Every finding on record at Cheney Care Center

Based on interview and record review, the facility failed to ensure residents who were identified as being high risk for falls were provided adequate supervision and care plan interventions were developed/implemented and revised timely for 1 of 3 sampled residents (Resident 1) reviewed for falls. Resident 1, who had seven documented in-facility falls between 04/17/2026 and 05/17/2026, experienced harm when they fell, had severe pain to their left side of their head, and required emergency transfer to the hospital where they were diagnosed with a subdural hematoma (bleeding on the surface of the brain caused by a head injury). Findings included.The facility's Fall Prevention Program policy, last reviewed 05/04/2026, documented upon admission, a fall risk assessment was completed to determine a resident's level of fall risk. Based upon the level of fall risk identified, interventions were to be initiated in the baseline care plan, an initial care plan developed within 48 hours of admission that instructed staff on the resident specific goals and interventions needed to meet the resident's needs while the comprehensive care plan was being developed. The policy instructed the nursing staff to provide interventions that addressed any unique risk factors for the resident and provide additional interventions such as a sitter, if indicated. Review of the admission transfer paperwork received by the facility at the time of Resident 1's admission on [DATE], documented Resident 1 had experienced an aneurysm, (an abnormal bulging in the wall of an artery) in their brain that had ruptured on 02/05/2026. This resulted in the placement of a Ventriculoperitoneal (VP) shunt, (a surgically implanted device that operated beneath the skin and consisted of a thin, flexible tube surgically implanted into one of the fluid-filled ventricles inside the brain, and another tube that runs under the skin down the neck and chest to the abdomen to drain excess fluid and relieve pressure from the brain). The facility admission assessment dated [DATE], documented Resident 1 had moderate cognitive impairment, was usually able to make their needs known, and had diagnoses which included stroke and nontraumatic subarachnoid hemorrhage, (a sudden bleeding into the fluid-filled space between the brain and the skull). In addition, the assessment documented, Resident 1 needed assistance from one nursing staff to complete activities of daily living such as toileting, ambulation, and moving back and forth between the bed to a chair. Review of Resident 1's care plan documented all care interventions, which included safety/fall interventions, were developed and implemented on 04/21/2026, five days after Resident 1 admitted to the facility. The safety/fall interventions listed for Resident 1 included staff ensuring the call light was within reach for the resident, anticipate the resident's needs, ensure the resident wore appropriate footwear, use the alarming fall mat, provide toileting assistance every two hours, keep the resident's room clean/uncluttered, keep the bed in the low position, and personal items within reach. Additional review of the 04/21/2026 care plan found no baseline care plan was developed or implemented within the required 48-hour time frame of admission. There was no information found that informed the staff that Resident 1 had a VP shunt, and there were not any interventions developed or implemented related to assessment/monitoring for any symptoms that would indicate complications. The baseline care plan did not have instructions on what to do or who to contact if any symptoms or indications of complications occurred. Review of the admission Fall Risk Assessment documented it was completed on 04/23/2026, seven days after Resident 1's admission to the facility, and not upon admission as instructed in the facility's Fall Prevention Program Policy. The assessment identified Resident 1 was at a high risk for falls, experienced multiple falls over the last six months, had decreased muscle coordination, and was unable to independently come to a standing position when their gait was assessed. Review of the facility reporting log, fall investigations and progress notes from 04/01/2026 through 05/19/2026 documented Resident 1 sustained falls on the following dates: - On 04/17/2026 at 8:30 PM, Resident 1 was found sitting on the floor. The call light had been activated, but Resident 1 did not wait for assistance and attempted to take themselves to the bathroom. No injuries were found upon assessment. - On 04/19/2026 at 1:45 PM, Resident 1 was found sitting on the floor next to their nightstand. Resident 1 stated they attempted to move towards the bed and slid out of the wheelchair and hit their head on the floor. Resident 1 complained of pain to their head and was sent to the hospital for evaluation. The hospital evaluation, which included x-rays and computed tomography (CT) scans, (advanced, painless imaging test that combined x-rays and computer technology to see inside the body), were negative for injury or changes and Resident 1 returned to the facility. - On 04/23/2026 at 5:00 AM, Resident 1 was washing their hands at the sink, lost their balance, and sat on the floor. Staff were present at the time of the incident and no injuries occurred. - On 04/28/2026 at 7:40 PM, Resident 1 was found sitting on the floor next to their bed. They