Every finding on record at Cascades of St Anne

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings included.Review of the key personnel list, provided by the facility on 01/13/2026, showed no staff names were listed under the dietary manager.In an interview on 01/13/2026 at 8:06 AM, Staff G, Cook, stated that they had no dietary manager and that they would report directly to Staff A, Administrator. When asked about the last time they had a dietary manager, Staff G stated, I don't [do not] know. In an interview on 01/16/2026 at 3:52 PM, Staff A stated that the facility did not have a dietary manager or a food services director since 12/05/2025. Staff A stated that they were in contact with the corporate resource person and that they had basically taken the role of a dietary manager. Staff A stated that they had a state food safety certificate but no degree in food or nutrition.Reference: (WAC) 388-97-1160(1)(2).

Based on observation, interview, and record review, the facility failed to follow and maintain food safety and services in accordance with professional standards by:1. Not having food items labeled, dated and/or covered for 1 of 1 Kitchen Refrigerator, 2. Not discarding cups of prune juice after their best-by-dates stored in the Steel Kitchen Rack,3. Not monitoring the dishwashing machine temperature,4. Not monitoring the sanitizing solution for the Three-compartment sink,5. Not maintaining the sanitizing solution within the recommended ppm (parts per million - a unit of measurement for concentration) for 1 of 2 sanitizing buckets,6. Not properly disinfecting the food thermometer for 1 of 1 staff (Staff M),7. Not maintaining milk temperature at 41 degrees Fahrenheit at serving time, 8. Not covering food items during meal tray delivery for 2 of 2 staff (Staff T and Staff I ), reviewed for food safety.These failures placed the residents at risk for food borne illness (caused by ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included. Review of the facility's policy titled, Food Receiving and Storage, dated 2001, showed, Foods shall be received and stored in a manner that complies with safe food handling practices. PHF [Potentially Hazardous Foods-foods prone to bacterial (organisms that can use illnesses) growth, requiring proper handling and storage to ensure safety] are stored at or below 41 [degrees] F [Fahrenheit]. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Review of the facility's undated document with a handwritten title, HPSI [Health and Personal Services, Inc (Incorporated)] Policy + [and] Procedure, showed that concentration in sanitizing buckets would be monitored using test strips regularly. The document showed, Use the provided test strips to test the concentration of the sanitizing solution and record on the sanitizing sink log. If the solution is incorrect, notify the supervisor and DO NOT use until the correct concentration is available and verified. The document further showed, The temperatures of the dish machine will be recorded three times a day.While the dishwasher is running with a rack going through it, the temperature of the wash tank and rinse tank will be recorded. Temperatures will be recorded prior to washing each meals dishes. Review of the undated facility's kitchen signage titled, Sanitizing Bucket Procedures, showed how to prepare a sanitizing bucket which included testing of solution with test strips for proper PPM and the required PPM of 200-400 ppm. Review of the Washington State Retail Food Code dated 03/01/2022, showed, Employees are properly sanitizing.multiuse equipment and utensils before they are reused, through routine monitoring. and exposure time for chemical sanitizing. including the application of sanitizing chemicals by manual swabbing.Contact times must be consistent with those on EPA [Environmental Protection Agency-United States agency safeguarding human health and protecting the environment]-registered label use instructions. KITCHEN REFRIGERATOR-FOOD LABEL/DATINGIn a joint observation and interview on 01/13/2026 at 8:06 AM with Staff G, Cook, showed the refrigerator had a transparent pitcher with a cream-colored mixture inside. The transparent pitcher was unlabeled and undated with a plastic cling wrap cover. When asked, Staff G stated that the transparent pitcher had a pancake mixture leftover from breakfast. Staff G stated that they were keeping it in case some residents may want it later. Staff G stated that their process was to put a date on food items. When asked why the pancake mixture was not labeled and/or dated, Staff G stated, because I know and I made it [pancake mixture]. Staff G had no response when asked how the other staff would know if the food items were not labeled and/or dated. A concurrent observation showed 11 uncovered, unlabeled and undated glasses with liquid substances in them. When asked, Staff G stated that the liquids in the fridge were five glasses of orange juice, a glass of cranberry juice, two glasses of milk, a glass of peach juice and two glasses of apple juice. Staff G stated that they did not know why the glasses were not covered, unlabeled and/or undated. CUPS OF PRUNE JUICE STORED IN THE KITCHEN STEEL RACKIn a joint observation and interview on 01/13/2026 at 8:35 AM with Staff G showed a steel rack in the kitchen had 54 cups of prune juice with a best by date of 06/29/25 [2025]. Staff G stated, I don't [do not] know why it is [prune juice cups] still here. Staff G further stated that they expected the cups of prune juice to have been thrown away. DISHWASHING MACHINE TEMPERATURE LOGIn an interview and joint record review on 01/15/2026 at 8:59 AM, Staff K, Dietary Aide, stated that they would check the dishwashing machine temperature every Breakfast, Lunch, Dinner, and would write the temperature on the log posted in the kitchen. Staff K showed a document entitled, Dishmachine Temperature Log, dated 1/26 (January 2026). A joint record review of the log showed missing entries for breakfast, lunch, and dinner on the following dates: 01/01/2026, 01/02/2026, 01/03/2026, 01/04/2026, 01/05/2026, 01/06/2026, 01/07/2026, 01/08/2026, 01/11/2026, and 01/13/2026. Further record review of the log showed missing entries for dinner on 01/12/2026 and on 01/14/2026. Staff K had no response when asked why there were missing entries in the dishwashing machine temperature log. THREE COMPARTMENT SINK-SANITIZING SOLUTION LOGIn an interview and joint record review on 01/15/2026 at 9:11 AM, Staff K stated that they checked the sanitizing solution every mealtime and that they would write the result in the log posted in the kitchen. A joint record review of the log entitled, Three Compartment Sink log, dated 1/26 (January 2026), showed the log was divided into AM [morning] and PM [afternoon/evening] with missing entries for the following dates: 01/01/2026, 01/02/2026, 01/03/2026, 01/04/2026, 01/05/2026, 01/06/2026, 01/07/2026, 01/08/2026, 01/09/2026, 01/10/2026 and 01/11/2026. Staff K had no response when asked why there were missing entries in the three-compartment sink log. SANITIZING SOLUTION BUCKET NEAR THE STOVEIn an interview and joint observation on 01/15/2026 at 9:20 AM, Staff G stated that they test the sanitizing bucket every three hours. A joint observation with Staff G showed the countertop area near the stove was a red bucket with a white, small dish towel inside. Staff G stated that they changed the water this morning. Staff G took a test strip (Hydrion-brand name, used to test ppm) and dipped it in the sanitizing bucket for 10 seconds. A joint observation of the test strip showed 0 ppm as indicated in the test kit color chart. Staff G took another test strip and repeated the process, and it showed 0 ppm as indicated in the test kit color chart. Staff G stated they changed the water that morning. On 01/15/2026 at 9:46 AM, Staff G provided a document entitled, Cloth bucket PPM Record, dated 1/1/26 [01/01/2026]. A joint review of the document with Staff G showed separate columns labeled, 6:00 AM, 9:00 AM, NOON, 3:00 PM and 6:00 PM and an instruction that stated, Check ppm at appropriate time and initial. Further review of the document dated 01/01/2026 showed no initials and no entries under the NOON column from 01/01/2026 to 01/14/2026. When asked, Staff G stated they had provided the January 2026 and November 2025 record and that they could not find the December 2025 sanitizing bucket ppm record. USE OF FOOD THERMOMETERAn observation and interview on 01/16/2026 at 11:57 AM, showed Staff M, Cook, used a food thermometer and checked the temperature of hamburger steak patties placed on a metal bowl and then Staff M took a small towel from the sanitizing bucket and wiped off the food thermometer. Staff M immediately proceeded to check the mashed potato and used the same towel to wipe off the food thermometer. When asked, Staff M stated that they had been doing the same process where they would use the towel from the sanitizing bucket to wipe off/sanitize the food thermometer. An observation on 01/16/2026 at 12:29 PM showed Staff A, Administrator, instructed Staff M about using the disposable probe wipes to sanitize the food thermometer. Staff A was heard telling Staff M, We do not use the towel from the sanitizing bucket to clean the [food] thermometer. We use these probe wipes for the food thermometer. In an interview and joint record review on 01/16/2026 at 3:52 PM, Staff A stated that they did not have a dietary manager or a food service director and that they had basically taken the role of a dietary manager. Staff A stated that they expected staff to use probe wipes to sanitize food thermometer. MILK TEMPERATUREOn 01/20/2026 at 11:50 AM, observation during a tray line showed three covered glasses of milk on a plastic tray with some ice cubes. Staff K was observed placing a glass of milk into one of the serving meal trays. Staff K was asked to check for the temperature of the milk, and they used a food thermometer. A joint observation showed the milk temperature was 49 degrees Fahrenheit. Staff K continued with the tray line and did not remove the milk from the tray. Another joint observation and interview on 01/20/2026 at 12:13 PM with Staff N, Cook, showed a glass of milk on a plastic tray with some ice cubes. Staff N was asked to check for the milk temperature. A joint observation showed the milk temperature was 51 degrees Fahrenheit. Staff N stated that 41 degrees Fahrenheit would be the expected temperature for the milk before it would be served to the residents. In an interview on 01/20/2026 at 1:56 PM, Staff F, Corporate Director of Nutrition Services/Registered Dietitian, stated that they provided guidance and served as a resource person for the facility. Staff F stated their expectations that food items in the refrigerator must be covered, labeled, dated by use by date. Staff F stated that food items must be thrown away or discarded and that food should be within the recommended temperature. Staff F further stated, Milk should be at 41 degrees [Fahrenheit] when it reaches the resident. In an interview and joint record review on 01/20/2026 at 3:04 PM, Staff A stated that they expected food items in the refrigerator to be covered, labeled and dated. Staff A stated that they expected staff to remove and toss away food items past their best by dates. A joint record review of the dishwasher temperature log and the three compartment sink log showed missing multiple entries. Staff A stated that they expected staff to monitor and document dishwasher temperature and sanitizing solution's ppm result regularly three times a day. Staff A stated that they expected staff to follow the correct guidelines in testing sanitizing solution and that staff should use the color chart. Staff A further stated that the food temperature must be within the recommended guidelines when served. UNCOVERED FOOD ITEMSObservation on 01/13/2026 at 12:17 PM, showed Staff T, Certified Nursing Assistant, was removing a lunch tray from the meal tray-cart parked in front of the kitchen. Further observation showed the dessert bowl on the tray was not covered, and Staff T walked down the hallway with uncovered dessert bowl, entered room [ROOM NUMBER] and delivered the tray to the resident in room [ROOM NUMBER]D. Observation on 01/13/2026 at 12:19 PM showed Staff T was removing another lunch tray from the meal tray-cart parked in front of the kitchen. Further observation showed the dessert bowl on the tray was not covered, and Staff T walked down the hallway with the uncovered dessert bowl, entered room [ROOM NUMBER] and delivered the tray to the resident in room [ROOM NUMBER]D. Observation and interview on 01/13/2026 at 12:21 PM, Staff I, Human Resources, was removing a lunch tray from the meal tray-cart parked in front of the kitchen. Further observation showed the dessert bowl on the tray was not covered, and Staff I walked down the hallway with uncovered dessert bowl, entered room [ROOM NUMBER] and delivered the tray to the resident in room [ROOM NUMBER]W. When asked if the dessert bowl was covered when was it was delivered, Staff I stated, No it was not covered. In an interview on 01/13/2026 at 12:35 PM, Staff T stated that the dessert bowls were not covered when they were delivered to residents in room [ROOM NUMBER]D and 174D. In an interview on 01/21/2026 at 1:36 PM with Staff F and Staff BB, Dietary Manager stated that staff should distribute and serve food under sanitary conditions and all food items on a tray should be covered when carrying a tray and walking down the hallway. In a phone interview on 01/21/2026 at 3:04 PM, Staff A stated that they would expect staff to distribute and serve food under sanitary conditions. Reference: (WAC) 388-97-1100 (3) .

Based on interview and record review, the facility failed to accurately assess 6 of 16 residents (Residents 7, 38, 36, 2, 3 & 19), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding documentation date of gradual dose reduction (GRD-tapering of medication dosage), immunization status and use of anticoagulants (medications used to prevent blood clots) placed the residents at risk for unidentified and/or unmet care needs, and diminished quality of life.Findings included. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). The RAI manual showed, .Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). The RAI manual further showed to follow Centers for Disease Control and Prevention (CDC-a public health agency) guidelines for coding instructions regarding influenza [an infection of the nose, throat, and lungs] vaccination [immunization to prevent influenza] /Pneumococcal Vaccination (to prevent pneumonia [a lung infection]) and that [Up to date] in item [Section] O0300A [Is the resident's Pneumococcal vaccination up to date?] means in accordance with current Advisory Committee on Immunization Practices (ACIP- a committee within CDC) recommendations. GRADUAL DOSE REDUCTIONRESIDENT 7Review of the medication review report printed on 01/14/2026 showed Resident 7 had been prescribed antipsychotic medication (used to treat symptoms of psychosis [mental health condition characterized by a loss of touch with reality]). Review of the annual MDS dated [DATE] showed Resident 7's MDS under Section N0450E (Antipsychotic Medication Review-Date physician documented GDR as clinically contraindicated (refers to a specific situation or condition that makes a medical treatment inadvisable because it may cause harm to the resident) was dated 09/04/2024. Review of Resident 7's progress notes dated 09/25/2025 showed their physician's mental evaluation and documentation of GDR as not clinically indicated at this time. In an interview and joint record review on 01/20/2026 at 4:13 PM, Staff D, Admission/MDS Nurse, stated that they followed the RAI manual in coding MDS. A joint record review of Resident 7's annual MDS showed Section N0450E was dated 09-04-2024. When asked if there were additional documentations after 09/04/2024 about Resident 7's GDR as clinically contraindicated, Staff D stated that there was a progress note dated 09/25/2025. A joint record review of that progress note showed Resident 7's physician's mental evaluation and documentation of GDR as not clinically indicated for Resident 7. Staff D stated that they should have documented 09/25/2025 in Section N0450E of Resident 7's annual MDS. IMMUNIZATION STATUSRESIDENT 38Review of Resident 38's quarterly MDS dated [DATE] showed Section O0250C- Influenza Vaccine was marked as received outside of this facility. Review of Resident 38's Electronic Health Record (EHR) did not show documentation that they received their influenza vaccine for the current influenza season. Review of Resident 38's immunization record showed that they refused the 2025/2026 trivalent (a type of) influenza vaccine with a confirmation date of 10/20/2025. A joint record review and interview on 01/20/2026 at 4:25 PM with Staff D showed Resident 38's quarterly MDS revealed they received their influenza vaccine outside of the facility. When asked to show documentation or records related to Resident 38's influenza immunization, Staff D stated that they would further review Resident 38's EHR and would provide information about Resident 38's influenza vaccination. In a follow-up interview on 01/21/2026 at 9:07 AM, Staff D stated that they did not see documentation that would support their MDS coding related to Resident 38's influenza vaccine status. Staff D further stated that it was an inaccurate MDS coding and that it would be modified. RESIDENT 36Review of Resident 36's face sheet printed on 01/20/2026 showed their birthdate of 04/20/1950. Review of Section O0300A in the annual MDS dated [DATE] showed Resident 36's pneumococcal vaccination was coded as up to date. Review of Resident 36's immunization record showed they received their initial dose of pneumococcal vaccine [PPSV23] on 10/19/2004 when they were [AGE] years old and another type of pneumococcal vaccine [PCV13] on 02/19/2019. Further review of the immunization record did not show Resident 36 received the recommended pneumococcal vaccine [PCV20 or PCV21] to be considered up to date per CDC guidelines. An interview and joint record review on 01/21/2026 at 9:09 AM, Staff D stated that a resident to be considered up to date with their pneumococcal vaccination should have received the recommended pneumococcal vaccines. A joint record review of Resident 36's immunization record showed they received two pneumococcal vaccines in which one of those were received before they were [AGE] years old. Staff D stated that Resident 36's pneumococcal vaccination was not up to date and that their MDS coding was inaccurate. RESIDENT 2Review of Resident 2's admission MDS dated [DATE] showed Section O0250C (influenza vaccine) was coded as offered and declined. Review of the EHR did not show documentation that Resident 2 was offered and declined the influenza vaccine on or prior to their admission MDS assessment date. A joint record review and phone interview on 01/21/2026 at 1:03 PM with Staff B, Director of Nursing Services and Staff C, Regional [NAME] President for Operations, showed Resident 2's admission MDS Section O0250C was coded offered and declined. Staff B stated that it's [it is] inaccurate coding. USE OF ANTICOAGULANTRESIDENT 3Review of the admission MDS dated [DATE] showed Resident 3's MDS under Section N0415 (High-Risk Drug Classes: Use of Indication) was marked for anticoagulant use during this assessment period. Review of the October 2025 Medication Administration Record (MAR) showed Resident 3 did not receive an anticoagulant medication during the 7-day look back period. In a joint record review and interview on 01/20/2026 at 4:04 PM with Staff D showed an anticoagulant was coded in Resident 3's admission MDS dated [DATE]. A joint record review of Resident 3's October 2025 MAR did not show an anticoagulant use during the 7-day look period. Staff D stated that Resident 3's MDS was not coded accurately. In a phone interview on 01/21/2026 at 12:04 PM with Staff B and Staff C, Staff B stated that they followed the RAI manual in coding the MDS. Staff B stated that they expected MDS to be coded accurately to reflect residents' status. RESIDENT 19Review of the admission record printed on 01/20/2026 showed that Resident 19 was admitted to the facility on [DATE]. Review of the quarterly MDS dated [DATE] showed Resident 19's was marked for an anticoagulant use during the assessment period. Review of the November 2025 and December 2025 MAR showed Resident 19 was not receiving an anticoagulant medication during the assessment period. In an interview and joint record review on 01/21/2026 at 9:26 AM, Staff D stated that they would follow the RAI manual and review the resident's medical records to complete MDS assessments. A joint record review of Resident 19's quarterly MDS dated [DATE] showed Resident 19's was receiving an anticoagulant medication during the assessment period. A joint record review of the November 2025 and December 2025 MAR showed Resident 19 was not receiving an anticoagulant medication during the assessment period. Staff D stated that Resident 19 was not on anticoagulant during the MDS assessment period and the MDS would be modified. In a phone interview on 01/21/2026 at 12:04 PM, Staff B stated that the facility would use the RAI manual as guidance for MDS coding, and that they expected MDS assessments to be completed accurately. Reference: (WAC) 388-97-1000 (1)(b) .

Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the facility name and the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 6 of 6 days (01/13/2026, 01/14/2026, 01/15/2026, 01/16/2026, 01/20/2026 & 01/21/2026), reviewed for sufficient and competent nurse staffing. The failure to post a complete and accurate nurse staffing form daily prevented the residents, resident representatives, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.Findings included .Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, showed that the information recorded on the Daily Posting of Nursing Staff form shall include the name of the facility and the actual time worked during that shift.Observations on 01/13/2026 at 2:09 PM, on 01/14/2026 at 12:44 PM, on 01/15/2026 at 2:11 PM, on 01/16/2026 at 3:26 PM, on 01/20/2026 at 2:56 PM and on 01/21/2026 at 10:00 AM, showed the facility's document titled, Daily Posting of Nursing Staff did not include the facility name and the actual hours nursing staff worked for the shift.In a phone interview on 01/21/2026 at 10:59 AM, Staff B, Director of Nursing Services stated that the facility completed the Daily Posting of Nursing Staff form daily and the actual hours were entered the following day. Staff B stated that the form should include the facility's name and that the actual hours should have been added each time the form was posted.In a phone interview on 01/21/2026 at 3:04 PM, Staff A, Administrator, stated that their expectation was for the Daily Posting of Nursing Staff form to be prepared and posted daily with the total number of staff and the estimated hours for each shift. Staff A stated that the actual hours worked were added to the form the following day. When asked whether they would expect the facility name to appear on the Daily Posting of Nursing Staff form, Staff A stated, No, I would not expect the facility name to appear on the form.No associated WAC.

Based on observation and interview, the facility failed to ensure residents' environment were maintained for 4 of 15 resident rooms (Rooms 159, 161, 170 & 162) and 1 of 1 therapy gym, reviewed for environment. The failure to ensure resident rooms and therapy gym were maintained, air vents were cleaned, baseboard heater cover were in good repair, and lower door frame and walls were repaired, placed the residents at risk for a less than homelike environment and a diminished quality of life.Findings included.AIR VENTroom [ROOM NUMBER]In an interview on 01/15/2026 at 10:04 AM, Resident 47 stated that they were concerned with the air vent in between the two televisions in their room was filthy. Observation of air vent showed dust towards the back of the vent louvers and dark grey discoloration at the top four vent louvers.BASEBOARD HEATERroom [ROOM NUMBER]Observations on 01/13/2026 at 8:48 AM, on 01/14/2026 at 9:00 AM, and on 01/16/2026 at 8:45 AM, showed the baseboard heater covers in room [ROOM NUMBER] were not covering the left side of the heater fins.room [ROOM NUMBER]Observations on 01/13/2026 at 8:52 AM and on 01/14/2026 at 9:05 AM, showed the baseboard heater cover in room [ROOM NUMBER] were not covering the left side of the heater fins.THERAPY GYMObservation on 01/16/2026 at 9:05 AM, showed the baseboard heater in the therapy gym had no cover covering the heater fins.DOOR FRAME AND WALLSroom [ROOM NUMBER]Observations on 01/13/2026 at 8:20 AM, on 01/14/2026 at 8:50 AM, and on 01/16/2026 at 8:40 AM, showed room [ROOM NUMBER] with scrapes and scratches on the lower door frame walls to each side of the bathroom door frame and floor molding.In an interview and joint observation on 01/16/2026 at 3:23 PM, Staff X, Maintenance Director, stated it was their process that they would do daily walk throughs of the building, repair, and repaint the building as they could. Staff X stated they would call a vendor for a repair that could not be done by them. Staff X stated that staff would verbally notify them and would write maintenance issues in logs located at the nurses' station and front desk. A joint observation of room [ROOM NUMBER] showed the air vent between the two televisions had dust and grey discoloration. Staff X stated they could see the dust and grey discoloration and that it should be cleaned. A joint observation of room [ROOM NUMBER] and 170 showed the baseboard heater covers were not covering the left side of the heater fins. A joint observation of the therapy gym showed the baseboard heater fins did not have covering. Staff X stated the baseboard heaters should have been fully covered. A joint observation of room [ROOM NUMBER] showed scrapes and scratches on the lower door frame walls to each side of the bathroom door frame and floor molding. Staff X stated, the damage is more than I can deal with myself. I would have to call a contractor.In a phone interview on 01/21/2026 at 3:03 PM, Staff A, Administrator, stated that they expected the air vent in room [ROOM NUMBER] to have been cleaned, the baseboard heaters in room [ROOM NUMBER], 170, and the therapy gym to have the covers fully covering the heater fins, and the scrapes and scratches on the lower door frame walls on each side of the bathroom door frame and floor molding in room [ROOM NUMBER] to be patched and painted.Reference: (WAC) 388-97-0880 (1)(2).

