J stated they would update and educate the dietary and nursing staff of resident's preferences. On 02/07/2022 at 1:56 PM the resident was observed eating their soup, and a tuna sandwich was observed on their meal tray. On 02/08/2022 at 9:15 AM Resident 44 stated they liked meatloaf, hamburgers, milk, fresh fruit, and most vegetables. This conflicted with the resident's 09/22/2021 food preferences that showed the resident disliked milk, raw vegetables and spicy foods and the resident's special likes were soup, sandwiches and macaroni and cheese. During an interview on 02/09/2022 at 10:31 AM Resident 44 stated they informed facility staff about the missing dentures but were still waiting to hear about replacements. The resident stated it was hard to eat without teeth and thinks it could have affected their intake, stating I want regular food back, it's hard to eat that stuff I am not used to, soft food, so I tell them to take it away but they do not offer to bring me anything else. I know I have lost weight and I want to gain it back. During an interview on 02/09/2022 at 1:16 PM Resident 44 was observed with their lunch tray, consisting of pureed taco seasoned beef and a pureed piece of bread. The resident stated, I can't eat it and I don't like it. Review of the resident's meal ticket showed the resident disliked beef. Resident 44 stated they liked beef and want to eat tacos, hamburgers, and hot dogs. Review of the resident's weight record showed on 02/09/2022 the resident weighed 129.8 lbs., a loss of 83.2 lbs. from their admitting weight of 213 lbs. During an interview on 02/09/2022 at 4:15 PM Staff B (Director of Nursing) stated the resident was on a pureed diet because the resident had difficulty swallowing and it was on the hospital discharge orders. Staff B stated there was no physicians order (PO) for a speech therapy consult, normally PT/OT (Physically Therapy/Occupational therapy) screen and refer to speech. Staff B acknowledged the screen did not occur and the resident did not but should have been seen by the speech therapist after admitting on a new altered textured diet. Staff B confirmed the resident admitted with the dentures and stated there was no grievance initiated and no progress on replacing the dentures. Staff B stated the lack of dentures could be a contributing factor to the resident's weight loss, but it is not a major factor. When asked about the resident's GI referral, Staff B stated the resident's RCM was not aware of the appointment. Staff B confirmed the appointment should have been made by now but was not. Staff B acknowledged the resident had lost a significant amount of weight. Resident 213 A 02/07/2022 Admission MDS showed Resident 213 was admitted to the facility on [DATE]. Resident 213 had an admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 213 was assessed to be developmentally delayed, was able to make own decisions, could understand others, and make self understood. In observations on 02/01/2022 at 9:43 AM, 02/02/2022 at 12:46 PM, 02/03/2022 at 2:43 PM and 02/07/2022 at 10:33 AM Resident 213 was in bed with cups of fluid on the bedside table. In an interview on 02/03/2022 at 2:43 PM Resident 213 stated I can have whatever I want to drink, don't tell me what I can and cannot have. A 01/31/2022 PO showed Resident 213 was on a fluid restriction of 2000 cubic centimeters (cc) per day with the schedule for dietary to provide 1440 cc per day, nursing to provide 560 cc per day. The nursing schedule for fluids showed day shift to provide 200 cc per shift, evening to provide 200 cc per shift and night to provide 160 cc per shift. The PO showed night shift was directed to review meal fluid intake and nursing fluid intake and calculate the 24-hour total fluid intake daily to evaluate and ensure the total intake was less than 2000 cc. Review of the 02/2022 fluid with meals intake log showed on 02/01/2022 breakfast was blank, lunch was blank, and dinner was 300 cc. Documentation for 02/02/2022 showed breakfast was blank, lunch was 480 cc, dinner was 400 cc; a total of 880 cc. Similar blanks in documentation were found on 02/03/2022, 02/04/2022, and 02/07/2022. Review of the 02/2022 Medication Administration Record (MAR) showed daily fluid cc totals for each shift. On 02/01/2022 day shift recorded 480 cc fluid intake; evening shift recorded 200 cc fluid intake; night shift recorded 160 cc intake, a 24-hour total of 840 cc. Documentation for 02/02/2022 showed day shift was blank; evening shift recorded 160 cc; night shift recorded 200 cc, a total of 360 cc in 24 hours. The 02/2022 MAR showed 24-hour night shift totals for 02/01/2022 were 160 cc instead of 1140 cc. On 02/02/2022 night shift documented 160 cc instead of 1240 cc. Similar findings on 02/03/2022 thru 02/06/2022 showed the 24-hour total recorded was the same as the night shift intake and not the complete 24-hour calculation. In an interview on 02/07/2022 at 11:37 AM, Staff J reviewed the 24-hour documentation on the MAR and stated the night nurse is expected to collect the amount from fluid intake at meals and the nursing shift intake and record the 24-hour total. Staff J stated there should be no blanks on the fluid intake for meals or for the nursing shift intake documentation. Staff J stated the staff is expected to document all fluid intake at all meals and all shifts. Staff J stated Resident 213 should not have fluids at the bedside because the fluids would not be able to be monitored and recorded. Staff J stated the night nurse was not completing a 24-hour totals and thus nurses could not determine if the fluid restriction was being followed according to the PO. Resident 42 According to the 1/12/2022 Quarterly MDS, Resident 42 was admitted to the facility on [DATE]. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PO's showed a 06/28/2021 PO for [MEDICATION(S)] (diuretic) 40 milligrams twice daily. Review of the resident's records showed Resident 42 had a weight gain of 10.5 Lbs. from 01/05/2022 at 201.8 Lbs. to 01/11/2022 at 212.3 Lbs. Review of Resident 42's weight record showed no reweight was documented within the next 24 hours as per the facility weight policy. Review of Resident 42's 01/04/2022 through 01/15/2022 progress notes showed no documentation nurses notified the physician about this weight gain. In an interview on 2/8/2022 at 12:04 PM Staff N (Resident Care Manager) stated the expectation is the nurse should re-weigh the resident and the weight change confirmed. The nurse should assess the resident, notify the physician, the nurse manager and the dietitian. Staff N acknowledged that staff should have reweighed the resident and notified the provider, but they did not. Resident 21 According to the 12/21/2021 Admission MDS Resident 21 admitted to the facility on [DATE] with multiple medically complex diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS showed Resident 21 had severe cognitive impairment and required physical assistance from staff for eating. Observations on 02/02/2022 at 2:04 PM showed Resident 21 consumed 25% of their lunch. On 02/03/2022 at 9:10 AM Resident 21's breakfast tray was sitting on an overbed table off to right side of bed. At this time Resident 21 was lying in bed asleep. Observation on 02/03/2022 at 9:53 AM, showed Resident 21's food remained untouched and was sitting on a cart in hallway. Review of the 12/22/2021 nutritional status Care Area Assessment (CAA) indicated .RD [Registered Dietician] to evaluate and recommend as indicated. Weekly weights are performed to assess for any new weight loss/gain and followed up as indicated. Nursing to continue to assist resident as needed. Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A nutrition risk CP initiated on 12/27/2021 revealed a goal of no unplanned significant weight loss or gain and directed staff to, weigh per center protocol. Review of weight records showed staff assessed Resident 21 with the following weights: 206 Lbs (12/15/2021); 193 Lbs (12/31/2021); 193.2 Lbs (01/01/2022); and 195.6 Lbs (01/11/2022). A 01/05/2022 Nutrition note evaluation completed by the RD showed Resident 21 was reviewed for a significant weight loss and the resident was at increased risk for decreased appetite/ intake. This evaluation indicated the plan was to notify provider, responsible party and to monitor weight and intake by mouth. Progress note by nursing staff dated 01/07/2022 showed that Resident 21 was identified with a .significant weight loss of 6.2% within one month . and indicated that the resident was at risk for decreased appetite/intake. Review of Resident 21's meal intake records showed no documentation as to how much the resident consumed for meals since 01/31/2022 until dinner on 02/03/2022, a full eight consecutive meals later. Similar findings of missing meal documentation were noted on 01/17/2022, 01/18/2022, 01/21/2022, 01/30/2022, 02/07/2022 and 02/08/2022. In an interview on 02/10/2022 at 1:55 PM, Staff N stated staff should be following the facility policy regarding weights and confirmed Resident 21 was not placed on weekly weights. Staff N stated their expectation was that staff document meal intake after each meal and the documentation accurately reflects the resident's intake. Staff N verified Resident 21 had missing meal documentation and indicated it would be hard to assess a resident's nutritional status without having all the data. REFERENCE: WAC 388-97-1060(3)(h).