stated they slid off the bed when they were reaching for their slippers and hit their head on the bed frame. Resident 1 was sent to the hospital for evaluation and x-rays, and CT of the head were negative for injuries and changes and returned to the facility. - On 05/11/2026 at 5:00 PM, Resident 1 was found lying on the floor. When asked what happened, Resident 1 stated they slid out of the wheelchair when they reached down to pick up an item off the floor and hit their head on the nightstand. Resident 1 was sent to the hospital for evaluation which showed a head injury, non-serious, and instructions were provided to monitor for symptoms what would indicate a more serious problem, and to seek emergency medical care if any symptoms occurred. Resident 1 returned to the facility later that same evening. - On 05/12/2026 at 6:50 PM, as a Nursing Assistant (NA) was leaving Resident 1's room after providing assistance, Resident 1 called to them, and the NA turned to see Resident 1 sitting on the floor in front of their wheelchair. Resident 1 stated they slid out of the wheelchair when they attempted to reach for a Mother's Day card that was under the bed. No injuries were found upon assessment. - On 05/13/2026 at 1:50 PM, Resident 1 was found sitting on the floor and reported they fell out of the wheelchair while trying to reach for something on the floor. No injuries were found upon assessment. Additional review of the fall documentation for the above incidents noted Resident 1's safety/fall care plan interventions were being followed at the time of the incidents, however, no documentation was found that showed the care plan was reviewed or assessed to determine if any other fall interventions should be implemented, until the fall on 05/13/2026, when Resident 1 was provided a reacher, (a long-handled gripping device used to pick up objects without bending down or stretching). This was the fourth fall Resident 1 had while attempting to reach for something. A progress note on 05/14/2026 at 11:03 AM, documented Resident 1 was impulsive, which created a barrier to preventing falls, and there was a discussion with Resident 1 about the importance of waiting for staff to assist. Resident 1 stated they did not have the patience to wait. The note further documented the facility recommended the family increase their visits, as Resident 1 appeared to do better when they were present, but the family stated that was difficult as the facility was quite a distance from their home. Additional review of Resident 1's record found no documentation that showed the facility assessed or discussed the possibility of a sitter as stated in the Fall Prevention Program policy to help prevent falls for Resident 1. - Review of the facility's incident log showed on 05/17/2026 at 11:30 PM, staff responded to the fall mat alarming and found Resident 1 lying on the floor holding the left side of their head. Resident 1 complained of severe pain to left side of their head, which was where the VP shunt was located, and the resident was sent to the hospital for evaluation. The hospital evaluation showed Resident 1 had a subdural hematoma, (bleeding on the surface of the brain caused by a head injury), and Resident 1 was placed on end-of-life care/comfort measures and subsequently passed away at the hospital. Review of the facility discharge assessment, dated 05/17/2026, documented Resident 1 discharged on that same date to the hospital and their return to the facility was not anticipated. In an interview on 05/29/2026 at 10:47 AM, Staff C, NA, stated Resident 1 was impulsive, would use the call light to get assistance, but would not wait for staff to assist. Staff C stated fall interventions included frequent checks, toileting every two hours, reminding the resident to wait for assistance, and even though the interventions were being done, the resident continued to fall. Staff C stated frequent checks were checks done randomly, no set schedule or times, throughout the shift to make sure the resident was safe and didn't need anything. When asked if a one-to-one staff or a sitter had been talked about or tried, Staff C stated the family was asked about increasing their visits, but a sitter or one-to-one staffing had not been tried or discussed that they were aware of. In an interview on 05/29/2026 at 10:56 AM, Staff B, Licensed Practical Nurse, stated Resident 1 was impulsive and knew to wait for staff, but would not wait. Frequent checks were done and Resident 1's room was moved closer to the nurse's station for better visibility, but no discussion of a sitter or one-to-one staffing occurred that they were aware of. In an interview with Staff A, Director of Nursing, on 05/29/2026 at 11:25 AM, the following investigation findings and concerns were discussed: lack of adequate supervision to prevent falls and not ensuring care plan interventions were developed/implemented and revised timely. Staff A acknowledged that the baseline care plan was not developed within the required 48-hour time frame of admission and safety/fall interventions were not reviewed/revised timely. With regards to providing a sitter or one-to-one staffing for Resident 1 to help prevent falls, Staff A stated Resident 1's frequent falls would be an indication for a sitter, and it had not been discussed or considered. Reference (WAC): 388-97-1060(3)(c)