Based on observation, interview, and record review, the facility failed to ensure a medication error rate was less than five percent (%). The failure to properly administer 3 of 28 medications for 4 of 5 residents (Residents 35, 10, 12 & 31), observed during medication administration resulted in a medication error rate of 10.7%. This failure placed the residents at risk for not receiving the correct form, dose, and/or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects.Findings included.RESIDENT 35According to the manufacturer's administration instruction revised in December 2024, Metoprolol succinate (a medication used to treat high blood pressure, chest pain, and heart failure) Extended Release (ER - designed to release active ingredients slowly into the body, rather than all at once) should be taken whole tablet and should not be crushed.Review of Resident 35's January 2026 Medication Administration Record (MAR) showed an order, Metoprolol Succinate 25 MG [milligram - unit of measurement] ER . Give 1 tablet by mouth one time a day for HTN [Hypertension - high blood pressure].Observation on 01/16/2026 at 8:28 AM, showed Staff Q, Registered Nurse, poured Resident 35's morning medication including Metoprolol Succinate 25 MG ER in a medication cup. Further observation showed Staff Q crushed Metoprolol Succinate 25 MG ER with the resident's other morning medications, mixed it with applesauce, and walked to Resident 35's room to administer the medication.In a joint record review and interview on 01/16/2026 at 8:41 AM with Staff Q, showed the January 2026 MAR revealed that Resident 35 had an order for Metoprolol Succinate 25 MG ER. Staff Q stated they crushed the medication due to Resident 35's swallowing difficulty.RESIDENT 10Review of Resident 10's January 2026 MAR showed an order, Aspirin [used to reduce pain, fever, swelling, and inflammation. It also acts as a blood thinner] 81 Oral Tablet Chewable.Give 1 tablet by mouth one time a day.Observation on 01/16/2026 at 8:45 AM, showed Staff Q was pouring Resident 10's morning medications. Staff Q poured an Aspirin Enteric Coated (designed to dissolve in the small intestine, potentially reducing stomach irritation) 81 mg tablet in a medication cup instead of the chewable form as ordered for Resident 10 and walked to Resident 10's room and administered the medication.In a joint record review and interview on 01/16/2026 at 8:48 AM with Staff Q, showed the January 2026 MAR revealed that Resident 10 had an order for Aspirin 81 Oral (by mouth) Tablet Chewable. Staff Q stated they did not have the chewable tablet in the medication cart. Staff Q further stated that the chewable tablet should have been administered.RESIDENT 12Review of Resident 12's January 2026 MAR showed an order, guaiFENesin [Guaifenesin] Oral Syrup [a drug that thins and loosens thick mucus in the chest and throat, making it easier to cough up phlegm] . Give 10 ml (milliliter - unit of measurement) by mouth four times a day for cough.Observation on 01/16/2026 at 10:16 AM, showed Staff R, Licensed Practical Nurse, poured 10 ml of Tussin DM (brand name - a medicine for cold symptoms, combining a cough suppressant [stop or reduce], Dextromethorphan [a drug used to temporarily relieve dry, hacking coughs caused by colds or flu]) and Guaifenesin in a medication cup instead of the Guaifenesin oral syrup as ordered. Further observation showed Staff R walked to Resident 12's room, attempted to administer the medication, and was stopped prior to administering the medication to Resident 12.In a joint record review and interview on 01/16/2026 at 10:23 AM with Staff R, showed the January 2026 MAR revealed that Resident 12 had an order for guaiFENesin Oral Syrup. Staff R stated, We do not carry Guaifenesin syrup. Staff R further stated they should have administered the actual medication as ordered, followed the physician order, and stated, I will call the doctor.RESIDENT 31Review of the quarterly Minimum Data Set (an assessment tool) dated 12/19/2025 showed Resident 31 had intact cognition.Review of Resident 31's January 2026 MAR showed an order, Fluticasone Propionate Nasal Suspension [medicine used to treat allergy symptoms] 50 MCG [microgram - unit of measurement]/ACT [actuation] . 1 spray in both nostrils [are the two external openings of the nose that lead to the nasal cavity] two times a day for allergies unsupervised self-administration.Observation on 01/20/2026 at 8:11 AM, showed Staff S, Registered Nurse, poured Resident 31's morning medication and administered the medication. The Fluticasone Propionate Nasal spray was not included in the resident's morning medication administration.In a joint record review and interview on 01/20/2026 at 8:58 AM with Staff S, showed the January 2026 MAR revealed that Resident 31 had an order for Fluticasone Propionate Nasal Suspension 50 MCG. Further review of the MAR showed the medication was marked as, U-SA [unsupervised self-administration] for this morning. When Staff S was asked how they knew if the resident self-administered the medication, Staff S stated that the medication did not show up on their Electronic Medication Administration Record (EMAR) to be administered. Staff S asked Resident 31 if they self-administered the nasal spray, Resident 31 stated that they were out of their nasal spray three days ago. Staff S stated that the EMAR self-marked as if the medication was administered and did not show in the morning schedule. In a phone interview on 01/21/2026 at 12:48 PM, Staff B, Director of Nursing Services, stated that they would expect nursing staff to follow the physician order, the medication administration rights, and professional standards.Reference: (WAC) 388-97-1060 (3)(k)(ii).

Based on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. In addition, the facility failed to ensure Transmission Based Precautions (TBP-specialized infection control measures used to prevent the spread of specific infections) were followed by 3 of 5 staff (Staff J, O & V), reviewed for infection control. The failure to change the face mask after exiting a TBP room, use of eye protection (face shield or goggles) before entering a TBP room and perform hand hygiene, placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included. According to Centers for Disease Control and Prevention (CDC-a public health agency) online publication titled, CDC's Core Infection Preventions and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024 showed that facility shall Provide written infection prevention policies and procedures that are available, current, and based on evidence-based guidelines. Review of the facility's policy titled, Infections-Clinical Protocol, revised in March 2018, showed, The physician or provider and staff will identify infection transmission risks and (in conjunction with the Infection Preventionist) will implement relevant precautions. Review of the facility's policy titled, Influenza [an infection of the nose, throat, and lungs], Prevention and Control of Seasonal, revised in March 2022, showed that one of the key aspects of infection control included review of TBP, appropriate use of personal protective equipment (PPE-gowns, gloves, masks, face shield/goggles) and hand hygiene. The policy further showed that droplet precautions (a TBP, measures taken to prevent spread of germs transmitted when a person coughs, sneezes, talks or breaths) were implemented for residents with suspected or confirmed influenza. IPCP ANNUAL REVIEW Review of the IPCP policies and procedures showed that they have not been reviewed at least annually. The following policies were last revised and/or dated below: -Antibiotic Stewardship was revised in December 2016 -Infection Surveillance was revised in September 2017 -Legionella (a type of waterborne organisms that can cause disease) Surveillance and Detection was revised in September 2022 -Influenza Vaccine (used to prevent influenza and Pneumococcal Vaccine (used to prevent lung infection) was revised March 2022 -Coronavirus Disease (COVID 19-a viral illness that causes fever, difficulty breathing or possibly death) Vaccination was revised in May 2023. In a telephone interview and joint record review on 01/21/2026 at 1:03 PM with Staff B, Director of Nursing Services/Infection Preventionist and Staff C, Regional [NAME] President for Operations, stated that they reviewed IPCP policies annually and that they talked about it in Quality Assurance and Performance Improvement (QAPI-a data driven and proactive approach to quality improvement) meetings. When asked, Staff B and Staff C stated that they would provide documentation of their IPCP annual review. On 01/21/2026 at 4:48 PM, no documentation regarding IPCP annual review was provided by the facility. TBP STAFF J Observation on 01/16/2026 at 8:43 AM, showed Staff J, Restorative Aide, had a face mask and wore a disposable gown, goggles and gloves and entered room [ROOM NUMBER] (a droplet precaution room). Another observation on 01/16/2026 at 8:47 AM, showed Staff J exited room [ROOM NUMBER] with their face mask on and walked towards the hallway to a room where they placed soiled linens in a covered bin. In an interview on 01/16/2026 at 8:49 AM, Staff J stated that they responded to the call light and provided a blanket to Resident 38 in room [ROOM NUMBER]. Staff J stated that Resident 38 was on droplet precaution due to influenza symptoms. When asked about donning (putting on) and removing PPE, Staff J stated that they did not change their face mask when they exited room [ROOM NUMBER]. Staff J further stated they were expected to remove and changed their face mask but I did not [change my face mask]. STAFF O Observation on 01/20/2026 at 8:09 AM, showed Staff O, Certified Nursing Assistant, delivered a breakfast tray meal to Resident 29 in room [ROOM NUMBER] who was on droplet precaution. Staff O had a face mask and did not have a face shield or goggles when they entered the room. Further observation showed Staff O was adjusting Resident 29's bed and was leaning over Resident 29 who could be heard coughing. Staff O then exited the room and went towards the nursing station and took a cup of coffee as requested by Resident 29. Staff O did not remove and/or change their face mask. In an interview on 01/20/2026 at 8:13 AM, Staff O stated that they knew about droplet precautions and stated, I should have put it [face shield] on. When further asked about their expectation regarding PPE, Staff O stated, I should have changed my mask and wear my face shield for residents on droplet precautions. In a phone interview on 01/21/2026 at 1:03 PM, Staff B stated that they expected staff to follow droplet precautions which included use of face shield or goggles. Staff B further stated that they expected staff to remove and/or change their face mask upon exit of rooms on droplet precautions. STAFF VObservations on 01/14/2026 at 10:46 AM, on 01/15/2026 at 2:32 PM, and on 01/20/2026 at 11:34 AM, showed droplet precaution signage was posted outside Resident 38's Room (room [ROOM NUMBER]). The droplet precaution signage instructed staff to clean their hands, including before entering and when leaving the room. It further instructed staff to make sure their eyes, nose, and mouth are fully covered before room entry and to remove face protection before room exit. Observation on 01/20/2026 at 8:37 AM, showed Staff V, Laundry Staff, delivering care supplies to residents' rooms. Staff V was observed wearing a mask and was not wearing a face shield or goggles and entered room [ROOM NUMBER] to deliver care supplies. Staff V did not change their face mask upon exiting room [ROOM NUMBER]. Staff V was then observed entering room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] to drop off care supplies. Staff V did not perform hand hygiene before entering and/or after exiting the rooms. In an interview on 01/20/2026 at 8:51 AM, Staff V stated that they were required to wear a face shield when they were entering room [ROOM NUMBER]. Staff V stated that they should have removed their mask before leaving room [ROOM NUMBER] and wore a new one before entering the next rooms. Staff V further stated that they should have performed hand hygiene before entering and after exiting each room. In a phone interview on 01/21/2026 at 10:59 AM, Staff B stated that staff were expected to follow all infection control protocols when providing care/dropping supplies to residents on droplet precautions. Staff B further stated that Staff V should have followed the droplet precaution signage instructions posted outside Resident 118's room. Reference: (WAC) 388-97-1320 (1)(a)(c),1780(2)(c)(d) .

Based on interview and record review, the facility failed to ensure a care conference or care plan meeting was conducted for 1 of 1 resident (Resident 3), reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed, Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care. The policy further stated, The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. Review of a face sheet printed on 01/14/2026 showed Resident 3 was admitted to the facility on [DATE]. In an interview on 01/13/2026 at 9:16 AM, Resident 3 stated that they did not remember participating in a care conference/care plan meeting. Review of Resident 3's Electronic Health Record (EHR-social services progress notes) dated 10/15/2025 showed a care conference was scheduled for 10/17/2025. Further review of the EHR did not show documentation that a care conference took place or Resident 3 had participated and/or refused to participate in the care conference/care plan meeting. In an interview and joint record review on 01/16/2026 at 3:29 PM, Staff E, Social Services Director (SW), stated that they scheduled care conferences/care plan meetings and would send invites to the Interdisciplinary Team (IDT) composed of the SW, therapist, doctors, nurses, the resident and/or their representatives. Staff E stated that they informed residents and/or their representatives in person, on the phone or email.depends on the person [resident]. Staff E stated that care conferences were documented and it [documentation] could be anybody or anyone attending the care conferences. A joint record review of Resident 3's EHR did not show IDT documentation regarding care conferences or if Resident 3 had participated or refused participation in the care planning process. Staff E stated they would follow up with Staff D, Admission/Minimum Data Set (MDS) Nurse, who was also involved with the care planning process. In an interview and joint record review on 01/21/2026 at 10:23 AM, Staff D stated that they developed care plans during the MDS (an assessment tool) process and upon a resident's admission to the facility. Staff D stated that they involved the resident and/or their representative in developing the care plan. When asked how they involved the resident and/or their representative in the care planning process, Staff D stated that they would conduct care plan meeting with the IDT and ask the resident and/or their representative to attend. A joint record review of Resident 3's EHR did not show a care plan meeting was conducted or that Resident 3 had been involved or refused to participate in the care plan meeting. Staff D stated, I don't [do not] see anything [care conferences/care plan meetings] in the record. No proof of it that I can find. In a phone interview and joint record review on 01/21/2026 at 12:17 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President for Operations, Staff B stated that they involved the resident and/or their representative and the IDT in care planning process. Staff B stated that the SW would inform residents about care conferences schedule and that the IDT would receive calendar/email invites about upcoming care conferences. Staff B stated that they expected residents were involved in the care planning process. A joint record review of Resident 3's EHR showed a care conference scheduled for 10/17/2025. Further joint record review did not show documentation that a care conference was conducted or that Resident 3 had participated or refused in the care conference/care plan meeting. Staff C stated, I search by progress notes.but I do not see anything. I personally could not find one that would show that there was a care conference held. Reference: (WAC) 388-97-1020 (2)(e)(f).

Based on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 1 of 1 resident (Resident 6), reviewed for Activities of Daily Living (ADL). The failure to provide bath/shower for a resident who was dependent on staff for assistance placed the resident at risk for poor hygiene, unmet care needs and a diminished quality of life. Findings included.Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Review the admission record printed on 01/20/2026 showed that Resident 6 was admitted to the facility on [DATE] with diagnosis that included generalized muscle weakness.Review of the quarterly Minimum Data Set (an assessment tool) dated 12/23/2025 showed Resident 6 had intact cognition and was dependent on staff for shower/bathing. Further review of the assessment showed that Resident 6's shower/bathing was important for them.In an interview on 01/13/2026 at 10:05 AM, Resident 6 stated they were not receiving bed bath consistently. Resident 6 further stated that there were times they went without a bed bath for two and a half weeks.Review of Resident 6's Kardex (care guide) printed on 01/20/2026 showed, BATHING: Requires dependent assistance with showering, offer bed bath if [Resident 6] chooses not to shower and notify the nurse .Bathing/Shower- Tues [Tuesday] and Sat [Saturday] Day.In an interview and joint record review on 01/21/2026 at 11:17 AM with Staff T, Certified Nursing Assistant, stated that Resident 6 was dependent with bathing. A joint record review of the undated shower schedule showed the resident was scheduled to have shower/bath every Tuesdays and Saturdays. Staff T stated if a resident refused shower/bath they would offer in another time and if they continued to refuse, they would document refusal and notify the Director of Nursing Services (DNS).Review of the November 2025 Documentation Survey Report showed that Resident 6's scheduled bathing/shower on 11/06/2025, 11/15/2025, and 11/23/2025 were blank or documented as, Activity itself did not occur.Review of the December 2025 Documentation Survey Report showed that Resident 6's scheduled bathing/shower on 12/02/2025, 12/06/2025, 12/09/2025, 12/13/2025, 12/23/2025, 12/27/2025, and 12/30/2025 were blank or documented as, Activity itself did not occur.Review of the January 2025 Documentation Survey Report showed that Resident 6's scheduled bathing/shower on 01/10/2026 and 01/13/2026 were documented as, Activity itself did not occur.Review of the progress notes from 11/01/2025 to 01/21/2025 showed no documentation that Resident 6 refused showers/bathing.In a phone interview and joint record review on 01/21/2026 at 12:03 PM with Staff B, DNS and Staff C, Regional [NAME] President for Operations, Staff B stated that staff were expected to provide shower/bath for residents as scheduled. A joint record review of Resident 6's Electronic Health Record under Task for 30 days look back period showed the resident's scheduled shower/bath documented as Activity itself did not occur on 12/27/2025, 12/30/2025, 01/10/2026, and 01/13/2026. Staff B stated if the resident refused shower, it should have been documented as a refusal and should have not been documented as, Activity itself did not occur.Reference: (WAC) 388-97-1060 (2)(c).

Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF - a method of delivering liquid nutrients, fluids, and medication directly into the stomach or small intestine through a flexible tube]) was administered in accordance with physician's orders and professional standards of practice for 1 of 1 resident (Resident 2), reviewed for TF. The failure to follow the physician's orders on the amount of formula to administer, document the amount of formula and water flush administered, and label, with date, and time TF formula bottle and water flush bag placed the resident at risk for unmet nutrition need, adverse health outcomes, and related complications.Findings included .Review of the facility policy titled, Enteral Nutrition, revised in November 2018, showed, Adequate nutritional support through enteral nutrition is provided to residents as ordered.Review of the admission record printed on 01/15/2026 showed that Resident 2 was admitted to the facility on [DATE].Review of the annual Minimum Data Set (an assessment tool) dated 10/15/2025 showed Resident 2 was severely impaired with cognition and dependent on staff with all aspects of care. Further review the assessment showed Resident 2 did not eat or drink and was receiving all nutrition and water through the TF.Review of Resident 2's TF physician order with start date of 12/12/2025, showed the resident had an order for, Osmolite 1.2 CAL [a type of TF formula] administer via Pump 85 ML [milliliter - unit of measurement] per hour. 60 ML water flushes every hour.Observation on 01/13/2026 at 8:27 AM, showed Resident 2 was receiving TF formula Osmolite 1.2 CAL running 75 ML per hour (10 ML less than what was ordered). Further observation showed both the TF formula bottle and water flush bag were not labeled or dated.Observation on 01/14/2026 at 8:07 AM, showed Resident 2 was receiving TF formula Osmolite 1.2 CAL running 75 ML per hour (10 ML less than what was ordered).Record review of the comprehensive care plan printed on 01/16/2026 showed Resident 2 had a TF care plan to, Provide enteral feeding as ordered. Record intake on MAR [Medication Administration Record].Review of Resident 2's MAR and Treatment Administration Record [TAR] for November 2025, December 2025, and January 2026 did not show records of the total amount of formula or water flush provided daily.In an interview and joint record review on 01/21/2026 at 9:09 AM, Staff Q, Registered Nurse, stated that they would follow Resident 2's TF physician order. Joint record review of Resident 2's January 2026 MAR and TAR showed there was no documentation of the total amount of TF formula or water flush provided daily. Staff Q stated they were not documenting the total amount of TF formula or water flush administered at end of their shift.Observation on 01/21/2026 at 9:13 AM, showed Resident 2 was receiving TF formula Osmolite 1.2 CAL running 75 ML per hour. Further observations showed both the TF formula bottle and water flush bag were not labeled or dated.In a joint observation and interview on 01/21/2026 9:17 AM with Staff Q showed Resident 2 was receiving TF formula and both the TF formula bottle and water flush bag were not labeled or dated. Staff Q stated that the formula bottle and the water flush bag were started by night shift and they were not labeled or dated. Staff Q further stated that it should have been labeled and dated.In a joint phone interview and record review on 01/21/2026 at 12:38 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President for Operations, Staff B stated that staff were expected to label the TF formula and the water flush bag with date and time, follow the TF physician order, and to document the amount of formula and water flush infused during the shift. A joint record review of Resident 2's January 2026 MAR/TAR did not show records of the total amount of TF formula or water flush. Staff B stated that they expected that the total amount of formula infused and water flush provided were documented each shift. Reference: (WAC) 388-97-1060 (3)(f).