Based on observation, interview and record review, the facility failed to prevent the development and/or worsening of pressure ulcers (PUs) for one supplemental resident (Resident 44) reviewed for PUs and 1 (Resident 27) of 4 sample residents. Failure to monitor, obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Included . According to the National Pressure Injury Advisory Panel (NPIAP) a Stage 2 pressure injury is defined as partial-thickness skin loss with exposed dermis (the inner layer of two layers of skin) and no granulation (a type of skin tissue indicative of healing), slough (yellow/white material in the wound bed), or eschar (dead tissue) present. A Stage 3 pressure injury is defined as full-thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be present. A Suspected Deep Tissue Injury (SDTI) is defined as persistent non-blanchable (the skin does not turn white when touched with a finger) deep red, maroon or purple discoloration in intact or non-intact skin. A SDTI results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Facility Policy According to the Facility's August 2009 Skin Integrity Policy (updated May 2019), a nurse should conduct a skin evaluation at admission, weekly for 3 weeks, annually, and with a change in condition. The policy stated the facility used the Braden Scale (a standardized tool, used to predict PU risk) for the assessment. The nurse should develop a care plan (CP) based on risk factors in an effort to limit their potential effects. Resident 44 According to the 01/31/2021 Medicare 5 Day Minimum Data Set (MDS-an assessment tool), the resident was readmitted from a local hospital on 01/24/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed the resident was at risk for developing pressure ulcers (PU), had one unstageable PU to the sacrum during the assessment period, and required pressure ulcer/injury care. Review of a 01/24/2022 Nursing Re-admission assessment completed by Staff U (Licensed Practical Nurse-LPN) showed the resident had a stage 2 pressure ulcer to the coccyx (tail bone) that measured 6 centimeters (cm) by 4.5 cm on re-admission from the hospital, with no purple or maroon discoloration surrounding the wound. The resident had a surgical wound to their right lower leg, and no other alterations in skin integrity were identified, including the heels. Staff U assessed the resident's bi-lateral pedal pulses (method of checking circulation to the extremity) as palpable (present), indicating circulation. According to a 01/24/2022 Braden Assessment, the facility assessed the resident to be at a high risk for PU development due to alterations in nutrition, incontinence of bladder and bowel, and problems with friction and shear due to the resident requiring frequent extensive assistance with repositioning. Review of a 06/14/2021 Baseline CP, showed staff were directed to elevate the resident's heels and to turn or reposition frequently. A 10/11/2021 Diabetes CP directed staff to inspect the resident's feet daily for open areas, sores, pressure areas, [CONDITION(S)], or redness. A 06/15/2021 Skin Integrity CP directed staff to identify and document potential PU causative factors and to eliminate them where possible. The facility identified poor appetite and limited mobility as possible causative factors for potential PU development. During an interview on 02/09/2022 at 5:32 PM, Staff J (Facility Wound Nurse, LPN) stated Resident 44 was not seen by the wound provider until 02/03/2022 and should have been seen on weekly wound rounds on 01/28/2022. Review of a 02/03/2022 note from a community wound provider showed the resident had a sacral (bone at the base of the spine) PU that measured 4.7 cm by 6.3 cm and had 100% eplithelialization tissue (process of new skin covering the wound) with scant (small) amount of clear drainage. Additional notes showed the wound had a purple maroon discoloration with partial thickness skin breakdown. The assessment concluded the resident had a pressure induced deep tissue damage of the sacral region and recommended a [MEDICATION(S)] dressing (creates a moist wound environment that promotes healing) to be changed every 3 days. Additional orders included to relieve pressure by repositioning and adding a low air loss mattress. The purple maroon discoloration was not observed on the 01/224/2022 admission skin assessment. Observations on 02/02/2022 at 10:20 AM showed Resident 44 was lying in bed on their back, in a gown with their heels resting on the mattress. Observations on 02/04/2022 at 11:55 AM showed Resident 44 was lying in bed on their back in a gown with their heels resting on the mattress, the resident had used the bed controls to raise the foot of the bed. On 02/07/2022 at 10:35 AM Resident 44 was observed lying in bed, on their back with their heels resting on the mattress. No positioning pillows were observed in the room or being used to float the resident's heels, to keep them off the mattress. At 1:02 PM the resident remained in their bed, lying on their back with their heels resting on the mattress. At 1:31 PM the resident remained in the same position lying on their back in bed, with their heels resting on the mattress. In an interview at this time, Resident 44 stated they didn't get out of bed. When asked why, the resident replied they were cold and had no clothes to put on. Observations on 02/08/2022 at 11:23 AM showed Resident 44 was sleeping in bed on their back, the bed was flat. At 12:20 PM the resident was observed in the same position, with their heels resting on the bed. No positioning pillows were observed in the room. At 12:51 PM the resident had lunch served, the resident raised the head of the bed (HOB) and stated they didn't want pureed food and put the hob down and turned the call light on. At 12:57 PM the resident spoke with a staff member and lowered their bed in a flat position, the resident was observed lying on their back with their heels resting on the mattress. At 1:22 PM the resident was observed lying in bed with the HOB slightly elevated, with their heels resting on the mattress, enjoying their sandwich. On 02/09/2022 at 11:25 AM Resident 44 was observed lying on their back in bed with their left heel resting on the mattress and the right leg resting on a pillow. At this time Staff J and Staff I (Resident Care Manager-LPN) were asked to provide wound care to the resident's sacrum and right lower leg. Staff I removed the dressing from the resident's sacrum, the skin was observed with open areas in the center surrounding tissue purple/maroon in color. Staff J stated the wound had changed, the wound bed was 90% slough and 10% epithelialization tissue (process of covering open wound) Staff J was asked to remove the resident's socks to look at their heels. A purple round area was observed to the resident's left heel. Staff J stated the area to the left heel was nonblanchable and was a suspected deep tissue injury (SDTI- purple area of discolored intact skin due to damage of underlying tissue from pressure or shearing). Resident 44 was observed to be grimacing and moaning in pain when turned during the wound dressing change to their sacrum. In an interview on 02/09/2022 at 4:15 PM Staff J stated today was the first time they noticed the wound was worsening and the typical process for a newly admitted resident with a wound was they place a referral to a wound provider and Staff J would review the skin assessments and assist with staging the wound. Staff J acknowledged they did not follow up with the wound after admission. In an interview on 02/09/2021 at 4:15 PM Staff B (Director of Nursing) stated the resident had poor nutrition, poor appetite, and refusals which they believed contributed to the resident developing PU's and they would expect PU prevention to include turning/repositioning the resident, floating or offloading the heels, increased hydration, and offering alternatives to meals if refused. Staff B stated Resident 44 was refusing the heel wedge. Review of Resident 44's behavior monitoring for January 2022 and February 1st-11th 2022 showed staff had documented no refusals of care. On 02/10/2022 at 9:20 AM Resident 44 was observed lying in bed on their back with their heels resting on the mattress . A wedge (used to elevate heels) was observed for the first time in 7 days lying in the resident's wheelchair, the wedge was not being utilized as ordered . Similar observations were made on 02/10/2022 at 2:18 PM. Resident 27 According to the 01/31/2022 Significant Change MDS, Resident 27 readmitted to the facility from a local acute hospital on 01/18/2022, was identified to be at risk for PUs, and did not have any unhealed PUs. The MDS assessed Resident 27 to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a 01/18/2022 progress note, Resident 27 was noted to have open areas (consistent with PUs) on both buttocks. Review of a 01/18/2022 skin assessment showed Resident 27's had a non-pressure ulcer on their left buttock measuring 3.7 by 4 centimeters (cm). Resident 27's right buttock was assessed as a non-pressure ulcer measuring 7.5 by 8 cm. In a 01/19/2022 progress note, Staff B wrote Resident 27 had open areas to their bilateral buttocks that were developed in the hospital. A progress note on 01/19/2022 by Staff D (Licensed Practical Nurse - LPN) showed Resident 27 had an open area on their right bottom. According to a 1/20/2022 Interdisciplinary Team (IDT - a team consisting of department managers that oversee resident care issues) progress note, Resident 27 was assessed by a wound specialist on 01/20/2022 and found to have a Stage 2 PU on their right buttock and a Stage 3 PU on their left buttock, developed during their hospital stay prior to readmission. Facility documentation did not address the discrepancy between this assessment of PUs on 1/20/2022 by the wound specialist with the 1/18/2022 description of non-pressure skin. According to a note from a 01/20/2022 encounter with an outside provider specializing in wound treatment, Resident 27 developed a Stage 3 PU on their left buttock, and a Stage 2 PU on their right buttock while hospitalized with a [CONDITION(S)]. According to the 01/20/2022 Facility weekly skin assessment, Resident 27's left buttock PU was assessed to have healed/resolved, and the right buttock was assessed to have healed/resolved, just 2 days after it was identified on admission on 01/18/2022. Record review revealed Resident 27 had a weekly skin assessment on 1/25/2022 that did not address the bi-lateral buttocks pressure ulcers, and also revealed that staff did not complete another weekly skin assessment until 02/08/2021 when an abrasion on the resident's head was assessed. Resident 27's pressure ulcer areas were assessed via weekly skin assessment on 02/09/2021. This assessment showed the resident with an open area on their left buttock measuring 1 x 1 cm with no depth. On 02/07/2022 at 9:25 AM during the provision of toilet care, Resident 27 was observed with zinc lotion applied to their buttocks, and to have a foam dressing partially covering both buttocks. Staff D removed the dressing and an open area was visible on Resident 27's left buttock. Review of Resident 27's PO revealed a 1/18/2022 order for Zinc Oxide to both buttocks and no order for a foam dressing. Review of Resident 27's comprehensive CP revealed there was not a CP to address their PUs. On 02/10/2022 at 10:18 AM, Staff J was observed providing wound care to Resident 27. Staff D stated Resident 27's left buttock wound was covered in slough with redness around the edge of the wound, and measured 3 cm x 1.3 cm. The soiled dressing was observed to have yellow drainage. In an interview on 02/10/2022 at 12:01 PM, Staff B stated Resident 27 readmitted with pressure ulcers on both buttocks, that both PUs healed, and since reopened. Staff B stated the Resident was not placed on alert charting for PUs, and the facility did develop a CP to address PUs. Staff B stated the PUs were not identified on The Resident's Baseline CP (an acute CP required to be developed within 48 hours of admission/readmission to a nursing home) and there were no orders to treat the PU. According to the 02/10/2022 wound provider paperwork, on 2/9/2022 Resident 27's left buttock wound had deteriorated and measured 2.0 x 1.0 x 0.2 cm. REFER to F- 692 Nutrition REFERENCE: WAC 388-97-1060(3)(b).