Based on interview and record review, the facility failed to develop procedures that ensured staff were educated on the risks, benefits and potential side effects of the COVID-19 (a virus that caused serious illness or even death) vaccine, that staff were offered information on obtaining the vaccine, and that the COVID-19 vaccination status of staff was maintained for 1 of 1 sampled staff (Staff H) reviewed. This failure placed staff and residents at risk of being uninformed of their vaccination choices, and at risk of becoming ill with COVID-19.Findings included.The 01/20/2024 facility COVID-19 Vaccination policy documented it was the policy of the facility to offer their residents and staff the COVID-19 vaccine to minimize the risk of acquiring, transmitting or experiencing complications from the COVID-19 virus. Staff documentation related to the COVID-19 vaccination was to include at a minimum:-education regarding the risks, benefits and side effects of the vaccine-the offering of the vaccine or information on obtaining the vaccine-documentation of any religious or medical exemption-the vaccine status of staff. During an interview on 08/20/2025 at 8:38 AM, Staff H, Nursing Assistant, was asked if they had been provided any information regarding the COVID-19 vaccine. Staff H stated they had been employed by the facility for 4 years and thought they were offered the vaccine when hired but was unable to recall. Staff H stated they did not remember receiving education regarding the vaccine or the risks or benefits of it. During an interview on 08/20/2025 at 9:49 AM, Staff E, Infection Prevention, was asked for documentation of COVID-19 vaccination education and vaccine status for staff H. Staff E stated they only offered staff an influenza vaccine and that staff were given information regarding Hepatitis vaccination, but not COVID. They can get their own insurance to pay for that. Staff E stated Human Resources kept a document from hire and also kept track of staff testing for Tuberculosis. During a follow-up interview on 08/20/2025 at 2:11 PM, Staff E stated they did not keep track of staff COVID-19 vaccinations. They were unable to ask staff what their vaccination status was because of HIPAA (the Health Insurance Portability and Accountability Act, a law meant to protect private health information.) During an interview on 08/20/2025 at 3:11 PM, Staff B, Director of Nursing, was asked what the facility's program for staff COVID-19 vaccinations was. Staff B stated they were unsure. At 3:40 PM, Staff B followed-up, and stated Staff N, Human Resources Director, discussed COVID-19 vaccinations with new employees, but acknowledged that did not include any employees that had been employed at the facility for longer periods.Reference: WAC 388-97-1320(1)(a)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves to prevent the spread of antibiotic-resistant bacteria or other infectious organisms) was implemented when indicated for 3 of 4 sampled residents (Residents 19, 31, and 48) reviewed. Additionally, Infection Prevention policies were not reviewed annually as required. These findings placed residents and staff at risk of spreading or acquiring infectious bacteria, and at risk of continued use of outdated policies and procedures.Findings included . The Centers for Disease Control and Prevention (CDC) April 2024 Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) documented MDROs may be indirectly transferred from resident to resident during high-contact care activities that included dressing, bathing/showering, transferring, providing hygiene, changing linens, device care, wound care or toileting. The use of gowns and gloves was indicated for nursing home residents with wounds and/or indwelling medical devices as well as for residents with MDRO infection or colonization.Enhanced Barrier Precautions<Resident 19>The 06/25/2025 annual comprehensive assessment documented Resident 19 had diagnoses that included osteomyelitis (infection of bone tissue), gangrene (death of tissue related to lack of blood supply or infection), and carrier of Methicillin-resistant Staphylococcus aureus (MRSA, a MDRO resistant to the antibiotics used to treat staph infections). Resident 19 was dependent on dialysis (a mechanical way of ridding the body of urinary waste when the kidneys no longer functioned) and was independent for most activities of daily living (ADLs).On 08/11/2025 at 1:36 PM, Resident 19 was observed sleeping in their room. There was no signage or PPE at the entrance to the resident's room that indicated EBP was implemented. On 08/12/2025 at 9:01 AM, Resident 19 was resting in bed. A bandage that had bloody drainage on it was on the floor by the resident's wheelchair. <Resident 31>A review of the record documented Resident 31 was admitted on [DATE] and had diagnoses that included urinary tract infection. On 08/12/2025, an order was entered for staff to use EBP every shift related to the use of a urinary catheter (a tube inserted into the bladder that allowed urine to drain into a collection bag). On 08/12/2025, the care plan was updated to include EBP. Staff were instructed to use gowns and gloves with all close resident contact. On 08/11/2025 at 2:41 PM, Resident 31 was seated in a wheelchair in their room visiting family. A urinary catheter collection bag was observed hung below the resident on the frame of their wheelchair. There was no signage or PPE receptacle at the entrance to the resident's room and none in their room that