Based on observation, interview, and record review, the facility failed to develop and/or implement a care plan for 3 of 15 residents (Residents 2, 15 & 36), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for pressure ulcer (bed sore), anticoagulant (blood thinner), diuretics (water pills-medications that make kidneys produce more urine) and dementia (memory loss) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set – an assessment tool] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. RESIDENT 2Review of the admission record printed on 01/15/2026 showed that Resident 2 was admitted to the facility on [DATE]. Review of the annual MDS dated [DATE] showed Resident 2 was severely impaired with cognition. Further review the assessment showed Resident 2 was receiving an anticoagulant medication during the assessment period. Review of the October 2025, November 2025, December 2025, and January 2025 Medication Administration Record (MAR) showed Resident 2 was receiving an anticoagulant and diuretic medications. Review of the weekly wound observation tool dated 12/03/2025 showed Resident 2 developed a facility acquired pressure ulcer wound on their left heel. Observation on 01/16/2026 at 3:36 PM, showed Staff D, Admission/MDS Coordinator and Staff P, Registered Nurse (RN), were providing wound treatment for Resident 2's left heel pressure ulcer. Staff P stated Resident 2's left heel wound was a pressure ulcer. Review of Resident 2's comprehensive care plan printed on 01/16/2025 showed that there was no care plans developed for Resident 2's pressure ulcer wound, anticoagulant or diuretic medications. In an interview and joint record review on 01/21/2026 at 10:46 AM, Staff D stated that the comprehensive care plan would be completed upon MDS completion and would be updated when there was a change in the resident's condition. A joint record review of Resident 2's comprehensive care plan printed on 01/16/2025 showed that there was no care plan developed for Resident 2's pressure ulcer wound, anticoagulant or diuretic medications. Staff D stated that there was no care plan initiated for Resident 2's pressure ulcer, anticoagulant or diuretic medications and it should have been. In a phone interview and joint record review on 01/21/2026 at 12:17 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President for Operations, Staff B stated that care plan would be initiated for residents with pressure ulcer wound and residents receiving anticoagulant or diuretic medications. A joint record review of Resident 2's comprehensive care plan showed there were no care plans for pressure ulcer, anticoagulant and diuretic medications. Staff B stated that care plans for Resident 2's pressure ulcer wound, anticoagulant and diuretic medications should have been initiated. RESIDENT 15Review of the provider order summary report and the January 2025 MAR printed on 01/14/2026 showed that Resident 15 was prescribed and given Torsemide (diuretic) for congestive heart failure (condition where the heart's inability to pump blood effectively). Review of a comprehensive care plan printed on 01/14/2026 showed that Resident 15 had no care plan for diuretic medication. In an interview and joint record review on 01/21/2026 at 10:58 AM, Staff D stated that they would update the care plan to reflect any new concerns, issues, or changes. A joint record review of Resident 15's comprehensive care plan showed that Resident 15 had no care plan for diuretic medication. Staff D stated they did not see a care plan for diuretic medication and that there should be. A joint record review and phone interview on 01/21/2026 at 12:17 PM with Staff B and Staff C, showed there was no diuretic care plan for Resident 15. Staff B stated that there was no diuretic medication care plan for Resident 15 and that they expected there to be.RESIDENT 36Review of the admission record printed on 01/14/2026 showed that Resident 36 was re-admitted to the facility on [DATE] with a diagnosis that included dementia. Review of a comprehensive care plan printed on 01/13/2026 showed that Resident 36 had no care plan for dementia. In an interview and joint record review on 01/20/2026 at 3:11 PM with Staff AA, RN, stated that Resident 36 had dementia. A joint record review of Resident 36's electronic health record (diagnosis and care plan) showed Resident 36 had a diagnosis of dementia and no care plan for it. Staff AA stated there was an impaired cognitive function care plan but no separate dementia care plan. A joint record review and phone interview on 01/21/2026 at 12:17 PM with Staff B and Staff C, showed there was no dementia care plan for Resident 36. Staff B stated, there was no care plan specifically for dementia but there are other care plans that included the interventions for dementia care. Reference: (WAC) 388-97-1020(1), (2)(a)(b) .

Based on interview and record review, the facility failed to provide bed hold and/or transfer notices to the residents and/or their representatives in writing for 2 of 2 residents (Residents 25 & 32), reviewed for hospitalization. These failures placed the residents at risk of not having an opportunity to make an informed decision about their transfers.Findings included. Review of the facility's policy titled, Bed-Hold and Returns, revised in October 2022, showed, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). The policy further showed, Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours). Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed that under certain circumstances such as when the safety or health of individuals in the facility would be endangered, when a resident's condition allows for a more immediate transfer or discharge, or when urgent medical needs require it the notice must be provided as soon as practicable but prior to the transfer or discharge. The policy further showed that residents and their representatives must be notified in writing of the specific reason for the transfer or discharge, the effective date, and the location to which the resident will be transferred or discharged . RESIDENT 25Review of a discharge Minimum Data Set (MDS- an assessment tool) dated 12/05/2025 showed Resident 25 had an unplanned discharge to a Short Term General Hospital. Review of a nursing progress note dated 12/05/2025 showed that Resident 25 discharged to the hospital on [DATE] for further evaluation. Further review of the note did not show a bed hold and/or written transfer notice was provided to Resident 25. In an interview and joint record review on 01/15/2026 at 9:14 AM, Staff E, Social Services Director, stated that the facility's process was that after a resident transferred to the hospital, the facility would provide the bed hold notice. Staff E stated that the bed hold notice was not provided to Resident 25 and/or their representative. A joint record review of Resident 25's Electronic Health Record (EHR) did not show that a bed hold notice was provided to Resident 25 and/or their representative. Staff E stated that the bed hold notice should have been provided to Resident 25 and/or their representative and documented in the resident's EHR. When asked whether a written notice explaining the reason for the transfer was provided to Resident 25 and/or their representative, Staff E stated that the communication was only verbal and that no written notice was given. In a phone interview on 01/21/2026 at 10:59 AM, Staff B, Director of Nursing Services (DNS), stated that their expectation was that an assessment was completed, communication had occurred with the provider, the family, and the hospital. Staff B further stated that the eINTERACT Transfer Form (an electronic guide tool completed during resident change of condition) should be completed and provided to residents for every transfer, and that a bed hold notice must be given to the resident and/or their representative. Staff B stated that the eINTERACT form should have been completed and a copy was provided to Resident 25 and/or their representative. Staff B further stated that a bed hold notice should also have been provided to Resident 25 and/or their representative. RESIDENT 32Review of Resident 32's EHR in the progress notes, discharge MDS, and miscellaneous/documents tab, showed Resident 32 was transferred to the hospital on [DATE]. Resident 32's EHR showed no written notification of transfer/discharge was provided to Resident 32 and/or their representative. In an interview and joint record review on 01/20/2026 at 11:29 AM, Staff D, Admission/MDS coordinator, stated that transfer/discharge process included provider notification, provider order, completion of eINTERACT Transfer Form, family notification, transportation communication, completion of progress note, and DNS notification. A joint record review of Resident 32's EHR showed no written notification of transfer/discharge was provided to Resident 32 and/or their representative. Further joint record review showed an eINTERACT Transfer Form that was incomplete and blank. Staff D stated the transfer form was not done. In an interview on 01/20/2026 at 11:46 AM, Staff E stated that there was no written notice of transfer/discharge provided to Resident 32 and/or their representative. In a phone interview and joint record review on 01/21/2026 at 12:17 PM with Staff B and Staff C, Regional [NAME] President for Operations, Staff B stated the eINTERACT Transfer Form was the written notification form given to the resident and/or their representative. A joint record review of Resident 32's EHR showed an incomplete/blank eINTERACT Transfer Form. Staff C stated that the eINTERACT Transfer Form was not complete for Resident 32. Staff B stated that the eINTERACT Transfer Form should have been completed and copy provided to Resident 32 and/or their representative when they were discharged /transferred to the hospital. Reference: (WAC) 388-97-0120 (2) (a-c) (4) .

Based on interview and record review, the facility failed to ensure report of an incident was thoroughly investigated for 1 of 2 residents (Resident 8), reviewed for accidents. The failure to investigate a fall incident placed the resident at risk for unidentified neglect or mistreatment and a diminished quality of life.Findings included.Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences.Review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting, revised in July 2017, showed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.Review of a face sheet printed on 01/14/2026 showed Resident 8 was admitted to the facility on [DATE].Review of the admission Minimum Data Set (MDS-an assessment tool) dated 11/28/2025 showed Resident 8 had intact cognition.In an interview on 01/13/2026 at 10:10 AM, Resident 8 stated that they went out for an appointment through a medical transport service. Resident 8 stated that they had an incident that happened last week [on] Thursday [01/08/2026]. [I] hit the ground. The driver pushed me up the ramp but then the wheelchair rolled back and I hit the ground. Resident 8 stated that they had informed a therapist about the incident when they returned to the facility after their appointment. Resident 8 further stated that they were sent out to the hospital for further evaluation on 01/08/2026.Review of Resident 8's Electronic Health Record (EHR) showed a therapy progress notes [documented by Staff U, Physical Therapy Assistant], dated 01/08/2026, showed Resident 8 had a fall when they went out for an appointment. Further review of Resident 8's EHR did not show other documentations related to a fall incident on 01/08/2026.Review of the facility's January 2026 Incident log did not show Resident 8's fall incident on 01/08/2026.In a follow-up interview on 01/20/2026 at 8:27 AM, Resident 8 stated that they had told other people about the incident on 01/08/2026 but I don't [do not] remember their names, but there is one person who always comes to the kitchen. I think she supervises them, I told her.In an interview on 01/20/2026 at 2:41 PM, Staff U stated that they provided Resident 8 physical therapy. Staff U stated that on 01/08/2026 Resident 8 complained about neck pain and informed them about the fall incident. Staff U stated that they documented it on their therapy notes and that Staff Y, Director of Rehabilitation, was present when Staff U was talking with Resident 8.In an interview on 01/20/2026 at 2:48 PM, Staff Y stated, I spoke with nursing.It may have been [Staff D, Admission/MDS Coordinator] and [Staff D] also works at the same time on the floor. I told them what happened to [Resident 8] and that [Resident 8's] wheelchair tipped over.In an interview on 01/20/2026 at 3:55 PM, Staff D stated that [Resident 8] told me about it on the 8th [01/08/2026]. The van was on a hill, and the ramp was kind of slanted and when the driver pushed the wheelchair, the wheelchair tilted. Staff D stated, I let [Staff B, Director of Nursing Services] know about it right after I have spoken to [Resident 8]. I informed [Staff B] verbally. Staff D further stated that Resident 8 was sent out to an acute care hospital for evaluation. When asked if there was an investigation about Resident 8's incident, Staff D stated, Not to my knowledge.In a phone interview on 01/21/2026 at 10:59 AM, Staff B stated that Staff D informed them about Resident 8's incident. Staff B stated that they did not do an investigation because [Resident 8] did not say that [they] had a fall. [They] said [their] wheelchair tipped. Staff B stated that they were expected to investigate accidents and/or incidents. Staff B further stated, I should have done more of an investigation about it.Reference: (WAC) 388-97-0640 (6)(a).

Based on interview and record review, the facility failed to provide information regarding advance directive (a written instruction, such as a living will or Durable Power of Attorney for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) for 1 of 3 residents (Resident 3), reviewed for advance directives. This failure placed the resident at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice.Findings included.Review of the facility's policy titled, Advance Directives, revised in September 2022, showed that the resident has the right to formulate an advance directive. The policy further showed that upon admission of a resident, the facility would inquire about existence of any written advance directive and that a written information about formulation of an advance directive would be provided to the resident.Review of the face sheet printed on 01/14/2026 showed Resident 3 was admitted to the facility on [DATE].Review of Resident 3's Electronic Health Record (EHR) did not show documentation that an advance directive had been discussed and/or Resident 3 had been provided information about advance directive.In an interview on 01/14/2026 at 9:00 AM, Resident 3 stated that they knew about what an advance directive is but I don't [do not] remember it being discussed.In an interview and joint record review on 01/15/2026 at 1:41 PM, Staff E, Social Worker, stated that their process was to discuss advance directives upon admission of residents, during care conferences and as needed. Staff E stated that they had informed Resident 3 about the advance directives and that most of the conversation was on the phone. A joint record review of Resident 3's EHR did not show documentation that an advance directives were discussed with Resident 3.In a follow-up interview on 01/16/2026 at 3:21 PM, Staff E stated, There is no documentation to support that the advance directive was discussed with [Resident 3].In an interview on 01/20/2026 at 2:54 PM, Staff A, Administrator, stated that if a resident do not [have an advance directives], we educate them.we should continue to document our efforts that we are asking for the advance directives. Staff A stated, I don't [do not] see any documentation that an advance directive was discussed or offered to [Resident 3]. Staff A further stated that it should have been discussed with Resident 3.Reference: (WAC) 388-97-0280 (3)(a)(c).

Based on observation, interview, and record review, the facility failed to ensure the resident was evaluated, assessed, and care planned for self-administration of medications for 1 of 1 resident (Resident 23), reviewed for self-administration of medications. This failure placed the residents at risk for medication errors, adverse reactions, and related complications.Findings included.Review of the facility's policy titled, Self-Administration of Medications, revised in February 2021, showed that the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do. The policy further stated, If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status.Review of Resident 23's electronic health record (EHR - assessments and progress notes), physician orders, and care plan printed on 01/15/2026 did not show documentation for assessment or evaluation, physician order, or care plan related to self-administration of medications.Observation on 01/13/2026 at 11:18 AM and on 01/15/2026 at 10:11 AM, showed that Resident 23 had two prescription tubes of Lidocaine (pain medication) cream 2% (percent) in individual box with instructions to apply topically (on the skin) as needed to fistula (a surgical connection made between an artery and vein to receive dialysis [medical treatment that filters waste and excess fluid from the blood]) for pain and one prescription bottle of Ammonium Lactate (lotion/cream used to treat dry, scaly, itchy skin conditions) 12% apply to dry skin topically two times a day on their bedside table.In an interview on 01/15/2026 at 10:11 AM, Resident 23 stated that they did not apply the Lidocaine cream, the nurse at the facility and at the dialysis center put the Lidocaine cream on them. Resident 23 stated that they would apply the Ammonium Lactate lotion themselves to their arms, feet, and legs. Resident 23 further stated that they would keep both the Lidocaine cream and Ammonium Lactate lotion on the bedside table.In an interview and joint observation on 01/15/2026 at 12:49 PM, Staff S, Registered Nurse, stated that if a resident wants to self-administer their medications, they would assess the resident's cognition and check the assessment in the computer and monitor the resident when they take the medications. A joint observation of Resident 23's room showed one prescription tube of Lidocaine cream 2% and one prescription bottle of Ammonium Lactate 12% on their bedside table. Staff S stated they would check if Resident 23 was able to self-administer their medications. A joint record review of Resident 23's January 2026 medication administration record, physician orders, and assessments showed no documentation for self-administration of medications. Staff S stated they did not see in the records that Resident 23 could self-administer their medications and that there should be a self-administration of medications assessment.In a joint phone interview and record review on 01/21/2026 at 12:17 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President of Operations, Staff B stated that they expected residents who want to self-administer their own medications would have an assessment, physician order, and care plan. A joint record review of Resident 23's EHR did not show an assessment, physician order, or care plan for self-administration of medications. Staff B stated that they expected Resident 23 to have a self-administration of medications assessment, physician order, and care plan.Reference: (WAC) 388-97-0440, 1060(3)(l).

Based on observation and interview, the facility failed to ensure the Oxygen Storage Room door electronic keypad lock was functioning for 1 of 1 oxygen storage room, reviewed for accident hazards. This failure placed residents at risk of accidents, injuries and a diminished quality of life.Findings included .Observations on 01/13/2026 at 2:58 PM, on 01/14/2026 at 8:29 AM, on 01/16/2026 at 3:51 PM, and on 01/20/2026 at 8:43 AM, showed the door to the oxygen storage room to be unlocked and accessible without inputting the code into the electronic keypad lock.In an interview and joint observation on 01/20/2026 at 9:42 AM, Staff W, Certified Nursing Assistant, stated that the doors with the electronic keypad locks were locked so the residents did not have access to those rooms and to prevent them from getting hurt. A joint observation of the oxygen storage room showed the door was unlocked and accessible without inputting the code into the electronic keypad lock. Staff W stated the door should have been locked due to residents could get hurt from the oxygen tanks.In an interview and joint observation on 01/20/2026 at 11:07 AM, Staff X, Maintenance Director, stated the doors with the electronic keypad locks were locked for safety. A joint observation of the oxygen storage room showed the door was unlocked and accessible without inputting the code into the electronic keypad lock. Staff X stated the door should have been locked and not accessible to residents and/or not qualified people due to the safety of oxygen tanks, oxygen liquid refill, and explosion risks.In a phone interview on 01/21/2026 at 3:03 PM, Staff A, Administrator, stated the oxygen storage room electronic keypad lock should have been functioning and should have been locked.Reference: (WAC) 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to employ sufficient staff that were adequately trained to properly perform kitchen sanitization practices (sanitizing buckets) and safely carry out functions of meal preparation (use of food thermometer) for 2 of 4 dietary staff (Staff L & Staff M), reviewed for food safety. These failures placed the residents at risk for food-borne illnesses (caused by ingestion of contaminated food or beverages) and a diminished quality of life.Findings included. Review of the Washington State Retail Food Code dated 03/01/2022, showed, Employees are properly sanitizing.multiuse equipment and utensils before they are reused, through routine monitoring.including the application of sanitizing chemicals by manual swabbing.Contact times must be consistent with those on EPA [Environmental Protection Agency-United States agency safeguarding human health and protecting the environment]-registered label use instructions. The policy further showed, Concentration of the sanitizing solution must be accurately determined by using a test kit [the strip is dipped in the sanitizing solution and compared the result with the color chart that indicates ppm range] or other device. Review of the undated facility's kitchen signage titled, Sanitizing Bucket Procedures, showed how to prepare a sanitizing bucket which included testing of solution with test strips for proper PPM (parts per million - unit of measure for concentration) and the required PPM of 200-400 ppm. SANITIZING BUCKETSTAFF LReview of the facility's staffing list showed Staff L, Dietary Aide, was hired on 11/16/2020. In an interview and joint observation on 01/16/2026 at 10:59 AM, Staff L stated that they test the sanitizing bucket three times a day and log the result in the form posted in the kitchen. When asked, Staff L took a test strip (used for measuring sanitizer ppm) and dipped it in the sanitizing bucket. Staff L stated, it is 200 [ppm without comparing it to the color chart]. A joint observation of the test strip showed a shade of green. When asked how they could tell that the test strip indicated 200 ppm, Staff L stated, because it is green. My manager told me that if it is green, that is 200 [ppm]. Staff L further stated that they had not used a color chart (indicating ppm range by color) to show the result of the test. STAFF MReview of the facility's staffing list showed Staff M, Cook, was hired on 12/23/2025. In an interview and joint observation on 01/16/2026 at 11:07 AM, Staff M stated that they prepared the sanitizing bucket in the morning. When asked where they took the water to fill in the sanitizing bucket, Staff M pointed to the three-compartment sink across the kitchen and showed the grey hose attached to a compartment with a connected plastic tubing attached to a container labeled Broad Range Quaternary Sanitizer [disinfectant to kill germs]. Staff M proceeded to take a test strip and dipped it in the sanitizing bucket. A joint observation showed the test strip turned pale green. Staff M stated, that is good [ppm range]. When asked how they could know that the sanitizing solution was good to use as disinfectant, Staff M stated, I just know because the color change. I don't [do not] know about the color chart. USE OF FOOD THERMOMETERObservation on 01/16/2026 at 10:28 AM showed Staff M wiping the kitchen countertops with a towel from the sanitizing bucket. Observation and interview on 01/16/2026 at 11:57 AM, showed Staff M used a food thermometer to check the temperature of hamburger steak patties on a metal bowl and then Staff M took a small towel from the sanitizing bucket and wiped off the food thermometer. Staff M immediately proceeded to check the mashed potatoes and used the same towel to wipe off the food thermometer. When asked, Staff M stated that they had been doing the same process where they would use the towel from the sanitizing bucket to wipe off/sanitize the food thermometer. Staff M stated that they removed the used towel from the sanitizing bucket and replaced with a new towel. When asked, Staff M stated that they did not change the water solution from the sanitizing bucket when they replaced the towel. Observation on 01/16/2026 at 12:29 PM, showed Staff A, Administrator, instructed Staff M about using the disposable probe wipes to sanitize the food thermometer. Staff A was heard telling Staff M, We do not use the towel from the sanitizing bucket to clean the [food] thermometer. We use these probe wipes for the food thermometer. On 01/16/2026 at 3:05 PM, Staff A handed in a three-page form titled, Skills Performance Check List. Review of the forms showed a first set of column labeled, Cook: Competency Skills Check with different skills listed below and another two separate columns labeled MET and NOT MET. Further review of the forms showed they were blank, undated, and did not show the employee and/or the evaluator signature as presented on the form. In an interview and joint record review on 01/16/2026 at 3:52 PM, Staff A stated that they did not have a dietary manager or a food service director and that they had basically taken the role of a dietary manager. Staff A stated that they talked to staff about sanitizing bucket and how to check and use the test strips. Staff A stated that there was no actual demonstration but just [a] review. And they [staff] trained with a seasoned [NAME] [Staff G). Staff A stated that they conducted orientation training and competencies skill checks for Staff M. A joint record review of the three-paged forms titled, Skills Performance Check list, showed that they were blank and unsigned. Staff A stated that the forms were used for Staff M. Further joint record review of the forms did not show if Staff M had met or not met the competencies skills. When asked, Staff A stated that the competencies were discussed with Staff M. When asked why they were blank and not signed, Staff A stated they verbally discussed the competencies with Staff M but did not complete the paperwork. Staff A stated that they did not have documentation to show Staff M had completed the skills checklist. Staff A further stated that they expected kitchen staff to follow procedures regarding proper testing of sanitizing bucket and using probe wipes to sanitize food thermometer between checking of food temperature. Reference: (WAC) 388-97-1160.

Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) were up to date and offered to 2 of 5 residents (Residents 2 & 36), reviewed for pneumococcal immunizations. This failure placed the residents at risk for acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal disease.Findings included. Review of the facility's policy titled, Pneumococcal Vaccine, revised in March 2022, showed, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility.The policy further showed that Administration of the pneumococcal vaccines is made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations. According to CDC's official website publication titled, Adult Immunization Schedule Notes, dated 10/07/2025, showed an adult who had previously received both PCV [Pneumococcal Conjugate Vaccine-a type of vaccine]13 and PPSV [Pneumococcal Polysaccharide Vaccine- a type of vaccine]23 but NO PPSV23 was received at age [AGE] years or older will have one dose PCV20 or one dose PCV21 at least 5 [five] years after the last pneumococcal vaccine dose. RESIDENT 2Review of a face sheet printed on 01/20/2026 showed Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Electronic Health Record (EHR) did not show immunization record for pneumococcal vaccine. Further review of the EHR did not show Resident 2 was offered the pneumococcal vaccine. RESIDENT 36Review of Resident 36's face sheet printed on 01/20/2026 showed their birthdate of 04/20/1950. Review of Resident 36's immunization record showed they received their PPV23 on 10/19/2004 when they were [AGE] years old and their PCV13 on 02/19/2019. Further review of the immunization record did not show Resident 36 was offered or received the recommended one dose PCV20 or one dose PCV21 at least 5 years after their last pneumococcal vaccine dose in 2019. In a joint phone interview and record review on 01/21/2026 at 1:03 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President for Operations, Staff B stated that they offered pneumococcal vaccines to their residents annually and that they followed the CDC immunization guidelines A joint record review of Resident 2's EHR did not show immunization record for pneumococcal vaccine or if the pneumococcal vaccine was offered to Resident 2. Further joint record review of the EHR did not show Resident 36 was offered or received the recommended dose of PCV20 or one dose PCV21 at least 5 years after their last pneumococcal vaccine dose in 2019. Staff B stated that Resident 36's pneumococcal immunization was not up to date. Staff C stated that they did not see Resident 2's pneumococcal immunization record and Resident 36's PCV20 or PCV21 record in the EHR. Reference: (WAC) 388-97-1340 (2).

Based on observation, interview, and record review, the facility failed to properly store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use and have a proper physician order in place for 1 of 3 residents (Resident 19), reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications.Findings included .Review of the facility policy titled, CPAP/BiPAP [Bilevel Positive Airway Pressure - breathing support device that delivers two pressure levels] Support, revised in March 2015, directed staff to document the CPAP settings in the resident's medical record.Review of the admission record printed on 01/20/2026 showed Resident 19 was admitted to the facility on [DATE] with diagnosis that included obstructive sleep apnea (a sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep and causes unrestful sleep).Review of the quarterly Minimum Data Set (an assessment tool) dated 12/03/2025 showed Resident 19 had intact cognition. The assessment further showed Resident 19 had obstructive sleep apnea.Review of the January 2026 Treatment Administration Record showed that Resident 19 had an order, CPAP assist to set up and take off daily two times a day with a start date of 09/05/2024.Review of the comprehensive care plan printed on 01/14/2026 showed Resident 19 had altered respiratory status/difficulty breathing related to sleep apnea and an intervention, CPAP SETTINGS: Per orders as tolerated.Review of the order summary report active as of 01/21/2026 did not show an order for Resident 19's CPAP settings.Observations on 01/13/2026 at 8:26 AM, on 01/14/2026 at 9:08 AM, on 01/15/2026 at 7:59 AM, and on 01/20/2026 at 7:57 AM showed Resident 19's CPAP machine was sitting on the resident's nightstand, and the CPAP nasal mask was not covered and sitting in the Resident's nightstand drawer with Resident 19's other personal items.In an interview on 01/20/2026 at 1:58 PM, Resident 19 stated that they did not know their CPAP settings. Resident 19 further stated that their CPAP nasal mask would always be stored in their nightstand drawer when not in use.In an interview and observation on 01/20/2026 at 2:07 PM, Staff D, Admission/MDS Coordinator, stated that CPAP mask would be stored in a bag when not in use. When asked Resident 19's CPAP setting order, Staff D stated, I do not see the setting of the CPAP in the resident's orders. A joint observation showed Resident 19's CPAP nasal mask was not covered and sitting on the resident's bed.In a phone interview and joint record review on 01/21/2026 at 12:14 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President for Operations, Staff B stated that CPAP nasal mask would be stored in a bag and labeled when not in use. A joint record review of Resident 19's active physician order as of 01/21/2026 did not show CPAP setting order. Staff B stated that CPAP setting order should have been entered in the resident's medical record.Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on observation, interview, and record review, the facility failed to properly store biologicals (diverse group of medicines made from natural sources) in accordance with Centers for Disease Control and Prevention (CDC) guidelines and accepted professional standards for 1 of 1 medication refrigerator (Medication Room Refrigerator), reviewed for medication storage. In addition, the facility failed to properly store drugs for 1 of 1 resident (Resident 23). These failures placed the residents at risk for receiving compromised and ineffective medications/biological and medication errors.Finding included. Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. MEDICATION ROOM REFRIGERATORAccording to the CDC's guideline titled, Vaccine Storage and Handling, dated 03/19/2024, showed, Keep your storage units and vaccines within the appropriate temperature ranges. Check and record storage unit min [minimum]/max [maximum] temperatures at the start of each workday. If your device does not display min/max temperatures, then check and record current temperature a minimum of 2 [two] times (at start and end of workday). In a joint observation on 01/21/2026 at 9:39 AM with Staff D, Admission/Minimum Data Set Coordinator, showed there were two vials of Pneumonia (a lung infection) vaccination stored in the facility's medication room refrigerator. Review of the facility's medication room refrigerator temperature log for January 2026 showed that the refrigerator's temperature was checked once a day in AM. The log had a written direction that stated, Temps [Temperatures] need to be taken twice daily when vaccines are present. Further review of the temperature log showed it was checked once a day during AM from 01/01/2026 to 01/19/2026 except on 01/13/2026. In a phone interview and joint record review on 01/21/2026 at 12:56 PM with Staff B, Director of Nursing Services, and Staff C, Regional [NAME] President for Operations, Staff B stated that they expected medication refrigerator temperature to be checked twice a day. A joint record review of the facility's medication refrigerator temperature log for January 2026 showed that the temperature was checked once a day during AM only. Staff B stated that the refrigerator temperature should have been checked twice a day. RESIDENT 23Review of the facility's policy titled, Self-Administration of Medications, revised in February 2021, showed, Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident request them. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Review of Resident 23's electronic health record (assessments and progress notes), provider orders and care plan printed on 01/15/2026 showed no resident assessment or evaluation for self-administration of medications, no provider orders, and no care plan for self-administration of medications. Observation on 01/13/2026 at 11:18 AM and on 01/15/2026 at 10:11 AM, showed that Resident 23 had two prescription tubes of Lidocaine (pain medication) cream 2% (percent) in individual box with instructions to apply topically as needed to fistula (a surgical connection made between an artery and vein to receive dialysis [medical treatment that filters waste and excess fluid from the blood]) for pain and one prescription bottle of Ammonium Lactate (lotion/cream used to treat dry, scaly, itchy skin conditions) 12% apply to dry skin topically two times a day on their bedside table. A joint observation on 01/15/2026 at 12:49 PM with Staff S, Registered Nurse, showed Resident 23's room had one prescription tube of Lidocaine cream 2% and one prescription bottle of Ammonium Lactate 12% on their bedside table. Staff S stated they would check if Resident 23 was able to self-administer their medications. Staff S stated they did not see in the records that Resident 23 could self-administer their medications. Staff S further stated the Lidocaine cream and Ammonium Lactate lotion should not be on the bedside table. In a phone interview on 01/21/2026 at 12:17 PM with Staff B stated that Resident 23's Lidocaine cream and Ammonium Lactate lotion should have been stored in a locked box with key or in a place where they could lock it up. Reference: (WAC) 388-97-1300 (2) .

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for weight loss and dehydration (lack of necessary fluid intake) were free from neglect when services to provide needed nutrition and hydration were not consistently provided. There was a lack of assessment, follow-up when food and fluid intake was significantly low, and involvement of healthcare professionals to address the low intake. This failure caused harm to Resident 1 who had a significant and unplanned weight loss, dehydration, decline in nutritional status and related complications. Findings included . The facility policy titled, Abuse and Neglect-Clinical Protocol, with a revised date of March 2018, showed Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Treatment/Management: The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. UNPLANNED SIGNIFICANT WEIGHT LOSS RESIDENT 1 Resident 1 readmitted to the facility on [DATE]. Review of a medical nutrition assessment dated [DATE], showed at the time of the assessment the resident weighed 142 pounds (lbs., unit of mass/weight). Supplements were appropriate to maximize intake and meet nutritional needs. Interventions included diet and supplements as ordered, and follow-up as needed. The medical nutritional assessment also showed the resident would meet nutritional needs with 62% of meal intakes. Review of the nutritional care plan dated 09/16/2022, showed the resident had a history of unplanned and unexpected weight loss related to poor food intake. Further review of the nutritional care plan, revised on 08/15/2023, showed the goal was for the resident to consume more than 50% of two of the three meals a day and to maintain weight between 135 to 150 lbs. Interventions included: give supplements as ordered, alert nurse/dietician (expert health professional in nutrition and human diets) if not consuming meals on a regular basis and monitor and evaluate any weight loss. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 10/09/2023, showed Resident 1 had a diagnosis of dysphagia (difficulty swallowing food or fluids) that resulted from a cerebral infarct (stroke). The MDS also showed Resident 1 had hemiplegia (weakness/loss of body function) [on the right side of the body] and required supervision and some [touching] assistance to eat. The resident's weight on 10/28/2023 was 139.7 lbs. and on 11/18/2023 it was 127.5 lbs., and continued to decline to 124 lbs. on 11/25/2023, which totaled a significant weight loss of 16 lbs. (11.4%) within a month. Review of Resident 1's meal intake record showed the following: 11/22/2023= two meal refusals; one meal at 0-25% consumed 11/23/2023= two meals at 0-25% consumed; one meal at 26-50% 11/24/2023= one refused meal; two meals 0-25% consumed 11/25/2023= one meal refused; one meal at 0-25%; one meal at 26-50% There was no documented meal intake on the electronic meal record for 11/26/2023 11/27/2023= two meal intakes at 0-25% Review of the November 2023 Medication Administration Record (MAR) showed an order dated 06/27/2023 for a nutritional supplement 90 milliliters (ml, unit of measurement) two times a day to maintain nutritional status. Further review of the MAR showed no documentation that the resident was administered the nutritional supplement from 11/20/2023 to 11/27/2023. Resident 1 had no documented meal intakes that showed more than 50% of two of the three meals a day that were consumed between 11/22/2023 to 11/27/2023. The resident weighed 124 lbs. on 11/25/2023. During an interview on 12/15/2023 at 10:50 AM with Staff C, Certified Nursing Assistant, stated the residents were offered a different meal or a snack if they ate less than 50% of a meal. Staff C also stated that whenever a resident had a meal, a snack or drank any fluids, it was documented on the electronic meal record. Staff C further stated that Resident 1 did require some assistance to eat and drink. During an interview on 12/15/2023 at 11:01 AM with Staff D, Registered Nurse, stated that the amount of the nutritional supplement the resident drank would be documented on the MAR. Staff D also stated that the Director of Nursing Services (DNS) would be informed if residents started to lose weight. During an interview on 12/15/2023 at 9:51 AM Staff B, DNS, stated the Registered Dietician (RD) was notified by phone when residents had a weight change and was also able to view weight changes electronically. Staff B further stated that they were aware of Resident 1's significant weight loss but did not notify the RD of the weight loss. FLUID INTAKE Resident 1 Review of the medical nutrition assessment dated [DATE], showed to meet 70% of Resident 1's fluid needs, 1,137 ml of fluid would need to be consumed daily. Review of the daily fluid intake from 11/15/2023 to 11/25/2023 showed the resident's fluid intake did not meet the recommended daily fluid needs with the exception on 11/20/2023, and there was no documented fluid intake for 11/26/2023. Review of the November 2023 MAR showed on 11/03/2023 and 11/04/2023, Resident 1 was administered sodium chloride intravenous (IV fluids administered through a vein) solution two liters one time a day for two days for dehydration. During an interview on 12/14/2023 at 3:45 PM with Collateral Contact 1 (CC1), stated I told the staff at the facility that there was weight loss, they lost like 10 lbs. in a month. I would go to the nursing staff and asked them what they were going to do and would never get a straight answer. I asked the nursing staff if we could get an IV to give them some fluids. They did it for a few days and then it stopped. We were never offered anything to help with the weight loss or the consistent poor fluid intake. We would have done a trial of a feeding by tube [medical device used to provide nutrition who cannot obtain nutrition by mouth] to try and get enough nutrition and fluid in them if someone would have offered it to us. Especially if there was nothing else left to do, but no one offered it to us. During an interview on 12/15/2023 at 11:37 AM with Staff E, RD, stated they did the nutritional assessments with the MDS schedule. The last nutritional assessment that was completed for Resident 1 was on 09/14/2023. Staff E also stated that they were not aware of Resident 1's significant weight loss, and that artificial nutrition (delivery of nutritional support when unable to take in food or fluid by mouth) should have been offered to CC1 to decide if that was an option for Resident 1 to sustain weight and fluids. Staff E further stated that the documentation of the supplements on the MAR were used as part of the nutritional assessment and the amount the resident consumed of the supplements should be recorded each time the resident consumed the supplement. In an interview on 12/15/2023 at 12:16 PM, Staff B stated the amount of the nutritional supplements should have been documented on the MAR for Resident 1. Staff B also stated the last medical nutritional assessment for Resident 1 was completed on 09/14/2023. Staff B further stated that Resident 1 had not been offered a source of artificial nutrition but had been on IV fluids a few weeks ago and should have been reassessed for further fluid needs after the IV fluids were discontinued. Review of a nursing progress note dated 11/28/2023 showed, It looked like Resident 1 had a silent seizure (or epilepsy - uncontrolled burst of electrical activity between brain cells). After the nursing staff assessed Resident 1, emergency transport was called, and the resident was transferred to the hospital. Review of a hospital record dated 12/02/2023, showed many of the laboratory abnormalities that were seen by the hospital staff were unlikely to have resulted from an event that occurred just now in the ED [emergency department] and would have taken days to evolve such as the severe dehydration. Reference: (WAC) 388-97-0640 (1)

Based on interview and record review, the facility failed to provide nutritional service including assessments and interventions to address significant weight loss and lack of intake for 2 of 3 residents (Residents 1 and 2), reviewed for nutrition/hydration. These failures placed Resident 2 at risk for unmet nutritional needs and caused harm to Resident 1 who had a significant and unplanned weight loss, dehydration (lack of necessary fluid intake), decline in nutritional status, and related complications. Findings included . UNPLANNED SIGNIFICANT WEIGHT LOSS RESIDENT 1 Resident 1 readmitted to the facility on [DATE]. Review of a medical nutrition assessment dated [DATE], showed at the time of the assessment the resident weighed 142 pounds (lbs., unit of mass/weight). Supplements were appropriate to maximize intake and meet nutritional needs. Interventions included diet and supplements as ordered, follow-up as needed. The medical nutritional assessment also showed the resident would meet nutritional needs with 62% of meal intakes. Review of the nutritional care plan dated 09/16/2022, showed the resident had a history of unplanned and unexpected weight loss related to poor food intake. Further review of the nutritional care plan, revised on 08/15/2023, showed the goal was for Resident 1 to consume more than 50% of two of the three meals a day and to maintain weight between 135 to 150 lbs. Interventions included: give supplements as ordered, alert nurse/dietician (expert health professional in nutrition and human diets) if not consuming meals on a regular basis and monitor and evaluate any weight loss. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 10/09/2023, showed Resident 1 had a diagnosis of dysphagia (difficulty swallowing food or fluids) that resulted from a cerebral infarct (stroke). The MDS also showed Resident 1 had hemiplegia (weakness/loss of body function) [on the right side of the body] and required supervision and some [touching] assistance to eat. Review of Resident 1's Weight Summary report showed the following weights: 10/28/2023=139.7 lbs. 11/04/2023=139 lbs. 11/11/2023=128.4 lbs. 11/18/2023=127.5 lbs. 11/25/2023=124 lbs. Resident 1's weight on 10/28/2023 was 139.7 lbs. and on 11/18/2023 it was 127.5 lbs., and continued to decline to 124 lbs. on 11/25/2023, which totaled a significant weight loss of 16 lbs. (11.4%) within a month. Review of Resident 1's meal intake record showed the following: 11/22/2023=two meal refusals; one meal at 0-25% consumed 11/23/2023= two meals at 0-25% consumed; one meal at 26-50% 11/24/2023= one refused meal; two meals 0-25% consumed 11/25/2023=one meal refused; one meal at 0-25%; one meal at 26-50% There was no documented meal intake on the electronic meal record for 11/26/2023 11/27/2023= two meal intakes at 0-25% Review of the November 2023 Medication Administration Record (MAR) showed an order dated 06/27/2023 for a nutritional supplement 90 milliliters (ml, unit of measurement) two times a day to maintain nutritional status. Further review of the MAR showed no documentation that the resident was administered the nutritional supplement from 11/20/2023 to 11/27/2023. Resident 1 had no documented meal intakes that showed more than 50% of two of the three meals a day that were consumed between 11/22/2023 to 11/27/2023. The resident weighed 124 lbs. on 11/25/2023. During an interview on 12/15/2023 at 10:50 AM with Staff C, Certified Nursing Assistant, stated residents were offered a different meal or a snack if they ate less than 50% of a meal. Staff C also stated whenever a resident had a meal, a snack or drank any fluids, it was documented on the electronic meal record. Staff C further stated that Resident 1 did require some assistance to eat and drink. During an interview on 12/15/2023 at 9:51 AM with Staff B, Director of Nursing Services (DNS), stated that the Registered Dietician (RD) was notified by phone when the residents had a weight change and was also able to view weight changes electronically. Staff B also stated that they were aware of Resident 1's significant weight loss but did not notify the RD of the weight loss. FLUID INTAKE Resident 1 Review of the medical nutrition assessment dated [DATE], showed to meet 70% of Resident 1's fluid needs, 1,137 ml of fluid would need to be consumed daily. Review of the daily fluid intake record for Resident 1 showed the following: 11/15/2023=600 ml 11/16/2023=480 ml 11/17/2023=630 ml 11/18/2023=960 ml 11/19/2023=240 ml 11/20/2023=1200 ml 11/21/2023=660 ml 11/22/2023=240 ml with a documented refusal 11/23/2023=960 ml 11/24/2023=880 ml 11/25/2023=480 ml There was no documented fluid intake for 11/26/2023. Review of the November 2023 MAR showed on 11/03/2023 and 11/04/2023, Resident 1 was administered sodium chloride intravenously (IV fluids administered through a vein) solution two liters one time a day for dehydration for two days. During an interview on 12/14/2023 at 3:45 PM with Collateral Contact 1 (CC1), stated I told the staff there was weight loss, we were never offered anything to help with the weight loss or the consistent poor fluid intake. We would have done a trial of a feeding by tube [medical device used to provide nutrition who cannot obtain nutrition by mouth] to try and get enough nutrition and fluid in them if someone would have offered it to us. Especially if there was nothing else left to do, but no one offered it to us. During an interview on 12/15/2023 at 11:37 AM with Staff E, RD, stated they did the nutritional assessments with the MDS schedule. The last nutritional assessment that was completed for Resident 1 was on 09/14/2023. Staff E also stated that they were not aware of Resident 1's significant weight loss, and that artificial nutrition (delivery of nutritional support when unable to take in food or fluid by mouth) should have been offered to Resident 1's representative to decide if that was an option for Resident 1 to sustain weight and fluids. Staff E further stated that the documentation of the supplements on the MAR were used as part of the nutritional assessment and the amount the resident consumed of the supplements should be recorded each time the resident consumed the supplement. RESIDENT 2 Resident 2 readmitted to the facility on [DATE]. Review of the medical nutritional assessment dated [DATE], showed Resident 2 weighed 90 lbs., had a varied appetite, and was able to receive nutritional supplements three times a day to promote and maintain weight stability. Review of the quarterly MDS dated [DATE] showed Resident 2 had impaired memory and required partial/moderate assistance to eat. Review of Resident 2's weight summary report showed the following: 11/29/2023 98.5 lbs. 12/06/2023 90.5 lbs. 12/06/2023 96.0 lbs. 12/13/2023 88.5 lbs. 12/14/2023 89.5 lbs. There was a documented significant weight loss of 9 lbs. (7.5%) in less than a month. Review of Resident 2's meal intake record showed the following: 11/23/2023= one meal consumed at 25%; one meal at 26-50%, there was no documentation that a third meal or snack was offered or consumed. 11/28/2023= two meals consumed at 26-50%, there was no documentation that a third meal or snack was offered or consumed. 11/29/2023= two meals consumed at 26-50%, there was no documentation that a third meal or a snack was offered or consumed. Review of the electronic food and fluid intake record dated 12/05/2023 to 12/14/2023 showed Resident 2 was frequently dependent on staff for food and fluid intake. Review of the MAR from 10/01/2023 to 12/15/2023 showed an order for nutritional supplement 90 ml three times a day. The MAR had no documentation to show how much supplement Resident 2 consumed. Review of the nutritional care plan dated 04/26/2022, showed to provide and serve supplements as ordered 90 ml three times a day for Resident 2. During an interview on 12/15/2023 at 11:01 AM with Staff D, Registered Nurse, stated the amount of the nutritional supplement the resident drank would be documented on the MAR. Staff D also stated the DNS would be informed if the residents started to lose weight. During an interview on 12/15/2023 at 2:30 PM with Staff E, RD, stated the last quarterly MDS for Resident 2 was scheduled on 11/28/2023, two weeks ago, but had not completed the medical nutrition assessment for Resident 2 yet. In an interview on 12/15/2023 at 12:16 PM, Staff B stated that the amount of the nutritional supplements should have been documented on the MAR for Residents 1 and 2 and that the medical nutritional assessment for Residents 1 and 2 had not been completed. Staff B further stated that Resident 1 had not been offered a source of artificial nutrition but had been on IV fluids a few weeks ago and should have been reassessed for further fluid needs after the IV fluids were discontinued. Reference: (WAC) 388-97-1000 (1)(b)(2)(k), 1060 (3)(h)