Based on observation, interview, and record review the facility failed to ensure residents were supervised and had resident-specific interventions implemented to prevent falls for 2 (Residents 206 & 39) of 11 sampled residents and 1 (Resident 12) supplemental resident reviewed for falls. The facility failed to ensure the environment remained free of accident hazards, including unsecured hazardous chemicals. These failures placed residents at risk of falling, injury, change of condition, and accidental ingestion of and/or exposure to cleaning chemicals. The failure to supervise and implement resident-specific fall interventions resulted in harm when Resident 206 sustained a significant head injury from an actual fall which required a transfer to the emergency room (ER). Findings included . Resident 206 Resident 206 was admitted to the facility on [DATE]. The 01/21/2022 hospital discharge documents showed Resident 206 had multiple diagnoses including an irregular heart rate, heart failure, [CONDITION(S)], [CONDITION(S)] (sight impairment), depression, anxiety, and Alzheimer's dementia. The hospital document showed Resident 206 was demonstrating a behavior of sundowning (increased confusion in the late afternoon and spanning into the night that could lead to pacing and wandering). Resident 206 was prescribed an antianxiety medication, a narcotic pain medication, and blood thinning medication upon discharge. A review of a 03/2018 facility policy titled Fall Evaluation and Management showed the nurse will complete a Morse Scale (a fall assessment) on admission, if the score is greater than 45, the resident is considered as having a high potential for falls. The policy instructed the nurse to implement appropriate Care Plan (CP) interventions for fall management. A review of the facility's 01/21/2022 Morse Scale for Resident 206 showed a score of 50. Staff assessed Resident 206 as a high risk for falls. This assessment showed Resident 206 had a history of falling, needed an ambulatory aid, had weakness while walking, and was not oriented to the time of day or their current location. A review of the facility's 01/21/2022 Brief Interview for Mental Status (BIMS- a cognition assessment) showed Resident 206 had severe cognitive impairment. The assessment showed Resident 206 could not retain information, could not learn new information, and was not able to problem solve for decision making. A review of the facility's 01/21/2022 nursing admission assessment showed Resident 206 had impaired vision and wore glasses, was incontinent of bladder and bowels, had impaired balance, and was assessed to require extensive assistance with mobility, transfers, standing, toileting, and hygiene. A review of the 01/21/2022 baseline CP showed Resident 206 was confused and forgetful, oriented to self only and did not know where they were, and could not recognize the time of day. The resident was incontinent of urine and bowels and needed assistance from staff to use the bathroom. The resident needed assistance from staff with all mobility, including bed mobility, transfers, and used a wheelchair for ambulation. The resident wore glasses for vision loss. Resident 206 required two staff for assistance with ambulation and bed mobility and one staff with extensive assistance for toileting and transfers. The resident had pain and staff was instructed to monitor pain and report to the nurse. The care plan specifically stated SAFETY: History of falls. The CP did not provide any resident-specific interventions to the staff on how to prevent Resident 206 from falling. A 01/21/2022 3:48 PM nurse admission progress note showed Resident 206 was taught how to use the call light, bed remote and television remote. The progress note stated Resident 206 was unable to demonstrate back how to use these devices. The resident did not know how to call staff for help using the call light. A 01/22/2022 8:16 AM progress note showed at 3:30 AM (approximately 14 hours after the resident arrived at the facility) Resident 206 fell . The resident was lying on the floor in the hallway, not wearing any clothes, with a large bump on the left forehead from the resident's head hitting the floor. The progress note described Resident 206 as confused, restless, had undressed, and walked to the hallway without assistance. Staff was not able to identify why Resident 206 got up from bed in the middle of the night. Resident 206 was reassessed at the time of the fall to have poor safety awareness, unsteady gait, and poor balance which contributed to the fall. Resident 206 was sent to the ER for further medical evaluation. A head Computerized Tomography (CT-a diagnostic test) scan was taken related to the use of blood thinners (and risk of internal bleeding from the head injury). A 01/22/2022 1:38 PM nurse progress note showed Resident 206 returned to the facility five hours later. In an observation and interview on 02/01/2022 at 2:05 PM (10 days after the fall), showed Resident 206 in a room next to the nursing station, sleeping in an extra low bed against the wall with a fall mat on the floor next to the bed. The resident had a large, raised, purple hematoma (swelling from blood and inflammation under the skin) the size of an egg on the left forehead. The left side of the resident's face and eye was purple, blue, and yellow from bruising. There was an abrasion (sheared skin) on the surface of the hematoma. The resident awoke and was not able to explain what happened to their face. The resident touched their forehead and asked what happened and stated the hematoma area was tender but they did not have a headache. In an interview on 02/01/2022 at 2:08 PM, Resident 206's collateral contact stated each time the resident visited the hospital, they showed another decline in function. The person stated the recent fall and visit to the ER set the resident back farther from being able to return home with their spouse. The person stated the fall situation was discouraging to the family and it was traumatic to Resident 206. In an interview on 02/10/2022 at 11:49 AM, Staff J (Resident Care Manager) stated all residents were assessed for fall risk on admission and basic fall precautions were in place including, basic items, and call light within reach, bed at lowest height, anticipate resident needs, provide toileting, and other care needs. Staff J stated the nurse was expected to identify the level of fall risk and put interventions in place right away including a toileting plan. Staff J stated when a resident was a high fall risk, the facility usually implemented a low bed, placed the bed against the wall, placed mats on the floor, had a routine toileting plan, and chose a room near the nurse's station to keep the resident in the line of sight for the staff. Staff J reviewed the CP and stated there was no fall risk interventions or a toileting plan to direct staff to provide specific interventions for Resident 206 according to the assessed needs. Staff J stated the information should have been on the CP, but it was missed. In an interview on 02/09/2022 at 1:00 PM, Staff B (Director of Nursing) stated after the fall, Resident 206 was moved near the nursing station for direct line of sight monitoring, received a low bed against the wall, mat on the floor, and was up at the nurse's station when awake for extra supervision. Staff B acknowledged the resident needed extra interventions for prevention of falls at the time of admission and stated the CP for Resident 206 did not have specific interventions to keep the resident safe from falling. Staff B stated the staff followed the standard fall interventions, but the resident-specific fall interventions were not on the care plan. Resident 12 Resident 12 admitted to the facility on [DATE]. According to the 12/01/2021 Quarterly MDS, the resident was cognitively intact, had a diagnosis of [CONDITION(S)], required continuous supplemental oxygen, was independent with activities of daily living (ADLs) including walking (with the use of a four wheeled walker) and sustained one fall since the prior assessment. During an interview on 02/04/2022 at 11:43 AM, Resident 12 stated they fell a couple of months ago while walking to the bathroom. The resident reported My legs gave out .they just got weak, so I lowered myself to the floor in the doorway of the bathroom. The resident indicated they were unable to self-recover and staff came to assist them off the floor. Review of the facility's incident log showed a 11/18/2021 entry for Resident 12. Review of the investigative documents showed the resident was found sitting on the floor in the doorway of the bathroom. According to the investigation the resident reported their legs became weak and gave out resulting in the resident lowering themselves to the floor. The resident denied any dizziness or lightheadedness preceding the fall and was assessed without injury. The facility requested the pharmacist perform a medication review to determine if the resident current medication regimen could be contributing to the resident's weakness and/or falls. According to the 11/22/2021 Interim Medication Regimen Review, the pharmacist assessed the resident was utilizing their PRN (as needed) Benadryl (an antihistamine) almost every night [which] may increase fall risk. The pharmacist recommended the Benadryl be discontinued and replaced with PRN Cetirizine (a less sedating antihistamine). Review of the November 2021 Medication Administration Record (MAR) showed on 11/23/2021, Resident 12's Benadryl was discontinued, and the PRN Cetirizine was initiated as recommended. However, the MAR showed on 11/29/2021 the Cetirizine was discontinued, and the Benadryl reinstated. Record review showed no documentation or indication why the change was made to the medication orders. Record review showed on 12/15/2021 an order was obtained to re-start Cetirizine daily, but no order was given to discontinue PRN Benadryl . Review of the December 2021 MAR from 12/15/2021-12/31/2021 showed the resident received both the Cetirizine and Benadryl on 14 of 17 days. Instead of providing an antihistamine whose adverse side effects caused less disorientation and sedation, as recommended by the pharmacist, to decrease the resident's risk for falls, the resident was actually provided two antihistamines increasing the risk for sedation, disorientation and falls. In an interview on 02/10/2022 at 11:03 AM, Staff C (Advanced Registered Nurse Practitioner) indicated once the 12/15/2021 order for Cetirizine was implemented, the PRN Benadryl order should have been discontinued. Resident 39 According to the 1/6/2022 Quarterly MDS, Resident 39 was assessed with moderate cognitive impairment, and diagnoses including right side [CONDITION(S)] (one-sided paralysis after a brain bleed), coronary artery disease, heart failure, muscle weakness, and arthritis. The MDS assessed Resident 39 to require extensive assistance with bed mobility, dressing, and toilet use. Resident 39's 10/18/2021 Actual Fall With Minor Injury CP included interventions for the bed to be placed against the wall to prevent rolling out of bed, the bed to be in its lowest position and a floor mat to prevent injuries. Resident 39's 10/18/2021 Refusals CP stated Resident 39 preferred to have their bed in a high position, and that the risks and benefits were explained. On 02/03/2022 at 09:17 AM, Resident 39 was observed in bed, with the bed in high position, with only the head of the bed against the wall, and no fall mats in place. On 02/07/2022 at 08:35 AM, Resident 39 was observed in bed with the bed in high position, with only the head of the bed against the wall, and no fall mats in place. On 02/08/2022 at 09:13 AM, Resident 39 was observed in bed with the bed in high position, with only the head of the bed against the wall, and no fall mats in place. In an interview on 02/09/2022 at 12:34 PM, Staff N (Resident Care Manager) stated Resident 39's CP was not clear regarding fall prevention and needed to be updated. Staff N stated fall mats should have been but were not in place to prevent injury in the event of a fall by Resident 39. Facility During observational rounds on 02/01/2022 at 12:28 PM, the room with a sign Floor Care was unlocked. A spray bottle with a brown chemical was hanging by the spray trigger at eye level, and reachable to residents. The Floor Care room was observed unlocked again on 02/02/2022 at 08:48 AM, on 02/02/2022 at 09:13 AM, and on 02/03/2022 at 08:14 AM. In an interview on 02/03/2022 at 10:45 AM, Staff Q (Maintenance) stated the Floor Care room was not, but should always be locked, and the facility struggled to get the staff to lock the door as required. Refer to F609 Reporting of Alleged Violations. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to adequately treat severe breakthrough pain for 1 (Resident 1) of 3 residents reviewed for pain management. The staff identified that Resident 1 did not respond to pain medications or non-pharmacological interventions, and failed to notify the physician and request additional pain management interventions. This failure caused Resident 1 to experience severe breakthrough pain and emotional distress for a period of over 4 hours. Findings included . Review of a 06/2016 Pain Management Policy and Procedure showed that staff evaluated and treated resident's pain levels every shift. This policy showed that when pain was not adequately controlled by the current pain regimen, that the nurse would contact the doctor for consideration of new or modified treatment orders. In an interview on 01/25/2022 at 12:50 PM, Staff B, Director of Nursing, stated that the staff used a Numerical Pain Rating Scale (NPRS) to assess the pain of alert and oriented residents. The NPRS is a subjective measure in which the residents rated their pain on an eleven-point numerical scale (e.g., 0 for no pain, 1 to 3 for mild pain, 4 to 6 for moderate pain, 7 to 9 for severe pain, and 10 for the worst possible pain). Review of a 12/14/2021 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 readmitted to the facility on [DATE] with medically complex conditions, to include cancer of the larynx (voice box), stroke, paralysis and stiffness from a stroke, and pain. This MDS showed that the staff assessed Resident 1 was cognitively intact. Review of an 11/25/2021 Care Area Assessment Worksheet showed that Resident 1's pain was mostly on the neck and lower body. This worksheet stated that staff would refer to the physician as needed for any issues with pain. Review of a Pain Evaluation dated 12/07/2021 showed that staff assessed Resident 1 experienced burning and aching pain to an open area to the bottom of the spine. This evaluation showed that Resident 1's pain affected their independence, quality of life, Activities of Daily Living, and sleep. Review of Resident 1's December 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications available for breakthrough pain included Tylenol 650 milligrams (mg) every four hours as needed for general pain and Oxycodone (an opioid) 5 mg every six hours as needed for severe pain. [MEDICATION(S)] 1000 mg was prescribed every six hours as needed for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A Collateral Contact interviewed on 01/18/2022 at 12:13 PM, stated that Resident 1 went 12 hours without their pain medication and complained of a lot of pain. The Collateral Contact stated that they could not remove the memory of hearing Resident 1 scream in pain and calling out their name. Review of a Pain Level Summary showed staff assessed Resident 1 experienced a pain level of 8, or severe pain, at 4:30 PM. Review of a 12/16/2021 progress note showed that staff administered the as needed Oxycodone 5 mg for severe pain at 4:30 PM. The 12/16/2021 progress notes showed that staff assessed Resident 1's pain level at 7:46 PM (3.5 hours later), and identified it remained at an 8, and that Resident 1 told the staff that, The medication only helped for about an hour. The staff then administered the as needed Tylenol 650 mg prescribed for general pain at 7:46 PM. Tylenol is commonly used to treat headaches, and other common aches and pains, not severe pain. Review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff documented in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At 10:05 PM on 12/16/2021, two hours later, the Pain Level Summary showed that staff followed-up on Resident 1's pain level and assessed that it remained at an 8, or severe. Review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/16/2021 progress note at 11:58 PM showed that staff acknowledged Resident 1's increased episodes of pain and discomfort, observed Resident 1 crying and yelling out intermittently throughout the shift, and the administration with routine and as needed medications had minimal effect. Review of the medical record showed no documentation that staff notified the physician of Resident 1's sustained level of severe pain from 4:30 PM to 10:05 PM, a period of 5.5 hours. The above findings were shared with Staff B, Director of Nursing, on 01/24/2021 at 12:31 PM. Staff B stated that, As a nurse when you evaluate relentless pain, you have to exhaust all the pain meds and, if not working, call the doctor for further management. Staff B stated that the staff should have, but failed to, call the provider for more aggressive pain management, the evening of 12/16/2021 for the unabated severe pain. Resident 1 discharged on [DATE]. Reference WAC 388-97-1060(1).