indicated EBP was implemented. During an observation and interview on 08/18/2025 at 2:50 PM, Resident 31 was seated on the edge of their bed. The urinary catheter collection bag was observed hanging on the frame of the bed. A bin of PPE was observed by the sink area. Resident 31 was asked if staff wore gowns or gloves when they assisted with caring for the resident's catheter. Resident 31 stated they did not remember staff wearing the gowns, so probably not. <Resident 48>A review of the record documented Resident 48 was admitted on [DATE] and had diagnoses that included enlarged prostate and urinary retention. A review of provider orders documented Resident 48 had a urinary catheter inserted on 08/01/2025. On 08/14/2025, an order was entered for Resident 48 to be on EBP related to use of a urinary catheter. During an observation and interview on 08/14/2025 at 12:16 PM, Resident 48 was observed seated in a recliner watching television. A urinary catheter collection bag was observed hanging on the edge of the garbage can next to the resident's recliner. Resident 48 stated the catheter had been inserted a couple of weeks ago because they had difficulty urinating and trying to do so made them extremely short of breath. They had problems with leaking urine as well. Resident 48 stated staff wore gloves when assisting with the catheter, but they had not seen any staff wearing gowns. There was no signage posted at the entrance to the resident's room or a bin of PPE in the room or at the entrance. During an interview on 08/20/2025 at 2:11 PM, Staff E, Registered Nurse, Infection Prevention, stated when a new admission arrived, they reviewed report sheets to look for the presence of wounds, oxygen use, or catheters. They also reviewed the 72-hour report. Staff E stated they were not aware Resident 48 had a catheter inserted as it occurred on a Friday when they were not at work. Staff E stated when they were not at work, the nurses were expected to implement EBP. Staff E stated a bin of PPE had been present in Resident 31's room since their admission on [DATE] and stated they were not aware Resident 19 had a diagnosis that they were a carrier of MRSA and stated, I missed that. Staff E stated they felt they had a pretty good system in place for identifying those residents that required EBP. Infection Prevention Policy ReviewOn 08/11/2025 at 8:55 AM, Infection Prevention Policies were requested during the recertification survey entrance conference. The following facility policies were reviewed, and all had a review date of 01/20/2024:-Infection Prevention and Control Program-Antibiotic Stewardship-Coronavirus Surveillance-COVID-19 Vaccinations-Employee COVID-19 Vaccinations-Employee Tuberculosis Testing-Enhanced Barrier Precautions-Infection Surveillance-Infection Reporting-Influenza Vaccination-Personal Protective Equipment-Pneumococcal Vaccine (Series)-Standard Precautions-Transmission Based PrecautionsDuring an interview on 08/20/2025 at 2:11 PM, Staff E stated they were not sure who was responsible for reviewing the Infection Prevention Program policies. During an interview on 08/20/2025 at 3:11 PM, Staff B, Director of Nursing, stated the policies provided to the survey team were the current active policies. Staff B stated the Administrator and the Director of Nursing worked together to review the policies to ensure they contained current guidelines. Reference: WAC 388-97-1320(1)(a)(2)(b)

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 1 of 1 sample residents (Resident 19) reviewed for dialysis care. Specifically, alternative arrangements were not made with the provider causing Resident 19 to have doses of their medications omitted on the mornings of their dialysis sessions. This failure placed the resident at risk for unintended health consequences and decreased quality of life.Findings included .The 06/25/2025 annual comprehensive assessment documented Resident 19 had diagnoses that included end-stage kidney disease dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer functioned), diabetes and high blood pressure. Resident 19 was independent for most activities of daily living, was cognitively intact and had dialysis treatments every Monday, Wednesday, and Friday.Resident 19 had the following medication orders:-hydralazine 10 milligrams (mg) three times daily for high blood pressure-Calcium acetate 667 mg, two capsules three times daily with meals to lower levels of phosphorous in the blood.Review of the medication administration record (MAR) showed Resident 19 did not receive morning doses of hydralazine or calcium acetate on 08/01/2025, 08/06/2025, 08/08/2025, 08/11/2025, 08/13/2025, and 08/15/2025. An administration code AB was entered on the MAR. The code key showed AB signified Resident 19 was absent from the facility. A review of progress notes had no entries that the provider was notified of the omitted doses of hydralazine and calcium acetate. On 08/15/2025 at 11:14 AM, Resident 19 was observed scooting in the hall in their wheelchair. Resident 19 stated their dialysis sessions went well. The resident stated they left the faciity on dialysis days at 5:00 AM, so did not bring food with them. They stated they did not receive breakfast so were hungry and tired so they ate and napped when they returned to the facility. During an interview on 08/20/2025 at 12:21 PM, Staff G, Licensed Practical Nurse, stated Resident 19 had several medications