Based on observation, interview and record review, the facility failed to ensure mechanical lift slings were in good working condition for 1 of 3 residents (Resident 1) reviewed for accidents and hazards. This failure to ensure an effective system was in place for inspecting and ensuring the good working condition of mechanical lift slings resulted in Resident 1 experiencing a fall while being transferred in a mechanical lift sling which broke while in use. The facility did not have a system in place to ensure mechanical lift slings were in safe condition for transferring residents which increased the likelihood of serious harm, injury, impairment, and death related to recurring incidents. The facility needed to take immediate action to prevent other residents from falling during mechanical lift transfers and constituted a situation of an Immediate Jeopardy (IJ) related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. The IJ was identified and communicated to the facility on [DATE] at 2 PM. An onsite survey on 10/06/2021 showed the facility had removed the immediacy on 10/04/2021 after implementation of a policy and procedures related to mechanical lifts and inspection process of mechanical lift slings, and by educating and training facility staff on these policies and procedures for inspection process of mechanical lift slings. Findings included . Resident 1 was a long-term care resident with multiple care needs. Review of the resident's Quarterly Minimum Data Set (MDS) assessment tool, dated 08/25/2021, showed the resident required extensive assistance of two staff for transfers. The resident's care plan showed he used a mechanical lift device for transfers. An investigation for a fall, dated 09/28/2021, showed the resident was being transferred from the shower chair to the bed when the mechanical lift sling, that the resident was being lifted with, broke and the resident fell to the floor. Review of [MEDICATION(S)] Industries manufacturer's information on the mechanical lift sling [used by the facility] showed the sling must be inspected prior to each use for any rips, tears, frayed, or bleached areas which are unsafe and could result in injury. Do not exceed max [maximum] weight specified. Refer to owner's manual for operation of your lift. On 09/29/2021 at 9:16 AM, Staff C, Licensed Practical Nurse (LPN) stated that Staff I, Nursing Assistant Certified (NAC) and Staff J, NAC, reported to her that they were transferring the resident back to bed after his shower, and the mechanical lift sling ripped while the resident was lifted up in the air, and that the resident had fallen from the sling and landed on the floor hitting his back. Staff C was asked regarding the facility's process for use of the mechanical lift sling. Staff C stated that she did not know who was responsible for monitoring/inspecting the mechanical lift and/or slings and did not know who was responsible for replacing used slings or how often the mechanical lift slings were replaced. Observation on 09/29/2021 at 10:17 AM with the Director of Nursing Services (Staff B) showed the mechanical lift sling used during the incident had fabric strap loops at each corner of the sling [used to attach the sling to the lift]. One of the loops on the bottom right corner of the sling was ripped apart. Further observation showed the sling also had other areas that were worn and fraying, including a fabric strap loop at a different corner of the sling. During an interview and observation on 09/29/2021 at 10:19 AM, Staff G, Housekeeping Manager (HM), stated that housekeeping laundered the mechanical lift slings, but said that housekeeping wouldn't know if slings were good to use because the nursing aides were the ones who used the slings. Staff G also stated that no one was assigned to order new mechanical lift slings because the person responsible for ordering quit three weeks ago. Staff G stated that she did not know the last time the facility had ordered new mechanical lift slings. A joint observation of the mechanical lift slings with Staff G showed no slings were available in the shower room, laundry room, and the facility linen closet(s), except for a purple sling found in the linen closet between Room 130 and 128. The purple sling had a hole in the middle measuring approximately 1.0 centimeter (cm) x 1.0 cm. Staff G stated the area where the hole was on the purple sling would be at the area of a resident's back and stated she would remove it and take the sling downstairs to the laundry room. On 09/29/2021 at 11:34 AM, Staff I, NAC, stated that management and housekeeping check the mechanical lift slings. Staff I stated she did not know the condition of the sling used during the incident because she did not help put the resident into the sling or help attach the sling to the mechanical lift. Staff I stated she helped with the resident's transfer from the shower room to the bed and was there when the sling broke and the resident fell to the floor hitting his back. Staff I stated that the resident complained of back pain after the incident. On 09/29/2021 at 12:02 PM, Staff J, NAC stated she did not know who checks or orders new mechanical lift slings. She stated the sling that was used with Resident 1 was a blue sling. Staff J said that the blue sling was not new, but she thought they could use it. Staff J stated that Staff I was assisting her with the transfer of the resident back to bed. She said they lifted the resident from the chair using the mechanical lift, but as they moved the resident [while in the sling] close to his bed, the sling broke, the resident fell to the floor and had complaints of back pain after the fall. On 09/29/2021 at 12:19 PM, Staff K, NAC, stated that laundry and housekeeping staff check the sling(s), and they report if the slings were old or broken, but she did not know how often slings were checked and could not remember the last time they were trained on use of slings during a mechanical lift transfer. On 09/29/2021 at 1:16 PM, Staff B was asked if the facility had a system for monitoring and inspecting the condition of the mechanical lift slings. Staff B stated, No, and she stated that she thought that housekeeping had been looking at them (the slings) as housekeeping was looking at the condition of things like linen, but that was not the case. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (Resident 1) reviewed was provided adequate supervision to prevent accidents. Failure to ensure Resident 1 was provided supervision and assistance with a hot beverage resulted in the resident sustaining [CONDITION(S)] on the bilateral thighs and lower legs, and experiencing pain associated with the injury which constitutes actual harm. Findings included . Review of a facility policy provided on 09/07/2021 and titled, Safety Guidelines, dated 2013, showed that the policy addressed the food service department. The policy indicated safe procedures were followed in daily work routines and equipment operations. The policy directed staff to monitor hot beverage and food temperatures on a regular basis at the point they are served, and noted that appropriate supervision must be provided to any individual demonstrating decreased safety awareness and/or anyone at risk for [CONDITION(S)]. Resident 1 admitted to the facility in 2011 with multiple medical diagnoses including [CONDITION(S)] (paralysis of the lower body and legs), dementia (memory loss), and brain injury. The quarterly Minimum Data Set (MDS) assessment, dated 05/27/2021, noted the resident had functional limitations in both the upper and lower extremities, needed physical assistance from staff to eat meals, and used a wheelchair for locomotion in the facility. The Brief Interview for Mental Status (BIMS a common assessment used to assess cognitive changes) had a score of 6, which showed the resident had severe cognitive impairment. The care plan directives included the following: Encourage fluids between meals (revised on 03/18/2016); the care plan addressing activities of daily living, indicated the resident sometimes needed assistance with meals, and noted Sippy Cup [lidded cup] for any hot drinks (revised on 10/31/2017). Joint observation with Staff J, Licensed nurse, and interview on 09/07/2021 at 11:50 AM showed Resident 1 in his room. Resident 1 was asked regarding a burn incident. Resident 1 initially indicated that he did not remember what happened, but then stated that he was in his power chair, got himself a cup of hot water, and then burned himself with the hot water. Observation of Resident 1's left lower leg (calf area) showed healed dark red skin running down the length of the lower leg, with an open area (approximately the size of a silver dollar). According to Staff J, non-stick dressing pads were being used in the treatment of the open area. Review of the accident incident log documented on 06/18/2021 that Resident 1 sustained a burn injury after spilling a hot beverage from a cup without a lid in their lap. A skin assessment, dated 06/18/2021 at 3:50 PM, identified [CONDITION(S)] on the right and left front thighs and knees, which Staff F referred to the areas as stage 1 non-blanchable redness. The assessment form documented that the back of the right and left thighs, had areas measuring 30 centimeters (cm) by 2 cm on each thigh, the nurse also identified these areas as with non-blanchable redness. A notation in the document noted, Blisters were noted on areas as indicated above. [There are 3 types of [CONDITION(S)] in which the severity of the harm to the skin is identified by the degree of burn, as follows: o First-degree [CONDITION(S)] involve the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. o Second-degree [CONDITION(S)] involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. o Third-degree [CONDITION(S)] penetrate the entire thickness of the skin and permanently destroy tissue.] The investigation, dated 06/18/2021, noted that at the time of the incident, Resident 1 was on the patio adjacent to the activities room. A witness statement from Staff C, Administrative Staff, attached to the investigation noted the incident occurred around 2:45 PM when they were present on the patio. The statement named a nurse, Staff D (RN), came out back to look at the resident's legs to measure any redness, and nothing was showing up. The statement showed the nurse reported she would check the resident's skin again later. Additional statements from staff were attached to the investigation, all dated 06/18/2021 at 1430 (2:30 PM): Staff E, the Nursing Assistant (NA) assigned to provide care, noted Resident 1 was provided a cup of coffee, however the statement did not indicate a lid was on the cup or what time it was served. Staff F, licensed nurse, (who completed the skin assessment dated [DATE]), documented the resident was yelling that he spilled hot liquids in his lap as they approached. The statement indicated an assessment and ice packs were applied, and the physician was notified, and orders for treatment were obtained. An additional statement, dated 06/22/2021, signed by Staff F, showed that when Resident 1 was approached, the resident reported that he had got himself some tea and said that he should have asked the staff for assistance [with getting the tea]. Staff B's, Director of Nursing, DNS, summary statement showed an immediate investigation was completed, which included checking the temperature logs (which recorded temperatures of hot beverages) and in-service training was provided immediately. However, the temperature of the beverages at the point of service were not identified. On 08/14/2021 at 2:00 PM, Staff B, DNS, reported that on the the day of the incident, Resident 1 accessed the hot beverages and poured a cup of tea without any staff assistance, placed it between his thighs and went out to the patio, where the hot beverage spilled onto his lap. When asked about the statement from Staff E, she said the coffee was provided to the resident after 3:00 PM [After the statement was provided and/or the spill occurred.] Staff B stated that after the spill, staff had to wait until the resident calmed down before transferring the resident out of the chair. The DNS explained she approached the scene at the nurses' station, removed pillows from under the legs, placed cool towels, and said Resident 1 was yelling and needed to calm down before transferring him with a mechanical lift back to bed. A copy of the June 2021 temperature log was provided via an email dated 09/07/2021. The hot beverage temperature log showed that the staff did not consistently monitor/document the temperature of the hot beverages. The document identified coffee temperatures were recorded, but temperatures of the hot water used to mix hot beverages, such as tea or hot chocolate were not documented. The coffee temperatures for 11 meals (between 06/01/2021 - 06/24/2021) were not recorded on the log. No temperature was recorded for the evening meal on 06/18/2021. One hot beverage temperature, dated 06/15/2021, was documented as 183 degrees Farhenheit (F) at the point of service, which according to the facility's Safety guidelines policy, temperatures at 150 degrees F could cause 2nd and 3rd degree [CONDITION(S)] in less than a second. Not ensuring the resident was provided adequate supervision resulted in the resident experiencing a burn injury, which caused the resident increased pain and changes in treatment. Reference: (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to develop and implement an effective infection control program related to the required screening of healthcare personnel (HCP) and visitors for COVID-19 (a highly communicable infection). Additionally, the facility failed to follow standards of practice and implement written policies and procedures for donning (put-on) and doffing (take-off) of personal protective equipment (PPE), hand hygiene, and the required precautions for known and/or suspected COVID-19 residents. These failures placed all twenty eight (28) residents of the facility in the likelihood of serious harm and for acquiring serious communicable infections including COVID-19. The facility's failure to ensure HCP and visitors were adequately screened for symptoms of COVID-19 prior to entering the facility, the failure to implement written procedures regarding the use of personal protective equipment (PPE) and the failure to follow and implement standards of practice and written policies and procedures for infection control, constituted a situation of an immediate jeopardy (IJ). On 12/16/20 at 5:30 PM, the facility was notified of the IJ related to CFR 483.80 F880, Infection Prevention and Control. Findings included . According to the Centers for Disease Control (CDC), COVID-19 is an illness caused by [MEDICAL CONDITION] (coronavirus) that can spread from person to person. The CDC also stated that a person can become infected from respiratory droplets when an infected person coughs, sneezes or talks. Symptoms of COVID-19 included: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting and Diarrhea. The CDC guidelines for COVID-19 included the following: A. Screen all Health Care Personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. B. Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). A review of the facility policy titled, Screening Procedure, dated 12/17/2020, showed, All staff and visitors must be screened before working on the floor and proceeding in the building. The policy directed the facility staff to: A. Staff entering the main entrance must check in at the business office or at the lobby. Staff cannot proceed in the building without being screened. B. Staff entering the south entrance must be screened before they proceeded in the building. C. All staff will be screened by having their temperature checked and asking COVID-19 screening questions. D. All staff screening must be logged on the screening logs with the person's name, temperature, whether they had any Yes answers to the screening questions and the initial of the screened. FAILURE TO EFFECTIVELY SCREEN HCP AND VISITORS FOR COVID-19 During an observation and interview on 12/16/2020 at 1:00 PM, two surveyors entered the facility to conduct a Focus Infection Control/COVID-19 survey. Both the surveyors were screened by the facility Administrator. The Administrator took the surveyors' temperature readings. However, both the surveyors were not screened for any other symptoms of COVID-19. The screening form did not have any information on what symptoms to ask about or check to effectively screen a staff or a visitor for COVID-19. The Administrator was not able to verbalize what were the signs and symptoms and the recommended screening questions for COVID-19. A review of the screening log from 12/13/2020 to 12/16/2020 showed no evidence or record of what signs and symptoms the employees and or visitors were screened for. During an interview on 12/16/2020 at 1:40 PM, Staff A, Housekeeping Aide (HA) stated that he would sometimes use the main entrance door or the south entrance door to enter the building. Staff A, HA, stated that he would enter the building, clock in (therapy gym area), and head back to the nurses station to get screened for COVID-19. During an interview on 12/16/2020 at 1:45 PM, Staff D, HA, stated that she usually used the main entrance door to enter the building. Staff D, HA, stated that she would enter the building, clock in, and head back to the nurse's station to get screened for COVID-19. An observation on 12/16/2020 at 1:58 PM showed incoming evening shift staff entered the facility (from either the main entrance door or south entrance door) without being (immediately) screened for COVID-19. From the facility's main entrance, the incoming staff/HCP would enter the building and walk/pass-by resident rooms, the dining room and the kitchen area before reaching the nurses station (COVID-19 screening area/location). From the south entrance, the incoming staff/HCP would enter the building and walk/pass-by resident rooms and the therapy gym before reaching the nurses station. Staff also clocked-in at the therapy gym before heading to the nurses station to be screened for signs and symptoms of COVID-19. During an interview on 12/16/2020 at the time of the observation (1:58 PM), Staff B, Kitchen Aide, stated that she has always been screened at the nurses station. Staff B also stated that she would always clock-in first at the therapy gym area before heading to the nurses station to be screened by a nurse. During a joint record review and interview on 12/16/2020 at 2:00 PM, Staff C, Licensed Practical Nurse (LPN) stated they have always been screening staff at the nurses station. According to Staff C, the facility sometimes had a person that screened staff and visitors at the main entrance door, but not all the time, and that staff who entered the facility through the south entrance door have always been screened at the nurses station. Staff C reviewed the screening log for 12/16/2020 and stated that she screened at least three (3) staff members (Staff A, HA; Staff F, Nursing Assistant Certified (NAC); and Staff G, NAC) at the nurses station that morning who entered through the south entrance door. Additionally, Staff C stated that the screening log did not have any information on what signs and symptoms were to be reviewed and screened for each employee. When asked, Staff C was not able to verbalize the signs and symptoms of COVID-19. During an interview on 12/16/2020 at 2:05 PM, Staff H, Registered Nurse (RN) stated that she usually used the main entrance door to enter the building. Staff H, RN, stated that she would go directly to the nurses station to get screened for COVID-19. When asked, Staff H was not able to verbalize the signs and symptoms of COVID-19. An observation on 12/16/2020 at 2:15 PM showed Staff L, NAC, entered the north hallway and approached room [ROOM NUMBER] to provide care. When asked if she had a temperature check and screening for COVID symptoms upon entering the facility, Staff L stated No. Staff L explained she worked for a staffing agency and had worked in the facility for the past several days. When asked, Staff L stated she entered that day (12/16/2020) through the main entrance doorway and had not been screened since entering the building on that day or on the previous day (12/15/2020). Staff L then walked to the nursing station for screening, however the nurses were busy and were unable to complete the task. Staff L then walked to the facility's main entrance door and the Administrator was notified that Staff L needed to be screened for COVID-19. The Administrator checked the temperature and asked, do you have any symptoms? Staff L stated, No and left the entrance area to care for residents. The screening was then documented on the log maintained at the facility entrance. Review of the screening logs did not have any documentation that showed Staff L was screened the previous day (12/15/2020). During an interview on 12/16/2020 at 2:10 PM, Staff E, NAC, stated that she usually used the main entrance door to enter the building. Staff E stated that she would enter the building, clock in, and head back to the nurses station to get screened for COVID-19. During an interview on 12/16/2020 at 2:12 PM, Staff I, LPN, stated that she usually used the main entrance door to enter the building. Staff I stated that she would go directly at the nurses station to get screened for COVID-19. Staff I, LPN, was not able to verbalize the signs and symptoms of COVID-19. During a joint interview on 12/16/2020 at 2:15 PM, Staff C, LPN, and Staff H, RN, both stated the purpose of the screening process for COVID-19 was to limit and deny access of any staff and/or visitors to the facility with known or suspected COVID-19 symptoms and exposure. Both Staff C and Staff H stated that if any visitors or staff had symptoms of COVID-19, they would not be allowed to enter the facility and would be sent home immediately. However, when asked about the facility's current screening process of allowing staff to enter the facility first and potentially exposing residents and staff before getting screened for potential signs and symptoms of COVID-19, both Staff C and Staff H were not able to provide an answer or explanation. TRANSMISSION BASED PRECAUTIONS, PPE USE AND HAND HYGIENE An observation on 12/16/2020 at 1:15 PM showed Staff E, NAC, providing resident care to Resident #1 and Resident #2 (room [ROOM NUMBER]). Both residents were positive for COVID-19 infection and on droplet precautions (requiring staff use of all recommended PPE, including an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a face shield), gloves, and gown. Staff E wore a surgical mask, goggles, gown and gloves during the observation. After providing care to Resident #1 and #2, Staff E left room [ROOM NUMBER] with her gown on and proceeded to provide care to another resident in the unit, Resident #3 (room [ROOM NUMBER]). Staff E used the same potentially contaminated gown she used for Resident #1 and #2 when she provided care to Resident #3. Resident #3 was also positive for COVID-19 infection. On 12/16/2020 at 1:30 PM, Staff E, NAC, left room [ROOM NUMBER]. Staff E entered another resident room, room [ROOM NUMBER], and provided care to Resident #5. Staff E continued to wear the same potentially contaminated gown she used for Resident #1, Resident #2 and Resident #3. Resident #5 had no known COVID-19 [DIAGNOSES REDACTED]. During an interview on 12/16/2020 at 2:10 PM, Staff E, NAC, stated that they were told to wear a gown at all times while at the facility. Staff E also stated that she did not change her gown and used it for all residents. According to Staff E, most residents of the facility were positive for COVID-19 except Resident #5. Staff E further stated that she was not aware that she was supposed to remove her potentially contaminated gown in-between residents, especially in-between caring from a COVID-19 positive resident/room to a non COVID-19 positive resident or room. Staff E NAC also stated she knew she was supposed to wear an N95 mask when caring for COVID-19 positive residents. However, Staff E stated she was not able to find an N95 mask this morning when she arrived to work, so she decided to wear a surgical mask instead. According to Staff E, she just came back from work today (12/16/2020) after completing a 14 day isolation due to COVID-19. The isolation carts located at each resident rooms did not have any surgical or N95 mask for staff to use. Shortly after the interview, Staff E received an N95 mask from Staff J, RN/Resident Care Manager (RCM). During an interview on 12/16/2020 at 2:12 PM, Staff J, RN, RCM stated she was not sure why Staff E, NAC, was not wearing an N95 mask, but the facility had adequate supplies of surgical and N95 masks and she kept some of them at her office and the nurses station. Similar findings were applicable to Staff A HA, Staff K, Social Services Director (SSD) and Staff L, Physical Therapy Assistant (PTA) with Observations on 12/16/20 from 1:05 PM to 1:40 PM as follows: Staff A, HA, provided housekeeping services to Rooms 119, 121, 122, and 118 (COVID-19 rooms and a non-isolation room) without an N95 mask, and without removing his potentially contaminated gown and gloves in between resident rooms (COVID-19 isolation rooms and non-isolation room). Staff A also emptied out the trash bins at the nurses stations, hallways, and therapy gym, including the dirty linen bins, and took them out at the dumpster outside the facility using the south entrance/exit doors without replacing his potentially contaminated gown and gloves. During an interview on 12/16/2020 at 1:40 PM, Staff A, HA, stated that he was not aware that he should have removed his gown in between resident rooms and to not wear the same potentially contaminated gown at the hallway, nurses station and other common areas. Staff A also stated that he should have changed his gloves and wash hands after contact with dirty and potentially contaminated surfaces, but he forgot. According to Staff A, he was not able to find an N95 mask this morning, so he used a regular surgical mask instead. During an observation on 12/16/2020 at 2:05 PM, Staff K, SSD, entered room [ROOM NUMBER] and conducted an interview with Resident #6. Resident #6 was COVID-positive and had an active COVID-19 infection. Staff K was not wearing an N95 mask or respirator during this observation. Staff K also entered and left the room wearing the same potentially contaminated disposable gown and proceeded back to the social services office and at the nurses station. During an interview on 12/16/2020 at 2:17 PM, Staff K, SSD, stated that she was told by the facility management that she was ok not to wear an N95 mask since she recently had a COVID-19 infection and she was told that she could not possibly get infected again within a certain period of time. An observation on 12/16/2020 at 2:30 PM showed Staff M, PTA, performing therapy exercises with Resident #6 in the resident's room [ROOM NUMBER] using a sit to stand machine (a type of mechanical lift device). Staff M was wearing full PPE including an N95 mask, face shield, gown and gloves. After the therapy session, Staff M left the room without removing his potentially contaminated gloves and gown. Additionally, Staff M took the sit to stand device out of room [ROOM NUMBER] and wheeled it back to the therapy gym without cleaning or sanitizing the machine. During an interview on 12/16/2020 at the time of the observation, Staff M, PTA, stated that it was ok for him to not remove his potentially contaminated gown and gloves since he was still in contact and touching the sit to stand machine. Staff M, PTA, stated that he was planning to remove his gloves and wash his hands after he had returned the sit to stand machine back to the therapy gym. Another observation on 12/16/2020 at 2:10 PM showed Staff L, NAC, entered the north hallway to begin a work shift. Staff L, NAC, wore a surgical mask and gown. Staff L NAC, member began to enter room [ROOM NUMBER], which had a notice posted indicating isolation precautions were required, including an N95 respirator mask, gown, gloves and face shield. Staff L was asked if she had an N95 respirator mask, she looked down at the isolation supply cart at the doorway to the room and commented Do they have one for me? The staff went to check with a nurse and then returned with a N95 respirator mask. During an interview on 12/16/2020 at 2:50 PM, the Administrator and Assistant Administrator stated that the expectation was for staff to remove contaminated gowns and gloves in-between resident care, especially when moving from caring for COVID-19 positive residents to non COVID-19 residents. Both the Administrator and the Assistant Administrator also stated that staff should wear an N95 mask when providing care to a COVID-19 positive resident and as far as they knew, they had an adequate supply of N95 and KN95 masks. Both the Administrator and the Assistant Administrator stated that visitors and staff should have been screened at either the facility's main entrance or the south entrance door, and should not be allowed to enter the facility without being properly screened for COVID-19 symptoms. The Administrator and the Assistant Administrator offered no explanation on why the current screening process of the facility allowed staff to enter the facility without being properly screened for recent exposure and sign and symptoms of COVID-19. The Administrator stated that as of 12/16/2020, the facility had 27 out of 28 residents test positive for COVID-19 infection (all facility-acquired infection) and had at least 36 staff members who also tested positive for COVID-19 infection. The Administrator stated that only Resident #5 tested negative for COVID-19. During an interview on 12/28/2020 at 10:00 AM, the Administrator stated that Resident #5 had also tested positive for COVID-19 following the week of 12/16/2020. FAILURE TO CONSISTENTLY MAINTAIN AN ACCURATE INFECTION CONTROL LOG: Review of the facility's infection control log and line list tracking of the Covid 19 outbreak showed that on 11/23/2020, five staff were tested for COVID 19, and those staff had positive results. The log showed the date the positive results were received, and showed that three of those staff did have symptoms. However, although a category of the log was to include Symptoms Onset Date, the Symptoms Onset date was not documented for two of those staff who displayed symptoms. During an exit interview on 12/30/2020 at 9:30 AM, neither the Administrator or the Assistant Administrator could provide clairification as to when the two staff members first displayed symptoms of COVID 19. A follow-up email response was received, however it was not consistent with the entries in the log. Reference: (WAC) 388-97-1320 (1)(a)(b)(c) (2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure that four of six (#1, #2, #3, #4) sample residents were free from abuse. Failure to implement an effective plan to supervise Resident #5, who yelled at and/or kicked or struck other residents resulted in actual harm for Resident #1 and #2 who expressed fear of the resident and fear for the safety of others. Findings included . The facility policy titled, Abuse Prevention Program, dated 12/2016, showed all resident would be protected from abuse by others, including verbal and/or physical abuse by other residents. RESIDENT #5 Resident #5 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and a history of a stroke. The admission Minimum Data Set (MDS) assessment, dated 10/31/2019, showed the resident had trouble with verbal communication, was rarely understood, no behavior issues, and noted a mood score of 3 (an indicator of mild depression). The most recent quarterly MDS, dated [DATE], showed the resident's mood score had increased to 12 (moderate depression), had verbal behaviors, and her behavior symptoms were worse. Observation on 10/20/2020 at 2:10 PM showed Resident #5 seated in a wheelchair in the dining room watching a movie with a staff member seated beside her. When greeted, the resident became teary-eyed and responded verbally, but the response was not understandable. Then at 2:45 PM, Resident #5 exited the dining room, self-propelling the wheelchair down the hallway toward her room when a Nursing Assistant (NA) entered the hallway and escorted the resident. Review of the physician orders [REDACTED]. An antidepressant, [MEDICATION NAME], which had been in place for several years, was decreased gradually between 09/10/2020 and 10/11/2020 (then discontinued). A mood stabilizer, [MEDICATION NAME] sprinkles, was initiated on 09/05/2020. The dose was increased on 10/08/2020. Another medication (a mood stabilizer) Neudexta was added on 09/10/2020, the frequency was then increased on 09/18/2020, and then discontinued on 10/19/2020. An anti-psychotic ([MEDICATION NAME]) added to the medication regime on 10/12/2020. Subsequent increases occurred on (10/14) increased to 1 mg twice a day (BID), 2 mg BID on (10/16), and up to 5 mg on 10/19/2020. During an interview on 10/20/2020 at 3:40 PM, the Director of Nursing stated the multiple changes in medications made it difficult to determine which changes were effective. Review of the facility's A & I (accident & incident) reporting log for September 2020 & October 2020 showed five resident to resident altercations/incidents involving Resident #5 who had directed verbal or physical behaviors toward other residents: RESIDENT #1 Resident # 1 was admitted to the facility on [DATE] for rehabilitation of a fractured wrist. The resident was discharged from the facility to a private home on 10/18/2020. The resident's admission MDS, dated [DATE], showed the resident was alert and oriented, and needed extensive assistance with most activities of daily living(ADL), such as dressing, grooming, hygiene, locomotion, and transfers. The care plan for Resident #1, created 08/04/2020 and updated 08/18/2020, showed that Resident #1 needed limited assistance with mobility and used a platform walker or a wheelchair (W/C) for locomotion. The A & I reporting log showed on 09/10/2020 and 10/14/2020 Resident #1 and Resident #5 were involved in resident to resident altercations. The investigation, dated 09/10/2020, showed Resident #1 reported to staff that Resident #5 entered her room (Resident #1's), yelling and screaming at Resident #1 to leave the room. The investigation showed that Resident #1 reported that Resident #5 was very threatening and that Resident #5 scares me. The investigation summary statement showed that a stop sign barrier was placed across Resident #1's doorway, in response to the incident. The second resident to resident altercation, involving Resident #5 and #1, occurred on 10/14/2020. The facility investigation report showed that on 10/14/2020 at 3:00 pm, Resident #1 was seated by the nurses' station. Resident #5 grabbed Resident #1's left shoulder and then hit Resident #1's left shoulder. According to the incident report, Resident #1 stated she was not hurt, but said I feel threatened. The investigation showed Resident #5 was placed on one to one supervision during waking hours. During a telephone interview on 10/22/2020 at 1:30 PM, Resident #1 stated that Resident #5 displayed aggressive behaviors toward her, and described 3 incidents that she thought were reported to the state. The accident incident log only identified two incidents (on 09/10/2020 & 10/14/2020). When asked if the stop sign barrier was effective, she stated it worked for a while, but did not always, and stated Resident # 5 was scary. Resident #1 stated that she was relieved she was discharged home (10/18/2020) and reiterated that she had told the facility staff on multiple occasions she was afraid of Resident # 5. She also expressed concern about the safety of other residents in the facility. Observation on 10/20/2020 at 3:30 PM showed a schedule for providing one to one supervision of Resident #5 was taped to the counter at the nurses station. The schedule did not show who had provided one to one supervision to Resident #5 during the morning of 10/20/2020. During a telephone interview on 10/22/2020 at 1:30 PM, Resident #1 stated that Resident #5 displayed aggressive behaviors toward her, and described 3 incidents that she thought were reported to the state. The accident incident log only identified two incidents (on 09/10/2020 & 10/14/2020). When asked if the stop sign barrier was effective, she stated it worked for a while, but did not always, and stated Resident # 5 was scary. Resident #1 stated that she was relieved she was discharged home (10/18/2020) and reiterated that she had told the facility staff on multiple occasions she was afraid of Resident # 5. She also expressed concern about the safety of other residents in the facility. During an on site visit to the facility, on 10/20/2020 at 3:30 PM, a schedule for providing one to one supervision of Resident #5 was taped to the counter at the nurses station. The schedule did not show any staff had been assigned to provided one to one supervision, between 8:30 AM and 2:30 PM. During an interview on 10/20/2020, at 3:40 PM, the Director of Nursing Service acknowledged Resident #5 did not have a staff assigned to supervise as the care planed. RESIDENT #2 Resident #2 was admitted to the facility in June 2020 with multiple diagnoses, including dementia and lower extremity (LE) wounds with LE pain. The admission MDS assessment, dated 07/03/2020, showed the resident had severely impaired cognition, sometimes made herself understood, and did not exhibit behaviors. The next quarterly MDS assessment, dated 10/03/2020, showed Resident #2 had exhibited verbal and physical behaviors directed towards others, and showed the resident needed extensive assist with ADLs, including mobility while in a wheelchair. Observation on 10/20/2020 at 2:45 PM, showed that Resident #2 was seated in a W/C near the nurses station. The resident was wearing a protective soft cushion boot that had Velcro straps to keep it in place on the right lower leg. Resident #2 was calling out for help, whereby two staff walked up to check with Resident #2, but the staff were not able to understand what the resident was saying. Review of a progress note written by the Director of Nursing (DNS), dated 10/12/2020 at 3:15 PM, showed that when she heard a change in Resident #2's yelling, the DNS went to check on the resident, and saw Resident #2 and Resident #5 kicking each other's lower legs in the hallway. The facility incident investigation, completed by the DNS and dated 10/12/2020, showed skin checks of both residents were completed and no injuries were found. The investigation also showed several changes in [MEDICAL CONDITION] medications had been implemented for Resident #5 since September 09/09/2020. On 10/12/2020, a new physician's orders [REDACTED].#2 to receive an antianxiety medication to be administered as needed (or PRN). A physician note, written on 10/12/2020 prior to the incident, showed the resident appeared agitated and angry. Initially the order showed the antianxiety medication could be given over the next 24 hours, but then the order was extended to 14 days (twice) and remained in place thorough the Resident #2's discharge date . During a telephone interview on 10/27/2020 PM at 2:20 PM, Resident #2's Representative stated that they had a window visit with Resident #2 after they had been informed the resident was involved in an altercation. During that visit, the representative stated that Resident #2 had expressed fear and reported a resident was threatening and harassing her. Resident # 2 told the representative that a resident was coming into her room and yelling at her, and that she was afraid of them. The Representative stated he did call the DNS and reported Resident #2's allegation, however there was no evidence any additional investigation was initiated by the facility. RESIDENT #3 Resident #3 was originally admitted to the facility in 2005. The last quarterly MDS assessment, dated 08/24/2020, showed multiple [DIAGNOSES REDACTED]. During an interview on 10/20/2020 at 3:00 PM, Resident #3 acknowledged there had been an altercation with Resident #5 and stated that he was not injured. When asked if the facility was a safe place, he stated yes. The facility investigation, dated 10/13/2020 at 12:06 PM, showed Resident #3 was seated at a table with items on the table before him. Resident #5 approached the table and grabbed the items away from Resident #3. The investigation showed that Resident #3 protested loudly and (Resident #5) kicked out and struck him, and then Resident #5 was redirected out of the common area. The investigation showed no injuries occurred. The investigation showed medication changes were implemented for Resident #5, and documented a care conference with Resident #5's family was scheduled for the following day. RESIDENT #4 Resident #4 was admitted to the facility in 2014. The last quarterly MDS assessment, dated 10/07/2020, showed the resident was alert and oriented, needed assistance with ADLs, and was independent with locomotion in a W/C. During an interview on 10/20/2020 at 3:10 PM, Resident #4 stated he was not hurt during an altercation with Resident #5 and stated he felt safe in the facility. A facility investigation showed that on 10/13/2020 at 4:00 PM, Resident #4 was in his w/c attempting to exit the dining room when Resident #5 yelled at him to get back into the room. Resident #5 then struck Resident #4 with a fist in the left shoulder. An undated summary statement written by the DNS showed medication changes were completed and care conference scheduled for Resident #5. The summary also showed Resident #5 was on increase surveillance, but did not include any specific directives to indicate how that would occur such as frequency or who was assigned to do the increased surveillance. Observation on 10/20/2020 at 3:30 PM showed a schedule for providing one to one supervision of Resident #5 was taped to the counter at the nurses station. The schedule did not show who had provided one to one supervision to Resident #5 during the morning of 10/20/2020. During an interview on 10/20/2020 at 3:40 PM, the DNS stated the altercations were abuse. When asked what the plan was at this time, she stated the Resident #5 was placed on supervision, and one to one staff supervision between 8:30 am and 8:30 PM. When asked who had provided one to one that morning, she stated We all did. The DNS stated that the one to one staff supervision for Resident #5 was initiated on 10/14/2020 after the second altercation with Resident #1. Although Resident #5 was involved in multiple verbal and or physical altercations, the facility failed to implement a plan to ensure safety of other residents. Even though the facility placed the stop sign barrier to deter Resident #5 from entering Resident #1's room, the resident stated it was not always effective. On 10/13/2020, after the fourth incident, the investigation showed Resident #5 was placed on increased surveillance, however there was no description of how the resident's supervision should be carried out such as how frequently staff monitored the resident or who was responsible for the task. On 10/14/2020, after the second altercation with Resident #1 occurred, Resident #5 was placed on one to one supervision, during waking hours, to prevent additional altercations. The facility's delay in initiating an effective plan to prevent abuse, contributed to Resident #5 displaying a pattern verbal and physical abuse towards other residents. (See F 610 Failure to conduct thorough investigations) Reference WAC 388 -97- 0640 (1)