Based on observation, interview and record review, the facility failed to prevent and/or contain COVID-19 (Coronavirus - a contagious disease) by not recognizing their own breech in infection control practices and not implementing the plans the facility developed. This failure prevented the facility from decreasing the spread of [MEDICAL CONDITION], and resulted in 61 residents (Resident #,[DATE] and 62 and 64) becoming positive for [MEDICAL CONDITION] and six residents (Resident 1, 2, 3, 7, 45, 64) becoming egregiously ill resulting in their deaths, in a span of 15 days. In addition, the facility failed to ensure a communicable disease/outbreak was reported to the Department of Social and Human Services (DSHS - a State Agency) within the required timeframe. Failure to complete required reporting of 59 COVID-19 (Coronavirus - a contagious disease) positive resident cases and 30 facility staff, prevented the state agency from being aware, and investigate circumstances surrounding the COVID-19 infections and/or death. On [DATE], the facility was notified of an Immediate Jeopardy related to Infection Control. On [DATE], the validation of the IJ removal for [DATE] occurred through observations, review of records, including staff education, audits, visitor screening logs, policies and procedures, and medical records. Findings included . INFECTION CONTROL As early as March of 2020 the Center for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) were advising healthcare providers to instruct their patients, and citizens of the United States at large, to stay home if they felt ill related to a developing [MEDICAL CONDITION] pandemic. According to the CDC, the quarantine of persons who had been in close contact with someone who had or potentially had COVID-19, for a period of 14 days, was an effective stratagem for preventing the spread of [MEDICAL CONDITION]. According to the facility's [DATE] COVID-19 policy, there was no instruction to staff on how to prevent the spread of the COVID-19 virus when residents and staff, were exposed to staff that were identified as being positive for the COVID-19 virus. STAFF D A [DATE] email from Staff A included, .Staff (D) called [DATE] notifying (the facility) that (Staff D) had (symptoms of COVID-19) .(could be related to weight loss medication). Review of the [DATE] COVID-19 Strategy Plan showed Staff D was exposed to persons who were ill four to five days before experiencing symptoms of [MEDICAL CONDITION]. According to the CMS Respiratory Line Listing Staff D, was tested for the presence of COVID-19 on [DATE]. The facility recommended this staff stay home for the day and observe for additional symptoms. By [DATE] Staff D had no symptoms, so the facility presumed the initial reporting of symptoms was related to something other than [MEDICAL CONDITION] and Staff D was allowed to return to work. Staff D did so, for at least two hours, before test results were known, during which time Staff D had close contact with Staff G (who tested positive on [DATE]). Staff D's test results came back positive for [MEDICAL CONDITION] on [DATE]. According to a [DATE] updated National Center for Immunization and Respiratory Diseases document provided by the facility, any HCP (Health Care Provider) who develop fever or symptoms consistent with COVID-19, . should not report to work when ill, and undergo active screening for fever or symptoms . According to [DATE] infection control surveillance documentation Staff D, Nurse, was tested positive on [DATE] and was identified as having the COVID-19 virus. Staff G, Nurse, tested positive for the COVID-19 virus on [DATE] according to the same documentation, and after direct exposure to Staff D. Other staff continued to develop [MEDICAL CONDITION]. In a separate COVID-19 incident Staff E and F, Certified Nursing Assistants, were exposed to [MEDICAL CONDITION] outside of the work environment and worked after their exposure until tested and positive for [MEDICAL CONDITION] on [DATE]. According to the surveillance data at least eleven residents were directly exposed to the COVID-19 virus by Staff D. Residents #'s 2, 10, 11, 12, 14, 27, 28, 32, 34, 35, and 64. Ultimately 61 Residents were found to be positive for the COVID-19 Virus. Residents 1 and 2 died shortly after being diagnosed with [REDACTED].#s 7, 64, 45, 62, died within the following 14 days. A total of six residents died . Staff B, Director of Nursing, and Staff C, Infection Preventionist, stated, in an interview on [DATE], at 11:15 AM, that Staff D exposed other staff and residents to [MEDICAL CONDITION]. When asked if the staff and residents were quarantined after being exposed, Staff B, stated no. Staff C stated in the same interview that the facility did not quarantine staff or residents, because it was a weekend when the information was obtained. No isolation or quarantine happened until three days after Staff D was initially identified as being positive and had exposed staff and residents. SCREENING VISITORS AND WEARING RECOMMENDED PERSONAL PROTECTIVE EQUIPMENT On [DATE] at 4:10 AM, the surveyor entered the facility through an unsecured door and into the Yellow Zone of the facility. The Yellow Zone was a unit where suspected COVID-19 residents resided. The surveyor was not screened by Staff H, Nurse, during the interaction. When asked who screened visitors/staff, Staff H stated the person who performed the screening arrived at 5:00 AM. Staff H did not screen or question the surveyor to verify if the surveyor was screened. When asked, Staff H directed the surveyor to exit the building and go around the building to enter the COVID-19 Unit. The surveyor entered the COVID-19 Unit through another unsecured door. Upon entry and to the surveyor's immediate right, Staff I, Certified Nursing Assistant (CNA), was observed to provide care to a resident with their lower torso exposed. On this same hallway, the surveyor observed the door of the staff breakroom open, and a sign next to the breakroom that instructed staff to keep the door closed. The door to the breakroom remained open during the entire surveyor's presence, approximately 15 minutes. The surveyor continued to walk down the hallway, unscreened, and made a right to another hallway, wherein three staff members passed the surveyor and did not question the surveyor as to who they were, or if the surveyor had been screened. The surveyor returned back to the initial hallway of entry and encountered Staff I, Certified Nursing Assistant, outside the room where he had just provided care. Staff I was observed to wear a face shield and a surgical mask under the face shield. When asked why he was wearing a surgical mask instead of an N95 in a positive area of the building, Staff I stated he did not have any of those masks on his side of the unit. When the surveyor asked Staff J why Staff I was not wearing an N95 mask, Staff J stated, He should have one on. An observation of the supply cart, identified by Staff J, showed available KN95 masks were in supply. Review of the the CMS Respiratory Line List, showed Staff I was identified by the facility as being COVID positive, and had not been allowed to work for 12 days, from [DATE] until [DATE]. In a follow-up interview on [DATE] at 5:42 AM, Staff K, Activity Director and the designated Screener, said there are screeners in the building from 5:00 AM to 10:00 PM. When asked who screened visitors otherwise, she said the COVID Unit did their own screening entirely, and Yellow Zone did the facility screening after hours. When asked if all doors are locked at night, she said Yes. When asked how do visitors get screened after hours, Staff K replied, One rings the door bell (to the Yellow Zone), the nurse allows them in, and they are screened. When asked if night shift secured the building manually, Staff K said the doors locked up automatically and, to her knowledge, staff couldn't bypass it. During observations on [DATE] there were no observations of screening equipment or screening station observed. The staff in the yellow zone did not screen the surveyor, even though the surveyor identified themself as a surveyor. REPORTING Review of the [DATE] Nursing Home Guidelines - The Purple Book showed the facility must report any communicable disease/outbreak to DSHS hotline within 5 days, and also call the State. According to the facility policy titled Novel [MEDICAL CONDITION] Prevention and Response dated [DATE], the center will communicate and collaborate with state agencies as appropriate and in accordance to CMS (Centers for Medicare and Medicaid Services) regulations. Review of the facility's May through [DATE] infection control data logs showed Staff L, Housekeeper, was positive for the COVID-19 virus in July of 2020. Review of the reporting logs showed the facility did not report this development to the State. Of the more recent November-[DATE] infection control documents, after Staff D was reported as COVID-019 positive [DATE], an entire day after the facility became aware of the results of the testing on [DATE], the facility reported no other staff as having the COVID-19 virus despite having at least 30 facility staff with [MEDICAL CONDITION], Staff E-JJ, from nursing, maintenance, rehabilitation, and the housekeeping departments. Staff D, tested positive [DATE], nine residents tested positive on [DATE], two residents and two staff tested positive on [DATE], five residents tested positive on [DATE]. On [DATE] one facility staff tested positive, one resident died due to COVID-19 and other related comorbidities. Two residents were transferred to emergency room for further management of Covid-19 and non Covid symptoms. On [DATE], 26 residents and seven staff tested positive. By [DATE], 61 residents and 30 staff had acquired the [MEDICAL CONDITION]. Review of facility's November and [DATE] infection control documents showed all Residents #,[DATE], 62, and 64, became positive for [MEDICAL CONDITION]. Residents #'s 1, 7, and 62 died of [MEDICAL CONDITION] while residing in the facility but the state was never made aware that these residents had passed away. Residents #'s 2, 45, and 64 were sent to the hospital because their conditions deteriorated significantly and passed away at the hospital. The State was never made aware this occurred. RESIDENT #3 Review of the facility's perpetual CMS Respiratory Line Listing, showed Resident #3 complained of a sore throat on [DATE], after no apparent exposure to Staff D. There was no data to support, that the facility notified the State's hotline about the resident's symptoms. In an interview on [DATE] at 11:45 AM, Staff B, Director of Nursing stated, the facility only reported the first staff who was positive for the [MEDICAL CONDITION] and not all of the other staff or residents who were identified, as having the contagious COVID-19 virus. In an interview on [DATE] at 3:50 PM, Staff A, Administrator, confirmed that she did not report positive COVID results of the residents and staff to DSHS Complaint Resolution Unit (CRU). Staff A stated, I really thought reporting to Public Health King County and NHSN (National Healthcare Safety Network) would be enough. SURVEILLANCE/ANALYSIS Review of the facility's COVID-19 Policy effective [DATE] and updated [DATE] showed no instruction to staff on how to ensure surveillance of COVID-19 was to be completed or how to analyze data collected during surveillance activities. Review of the facility's [DATE] Surveillance for Infections policy showed staff were instructed to collect and analyze data, to identify trends in infectious diseases, that would permit interventions to control the spread of communicable infectious diseases and prevent future infections. The policy provided the staff with instruction to review facilty changes in process, events or activites that could influence infection control. The undated facility Root Cause Analysis Worksheet, Published in 2015 and updated in [DATE], showed no analysis of data from the facility's present COVID-19 outbreak that began [DATE]. Staff documented on this form, .Main root cause is the surge of COVID-19 cases in the community during the fall and winter season as was expected according to CDC. This fact placed the population at increased risk of COVID-19 exposure and unknowingly become a carrier of [MEDICAL CONDITION] and work in a SNF (Skilled Nursing Facility) setting . There was no entry supporting the behaviors of staff that resulted in staff acquiring COVID-19. Or the facility's response to staff with possible symptoms returning to work. There was no entry to support the facility considered how the staff affected, which residents, or how residents who wandered, might have infected other residents. There was no consideration of sanitation of eating utentsil or dishes, how residents who might have been smoking impacted the spread of [MEDICAL CONDITION]. The form included no specific facility data that would support an analysis of any variable was performed. In an interveiw on [DATE] at 10:55 AM, Staff B and C stated there was no way the facility was ever going to identify how the COVID-19 virus spread throughout the facility. in an interview on [DATE] at 1:40 PM, Staff A stated the current COVID-19 policy included no instruction to staff on how to analyze data collected during surveillance. See also F-838, Facility Assessment for further details of the lack of planning. REFERENCE: WAC [DATE] (1) (a) (c).