ordered to take in the morning. If the resident returned too late from dialysis, they missed those and got the next dose at lunch. Staff G stated medications were not sent to dialysis with the resident. Staff G stated to their knowledge, no one had discussed Resident 19's medications with the provider. They would need the orders or the administration times changed. Staff G stated Resident 19's blood pressure was all over the place so it was important for the resident to get their medications. During an interview on 08/20/2025 at 1:07 PM, Staff C, Assistant Director of Nursing, stated nurses had a wide range of times medications were able to be administered, so Resident 19 might be able to receive their medications when they returned from dialysis. Staff C stated they expected nurses would be communicating with the providers when the resident had not been receiving their medications. During an interview on 08/20/2025 at 3:12 PM, Staff B, Director of Nursing, stated if Resident 19 missed medications on the days they went to dialysis they expected nurses to discuss this with the provider so the orders could be adjusted. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure consistent communication with the dialysis center regarding fluid restrictions occurred for 1 of 1 sample residents (Resident 19) reviewed. This failure placed the resident at risk of fluid weight gain, fluid overload and unintended health consequences.Findings included .The 07/08/2025 facility Hemodialysis policy documented the facility provided necessary care and treatment consistent with professional standards and the resident's person-centered care plan to meet the special medical, nursing and psychosocial needs of residents receiving dialysis. The facility was to coordinate and collaborate with the dialysis facility to ensure there was ongoing communication and collaboration for the implementation of the dialysis care plan by nursing home and dialysis staff. The 06/25/2025 annual comprehensive assessment documented Resident 19 had diagnoses that included end-stage renal disease (ESRD, kidney failure) and was dependent on dialysis (a mechanical way of removing waste from the body when the kidneys no longer functioned). The resident was cognitively intact and was independent for most of their activities of daily living (ADLs). On 08/13/2025 at 11:30 AM, Resident 19 was in their room seated on the edge of their bed. They stated they had just returned from their dialysis treatment. Resident 19 stated they did not eat while they were at dialysis because they left so early in the morning, so they were hungry when they got back. There were potato chips, a hard-boiled egg and fruit cocktail on their overbed table, partially eaten. A large, lidded mug full of water was on the table, and an unopened can of soda and unopened bottle of water were on the nightstand. Resident 19 stated they were only supposed to drink small amounts of fluids but was unsure how much and who monitored this.On 08/15/2025 at 9:37 AM, Resident 19 was out of the facility for their dialysis treatment. The resident's breakfast tray was left on the overbed table. An empty coffee mug was observed, and there were two juice glasses, one containing water and one containing apple juice on the tray left with the lids on at this time. A review of Resident 19's care plan documented the following:-the resident received dialysis related to kidney failure; staff were to monitor the dialysis access site every shift, monitor labs, obtain vital signs and weights per protocol, and report any signs of bleeding or infection to the provider and report any significant changes in pulse and respirations immediately.-The resident had nutritional problems related to ESRD dependent on dialysis; staff were to provide a General Renal diet, with thin fluid consistency, provide 1ounce (oz) prostat (a protein supplement) in 4-6 oz water twice daily between meals, provide and serve supplements as ordered, and monitor meal intake and record. The Registered Dietician (RD) was to evaluate and make diet changes. The care plan and provider orders did not include oral fluid restrictions, or interventions to monitor the amounts of fluid consumed. A review of the July and August 2025 Medication/Treatment Administration Records (MAR/TAR) had no entries documented for Resident 19's fluid intake. A review of Nursing Assistant (NAC) documentation of Fluid Intake for the previous 30 days from 08/17/2025 showed varied intake amounts and many shifts with blanks and omissions. The NAC documentation for Fluids Given PRN (as needed or requested) had no data documented. During a telephone interview on 08/18/2025 at 9:21 AM, the dialysis center Registered Dietician stated they had talked with Resident 19, and the resident was supposed to be on a fluid restriction of 1200 milliliters (ml) daily. The RD stated the resident chose to drink more than that and often went to restaurants with friends and family. The RD stated they tried to converse with nursing staff at the facility quarterly, but they had not spoken with the long- term care facility's Registered Dietician. During an interview on 08/18/2025 at 10:06 AM, Staff O, RD, stated if the dialysis center had dietary or fluid recommendations for a resident, nursing staff were the ones to enter any of those orders. Staff O was not aware an oral fluid restriction was recommended for Resident 19 and stated they had not