Based on observation, interview and record review, the facility failed to follow and implement resident directed care and treatment consistent with the resident's plan of care, physician orders and professional standards of care for one of five residents (39) reviewed for decline in the facility, and four of six residents (26, 32, 16 and 15) reviewed for medications and treatment administrations. The facility's failure to monitor blood sugar readings and administer insulin as ordered, failure to monitor weight, fluid intake/output, failure to act timely and notify the physician for potential drug to drug interactions and failure to develop written directives and plan of care constituted an immediate jeopardy (IJ) on [DATE], caused harm to Resident 39 and Resident 26, and placed other residents at risk for serious harm, injury and diminished quality of life. Findings included: RESIDENT 39 Resident 39 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. Review of the resident's Physician's Order for Life Sustaining Treatment (POLST) form dated [DATE] showed the resident was a full code and wanted Full Treatment/cardiopulmonary resuscitation in the event of an emergency. A review of the resident's Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and needed 2 person extensive assistance with bed mobility and toilet use. The MDS also showed the resident had no condition or disease that may result in a life expectancy of less than 6 months. Review of the resident's care plan created and initiated on [DATE] (11 days after admission) showed the resident had [MEDICAL CONDITION], diabetes, heart failure/[MEDICAL CONDITION] and hypertension. The care plan directed the facility staff to: A. Auscultate (listen using a stethoscope) heart and lung sounds. B. Give medication as ordered by the physician. Give Cardiac medication as ordered by the physician. C. Monitor lab results and report to the physician. D. Monitor/document/report [MEDICAL CONDITION] (swelling), weight gain over 2 lbs. per day, increased heart rate, elevated blood pressure, and monitor breath sounds for crackles. E. Fasting serum blood sugar as ordered. The facility failed to timely develop and implement written plan of care/resident directed care to provide and meet the resident's needs that meets professional standards of quality of care. (Refer to F655 - Baseline Care Plan for more information.) Review of the Hospital admission orders [REDACTED] A. Follow-up with in-house MD (nursing facility physician) in 1 to 3 days from discharge to hospital. B. Obtain a Computerized Tomography (CT) scan of the chest in 1 week to follow-up on the nodules (swelling/small lump) described on a chest x-ray completed on [DATE]. C. Monitor input and output. D. Weight daily and notify the doctor. E. Monitor blood pressure and adjust prescription as needed. Monitor of [MEDICAL CONDITION] (slow heart rate). F. Dietitian to follow and enforce strict low potassium diet. G. Blood chemistry and specific laboratory testing every Monday, Wednesday and Friday. H. [MEDICATION NAME] Insulin (rapid acting) 3 units subcutaneously (administer through injection under the skin) with meals routinely and; I. [MEDICATION NAME] Insulin sliding scale (dose per blood sugar level) as follows: Blood Sugar (BS) < (less than) 50, = no insulin, BS of 151 to 200 = give 2 units, BS of 201 to 250 = give 4 units, BS of 251 to 300 = give 6 units, BS of 301 to 350 = give 8 units, BS of 351 to 400 = give 10 units, BS of greater than 401 = give 10 units and call the physician. Blood sugar checks before meals and at bedtime. J. [MEDICATION NAME] 4 milligram (mg) tablet 3 times a day. Hold for systolic blood pressure (SBP) under 120. K. [MEDICATION NAME] (a heart/anti-hypertensive medication) 100mg 3 times a day. Hold for SBP under 100. L. [MEDICATION NAME] (a heart/anti-hypertensive medication) 300mg 3 times a day. Hold for SBP under 100 or heart rate under 70. M. [MEDICATION NAME] (a heart/anti-hypertensive medication) 15mg daily for Hypertension. N. [MEDICATION NAME] (a diuretic medication) 40mg tablet daily for [MEDICAL CONDITION]. O. [MEDICATION NAME] (a heart/anti-hypertensive medication) 120mg extended release daily for heart failure. Review of the facility admission orders [REDACTED] A. The facility failed to obtain and monitor the resident's weight on daily basis as ordered by the physician. The resident documented weight on admission (weight recorded by the hospital) was 185.80 pounds (lbs.). The only documented weight taken by the facility was documented on [DATE], (6 days after admission) at 199.0 lbs. The resident had gained a total of 13.2 lbs. in 6 days without any follow-up/notification to the facility's physician. B. The facility failed to monitor the resident's fluid input and output as ordered by the physician. The resident's input and output were not monitored or analyzed for the month of (MONTH) (YEAR). C. The facility failed to obtain and monitor the resident's blood pressure and heart rate as ordered by the physician. The resident was taking 5 different heart medications with specific parameters, and the facility failed to monitor/evaluate the resident's vital signs prior to the administration of each cardiac medication. D. The facility failed to obtain, monitor and administer insulin as ordered by the physician. The resident's blood sugar was not taken nor monitored by the facility, and no insulin was administered from [DATE] to [DATE] per the medication administration record. E. The facility failed to ensure the resident was seen and evaluated by the facility physician within ,[DATE] days from admission to the facility. The resident's only documented visit/face to face evaluation by a licensed practitioner (Advanced Registered Nurse Practitioner/ARNP) was on [DATE] (13 days after admission to the facility and 1 day before the resident died in the facility). Refer to F712 - Physician Visits Frequency/Timeliness/Alternate NPP's for more information. F. The facility failed to obtain specific blood chemistry and laboratory testing as ordered. The resident had only completed 3 laboratory tests while in the facility ([DATE], [DATE] and [DATE]). All lab results showed abnormal readings such as elevated Blood Urea Nitrogen (BUN) and Creatinine level, both indicative of poor hydration or poor kidney function. Additionally, all laboratory results and testing were not reviewed by the ARNP until [DATE] (9 days after the initial blood test was taken, and 1 day before the resident died in the facility.) G. The facility failed to obtain or coordinate the CT scan as ordered within 1 week from admission to the facility. The records showed no evidence that the facility had followed up on the CT scan or had attempted to schedule the scan or obtain an appointment as ordered. Further review of the resident's clinical records showed the facility received seven pharmacist recommendations following medication regimen reviews for appropriateness of specific medication therapy and potential drug to drug interactions on [DATE]. However, the recommendations from the pharmacy were not reviewed by a medical practitioner(see ARNP interview below) until [DATE]. Review of the nursing progress notes dated [DATE] documented, At approx. (approximately) 4 AM caregiver (went to the resident's) room to change and check on resident found her non-responsive and deceased . Body was still warm but her was blue tinged. Chest compressions started by both LN (licensed nurse) and caregiver for about 20 minutes. Caregiver continued compressions while LN called 911 for medical response. When medics arrived they were unable to revive her. The notes indicated the staff on duty provided chest compressions to the resident for at least 20 minutes before contacting 911. The facility failed to immediately call 911 for the resident to immediately receive advanced lifesaving interventions as needed and directed by the resident's POLST form. During a meeting and joint record review on [DATE] at 2:24 PM with the Administrator and the Director of Nursing (DNS), the DNS stated the resident admitted to the facility for rehabilitation therapy with known several cardiac conditions and yes, it was an unexpected but expected death. The DNS stated the resident had coded twice in the hospital from [MEDICAL CONDITION]. The Administrator and the DNS both verified the facility failed to follow the hospital and physician orders as required. During a phone interview and joint record review on [DATE] at 4:44 PM, the facility's ARNP stated he was not aware that the facility did not follow written physician orders and had not been monitoring the resident's vital signs, including the resident's blood pressure, heart rate, and daily weights. The ARNP also stated he was not aware that the resident's blood sugar was not being monitored and insulin was not given as ordered. The ARNP confirmed he did not see the resident in person until [DATE] and all clinical records, including the pharmacy recommendations, were all reviewed the same day. The ARNP further stated the facility's Medical Director/Medical doctor did not see the resident nor provide any consultation since admission to the facility. The ARNP stated he was on vacation when the resident was admitted to the facility but I covered for my own vacation. According to the ARNP, the facility should have not admitted the resident from the beginning because of the complexity of the resident's case. The ARNP stated the facility was not able to care and meet the resident's needs. Review of Resident 39's death certificate showed the resident's immediate cause of death was cardiopulmonary arrest due to or as a consequence of arrhythmia and and electrical dysfunction of the heart. In a follow-up interview on [DATE] at 5:25 PM with the Administrator and the DNS, both stated they would immediately look at Resident 39's record and death, educate and train nurses regarding the importance of following physician orders, and evaluate the need for a new medical director and pharmacy to meet the needs of the residents. RESIDENT 26 Resident 26 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had intact cognition and needed one person assistance with activities of daily living. Review of the Physician Order sheet with current physician orders as of [DATE] showed the following: A. Check the blood sugar 3 times a day before meals and check the resident's blood sugar at 5 AM every Tuesdays, Thursdays and Saturdays. B. [MEDICATION NAME] Injection (an emergency medicine used to treat severe [DIAGNOSES REDACTED]), inject 0.5 milligram (mg) intramuscularly (IM) as needed for blood sugar of 50 to 70 and if the resident is symptomatic (showed signs of low blood sugar). C. [MEDICATION NAME] 4grams chewable, give 1 tablet as needed for blood sugar of 50 to 70 and if the resident was asymptomatic (showed no signs of low blood sugar). D. If blood sugar is less than 50, give [MEDICATION NAME] 1mg IM as needed. E. Weight daily and notify the doctor for weight gain or loss of 3 lbs. or more or 5 lbs. in 3 days. F. Give and encourage the resident to eat bedtime snack. G. The orders did not show any blood sugar parameters on when the staff should call and notify the doctor/physician Review of the resident's care plan dated [DATE] showed the resident had impaired physical mobility and diabetes. The care plan directed the facility staff to: A. Monitor, document and report to the doctor sign and symptoms of [DIAGNOSES REDACTED] (low level of blood sugar) such as sweating, tremors, increased heart rate, pallor (pale skin), nervousness, confusion, slurred speech, lack of coordination and staggering gait. B. Diabetes medication as ordered by the doctor. Monitor/document for side effects and effectiveness. During an observation and interview on [DATE] at 5:13 AM, the resident was at the nurse's station sitting in her wheelchair with visible tremors of the arms and pale skin. The resident was eating crackers and a banana. The resident stated, she had a low blood sugar episode and it happens almost every day. The resident stated her blood sugar was 56 (normal range ,[DATE]) this morning and that was the reason why she was shaking uncontrollably. According to the resident, she did not get snacks at night and most of the time she did not eat meals because she did not like the food. During the time of the interview with the resident, Staff C, Licensed Practical Nurse (LPN), interjected into the conversation and stated, Yes, her blood sugar is always low in the morning. I know her. It should go up now. During an interview and observation on [DATE] at 5:20 AM, Staff C, LPN, checked the resident's blood sugar. The reading was 104 and Staff C stated, She should be good by now. Staff C stated this episode of low blood sugar reading happened when the resident did not eat dinner or if she doesn't get her snacks. Review of the facility admission orders [REDACTED] A. The facility failed to obtain and monitor the resident's weight on daily basis as ordered by the physician. The resident's weight on [DATE] was 171.6 lbs. and on [DATE] was 161 lbs. The resident's lost a total of 10.6 lbs. in 5 days. The resident weight on [DATE] was 168.4 lbs. The resident gained a total of 7.4 lbs. in 3 days. There were no weights taken in between these dates and the facility failed to notify the physician of the weight changes as ordered. The resident's current weight was 173.3 lbs. and the facility failed to monitor and record weight as ordered by the physician. B. The facility had no record of the 5 AM blood sugar checks for the entire month of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) 2019. C. The facility failed to administer [MEDICATION NAME] as ordered. The resident had documented low blood sugars (20 days on (MONTH) (YEAR), 21 days on (MONTH) (YEAR) and 6 days for (MONTH) 2019 from [DATE] to [DATE]) that met the parameters set by the doctor to administer [MEDICATION NAME], but the facility failed to administer the medication, failed to document interventions provided and failed to notify the doctor for a pattern of repeated low blood sugar episodes. D. The facility failed to provide and document the resident's snacks as ordered by the physician. During a joint interview and record review on [DATE] at 6:42 AM with Staff C, LPN, and Staff D, LPN, Staff C stated the normal range for a blood sugar should be 60 and above and you should not worry about it if the blood sugar reading is within that range. According to Staff C, a high blood sugar range was ,[DATE] and there should be a parameter in the orders on when to call the doctor and when to administer interventions. Staff C further stated, if Resident 26's blood sugar was less than 60, she would administer the [MEDICATION NAME] tablet and give the resident orange juice and food like what she gave Resident 26 early this morning. However, Staff C stated she did not administer the [MEDICATION NAME] as ordered based on nursing judgment. Both Staff C & D stated there should be a parameter in place on when to call the doctor. Both stated there was no documentation in the record that the resident's blood sugar was checked and monitored at 5 AM as ordered by the physician every Tuesday, Thursday and Saturday. According to Staff C, the doctor or the nurse practitioner should have been notified of the resident's low blood sugar episodes. Both staff members stated there was no documentation in the record that the resident received any [MEDICATION NAME] as ordered by the physician for the month of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) 2019, even when the resident's recorded blood sugar met the parameters set by the doctor. Both Staff C & D stated the doctor was not notified of the resident's consistent low blood sugar episodes and that there was no documentation of any interventions provided to the resident related to the low blood sugar episodes. Both Staff C & D stated there was no documentation of the resident receiving and consuming/monitoring of snacks as ordered by the physician. Staff C & D stated the resident needed a bedtime snack because she was diabetic. In an interview on [DATE] at 12:30 PM with the Director of Nursing (DNS) stated the physician's orders should have been followed and staff should have documented any interventions provided to the resident. The DNS further stated the doctor should have been notified of the resident's pattern of low blood sugar episodes and that a follow-up should have been completed. In a follow-up interview with the resident on [DATE] at 10:01 AM, the resident stated the episodes of low blood sugar happened about five days a week and it made her feel afraid of her life because she would wake up in the morning shaking and confused. The resident stated her low blood sugar episodes affected her quality of life because I cannot enjoy my day. The resident stated she was always dizzy and tired, and was afraid of falling or hurting herself. The resident further stated, I just want to feel better. The resident stated she had not seen the doctor to discuss her blood sugar situation. The facility's failure to follow written physician's orders and current professional standards of practice/care as detailed above caused harm to Resident 26 who experienced continued episodes of untreated [DIAGNOSES REDACTED], feelings of fear and diminished quality of life. Resident 16 Resident 16 was admitted on [DATE] with [DIAGNOSES REDACTED]. In an observation and interview on [DATE] at 1:35 PM, Resident 16's right leg was red, dry, and scaly and had scratch marks. The resident was wearing a blue foam boot on his right foot. Resident 16 stated his right leg was itchy, but he did not get a cream every day for the itchiness and it made him uncomfortable. Record review of the TAR (Treatment Administration Record) showed an order to apply Men-phor (anti-itch lotion) to right lower extremity (RLE). The lotion was to relieve the itching and prevent further scratching. The lotion was to be applied twice a day until resolved. The order also included an oil-based [MEDICATION NAME] (A and D [MEDICATION NAME]) to be applied to both lower extremities every PM (evening). The TAR showed no documentation or evidence that the treatments for itchiness were provided. Further record review of the resident's care plan showed there was no evidence of a care plan for the dry, itchy right leg. In addition, review of the Weekly Skin Assessment conducted on [DATE] reflected no mention of the dry, scaly right leg. In an interview on [DATE] at 6:31 AM, Staff C stated there was no treatment administration documentation for the right lower extremity itching. In an interview on [DATE] at 12:14 PM, the Director of Nursing (DNS) stated that the order of Men-phor to RLE was current. The DNS also stated, I'm aware that nurses were not doing the treatment. RESIDENT 32 Resident 32 was alert and oriented. The resident needed assistance with oral care, including brushing of teeth. In an interview on [DATE] at 1:29 PM, Resident 32 brought up a medication to be used when his teeth were brushed. He said he was not receiving it anymore and did not know why. Review of the clinical record found a physician order, dated [DATE], for [MEDICATION NAME] 0.12% solution - pour ½ ounce into cup, dip toothbrush into solution and brush teeth/gums BID (twice daily); an oral rinse to treat swollen gums in the mouth. There was no physician order to discontinue the medication found. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) found Resident 32 received the [MEDICATION NAME] solution in (MONTH) (YEAR), but not (MONTH) or (MONTH) (YEAR), and not in (MONTH) 2019. Further review showed the [MEDICATION NAME] solution was not listed on the (MONTH) (YEAR), (MONTH) (YEAR) or (MONTH) 2019 MARs or TARs. In an interview on [DATE] at 1:51 PM, Staff H, Registered Nurse/Resident Care Manager, said she did not know why the resident was not receiving it any longer. At 2:05 PM, Staff H stated It looks like it dropped off. I cannot tell why. RESIDENT 15 Resident 15 was a long term resident of the facility. A review of the physician's order dated [DATE] showed the resident was taking [MEDICATION NAME] (antidepressant). Further review showed the resident had an order with a start date of [DATE] for postural (lying, sitting and standing) blood pressure monitoring once monthly related to antidepressant use. A review of the MAR for: (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), showed no postural blood pressure documented during the months, and no refusals from the resident documented. In an interview on [DATE] at 2:33 PM the DNS verified the postural blood pressure monitoring had not been done. She stated it should have been done and documented on the MAR or in the electronic record. Reference WAC [DATE] (1)