Based on interview and record review, the facility failed to ensure 13 (#s 81, 79, 6, 48, 53, 46, 73, 24, 57, 135, 3, 287, & 64) of 15 residents reviewed for insulin administration received medications appropriately, in accordance with physician's orders [REDACTED]. This failure resulted in an immediate jeopardy situation (IJ) on 4/6/18, related to numerous significant medication errors placing residents at a likelihood of serious harm or death pertaining to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and other complications of diabetes and insulin administration. Findings include: Refer to CFR: 483.21(b)(3)(i), F-658, Services Provided Meet Professional Standards FACILITY POLICY According to the facility's Blood Glucose Monitoring Protocol dated (MONTH) 2004, Blood glucose levels are monitored per physician orders. The physician is notified when levels are below 80 or above 350 unless otherwise specified by physician. This policy clearly indicated, The nurse initiates or obtains orders for blood glucose monitoring from the physician and In the absence of a specific physician order [REDACTED]. The policy further directs staff that, In the event the resident's blood glucose is (less than) 80 mg/dL or the resident exhibits signs/symptoms of [DIAGNOSES REDACTED], the licensed nurse holds insulin or oral anti-diabetic medication and institutes [DIAGNOSES REDACTED] protocol, then notifies the physician. RESIDENT #81 Resident #81 admitted to the facility on [DATE] and according to the Annual 03/27/18 MDS, the resident had [DIAGNOSES REDACTED]. Review of current Physician order [REDACTED]. The SSC directed staff to administer two units of insulin for Blood Sugar (BS) 131-151, four units for BS 151-200, and six units for BS 201-250. In an interview on 04/06/18 at 1:00 p.m. Staff G (Resident Care Manager - RCM) said the routine and sliding scale should be separate orders, not combined into one order. According to the Medication Administration Record [REDACTED]. While there were two directions for insulin administration, regularly scheduled insulin and SSC, to staff in the body of the order, there was only one entry line on the MAR for staff to document what insulin was administered. Although the PO included parameters to notify the MD (Medical Doctor) if BS less than 60, there were no parameters to hold the insulin. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The record was not clear as to if the nurses initials which were documented, indicated the regularly scheduled 4 units were administered, or if no insulin was administered. Review of the (MONTH) (YEAR) MARs revealed staff administered four units of sliding scale insulin on 04/03 at noon for a BS of 130, when no SS insulin was required. Staff administrered four units of insulin on 04/06 at 8:00 a.m. for a BS of 160, and six units on 04/01 at 4:00 p.m. for a BS of 146, on 04/02 at 8:00 a.m. for a BS of 150, on 04/04 at 8:00 a.m. for a BS of 143, and on 04/06 at 12:00 p.m. for a BS of 214. There were no means to determine whether the insulin being administered was combination scheduled and sliding scale. Similar findings were noted in (MONTH) (YEAR) when staff administered varying amounts of insulin, for similar BS readings. For example at 12:00 p.m. on 03/13 staff administered four units for a BS of 97, and on 03/14 no insulin for a BS of 98, and on 03/24 staff administered four units for a BS of 121 and on 03/26 no insulin for a BS of 120. At 8:00 a.m. on 03/29 staff administered four units for a BS of 156 and on 03/30 staff administered six units for a BS of 150. On 03/09 at 12:00 p.m. staff administered six units for a BS of 216 and on 03/30 at 4:00 p.m. staff did not administer any insulin for a BS of 207, and there were no means to determine whether the insulin administered was routine or sliding scale. In addition, there was a 07/21/17 PO for Basaglar KwikPen 20 units SQ one time daily. Staff documented administration in (MONTH) through (MONTH) 06, (YEAR) without documentation of the injection site. RESIDENT #79 A review of the 03/27/18 Quarterly Minimum Data Set (MDS - an assessment tool) revealed, Resident #79 was admitted to the facility on [DATE] with multiple complex medical [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) (YEAR) MARs revealed instructions for Sliding Scale Insulin (SSI) administration that read Humalog insulin . 20 units + SSI (combined order of routine and sliding scale insulin) three times daily starting 03/26/17. The SSI directed staff to administer 5 units for BS 100-150, 8 units for BS 151-200, 10 units for BS 201-250, 12 units for a BS 251-300, 15 units for a BS 301-350, 18 units for a BS 351-400 and 20 units for BS over 401. On 03/01/18 at 4:00 p.m., staff documented the resident had a BS of 119. According to the PO the resident should receive a total of 25 units of insulin, 20 units plus an additional 5 units of SSI, instead staff didn't administer any insulin. On 03/03/18 at 8:00 a.m., staff documented the resident had a blood sugar of 241. According to the PO the resident should have received a total of 30 units of insulin; 20 units plus an additional 10 units of SSI, instead staff administered 28 units of insulin. On 03/20/18 at 8:00 a.m., staff documented the resident had a blood sugar of 230. According to the PO the resident should have received a total of 30 units; 20 units plus an additional 10 units, and instead staff administered 12 units. In an interview on 04/06/18 at 8:44 a.m., Staff G Stated, When I reviewed these orders I have to admit I was confused. Staff G further stated, the nurses should have clarified these insulin orders before administering them. According to Staff G, the routine and SS should have been written as two separate orders to decrease confusion and potential for errors. Similar findings were noted in (MONTH) (YEAR) when staff administered varying amounts of insulin, for similar BS readings. For example, for BSs of 178: on 03/05/18 at 8:00 a.m. staff administered 8 units, whereas on 03/16/18 at 8:00 a.m. and 03/02/18 at 4:00 p.m., staff administered 28 units. In addition, in an interview on 04/06/18 at 8:44 a.m., Staff G said it appeared that some of the licensed nurses documented the total number of units administered and other nurses only documented the amount of SSI insulin administered. Also another nurse failed to document when a dose wasn't administered or if the resident had refused the dose. Staff G stated the best way to write insulin on the MAR indicated [REDACTED]. RESIDENT #6 Review of Resident #6's record revealed a 11/10/17 PO to D/C (discontinue) [MEDICATION NAME] 25 mg QD (every day) and Sliding Scale. [MEDICATION NAME] 25 units SQ BID (twice a day), [MEDICATION NAME] 5 units SQ (subcutaneous) TID (three times a day) with meals, and Hold if BS less than 200. In an interview on 04/06/18 at 01:26 p.m. Staff G said the hold parameters were for the [MEDICATION NAME], not the [MEDICATION NAME]. Review of the current physician orders [REDACTED]. In an interview on 04/06/18 at 1:16 p.m. Staff G said when the order was switched from [MEDICATION NAME] to Humalog the parameters should have been included, but weren't carried over. Review of the MARs revealed staff administered Humalog 5 units for a BS less than 200 in (MONTH) (YEAR) on 25 occasions when it should have been held. In (MONTH) (YEAR), staff administed 5 units of insulin on 38 occasions when it should have been held. In (MONTH) (YEAR), on five of five occasions of a BS below 200, staff administered the 5 units of insulin when it should have been held. RESIDENT #48 Review of Resident #48's current orders revealed the resident had a [DIAGNOSES REDACTED]. Review of the MARs, revealed in (MONTH) (YEAR) staff failed to hold the insulin as ordered, on 03/11 for a BS of 165, 03/20 for a BS of 88, 03/21 for a BS of 80, 03/22 for a BS of 177 and 03/27/18 for a BS of 83. Similar findings were noted on two of six days reviewed in (MONTH) (YEAR) when staff failed to hold the insulin as ordered on 04/01 for a BS of 145 and on 04/05 for a BS of 161. In an interview on 04/11/18 at 9:30 a.m. Staff G confirmed the insulin should have been held as ordered. In addition there was a 02/19/18 PO for Humalog SSI one time daily, which was scheduled for 8:00 a.m. According to the SS staff were to administer four units for a BS 301-350, and five units for a BS of 351-400. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 04/11/18 at 9:30 a.m. Staff G indicated staff should have administered the insulin as ordered. In addition the was a 01/31/18 PO for Humalog SSI one time daily, which was scheduled for 11:30 a.m. and 5:30 p.m. According to the SSI, staff were to administer one unit for a BS of 161-200, two units for a BS of 201-250, four units for a BS 301-350, five units for a BS of 351-400, and if greater than 450 notify MD. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. There was no order for coverage of a BS range between 401-450. Similar findings were noted in (MONTH) (YEAR) when on 03/20 at 11:30 a.m. staff administered eight units rather than four units ordered for a BS of 311, on 03/21 at 11:30 a.m. staff administered six units, rather than the two units ordered for BS of 230, on 03/30 at 11:30 a.m. staff administered four units rather than the five units ordered for a BS of 352, and on 03/31/18 at 11:30 a.m. administered five units rather than the one unit ordered for a BS of 199. Additionally, staff administered five units at 5:30 p.m. on 04/02 for a BS of 450, on 04/03 for a BS of 449, on 03/05 for a BS of 489, on 03/06 for a BS of 440, on 03/09 for a BS of 429, on 03/11 for a BS of 440, on 03/18 for a BS of 407, on 03/24 for a BS of 426, and on 03/25 for a BS of 448. Review of the SSI revealed no ordered insulin dose for BS greater than 401. In an interview on 04/11/18 at 9:30 a.m. Staff G confirmed the nursing staff administered the insulin without a PO, yes. There were no parameter for SSI. RESIDENT #53 Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The SSI orders directed staff for BS of 61-130 = 0 units, 131-150=2 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, 351-999 = 12 units. Note Sliding Scale insulin Blood Sugar < less than) 60 or >(greater than) 350 notify MD. On 03/01/18 at 8:00 p.m., facility staff documented the resident had a BS of 146 and required no insulin however, according to the SSI the resident should have received 2 units of Humalog U-100 insulin. On 03/09/18 at 8:00 p.m., staff documented the resident's blood sugars was 150, Staff didn't administer any insulin, however, the resident should have received 2 units of Humalog insulin. On 03/26/18 at 4:00 p.m., staff documented the resident BS as 177 and should have administered 4 units of Humalog, but staff administered no insulin. On 03/26/18 at 8:00 p.m., staff documented the resident's BS as 170. According to the SSI the resident should have received 4 units of Humalog SSI but staff administered no units of insulin. On 03/06/18 at 8:00 a.m., staff documented the resident's BS was 157 and they administered 2 units of SS insulin however the resident should have received 4 units. On 03/28/18 at noon, staff documented the resident had a BS of 202 and staff administered 4 units of of Humalog instead of the required 6 units. RESIDENT #46 Similar findings were noted for Resident #46 whose record revealed the resident had a [DIAGNOSES REDACTED]. The previous PO of Humalog KwikPen four times daily per SS, was discontinued on 7/2/17. The current SSI orders directed staff to administer two units for a BS 150-200, four units for BS 201-250, and six units for BS 251-300. Review of the MARs revealed on 03/03 at 8:00 a.m. staff administered no insulin, rather than the four units ordered for a BS of 212. on 03/04 at 5:00 p.m. staff administered four units, rather than the two units ordered for a BS of 196, on 03/10 at noon, staff administered eight units, rather than the six units ordered for a BS of 300, and on 04/06 at 8:00 a.m. staff administered two units, rather than the four units ordered for a BS of 220. In addition, On 03/25/18 at 5:00 p.m. the resident's