communicated with the dialysis center. During an interview on 08/20/2025 at 10:56 AM, Staff G, Licensed Practical Nurse, stated for any resident getting dialysis treatments, they monitored those residents for bleeding from their access site, monitored their vital signs and weights, and it was important to monitor for fluid balance and fluid intakes. Staff G stated Resident 19 kind of knew that they were not to overdo their fluids, but Staff G was uncertain if the facility or the dialysis center determined if the resident required a fluid restriction. They had cared for other residents who needed dialysis and those residents had their fluids monitored, but Resident 19 did not, and Staff G was unsure why.During an interview on 08/20/2025 at 1:07 PM, Staff C, Assistant Director of Nursing, Resident Care Manager, stated they communicated with the dialysis center using a sheet that went to dialysis with the resident. The sheet was returned with any comments from the dialysis staff or new orders and the nurse on the floor reviewed it once returned. At times, the dialysis center might call if there was something urgent. Staff C stated they were unsure what the process was if there were diet or nutrition needs, but that might also be on the communication sheets. Staff C stated they expected the dialysis RD and the facility RD would be communicating about those things. Staff C was not aware the dialysis center had recommended a 1200ml fluid restriction for Resident 19. To their knowledge, there had not been a conversation with the dialysis center regarding fluid restrictions for Resident 19. Reference: WAC 388-97-1900(1), (6)(a-c)

Based on observation, interview and record review, the facility failed to consistently provide bathing and personal hygiene/grooming for 1 of 2 sampled residents (Resident 41) reviewed for activities of daily living (ADLS). Failure to provide bathing, shaving and nail care placed Resident 41 at risk for poor personal hygiene, diminished quality of life and unmet care needs. Findings included . The 07/11/2025 quarterly assessment documented Resident 41 had diagnoses which included stroke and diabetes. Resident 41 needed assistance from nursing staff to complete ADLs for bathing and personal hygiene/grooming tasks such as nail care and shaving. On 08/11/2025 at 11:45 AM, Resident 41 was observed lying in bed watching television. Resident 41's hair appeared greasy, facial stubble covered their cheeks, chin and upper lip, and the fingernails of both hands were long with black debris underneath them. When asked if they had any concerns about their care, Resident 41 stated it had been a week since they were last bathed. Staff would inform Resident 41 that they were on the bath schedule for the day, but the bath often wasn't provided. On 08/13/2025 at 9:41 AM, Resident 41 was again observed with greasy hair, facial stubble, and long fingernails with black debris underneath them. Resident 41 stated they were scheduled to be bathed sometime that day. At 12:29 PM, Resident 41 still had greasy hair, facial stubble, and long dirty nails. Resident 41 stated staff had started to get them ready for a shower, but then lunch trays arrived, so the shower was postponed until after lunch. At 2:51 PM, Resident 41's hair and fingernails were observed to be clean, but the nails were still long, and the resident remained unshaved. Resident 41 stated they had been bathed, but there had not been enough time to be shaved, and the staff promised to shave them tomorrow. Resident 41 then raised their right hand up and stroked the facial stubble and stated they hoped they could wait because it started to get itchy when it was not done. When asked when nail care was done, Resident 41 stated because they were diabetic, their fingernails were trimmed by the nurse, and when they had asked earlier, the nurse stated their nails would be trimmed tomorrow. Subsequent observations of Resident 41 unshaved and with long fingernails were made on 08/14/2025 at 9:12 AM, 08/15/2025 at 10:11 AM, and 08/18/2025 at 10:27 AM. Review of the ADL care plan found interventions that informed nursing staff of Resident 41's care needs related to bathing, toileting, oral care and dressing, but no interventions or instructions related to Resident 41's personal hygiene/grooming needs, preferences, or assistance required from nursing staff related to nail care or shaving, were included. Review of the bathing records from 07/16/2025 through 08/04/2025 documented Resident 41 was showered on 07/16/2025, 07/19/2025, 07/30/2025, and 08/04/2025, a total of four showers provided out of seven showers scheduled. The documentation further showed that 11 days had lapsed from the shower on 07/19/2025 until Resident 41 received the shower on 07/30/2025. No documentation was found that showed Resident 41 had refused to be bathed. Review of the personal hygiene/grooming records during the same time period documented the type of assistance Resident 41 needed to maintain personal hygiene but did not include what type of personal hygiene the resident received. In addition, the documentation indicated Resident 41 had refused assistance twice but did not specify which type of personal hygiene was refused. In an interview on 08/18/2025 at 10:16 AM, Staff F, Nursing Assistant, stated nail care and shaving were completed during morning cares and when a resident was bathed, unless the resident was diabetic, then the nurses trimmed the nails. Staff F further stated when a resident missed a shower, the next shift offered to bathe them, and Sundays were shower make-up days to provide bathing for any that had been refused or missed. In an interview on 08/18/2025 at 12:41 PM, Staff B, Director of Nursing, was informed of the observations of Resident 41 not being bathed or assisted with grooming consistently, and the lack of grooming/personal hygiene interventions in the resident's care plan. After reviewing Resident 41's record, Staff B stated it was the facility's expectation that bathing and grooming/personal hygiene were provided, and the care plan should include interventions related to the resident's care needs and preferences. Reference: WAC 388-97-1060 (2)(c)