Based on observation, interview and record review, the facility failed to actively and consistently provide medically-related social services to attain the highest level of mental and psychosocial well-being for 1 of 3 residents (50) reviewed for social services and social services support. The failure to provide sufficient language or interpretive services that would enhance the resident's mental health and overall well-being and quality of life, caused the resident to have verbal outbursts, combative behavior with staff, nocturnal restlessness with no interventions resulted in psychosocial harm and isolation. Findings include: Resident 50 admitted to the facility on [DATE]. Progress notes showed the resident was alert and able to make needs known using gestures, he was Spanish speaking only. Observations made, interviews conducted with staff and family and record reviews showed the resident's family was mostly present during the day to communicate needs on the resident's behalf. The records showed that overtime the resident began yelling out frequently, had sleeplessness, combative behavior at night and crying at times when family was not present. Review of Section A of the Minimum Data Set (MDS) on multiple assessment dates showed the resident needed a translator. Review of the resident's Activities care plan dated 03/24/17, identified the resident to have a language barrier and stated I have a language barrier, I speak Spanish and I have difficulty making self-understood and understanding others. Interventions included: 1. Anticipate and meet needs. 2. Provide translator as necessary to communicate with the resident. 3. Use communication techniques which enhance interaction: Allow adequate time to respond, repeat as necessary. Do not rush, request feedback, clarification from the resident to ensure understanding. Use alternative tools as needed such as communication book/board, writing pad, gestures, signs and pictures. Review of the entire care plan showed the facility did not identify or develop interventions to the resident's increase in agitation, frequent yelling out loud and combative behavior to a qualified professional for further evaluation, monitoring and interventions. Review of the Nursing progress notes showed the resident had multiple nightly episodes of restlessness, where he would call out for help with bed controls wrapped around him. The resident also had nocturnal episodes where he was found out of bed, lying or sitting on the floor by his bedside. The progress notes also stated on several occasions the resident was restless, combative, yelling at staff, tearing his bed apart and throwing wet briefs on the floor. All of these episodes were documented happening at night or the early hours of the morning with the staff unable to communicate with resident due to the language barrier. None of these behaviors were observed or documented during wake hours when family members were present and were able to communicate the resident's needs to the staff. Review of the entire chart revealed there was no documentation from Social Services, Activities or the Interdisciplinary Team (IDT) to show how the facility accommodated or addressed the resident's language barrier, increasing agitation, combative behavior and frequent yelling out loud, since the resident was admitted to the facility. There were no referrals or documentation the facility reported these behaviors to a qualified professional for further evaluation monitoring and interventions were not found or available upon request. Review of the resident's [DIAGNOSES REDACTED]. In an observation on 10/24/17 at 2:30 PM, the resident sitting was at the dining room table during a bingo activity with other residents. The activity was in English with no one assisting the resident with translation and upon passing by, the resident yelled out to the Surveyor, motioning for the Surveyor to come. Resident 50 yelled out loud in Spanish, shaking his wheelchair vigorously and kept pointing to the door of the dining room. When the activities assistant was asked if she knew what the resident was saying she stated No. In an Interview with the resident in Spanish, the Surveyor told the activities assistant that the resident wanted to go to his room of which then, she called out for someone to assist. In an observation on 10/27/17 at 10:04 AM, the resident was sitting in the dining room with other residents during a coffee and news activity. Staff O, Activities Assistant who conducted the activity was interacting with the other resident's at the table in English, telling jokes and reading the daily newspaper. The resident sat quietly with a Spanish/English communication book open in front of him. One of the residents at the table asked the Surveyor if the Surveyor spoke any Spanish to assist the resident with translation. Throughout the activity no one assisted the resident with translation. Throughout the survey there were no observations made of the staff implementing care plan interventions to accommodate the resident with his language barrier. In an interview on 10/23/17 at 12:24 PM, the resident's son stated the resident was Spanish speaking only and was not sure how nursing staff was communicating with him. The son stated because they felt the resident was not getting the care and services he needed with his language barrier, they were considering taking him home. He stated the resident was getting increasingly frustrated. In an interview on 10/26/17 at 4:10 PM, Staff E, Nurses Assistant (NA) stated she spoke different languages such as French, German, Greek, Spanish and English. When Staff E was asked to demonstrate how to say I need to give you a shower in Spanish she was not able. She stated she used google on her phone to communicate with the residents who spoke a different language. Staff E stated there were no interpretive services available such as a language line. When asked if the residents who spoke a different language would have better care if staff had a better way of communicating with them, Staff E stated Yes. She stated that she has learned to communicate with the resident, however it would be an issue if the resident had a new aide. At 5:08 PM spoke to another family who stated a communication book was just recently placed in the resident's room two days ago and that nothing had been in place prior to survey. When asked if he thought the staff communicated well with the resident he stated No. He also stated the lack of communication with the resident had caused the resident to yell out loudly, got frequently agitated and sometimes cried out of frustration. He stated the screaming had staff members asking if the resident had mental problems. In an observation on 10/27/17 at 9:03 AM, Staff J, Housekeeping Supervisor, attempted to relocate the resident to another part of the facility. Staff J spoke to the resident in English and proceeded to move the resident in his wheelchair. The resident began to yell at the Staff J in Spanish, I dont want to be moved but the Staff J not understanding what the resident was saying, continued to move the resident until the son came to the resident's wheelchair, upon which the resident stopped yelling. On 10/27/2017 at 9:28 AM, Staff B, Licensed Practical Nurse (LPN) stated she knew enough Spanish to ask the resident about his pain levels and other basic questions. When asked how other staff members were communicating with the resident, she stated most of the staff used gestures and there were no other language services available such as a language line. When Staff B was asked why the resident yelled so much, she stated It may be a part of his Dementia. When asked if she thought the resident was yelling out of frustration she stated Yes. When asked why she thought the resident was frustrated, she stated it could be a number of things like being in the nursing home. When asked if she thought the language barrier was an issue, she stated Well I can communicate with him and when asked if she thought the staff's inability to communicate with the resident might be a factor, she stated Yes In an interview on 10/27/17 at 9:42 AM, Staff L NA, was asked how she communicated with the resident, she stated she spoke a little Spanish enough to complete her tasks. She also stated there was a communication book that was recently placed in the resident's room. When asked why she thought the resident yelled so much she stated that it was just his character. When asked if she thought the resident was frustrated she stated Yes but did not know why. In a joint observation and interview on 10/30/17 at 9:33 AM, with the resident's son a Spanish/English communication book was observed on the resident's bedside table .The son stated the communication book must have been placed two days ago and had not been there prior. In an interview 10/31/17 at 10:44 AM, Staff A LPN, was asked what the facility was doing to accommodate the residents language barrier. He stated the family was always there to translate. When Staff A was asked if the facility was dependent on the family for interpretation, he stated in the past we involved Occupational Therapy (OT) to create a picture communication grid. When asked if the picture grid was used to communicate with the resident he stated As far as I am aware, the family is the only source of communication. He stated having the family there made communication with the resident convenient. When asked if the facility had a system of communicating with the resident when family was not there, he stated there was none. When asked if he thought using gestures were an effective way of communicating with the resident to achieve good quality of life and care, he stated No. At 10/31/17 at 11:34 AM, Staff M, Social Services Director (SSD), stated that family was available to help communicate with the resident. When asked how the staff was communicating with the resident when family was not present she stated a communication book was implemented a few days ago to help with communication, but apart from that, she was not aware of any system in place or more effective ways of communicating with the resident since he was admitted . When asked if a language barrier had anything to do with his yelling out constantly, she stated she did not know why he was yelling out and had not looked into what might be causing the resident's unrest she stated, It might be because of his Dementia. In an interview on 11/01/17 at 12:16 PM, Staff D, Activities Director stated the reason why the resident yelled so much was because she felt the resident was not being heard so he yelled out louder to try and communicate what he wanted to say. When asked what communication system was in place to communicate with the resident Staff P stated the family was primarily the only method of communicating with the resident. Summary The resident was Spanish speaking only and the facility failed to accommodate the resident with an effective communication system that ultimately compromised the resident's quality of life and psychosocial health. After he was admitted to the facility, the resident started to exhibit signs and symptoms of mental health decline shown by frequent yelling out loud, combative behavior and nocturnal unrest. By not identifying or reporting these behaviors to a qualified professional for further evaluation, monitoring and interventions; or reporting the resident's behavior the facility did not advocate for the resident which resulted in psychosocial harm. REFERENCE (WAC): 388-97 -0960 (1)