blood sugar was 382. Staff documented Resident's ride here at 1650 (4:50 p.m.), no food yet, insulin held. RESIDENT #73 According to (MONTH) (YEAR) MARs, Resident #73's [DIAGNOSES REDACTED]. On 02/05/18, nursing staff documented that 235 units of insulin was administered for a BS of 235. Record review revealed nursing staff administered 12 units of insulin, when only 10 units was ordered, on 03/25/18. RESIDENT #24 According to the 02/09/18, Quarterly MDS, Resident #24 admitted to the facility on [DATE]. This MDS indicated the resident had [DIAGNOSES REDACTED]. Review of (MONTH) MARs revealed nursing staff administered two units of insulin, rather than four units which was ordered by the physician for a BS of 161 on 02/04/18. On 02/05/18, nursing staff documented the resident had a BS of 19 and received 6 units of insulin. According to POs, there were no directions to staff to administer insulin for BSs of 19. According to (MONTH) (YEAR) MARs, nursing staff documented that the resident's [MEDICATION NAME]for 8:00 a.m. on 02/20/18 was not administered because, resident sleeping. According to (MONTH) (YEAR) MARs, nursing staff held Resident #24's [MEDICATION NAME]on 03/12/18 at 4:00 p.m., because, .did not eat until after 7:00 p.m. Record review revealed no indication nursing staff obtained a physician order [REDACTED]. According to POs dated 04/07/18, nursing staff were directed to administer [MEDICATION NAME]three times a day, including at 4:00 p.m. This medication was directed to be given, with meals, however, the dinner meal was served at 6:00 p.m., considerably after 4:00 p.m. The facility failed to clarify the order time of administration to ensure the insulin was administer with meals. According to (MONTH) (YEAR) MARs, [MEDICATION NAME]was not given on 04/02/18 at 8:00 a.m. because resident did not eat breakfast. There was no indication nursing staff obtained a physician order [REDACTED]. Additionally, observation of medication pass on 04/12/18 at 8:19 a.m. revealed Staff N (LPN) prepared and administered medications to Resident #24. Staff N said the resident's blood sugar taken before 7:30 a.m. was 220. Staff N was observed to dial 15 units of [MEDICATION NAME] and administer in the resident's left arm with an injectable pen. Staff N was observed to draw 10 units of [MEDICATION NAME] from a vial and administer in the resident's right arm subcutaneous with a needle. Review of the POS [REDACTED]. In an interview on 04/12/18 at 08:59 a.m. Staff G reviewed the orders, said oh they are crisscrossed. Upon further questioning, Staff G said it's the same medication, yes, I would expect the orders to be clarified. RESIDENT #57 Record review revealed nursing staff documented the following sites of injections, 156, 4, 2. However, review of the subcutaneous injection sites form revealed no such locations associated with these numbers. In an interview on 04/06/18, Staff G indicated that staff should use this form as a reference when documenting injection sites. On 04/01/18, nursing staff documented [MEDICATION NAME] was not administered and was not available but there was no supporting rationale as to why it was not available as this type of insulin was listed in the facility emergency medication supply. A separate order dated 02/23/18 directed staff to administer Humalog kwikpen 5 units three times daily. There was no indication staff documented the injection sites. This order also directed nursing staff to, hold (insulin) if BS <200. Review of the MARs revealed no indication staff were monitoring BS as directed by the physician and thus would be unable to determine if the insulin needed to be held. RESIDENT #135 Review of the (MONTH) (YEAR) MARs revealed the Resident #135's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. On (MONTH) 1, (YEAR), nursing staff documented that no insulin was administered, but indicated 75 as an injection site at 8:00 am. and 12:00 p.m. RESIDENT #3 Review of the (MONTH) (YEAR) POs revealed Resident #3 had a 12/05/16 order for Humolog Kwikpen 6 units two times daily. No parameters were identified as to when to hold the medication, or when to notify the doctor. On 04/06/18 at 4:20 p.m. Staff L (Corporate nurse) stated staff were then to follow the facility blood glucose (BG) monitoring protocol, which directed licensed staff to hold insulin and notify MD if BG was less than 80 mg/dL or if there were sign/symptoms of [DIAGNOSES REDACTED]. According to the (MONTH) (YEAR) MAR, the residents BS was 77 at 8:00 a.m. on 03/06/18. The 6 units of Humolog should have been held but were administered. On 03/08/18 at 4:00 p.m the residents BS was 85, in the absence of signs/symptoms of [DIAGNOSES REDACTED] (None were documented) the insulin should have been administered, but was held. Similar findings were noted on 03/20/18 at 4:00 p.m., the BS was 82 but the insulin was held without signs/symptoms of [DIAGNOSES REDACTED] and again on 03/22/18 at 4:00 p.m. when the BS was 94, and again the insulin was held. Additionally, documentation was requested of physician notification on the above occasions and none was provided. RESIDENT #287 Resident #287 admitted to the facility on [DATE] with multiple medical care needs, including the treatment of [REDACTED]. Observation on 04/06/18 at 8:38 a.m. revealed Staff I (Licensed Practical Nurse) prepared and administered two different insulins to Resident #287. Review of current POs revealed direction to nursing staff to administer [MEDICATION NAME]10 units .give 10 minutes before each meal and [MEDICATION NAME] N NPH Insulin 25 units .two times a day . Observation at the time of the insulin administration revealed the resident was in his room, working with therapy staff, a finished breakfast tray was on the resident's overbed table. Nursing staff failed to follow physician orders [REDACTED]. Additionally, while Staff I documented the location of the [MEDICATION NAME] insulin, record review revealed no cue to nursing staff to document the location of the [MEDICATION NAME]injection. In an interview on 04/06/18 at 11:28 a.m., Staff I confirmed the resident had eaten breakfast prior to the insulin administration and she should have given the insulin when ordered. Staff I also indicated there should be a place to document the injection sites so staff could ensure to rotate sites. Additionally, there were 03/21/18 POs for BS monitoring four times a day and [MEDICATION NAME]before meals without parameters to hold the insulin or notify the physician. Review of the resident's blood sugars in (MONTH) (YEAR), revealed a range from 147 to 386. RESIDENT #64 Review of the resident's record revealed a 12/23/17 PO for [MEDICATION NAME] 25 units two times daily. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In addition, staff did not rotate administration sites as the insulin was administered in site 76 on 04/02 at 8:00 p.m., on 04/03 at 8:00 a.m., 04/04 at 8:00 a.m. , then in site 74 on 04/04 at 8:00 p.m., 04/05 at 8:00 p.m., and 04/06 at 8:00 a.m. Additionally there were 12/22/17 POs for BS monitoring two times a day without parameters to hold the insulin or notify the physician. Review of the resident's blood sugars in (MONTH) (YEAR), revealed a range from 83 to 325. In addition, on 03/29/18 nursing staff documented a BS of 219, and noted it was taken After breakfast. In an interview on 04/06/18 at 4:42 p.m., Staff K (Medical Records) was asked how nursing staff ensured physician orders [REDACTED]. Staff K indicated the facility did not do end of month recapitulations and hadn't since, we went electronic (over a year). Staff K stated, I input new admission orders [REDACTED]. Staff K indicated, A second nurse is suppose to check to make sure they (Physician Orders) are correct. That is how it's suppose to go. Staff K confirmed at this time, that nursing staff should make sure the injection sites are documented. She also indicated , when asked how staff verify TOs (telephone orders) were correct, that not all the doctors write out TOs. If they are oral the nurse directly inputs the orders into the computer. When asked how accuracy of TOs were ensured, Staff K stated, I don't know, they do it on their own. In an interview on 04/06/18 at 4:45 p.m., Staff B (Director of Nursing) , Staff G, Staff C (Staff Development), all indicated that end of month recaps had not been done since the facility, went electronic over a year ago. Reference WAC 388-97-1060(3)(k)(iii)

Based on interview and record review the facility failed for one (Resident #1) of seven residents reviewed for refusal of care and services, to provide social services that addressed the reasons and remedy for the resident's refusals. This failure prevented the resident from attaining their highest practicable level of biopsychosocial health and contributed to the worsening of a pressure ulcer that developed into a life threatening medical condition for Resident #1. Findings included: According to the 08/09/17 admission Minimum Data Set (MDS) an assessment tool, Resident #1 was cognitively aware, able to make his own decisions, exhibited no behaviors, required extensive assistance from one to two staff for activities of daily living, and had [DIAGNOSES REDACTED]. The resident was reviewed as a closed record and not available for interview. Hospital Records obtained by the facility and available to the facility at the time Resident #1 transferred to the facility revealed, Resident #1 refused to participate in bowel and bladder programs, designed to assist Resident #1 to become independent. So the facility was aware Resident #1 had a history of [REDACTED]. The facility's August 3, 2017 Medication Administration Records (MAR) revealed, Resident #1 refused this same program. Staff further assessed Resident #1 at risk for pressure ulcers on the initial 07/31/17, and subsequent 08/18/17, 08/21/17 and 10/19/17 Braden Scale skin assessments as at Moderate Risk for development of pressure ulcers. Staff documented on the Wound/Skin Evaluation Form, weekly, beginning on 07/31/17 the day of admission when, Resident #1 presented with a coccyx ulcer measuring 1.00 by 1.00 centimeters (cm) and of irregular shape. Staff continued this weekly documentation of the coccyx wound, even as it became progressively worse measuring 3.50 cm by 2.30 cm on 08/30/17 and 6.40 cm by 4.20 cm on 09/20/17. Staff D documented on 09/27/17 the coccyx wound was, a chronic unstageable pressure injury .7.5 cm length x 5 cm width 0.3 cm depth (which not previously identified) .losing skin layers and has slowly been involving a wider area of tissue . Staff D also documented two other PUs developed while Resident #1 resided in the facility. One PU was on the left ischium and measured .and was documented as limited to the dermal layers .continue offloading and monitoring for complications. The third pressure ulcer was identified on the left heel and, appears to be a large dry blister working through the outer skin layers . Staff D continued with, .Nutritional status is a little unclear, though chronic (liver disease) might have compromised the (resident) .focus on protein .for wound healing. On 09/27/17 Staff C and Staff D the consulting physician, identified a third PU on the left ischium measuring 2.00 cm in length by 1.50 cm in width and .10 in depth. Staff D documented this wound as, .is a chronic Stage 2 Pressure Injury Pressure Ulcer .The patient reports no wound pain due to the wound being insensate (lacking feeling related to spinal cord injury) . Review of Progress notes, MAR and Treatment Administration Records from 07/31/17 through 10/19/17 revealed, numerous refusals of care and services. However the beginning of October 2017, staff documented Resident #1 refused care and services on an almost daily basis including but not limited to catheter care, wound care, medications including pain medication, and pressure relieving interventions such as the low air loss mattress. Examples of these refusals were included by staff when documenting care such as, 08/07/17, .refused to have this (Licensed Nurse) do (post surgical care), redness noted around (site). On a 10/10/17 progress note, staff documented Resident #1 said they had a hard night and was offered pain medication which Resident #1 refused. On 10/1317 Resident #1 refused to let the nurse provide care and treatment to the heel wound, according to the progress note. A 10/19/17 provider note included, .Nurse reports (patient) has been refusing wound care now with foul smell possibly eschar? slough? getting worst. This provider's note also included Apparently the Police was called last Friday for the suspicion of dealing (with)/drugs per nurse. Patient was found to be pocketing Morphine meds .Nursing also reports that (resident) has not taken medications since (10/18/17). A 10/19/17 nursing note revealed Resident #1 refused to see the wound specialist. According to 10/20/17 progress notes, Resident #1 was discharged from the facility and received by a local hospital. The hospital's emergency room provider documented, .external assessment (of the coccyx wound) looks to be tracking deep, with question of possible fistualization .significant worsening (of the coccyx wound) .but elevated inflammatory markers (blood components that indicate the body's response to infection and wounds) . The hospital's 10/25/17 progress notes included, .