Based on observation and interview, the facility failed to ensure medication was administered per professional standards of practice for 1 of 8 sampled residents (Resident 31) reviewed during one medication administration observed. Specifically, a licensed nurse left medications at the resident's bedside without observing the medications being taken. This failure placed the residents at risk of not receiving the ordered medication and placed all residents at potential risk of medication errors.Findings included .The 01/20/2024 facility Medication Administration policy documented medications were to be administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice. The policy documented the nurse was to observe the resident take the medications.During an observation on 08/18/2025 at 10:22 AM, Staff G, Licensed Practical Nurse (LPN), prepared the medication Fosfomycin Tromethamine (an antibiotic) by mixing it with water for Resident 31. After giving Resident 31 other medications and watching them swallow them, Staff G handed Resident 31 the cup containing the Fosfomycin Tromethamine mixed with water and instructed Resident 31 to work on drinking it. Staff G stated they would check in with the resident later then left the room without watching the resident consume the medication.In an interview on 08/18/2025 at 10:47 AM, Resident 31 stated they had consumed the medication Staff G had left with them and stated that Staff G had not returned to check on them to see if they had taken the medication. The cup that had contained the medication was observed to be empty at that time.In an interview on 08/18/2025 at 11:40 AM, when asked why they had left the medication with Resident 31 and did not watch them take it, Staff G stated that the resident had the cup containing the medication in their hand, so they assumed the resident was going to consume it. Staff G confirmed they had not checked to see if the resident had taken the medication. When asked, Staff G stated it was not normal practice to leave medication with a resident and not watch the resident consume it. Staff G stated they shouldn't have left the medication with the resident unsupervised because there was no way to guarantee the resident took the medication.Reference: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)

Based on observation, interview and record review, the facility failed to consistently monitor the medication refrigerator temperatures for 1 of 1 medication storage rooms to ensure they were at safe storage levels. This failure placed residents at risk for receiving compromised or ineffective medication. Findings included.The 01/20/2023 article titled Storage and Handling of Immunobiologics published by the Center for Disease Control, documented failure to follow recommended storage and refrigerator temperatures for immunobiologics (a medicinal preparation made from living organisms and their products, such as a serum or vaccine) reduced or destroyed their potency which resulted in inadequate or no immune response in the recipient. Refrigerator storage temperatures needed to be kept between 36 through 46 degrees Fahrenheit and prompt immediate action needed to occur when the temperature was out of range. During the review of the medication storage room with Staff E, Infection Preventionist, on 08/20/2025 at 9:06 AM, the medication refrigerator temperature log form was observed to be posted on the refrigerator and included documentation for June through August 2025. Review of the form found refrigerator temperatures were not documented nine times in June 2025, 11 times in July 2025, and 9 times in August 2025. Review of the dates when the temperatures had been documented showed they were within normal, safe levels. The refrigerator contained 10 boxes of unopened tuberculin solution, an injectable solution used to screen for Tuberculosis, a lung infection. When asked about the missing temperature values, Staff E stated it was the responsibility of the night shift nurse to check and record the refrigerator temperatures daily to ensure the temperature was at safe levels. Staff E acknowledge the temperatures had not been consistently monitored. Reference (WAC): 388-97-1300 (2), 2340