Based on observation, interview and record review it was determined the facility failed to provide necessary care and services to prevent pressure ulcers for 1 of 1 residents (58) reviewed for facility acquired pressure ulcers. The facility's failure to provide preventative interventions caused harm to Resident 58 who developed an unstageable pressure ulcer. Findings include: According to The National Pressure Ulcer Advisory Panel, unstageable pressure ulcers are wounds that have eschar (tan, black or brown) or slough (yellow, tan, gray, green or brown) tissue present. The anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed. Resident 58 was admitted to the facility in July 2017 after hospitalization for a blood clot of the resident's right leg along with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment as well as the follow up MDS dated [DATE] revealed the resident was identified to be at risk for pressure ulcers and was extensive assist assist of two persons for bed mobility. In an interview on 10/24/17 at 3:55 PM, Staff B, Registered Nurse (RN) stated the resident had an unstageable ulcer. Review of the admission progress note revealed the resident was admitted with no noted skin problems. Review of a skin assessment dated [DATE] revealed the resident was assessed to have no skin issues. A progress note dated 09/26/17 showed a Skin/Wound Note for the stage 2 on her left plantar heel by a consultant wound care nurse who documented a 2.5 by 2 centimeter (cm) eschar with periwound [DIAGNOSES REDACTED] and deep tissue injury measuring 0.7 by 0.7 cm. The consultant identified the resident had pain of a 10 out of 10. [MEDICATION NAME] gel was applied prior to the consultant's debridement of soft eschar and applied post debridement. [MEDICAL CONDITION] (infection to the wound) was identified and the Charge Nurse, Staff A, RN was to consult with the physician. Review of progress note dated 09/27/17 revealed the resident was started on an antibiotic for an infection for the pressure ulcer. Review of a Skin assessment dated [DATE] showed the resident developed a 2.5 by 2 cm unstageable pressure ulcer to the left heel with surrounding skin impairment of 4 cm and lateral deep tissue injuries measuring 0.7 by 0.7 cm. Review of a progress note dated 09/29/17 showed the resident complained of pain to the left heel. Review of a progress note dated 10/04/17 revealed the pressure ulcer was noted to have yellow drainage, the resident was in discomfort and a culture was obtained from the pressure ulcer. Review of a Skin/Wound Note progress note dated 10/17/17 by the consultant wound care nurse revealed, .probable con't (continued) area of pressure. Dry-eschar measures 6 x 3 cm. (Staff A, RN) Charge aware of con't pressure. Review of the resident's care plan showed the facility did not care plan interventions to address the resident's risk of pressure ulcers prior to the resident's development of an unstageable pressure ulcer. In an observation on 10/30/17 at 1:24 PM, the consultant wound care nurse conducted a sharps debridement to the resident's left heel. As the consultant wound care nurse and Staff H, Licensed Practical Nurse applied ointment to the resident's heel, the resident stated, No, no, no please no, please no, don't, please, don't. In an interview on 10/31/17 at 9:03 AM, Staff A, confirmed the resident was admitted without any pressure ulcers and subsequently developed an unstageable pressure ulcer. Staff A was unable to locate a pressure ulcer prevention care plan prior to the development of the unstageable pressure ulcer. In an interview on 11/01/17 on or about 10:00 AM, the Director of Nursing Services confirmed the facility had not developed or implemented a preventative care plan for the resident's risk of developing a pressure ulcer until after the resident developed an unstageable pressure ulcer. The facility failed to implement timely interventions to prevent a pressure ulcer for Resident 58. The facility had identified the resident on admission, to be at risk of pressure ulcers. This caused harm in the form of the development a preventable facility acquired non-stage able pressure ulcer for Resident 58, which resulted in pain and discomfort. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 2 of 2 residents sampled for substantial injuries (Resident 1 and 2). This failure led to Resident 1's substantial burn from hot tea, and Resident 2's fall with a fractured arm and pain. Findings include: RESIDENT 1 Burn Review of facility medical records revealed, Resident 1 admitted to the facility for long term care needs and had MS, (a debilitating progressive nerve and muscular disorder), muscle weakness, muscle spasms and was alert and oriented times three. According to the facility Minimum Data Set assessment ((MDS) dated [DATE], Resident 1 had a BIMS score of 15/15, needed extensive assistance from two staff for bed mobility and transfers, needed set up and supervision for eating, and setup and one person assist for locomotion on the unit. The MDS also revealed, Resident 1 had impairment of both upper extremities and used a wheelchair for mobility. Observation on 06/01/17 at 10:25 a.m., revealed Resident 1 was sitting in an electric wheelchair that tilted back when Staff A, a caregiver, entered the room and handed Resident 1 a plastic cup with two handles and a lid filled with hot tea. Resident 1 took the cup and held it with both hands with fingers through the handles and knuckles against the side of the cup. It was observed and demonstrated by Resident #1 that his hands and fingers were slow to grip the cup and had limited range of motion of the hands and fingers to grip the small handles. During the above observation, there was no cup holder, lap tray or device observed on the wheelchair for Resident 1 to place the hot cup of tea. Resident #1 stated he did not have a lap tray or other device to help hold the hot beverage cup. During the above observation, Staff A stated she sometimes adds cold water to the boiling water for hot tea that comes from the kitchen because sometimes is too hot to serve it to the residents right away. During the above observation, Resident 1 stated the hot tea was warm to touch because Staff A is one of the staff who adds cold water to the boiling water before giving it to him. Resident 1 stated not all of the staff add the cold water to the boiling tea because they are too rushed or they do not think about it, and they do not take the time to consider how hot the boiling water is. Resident 1 stated he drank three cups of hot tea every morning and sometimes it is way too hot and needs to be cooled down. Review of the facility incident investigation dated 05/19/17 revealed, Resident 1 sustained a burn on his right thigh from spilled hot tea in the dining room at 11:30 a.m. (unwitnessed). The report noted Resident 1's skin had a burn with blisters on it and was about 2 by 2 centimeters. Observation on 06/01/17 at 1:20 p.m., revealed, Resident 1 had two areas on the right thigh: one red area about one inch by three inches; another red area about two inches by one inch with a dark brown scab about one half inches long. Both burn areas had peeling dried skin. On 06/01/17 at 10:20 a.m., Resident 1 stated that the burn happened because he was given a cup of hot tea that was too hot that day and he could feel it burning his knuckles on his left hand which caused him to drop the cup because it was too hot. The hot tea cup landed in his lap and he yelled for help from the staff as it was burning his thigh. Resident 1 stated he tried to sit the hot tea cup on his lap to cool because it was so hot, but it slipped from his left hand because it was too hot and was burning his knuckles, so it fell on his lap and leaked onto his thigh and burned him resulting in immediate pain. Resident #1 stated he is right handed but he takes the cup with his left hand because he drives with his right hand. He said he was not driving that day, he was in the dining room before lunch when he was handed the hot cup of tea. Resident #1 also stated he had spilled hot tea on his lap before about a year ago but it just made a small light pink burn spot and the facility knew about it. (There was no documentation of this and no facility knowledge of this was identified). In an interview on 06/02/17 at 10:00 a.m., Staff B stated Resident 1 drinks hot tea and he usually cools it down in his lap before drinking it. Staff B stated the day of the burn, he handed Resident 1 the hot tea in the dining room by a table and Staff B got busy with other residents. Staff B stated a few minutes later Resident 1 yelled that he had spilled the hot tea in his lap so Staff B placed a cold washcloth on it. Staff B stated there was not much tea that had leaked from the cup, and it took just a small amount to burn Resident 1. In an interview on 06/01/17 at 11:15 a.m., Staff D, an activity director, stated activity staff give hot beverages to residents and sometimes she adds cool water to the beverage to cool it off for some residents, like the people with dementia, but it is not a policy and she did not know if other employees did that. Review of a facility progress note dated 05/19/17, the day of the burn, a licensed nurse wrote Resident 1 was handling his sippy cup with one hand instead of two, so the resident was educated about importance of holding the cup with two hands and asking staff to move his beverage when he needs to drive his chair. There was no facility assessment or care plan for Resident's 1's ability to use the cup for hot liquids, where to use the cup, how to drive his electric chair with the cup of hot tea, or when he should ask staff for help while driving his chair with hot tea. Observation on 06/01/17 at 10:40 a.m., revealed two hot beverage dispensers in the dining room on the counter. In an interview on 06/01/17 at 10:45 a.m., Staff C, a kitchen cook, stated he fills the hot beverage dispensers with coffee and hot water from the machine in the kitchen every morning about 30 minutes before meals, the staff pick them up and take them to the dining room to serve hot coffee and hot tea to the residents about 30 minutes after he fills the dispensers. Staff C stated he checks the temperatures of the hot liquid in the early morning around 6:00 a.m. but not at any other time of day. Record review of the facility policy for Holding and Serving Temperatures of Hot Beverages revealed, Dietary Staff will check temperatures of hot beverages before distribution of hot beverages to the resident areas to ensure hot beverages are within the average serving temperature of 155-175 degrees Fahrenheit. Record review of the facility tray line Temperatures Log revealed, the facility had one line on the log for temperatures of hot heverage with a temp goal of 170. The log did not specify which hot beverage was to be checked, coffee or hot water. There was also no recheck line on the log per policy before the hot beverages go to the residents. Staff C stated in the above interview that the hot beverage on the log is probably coffee. He did not clearly specify if the hot water for tea was also checked in the early morning after being asked several times. Staff C, the facility cook, again stated he did not check hot beverage temperatures after 6:00 a.m. each morning, and did not check them on 05/19/17 the day of the burn at 11:30 a.m. Observation on 06/01/17 at 10:55 a.m. revealed, the hot water/coffee machine in the kitchen by the door, dispensed hot coffee and hot water into the dispensers that go to the dining room, Staff C checked the temperatures: coffee was 185 degrees Fahrenheit and the hot water for at was 185 degrees Fahrenheit. Staff C stated the dispensers usually sit in the kitchen for about 30 minutes before going out for the residents for meals. Observation on 06/01/17 at 11:25 a.m., 30 minutes later, revealed Staff C checked the temperature of the dispensers and coffee was 180 degrees Fahrenheit and hot water for tea was 183 degrees Fahrenheit. (At 11:35 a.m., Staff C opened the tops of the dispensers and released steam and heat and then checked the temperatures again in the dining room, however he confirmed the staff do not open the dispensers to release heat when they fill the cups from the dispensers.) In an interview on 06/02/17 at 11:05 a.m., the Director of Nursing (DNS) stated the facility gives a sippy cup with two handles to most residents to make it easier and for safety. The DNS also stated Resident 1 was holding his hot sippy cup while traveling in his chair which made it spill (different than what Resident 1 said). The DNS also stated it is not realistic to have a general policy for cooling hot beverages for safety because the residents want hot coffee/tea. The DNS also said a resident with MS would be at risk, and the facility did not have a policy for adding cool water to hot beverages. The DNS further stated Resident 1 had a lap tray (Resident 1 said he did not have a lap tray). There was no lap tray observed for Resident 1 on 06/01/17 or 06/02/17, and no lap tray on the care plan. Review of an occupational evaluation completed after the burn dated 05/24/17 revealed, Resident 1 had moderately impaired fine motor control of his upper extremities and was at risk for accidents. The facility failed to provide adequate supervision to prevent a burn from hot tea for Resident 1, and failed to provide devices such as a tray or cup holder to prevent the accident that resulted in a burn for Resident 1. RESIDENT 2 Fall with fractured arm Review of facility medical records revealed, Resident 2 was admitted to the facility for rehabilitation/long term care and had a history of [REDACTED]. Review of the facility Minimum Data Set ((MDS) dated [DATE] revealed, Resident 2 had a BIMS score of 13/15 and needed extensive assistance from one staff for bed mobility, transfers, and hygiene. Resident 2 used a walker and a wheelchair. Review of the facility investigation dated 05/17/17 revealed, Resident 2 had a history of [REDACTED]. On 05/16/17 at 4:00 p.m., Resident 2 was in the dining room and had an unwitnessed fall that resulted in a fractured arm and pain. Resident 2 had been sitting in a regular dining room chair after being transferred from the wheelchair. The investigation concluded that Resident 2 attempted self transfer, although the fall was unwitnessed by staff who were transporting other residents. The facility investigation stated Resident 2 said she was trying to self transfer and used her arms to control the fall. In addition, the facility investigation noted Resident 2 was provided with a wheelchair on dialysis days because of increased weakness. In an interview on 06/02/17 at 11:00 a.m., the DNS stated Resident 2 had dialysis that day and was weak so she was in a wheelchair. Review of the facility Care Plan dated 04/27/17 revealed Resident 2 had poor safety awareness and was at high risk for falls. There was no interventions on the care plan for Resident 2 to safely sit in a regular dining room chair in the dining room, or interventions for dialysis days when Resident 2 was weak although she was at high risk for falls due to poor safety awareness. Review of the facility Fall Risk assessment dated [DATE] revealed, Resident 2 was at high risk for falls, sometimes had memory and recall ability, had poor balance and decreased muscle coordination, and was alert but forgetful. Observation on 06/01/17 at 2:00 p.m., revealed Resident 2 lying on the bed with a sling on the left arm and wincing facial expression. During the above observation, Resident 2 stated her arm hurt 8/10 and sometimes was 10/10. The facility failed to provide adequate supervision for Resident 32 who had a history of [REDACTED]. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to perform a comprehensive nutritional assessment or to provide the appropriate nutritional care and services for 1 of 1 sampled residents (41) reviewed that sustained significant weight loss. This failed practice resulted in Resident 41 losing 18 lbs in 15 days (12% of body weight) without facility assessment or intervention for 18 days after being identified. Findings include: The facility policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revision date of September 2012, stated The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Resident 41 was admitted to the facility in June 2015 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated 06/12/15, he was cognitively intact. The MDS also indicated the resident required 1 person staff assist with eating and was receiving a mechanically altered diet. Resident 41's weight on 06/06/15 was 150 lbs. His weight on 06/21/15 was 132 lbs. Between 06/06/15 and 06/21/15, 15 days, the resident lost 12% of his body weight. A review of Resident 41's medical record on 07/08/15 revealed no documentation the resident's Physician, Registered Dietitian (RD), or Resident Care Manager (RCM) were aware of, or had assessed the resident's weight loss that was identified on 06/21/15. In an interview on 07/08/15 at 2:32 PM, Staff B, RD, and Staff A, RCM, were asked if they were aware of Resident 41's weight loss between 06/06/15 and 06/21/15. They both stated No. Staff A was asked to provide any documentation the resident's physician had been notified of the weight loss. Staff A was unable to provide any information. Staff B stated we just missed it (the weight loss). Staff A & B were asked if they had weighed the resident on any other dates. They stated No. Staff A & B were asked why the resident's weight wasn't taken weekly per the care plan. They were unable to provide any information. In an interview at 2:52 PM, Staff A & B stated they had re-weighed the resident and his weight was then 135 lbs. On 07/09/15, a review of the RD's progress note dated 07/08/15 at 5:59 PM, revealed the RD had ordered fortified foods, a nutritional supplement, and had notified the resident's physician of the weight loss. The RD also noted that the resident had [MEDICAL CONDITION] during his recent hospitalization , which she indicated, could have caused the weight loss. In an observation on 07/09/15 at 8:11 AM, the resident's breakfast tray was observed and he had eaten 100% of his food and drank 100% of the fluids that were on the tray. In an interview at 8:11 AM, the resident was asked if he was getting the care and assistance he needed to eat. He stated Yes, but I'm not getting enough to eat. I've told the staff that for about the last 5 days I've still been hungry after eating my meals.

Based on interview and record review, the facility failed to provide professional standards of quality for management of chronic intractable foot pain and long term opioid medication use for 1 of 1 sampled residents (Resident #1) with a [DIAGNOSES REDACTED]. Findings include: Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident used a wheelchair for mobility and was non-weight bearing. Physician note dated 03/09/12 revealed the resident ' s right foot was very painful, 10/10 per pain scale before medication, 7/10 after medication (10 being the highest painful rating on a scale of 1-10, and resident "very anxious" about the foot. Medication orders dated 03/09/12 were: [MEDICATION NAME] 60 mg CR tablet twice per day by mouth and [MEDICATION NAME] 10 to 20 mg every 3 hours as needed for pain. Medication Administration Record [REDACTED]. Multi-Disciplinary notes dated 03/09/12 through 03/10/12 revealed Resident #1 was alert and oriented to person, place, and time and was able to express needs clearly and was cooperative and pleasant. On 03/11/12, nursing documented Resident #1 asked for pain medication early in the morning at 05:00 AM and informed him it would not be given until 8:00 a.m. Resident #1 asked nursing to give the OxyCotin every 12 hours rather than 8 am and 5 pm, and reported his pain to be 8-10. The facility documented in the progress notes the resident was "narcotic seeking." Subsequent multi-disciplinary notes dated 3/12/12 revealed the resident continued to ask for a change in time of the [MEDICATION NAME] for better pain management and explained that by receiving the medication at 5:00 p.m. in the evening, the following morning dose was administered 16 hours later resulting in uncomfortable pain. The resident continued to request the medication every 12 hours. The facility continued to give the Ocycotin at 8:00 a.m and 5:00 pm. The facility documented Resident #1 was "frustrated". Staff B reported on 03/12/12 the resident at admission had requested the Oxycotin be given at 5:00 a.m. and 5:00 p.m. The resident was use to this medication administered at different times that provided him better pain control. In an interview on 03/20/12 at 3:40 p.m., Resident #1 stated the facility refused to change the medication time, told him he was taking "too much pain medication," would not listen to him or give the resident a chance to talk about his pain. He stated he was " unhappy " . He said the facility brought medications to his room and placed them in a pain medication cup on the sink counter by the doorway. He had to get up in a wheelchair to get the medication. Lippencott, an online professional standards medical reference, identified caring for a patient with osteo[DIAGNOSES REDACTED] included managing immediate problems, making sure ongoing treatment was safe and effective, and controlling the patient's pain with prescribed [MEDICATION NAME] and nonpharmacologic techniques. Standards of quality pain management were lacking for the individualization of Resident # 1 ' s pain control. The facility did not assess the resident's quality of pain management related to osteo[DIAGNOSES REDACTED], chronic pain, and use of opoid narcotics to meet his individual needs. Prior to admission, the resident was used to around-the-clock pain management with long term use of opoids, realized he was not getting around-the-clock pain control at the facility with Oxycotin, requested better pain management of this medication scheduling, and was denied for a period of time, resulting in uncontrolled pain.

Based on interview and record review, the facility failed to manage pain caused by osteo[DIAGNOSES REDACTED] for 1 of 1 sampled residents (Resident # 1) who experienced ongoing chronic bone pain due to osteo[DIAGNOSES REDACTED]. This failure resulted in actual harm. Findings include: Refer to F281 for findings the facility failed to provide standards of quality in pain management for Resident #1 who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility failed to individualize Resident #1 pain management for pain control. This failure led to the resident's experience of uncontrolled pain. According to the Lippincott's 2011 Nursing Drug Handbook, the drug [MEDICATION NAME] was usually given on a 12-hour schedule and treatment should be continuously assessed and adjusted based upon the patient's own reports of pain and side effects and the physician's clinical judgment. The facility did not do this for the resident who mentioned at admission he was use to taking pain medication at 5 am and 5 pm vs. 8 am and 5 pm, and had been treated every 12 hrs at former health care settings. Review of Resident #1 ' s pain flow sheets since admission indicated there was no accurate and completed pain monitoring for individualized pain control in place. It had been documented the time of assessment under pain scale. There was no evidence the facility tracked the resident ' s pain level consistently and communicated to the resident ' s physician the resident ' s need for better around-the-clock pain management, and there was no evidence any care plan changes were implemented. According to the nursing progress note dated on 03/13/12, Resident # 1 declined therapy treatment due to left and right leg pain. Not having consistent and accurate assessments, information needed to monitor the pain management program, and care plan in place resulted in the facility ' s failure to ensure the pain medication the resident took was effective for pain control.

Based on observation, interview, and record review the facility failed to provide care and services to prevent the development of pressure ulcers for 2 of 3 sample residents with pressure sores (Residents # 21 and #34). Failure to accurately assess risk factors, put preventive measures in place, promptly identify pressure ulcers, promptly notify the physician of new pressure ulcers, and thoroughly assess new and ongoing pressure ulcers caused harm for Resident #34 who developed painful pressure ulcers with deep tissue injury on each heel. The facility's failure also may have contributed to the development of unstageable pressure ulcers with deep tissue injury for Resident #21. Findings include: 1. Resident #34 Resident #34 was admitted to the facility 7/29/10 with a fractured pelvis and a history of a stroke. The Minimum Data Set assessment ((MDS) dated [DATE] indicated Resident #34 needed extensive assistance from two persons for bed mobility and transferring between the bed or chair and another surface. The MDS indicated she had no pressure ulcers at the time of admission. The resident's heels were observed with a licensed nurse on 10/14/10 at 11:30 a.m. The right heel had an Stage II pressure ulcer ( a partial thickness superficial skin loss which presents as an abrasion, blister, or shallow crater) which looked like a cream colored shallow crater surrounded by macerated skin which measured 0.4 x 0.3 cm (centimeters) and 0.1 cm in depth. The left heel had an area of black eschar, indicating an unstageable area of deep tissue injury, which measured 2.3 cm x 1.9 cm. The facility had assessed Resident #34's risk for the development of pressure ulcers by coding a pressure ulcer risk identification tool incorrectly, indicating the resident made frequent changes in her position independently even though the admission MDS stated she required extensive assistance from two persons to move in bed. Facility staff also coded the assessment tool to indicate she "moves freely or requires minimum assistance" even though the admission MDS stated she required moderate to extensive assistance in moving in bed. The resident's final score on the assessment tool fell into the category of "not at risk" for pressure sore development. On the basis of this inaccurate assessment, the facility failed to accurately identify her risk for the development of pressure ulcers and put interventions in place for prevention. The admission Resident Assessment Protocol (RAP) for pressure ulcers stated the resident had no pressure sores, and listed no risk factors other than incontinence. Based on the facility's assessment only one intervention was implemented for pressure relief, that of pressure relieving chair and bed. No interventions were implemented to decrease pressure on her heels, although the facility's MDS identified her as unable to move in bed by herself. The RAP did not mention her reduced mobility as a risk factor or direct staff in interventions which may have prevented heel pressure ulcers, or recommend floating her heels to prevent pressure. Review of the record revealed between 8/11 and 8/25 the resident complained of heaviness in her right leg, increased discomfort in her sacral area, and being very tired. This resulted in documented reluctance to move or turn in bed at times, and refusal of therapies at times. There was no indication the resident's impaired mobility was recognized as an increased risk for the development of pressure ulcers, or a new assessment of her risk was conducted at this time. Facility documentation indicated on 8/23/10 a pressure ulcer was discovered on Resident #34's right heel. The description in the progress note stated the ulcer was Stage I and was non-blanchable, but did not indicate the color of the ulcer, measurements, or the condition of the surrounding skin. In spite of their awareness of her impaired mobility, it was not until 8/25/10 that facility staff documented her heels needed to be floated. By this time it was more than three weeks since her admission to the facility, and the pressure ulcer had already been discovered. The facility failed to notify the physician promptly of the new pressure ulcer, and not until 8/25, two days after the ulcer was discovered, was the physician notified and orders for wound care obtained. No description or measurements of the pressure ulcer were documented until 8/27/10, four days after it was discovered. It is not known if the ulcer worsened since discovery, since lack of description upon discovery made comparison impossible. By 8/27 the weekly pressure ulcer report described the ulcer as "deep purple", which indicated deep tissue injury. By 9/9/10 the weekly pressure ulcer report documented a blister measuring 1.8 x 1.5 cm was now also present on the resident ' s left heel, with a documented date of onset of 9/7/10. The color of the ulcer was not given, or the condition of the surrounding skin. No progress note describing the ulcer was present on the date the pressure ulcer was discovered to establish a baseline for monitoring the ulcer and evaluating effectiveness of treatment. No description of the color of the pressure ulcers was present until 9/30/10, 23 days after it was discovered, by which time both the pressure ulcers were described on the weekly pressure ulcer report as black, dry areas, indicating unstageable pressure ulcers with deep tissue injury. In an interview with the resident on 10/15/10 at 12:15 p.m. the resident stated, "they dragged their feet in helping me with the pressure sores after I complained that my heels hurt." 2. Resident #21 Resident #21 was admitted to the facility on [DATE] at 4 p.m. The facility form titled "Admission Skin Assessment-Status Upon Admission" dated 10/2/10 was completed by the evening shift licensed nurse (LN) (Staff F) on 10/2/10. The form documented various bruises and discolorations to Resident #21's abdomen, thighs, and legs. No open areas were identified on the resident's coccyx or buttocks. In different ink and handwriting the phrase "open areas came with on admission 10/2/10" was written on the form. Staff G was interviewed on 10/14/10 at 2:30 p.m. and stated she added the information to the admission assessment the evening of 10/3/10 when she observed the skin problems. Resident #21's skin was observed on 10/12/10 at 3 p.m. with two facility staff. Two areas of eschar indicating unstageable pressure ulcers with deep tissue injury were noted on her buttocks. The lower ulcer was black, hard, and leathery appearing and was approximately 1/2 x 3/4 inch in diameter. The higher ulcer was approximately 1 1/2 inches in diameter, and was hard, leathery, and brownish in color. Staff H, the LN who had been caring for the resident, stated on 10/12/10 at 3:15 p.m. she did not know what eschar was or what it indicated, and had not noticed eschar on the resident's skin. In a subsequent interview on 10/14/10 at 4 p.m. Staff H stated an antifungal cream applied to the resident's buttocks was so thick she couldn't visualize the skin well enough to tell what was under it. She was concerned because the cream was so thick it was difficult to remove from the skin and would not come off when the skin was cleansed with the facility's peri- care wipes. She wondered if the cream was saturated with urine which remained in contact with the skin when the cream was not completely removed, irritating the skin. Staff J, another LN caring for the resident, was interviewed on 10/14/10 at 7:15 a.m. and stated he had noticed excoriation of the resident's buttocks, but prior to today he "couldn't see the skin very well because there was cream on it." He stated "today I saw the eschar, because there was no cream covering it." Review of the resident's record revealed the day after admission, 10/3/10, facility staff called the physician to request an order for [REDACTED]. No documentation was present describing a fungal type skin condition which would justify use of an antifungal treatment. Review of the facility's treatment record (TAR) revealed facility staff applied the antifungal cream, called "Antifungal extra thick" three times daily. The first description of the ulcers in the progress notes was 10/6/10, which stated, "red coccyx area, but no breakdown. Cream applied." A note from 10/7/10 stated the skin was"excoriated", and on 10/9/10 the progress note stated, "cream to OA (open areas) buttocks". Staff were applying antifungal cream to treat areas they described as excoriation, failing to identify the effects of pressure on the skin. Use of the antifungal cream without thoroughly cleansing the skin to ensure the cream was completely removed after incontinent episodes resulted in the cream obscuring the skin from the view of staff and possibly kept urine in the cream in contact with the resident's skin. This may have contributed to the development of two unstageable pressure ulcers with deep tissue injury which were not noticed until the surveyor called it to the facility's attention on 10/12/10, 10 days after Resident #21's admission to the facility.