(resident) self-discontinued his (medications) .CT (diagnostic scan) showed possible fistulous tract (from coccyx wound) and osteo[DIAGNOSES REDACTED] (of the coccyx) . This provider noted the wound required, .aggressive but routine wound care. What was not prevalent in Resident #1's record was any indication Social Services (SS) staff intervened when Resident #1 began refusing care and services at any time during Resident #1's residency in the facility. The SS Staff E was interviewed on 11/09/17 at 7:50 a.m. and asked how they were actually involved in Resident #1's care. Staff E responded, I know I did not talk to him about Risks and Benefits (R&B) (of refusing care). There is no (progress) note from me. There are notes from the SS department but about other things. Nursing didn't come to us so I didn't know he was refusing (care and services). Staff B was asked how the nursing department conveyed resident specific information to the SS department, in an interview on 11/09/17. Staff B said, resident (issues) are discussed in the (morning) meeting (stand-up). I talked to (the SS staff) (this morning). (Resident #1's) behavior escalated more, later in (Resident #1's) stay. He was refusing constantly. Staff E was re-interviewed on 11/09/17 at 8:07 a.m. with the information Staff B provided about resident information being passed on to other staff during the morning meeting. Staff E said they went to morning meetings, But if I wasn't there or didn't hear what was said I wouldn't know (Resident #1 refused care and services). The Residential Care Manager Staff F was interviewed on 11/09/17 at 2:25 p.m. and said, (if a resident refuses care) nursing staff should document (the resident) refused (as well as the provision of ) R&B .As far as I know nurses provide R&B .this is not a policy it is a procedure . When asked if the facility had a policy and/or procedure for SS notification of resident refusals, no policy was provided. The facility failed to provide medically related and appropriate social services that addressed Resident #1's copious refusals of care and services, resulting in a more extensive coccyx PU and subsequent life threatening medical conditions preventing Resident #1 from attaining their highest biopsychosocial potential Refer to WAC 388-97-0960 (1) Social Servcies

Based on observation interview and record review the facility failed to ensure one of five sampled residents (Resident #1) was free of significant medication error. This failure caused Resident #1's blood glucose to decrease resulting in a physician ordered emergency room visit, had the potential to negatively impact Resident #1's blood pressure and placed the resident at risk for death. Findings included: Refer to CFR 483.21(b)(3)(i) F-281 Services Provided Meet Professional Standards Resident #1 had resided in the facility since 2010 and had [DIAGNOSES REDACTED]. Staff documented on this assessment Resident #1 was able to communicate his needs, was not always able to make his own decisions and exhibited disorganized thinking. Review of April 2017 Physician Orders (PO) and Medication Administration Records (MAR) revealed Resident #1 received Metroprolol for his blood pressure and no medication for his diabetes. Resident #2 had [DIAGNOSES REDACTED]. Staff documented on this assessment Resident #2 was more cognitively impaired than Resident #1. Resident #2's April 2017 PO and MAR indicated [REDACTED]. All of these medications have side effects but none more serious to a person who did not require them than the medications for diabetes and hypertension. Side effects ranged from lowered blood glucose and pressure to reactions at the site of the insulin injections to sweating, confusion, dizziness and [MEDICAL CONDITION] according to pharmaceutical data. Staff documented on the facility's 04/29/2017 evidence of investigation Staff C, a Student Nurse, correctly identified and obtained medications for Resident #2 from Staff D but administered the medications, as listed above, to Resident #1, who was in a different but adjacent room. Staff documented on the investigative report Resident #1's blood glucose was 128 mg/dl (milligrams per deciliter) at 9:15 a.m. on 04/29/2017 and had decreased to 96 mg/dl by 10:10 a.m. on 04/29/2017 and for which the facility administered sugared soda. The facility documented a telephone call to Resident #1's physician who ordered Resident #1 to the emergency room via 911. This information was confirmed in an interview with Staff B, the Director of Nursing, on 05/02/2017 at 8:05 a.m. who said the precepting nurse (facility licensed nurse), Staff D, did not witness the error in medication administration but identified the error when Staff C was asked to provide medications to Resident #2. Staff C's response indicated he had already administered medications to Resident #2 when in fact the medications were administered to Resident #1. 04/29/2017 hospital records recorded Resident #1's blood glucose as 79 mg/dl, a 17 point drop in blood glucose from the last blood glucose of 96 mg/dl obtained at the facility prior to being transported to the emergency room . emergency room staff administered [MEDICATION NAME] 50% IV (intravenous) solution 50 ml (milliliters), initiated one liter of intravenous fluid and provided Resident #1 with a meal. The facility did not correctly identify Resident #2 as the resident for whom the medications were intended and obtained. As a result the facility erroneously administered ten medications to Resident #1 for which there was no physician's order. Three of the medications were intended to treat Resident #2's diabetes including two insulin injections and were administered to Resident #1 who required no medications to treat his diabetes resulting in a decreasing blood glucose and an emergency room visit with subsequent treatment for [REDACTED].#1's blood glucose as harm. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure residents were safe when smoking. Failure to perform accurate assessments, and/or initiate care plans, and/or implement interventions including safety devices, and/or provide adequate supervision when residents smoked, placed eight of eight residents (#27, 211, 57, 52, 202, 31, 192, 217) at risk for immediate harm. This was determined to be an immediate jeopardy situation. Findings include: The Facility Smoking Policy, dated December 2005, indicated if a resident desired to smoke, a Smoking Safety Evaluation (SSE) would be completed. Appropriate interventions would be care planned and implemented based on the results of the SSE. The SSE was to be reviewed quarterly and upon a change in condition affecting the resident's smoking ability. Based on the results of the evaluation, smoking materials were either kept at the nurses' station or in a locked cabinet/drawer in the resident's room. If a resident was found with unauthorized smoking materials, the nurse would be notified, and the materials removed and secured in accordance with the facility policy. RESIDENT #27 Resident #27 was admitted to the facility in August 2007. The 1/13/11 Quarterly Minimum Data Set (MDS) assessment indicated Resident #27 exhibited both short and long term memory problems, and had moderately impaired decision making which required cues and supervision. On 3/29/11 at 10:34 a.m., Resident #27 was observed seated in a wheelchair, outside in the designated smoking area, talking on a portable phone. She said, "I'd talk to you more, but I'm in a lot of pain. I'm not feeling good." A burning cigarette was observed on a table near the resident. Resident #202 was observed to assist Resident #27 to turn the phone off after the call. Resident #27 retrieved the cigarette from the table, was unable to draw from it, as it appeared to have extinguished, and put it back in her purse. Resident #202 then assisted Resident #27 into the facility. Resident #27 was not observed wearing a smoking apron, contrary to her Care Plan (CP). On 3/29/11 at 2:54 p.m., Resident #27 was observed to be assisted out to the smoking area by Resident #192. Resident #27 was observed to retrieve a cigarette and a lighter from her purse. Resident #27 lit the cigarette and smoked it without wearing a smoking apron. At 3:01 p.m., Resident #27 rubbed the end of the lit cigarette on the rod iron gate, then placed the cigarette back into her purse. The 1/13/11 Smoking Safety Evaluation indicated Resident #27 had a history of [REDACTED]. According to this document, in the presence of these risk factors, staff assessed the resident was independent with smoking, but required the use of a smoking apron. The most recent SSE, dated 2/28/11, was incomplete and did not identify the level of assistance Resident #27 required to smoke safely, nor were safety interventions listed. Smoking Care Plans, dated 11/30/10 and 2/28/11, indicated the resident required a smoking apron and the facility stored tobacco products and fire materials, although these interventions had not been identified on the SSE, per facility policy. On 1/12/11, staff documented in an Interdisciplinary Progress Note that the resident stated she was missing a pack of cigarettes and staff advised the resident to put her valuables in the drawer. On 1/14/11, staff documented the resident's cigarettes almost fell out of her purse. Staff notified the resident, who pushed them back inside her purse. On both occasions, facility staff acknowledged the resident had tobacco products contrary to the resident's CP and facility policy. In an interview on 3/30/11 at 8:48 a.m., when asked how staff ensured the residents who were assessed to require smoking aprons utilized them, Staff B, stated, "we gave the aprons to the residents and they wore them." When asked how it was that Resident #27 wasn't observed wearing a smoking apron on several occasions, Staff B replied, "...I'll have to talk to the staff....I'll get back to you on that." At 9:34 a.m. on 3/30/11, when asked how staff ensured residents wore smoking aprons when they had been assessed to require their use, Staff C, an RCM, responded, "we do an evaluation to make sure they would remember to use it. Then do an evaluation to ensure they are using it...after we have made it available...". When asked where these interventions were documented, Staff C replied, "that's my own interventions, I don't think there's a form..." to ensure safety devices were utilized. When asked if it was safe practice to smoke a cigarette, put it out and place the cigarette in a pocket or purse, Staff C responded, "no". In an interview on 3/30/11 at 9:51 a.m., Staff E, an RCM, indicated that putting out a cigarette then placing it in a purse or pocket was "not an appropriate way of putting out (a cigarette)...". When asked how staff ensured residents wore smoking aprons when they were assessed to require their use, Staff E replied, "that's a really good question". RESIDENT #211 Resident #211 was admitted to the facility on [DATE] with care needs related to a recent amputation. According to a CP dated 3/21/11, the resident required the use of anti-anxiety and antidepressant medications. Review of the 3/11 Medication Administration Record (MAR) revealed the resident received multiple narcotic pain medications and an anti-anxiety medication which had as side effects, sedation, dizziness, confusion and seizures. The admission skin assessment dated [DATE], indicated staff identified Resident #211 with multiple cigarette burns on his chest, abdomen and upper thighs. Review of the undated SSE form revealed staff assessed the resident with sensory deficits "feeling in hands somewhat impaired" which might "impact... ability to smoke". Staff assessed the resident with a "History of Smoking Related Incidents" including "drops ashes on self ". The sections of the assessment regarding visual and range of motion limitations which might impact the resident's ability to smoke were left blank. The section of the SSE which addressed staff observation of the resident's ability to smoke was also blank. The section regarding medication use which might cause "drowsiness, confusion, seizures.." was also left blank despite the resident receiving regularly scheduled narcotic medications with these side effects. On 3/29/11 at 3:14 p.m., Resident #211 was observed to enter the outdoor smoking area with cigarettes in his shirt. While smoking, Resident #211 was observed to flick ashes on the ground in front of him. On 3/29/11 at 3:31 p.m., Staff D posted a copy of the facility smoking policy on the smoking porch. Resident #211 looked at it and said, "That's the first time I've ever seen it." In an interview on 3/29/11 at 3:58 p.m., Resident #211 indicated he would not give cigarettes to any one except for his roommate, Resident #202. Facility failure to provide supervision to ensure residents did not provide smoking materials to other residents placed these residents at risk for smoking accidents. According to the Smoking Safety Evaluation, staff determined Resident #211 was an independent smoker, despite an assessed history of cigarette burns, sensory limitations, use of multiple sedating medications and an incomplete SSE. Record review revealed no CP was developed for this resident related to smoking safety. In an interview on 3/30/11 at 9:51 a.m., Staff E confirmed Resident #211's SSE was incomplete and was unable to explain why it was not completed. When asked why there was no CP developed for smoking safety, Staff E indicated she believed only one care plan needed to be completed upon admission and that comprehensive CPs were to be developed after the MDS assessment was completed. RESIDENT #57 An SSE dated 1/31/11 indicated the resident did not require facility storage of smoking materials. According to Resident #57's "Alteration in safety related to smoking" CP, dated 3/13/11, the resident "requires assistance to smoke safely, reminding to remove (oxygen) prior to smoking." Interventions included, "facility storage of tobacco products and fire materials" with an undated entry of "res(ident) can smoke independently now." Failure to ensure the CP reflected the most recent assessment placed the resident at risk for safety issues related to smoking. On 3/29/11 at 3:03 p.m., Resident #57 was observed to self propel his wheelchair outside, wearing socks and no shoes. His wheelchair was soiled with ashes and other debris. Resident #57 was observed to put on a smoking apron. He lit a cigarette, and stated "I keep them (cigarettes) myself". Resident #57 was observed to flick the ashes with one hand, onto the cement ground. The wind blew the ashes back into the resident smoking area as he flicked them. Failure to ensure appropriate footwear in the presence of unsafe ash disposal placed the resident at risk for burns to his feet. Failure to ensure the resident's ability to use the ashtray or extinguish the cigarette safely, according to the SSE, constituted a fire safety risk. Observation on 3/29/11 at 3:15 p.m., revealed Resident #57 lying in bed receiving oxygen. A large bag of loose leaf tobacco was noted at his bedside along with a container of filters. According to the resident he "rolls my own cigarettes." The tobacco products were not safeguarded or secured according to facility policy. RESIDENT #52 Resident #52 admitted to the facility 3/31/08. According to the most recent MDS, dated [DATE], the resident had care needs related to a stroke, depression, and chronic obstructive pulmonary disease. He also exhibited poor short term memory. The most recent SSE was completed on 3/15/11. The evaluation indicated the resident had a history of [REDACTED]. Based on this evaluation, staff determined the resident was independent with smoking, but required the use of a smoking apron. The Smoking CP, dated 3/15/11, revealed the resident "requires smoking apron" as an intervention. The Cognitive Loss/Dementia CP, dated 2/21/11, indicated the resident had impaired short term memory and moderately impaired decision making skills. One of the goals of this CP was for the resident to "continue to smoke safely." On 3/25/11 at 10:22 a.m., Resident #52 was observed to propel his wheelchair outside to the smoking patio. He smoked a cigarette, without wearing a smoking apron. On 3/30/11 at 9:35 a.m., Resident #52 was observed to wheel himself outside to the smoking area and lit a cigarette without first donning a smoking apron. Failure to ensure residents utilized care planned safety devices placed the resident at risk for burns. RESIDENT #202 According to CP documents, dated 2/11/11, the resident required use of sedative hypnotic medications. The SSE, dated 2/09/11, was incomplete and reflected staff failure to assess for any medications the resident took which might impact his ability to safely smoke or the existence of hand tremors. Failure to ensure SSEs were complete placed residents at risk for incomplete or inaccurate assessments. The 2/09/11 SSE reflected the resident had a history of [REDACTED]. Staff determined the resident was an independent smoker and required facility storage of tobacco products and fire materials. Review of the "alteration in safety related to smoking" CP dated 2/11/11, identified the intervention of "facility storage of tobacco products and fire materials." On 3/29/11 at 3:15 p.m, Resident #202 said "Most of time my cigarettes and lighter are in my coat pocket, and when I'm inside I leave my coat in my room." Failure to ensure identified interventions regarding smoking safety were implemented placed this resident at risk for smoking accidents. RESIDENT #31 On 3/31/11 at 10:00 a.m., Resident #31, who was assessed to require staff supervision, was observed with a burning cigarette to say "I was told I could put this on the floor". Resident #202 said "No, no don't put it on the floor". Resident #202 intervened, taking the burning cigarette from Resident #31, which he then discarded in the ashtray. Staff D, who was present during this observation, did not redirect Resident #31 regarding the safe disposal of cigarette ashes and failed to intervene when Resident #202 took a burning cigarette from Resident #31. Failure to ensure the safe disposal of burning materials, and allowing residents to dispose of other resident's smoking materials, placed residents at risk for burns. RESIDENT #192 Resident #192 was admitted on [DATE]. The SSE dated 12/25/10, noted indicators of Delirium were not present, and the resident could smoke independently without interventions. The 1/21/11 MDS assessed Resident #192 as exhibiting signs and symptoms of Delirium including inattention and disorganized thinking. Failure to reassess the resident's smoking ability based on the change in cognitive status placed the resident at risk for injury due to unsafe smoking. On 3/29/11 at 2:54 p.m., Resident #192 was observed with a pack of cigarettes and a lighter in her pocket. Resident #192 said staff had told the residents who smoked not to give Resident #57 any cigarettes if he asked, because "he has emphysema". The facility practice of relying on residents assessed with [REDACTED]. RESIDENT #217 In an interview on 3/29/11 at 2:50 p.m., Staff J indicated, "I don't know if he smokes here...he hasn't asked to smoke but Resident #217 has cigars in the med(ication) cart." Review of the Nursing Admission Evaluation dated 3/21/11 revealed staff assessed Resident #217 was a smoker. According to this document staff were directed to "complete Smoking Safety Evaluation and initiate alteration in safety related to smoking care plan." Record review revealed no SSE or CP was completed for Resident #217. Failure to ensure smoking evaluations were completed according to facility policy, and a plan was established for a resident who was identified as a smoker on admission, placed Resident #217 at risk for smoking accidents. SMOKING ASSESSMENTS Staff B, the Director of Nursing, in an interview on 3/30/11 at 8:48 a.m., indicated the RCMs (Resident Care Managers) were responsible for performing smoking assessments. In an interview on 3/30/11 at 9:51 a.m., Staff E, an RCM, indicated smoking assessments were completed, "at admission" and "also if we see a change in their cognitive/physical ability... and also quarterly". Staff E indicated, "first (we) start out with questions that pertain to medical history, and also what we see on a physical assessment and then the observation would be after that, if they (indicated they smoked) on the nursing admission assessment, then we go to the smoking safety evaluation." Staff E stated, "then we go outside and watch them smoke...functional status, are they independently mobile do they need assistance to get out there, vision..." In an interview on 3/29/11 at 2:50 p.m., two Licensed Nurses, Staff H and Staff J were asked which residents on their unit smoked. Staff H indicated there was "one smoker (on the unit), (Resident #211) is a smoker." Staff J stated, "I didn't know that." Staff J further indicated, "I don't know if he smokes here...he hasn't asked to smoke but (Resident #217) has cigars in the med(ication) cart." Further investigation revealed at least three residents on this unit were current smokers. Staff interview revealed no system by which staff were aware which residents smoked or what interventions each resident required. Facility failure to ensure staff were aware of residents who smoked detracted from their ability to provide adequate supervision. At 9:34 a.m. on 3/30/11, Staff C, an RCM, indicated, "On my hall I am responsible for completing smoking assessments. I perform them on admission and I think quarterly... I've got to check to see if it's quarterly...for sure any change in condition or incidents related to smoking, usually they aren't here long enough..."

Based on observation, interview and record review, the facility failed to administer a system for smoking in a manner which assured residents who smoked were protected from [MEDICAL CONDITION] injury. The facility administration failed to ensure and implement accurate and comprehensive assessments, plans of care for smoking safety and/or provide the necessary supervision and monitoring for 8 of 8 residents who smoked which constituted an immediate jeopardy. Findings include: Refer to CFR 483.25(h)(2), F-323 The facility administration failed to recognize the danger of access to smoking materials (for residents who were assessed to require facility storage of those items), or dangerous behavior (placing smoked cigarettes inside a purse, without ensuring they were extinguished) or failed interventions (failure to wear smoking aprons) and placed residents at risk for serious harm and/or death. In addition, there was no documented evidence the facility followed their established policies and procedures for assessment, care planning and provision of safety for smoking residents. There was no documented evidence to demonstrate the facility had a mechanism in place to accurately implement required safety interventions. This constituted Immediate Jeopardy. .