Based on observation and interview, the facility failed to serve food that was palatable and had an appetizing appearance, and temperature for 2 of 2 meals observed and 1 of 1 test tray sampled. This failure resulted in the potential for all residents to have decreased appetite and decreased quality of life.Findings included .In an interview on 08/11/2025 at 11:33 AM, Resident 34 stated the food was bad and did not look good.In an interview on 08/11/2025 at 11:55 AM, Resident 48 stated that the food was terrible. They said it had no seasoning, everything was bland, and the appearance was unappetizing.During an observation on 08/11/2025 at 12:00 PM, a lunch tray was delivered to Resident 16. After seeing the food, Resident 16 stated it did not look very appetizing, took a bite then requested a cheeseburger.During an observation of the lunch meal on 08/11/2025 at 12:14 PM, in the main dining room, the food served was light brown pasta and light brown meat in a light brown gravy, dull green peas or green beans, and brown apple juice. The food lacked bright and varied colors.The lunch meal test tray on 08/15/2025 at 12:41 PM, was observed to consist of meatloaf, scalloped potatoes, zucchini, cottage cheese, plain yogurt, and apple juice. Per the Food and Drug Administration, the holding temperature for hot food was to be served above135 degrees Fahrenheit and cold food was to be served at less than 41 degrees Fahrenheit. The temperatures, in degrees Fahrenheit of the hot food items, served on the lunch test tray were: meatloaf 129, Scalloped potatoes 120.9, zucchini 114, and the cold food items were cottage cheese 57.3, yogurt 58.4, and apple juice 64.9. The food items were mostly brown and off-white in color.In an interview on 08/15/2025 at 2:45 PM, Staff M, Dietary Manager, stated that they had received complaints from residents and families about the appearance of the food and that sometimes they also thought the food did not look appetizing. Staff M stated when the food was all the same color, it did not look appetizing and something should have been switched in order to have different colors and make it look better. Reference: WAC 388-97-1100(1)(2)

Based on interview and record review, the facility failed to ensure 2 of 5 sampled residents (Resident 34 and 29), reviewed for unnecessary medications, were informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors) and that their consent was obtained prior to administering psychotropic medications. This failure placed the residents at risk of not being fully informed of the potential risks and benefits of taking the medications.Findings included <Resident 29> The 06/28/2025 quarterly assessment documented Resident 29 had diagnoses that included Parkinson's disease (a disorder of the nervous system that affected movement), malnutrition, and anxiety. Resident 29 was severely cognitively impaired and took medications for depression and anxiety (psychotropic medications) daily. A family member had been designated to make decisions for the resident. A review of provider orders documented on 06/30/2025, an order was given to administer mirtazapine, a psychotropic medication used to treat depression but was prescribed for Resident 29 to stimulate appetite, daily at bedtime. Review of the July and August 2025 medication administration record (MARs) documented Resident 29 received mirtazapine as prescribed. Review of consents showed there had been no consent that described the risks and benefits of the medication obtained at the time mirtazapine was prescribed for Resident 29. <Resident 34> The 06/11/2025 quarterly assessment documented Resident 34 had diagnoses which included depression. In addition, the assessment showed the resident received psychotropic medication to treat the symptoms of the depression. On 08/15/2025 at 10:03 AM, Resident 34 was observed lying in bed in their room. When asked how they were doing, Resident 34 stated they felt depressed, and was taking medications to treat their depression. A review of the Order Summary Report from 02/27/2024 through 08/31/2025 documented the psychotropic medications escitalopram and mirtazapine were prescribed to Resident 34 when they admitted to the facility on [DATE]. In addition, the report documented the physician prescribed an additional psychotropic medication (Wellbutrin) on 11/06/2024. Review of the Medication Administration Records (MARs) from February 2024 through August 2025 documented the medications had been administered to Resident 34 as prescribed. Review of Resident 34's record found an Informed Consent for Psychotropic Medication form for escitalopram and mirtazapine had been completed and signed by Resident 34 on 02/29/2024, two days after the medication was prescribed and Resident 34 began taking the medication. Additional record review found no documentation an informed consent related to the Wellbutrin was discussed, either verbally or written, with the resident prior to the resident receiving the medication. In an interview on 08/15/2025 at 3:15 PM, Staff D, Registered Nurse, stated informed consents for psychotropic medication needed to be obtained before the resident received the medication. In an interview on 08/18/2025 at 12:20 PM, Staff B, Director of Nursing, confirmed informed consents needed to be obtained prior to the resident receiving the medication, and upon admission when a resident admitted with orders for psychotropic medications. Reference: WAC 388-97-0300(3)(a), -0260, -1020(4)(a-d)

Based on interview and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman received written notification of a hospital transfer and/or discharge, for 3 of 3 sampled residents (Residents 50, 7, and 2), reviewed for hospitalization/discharge. This failure placed the residents at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman. Findings included. <Resident 50> The 07/07/2025 entry assessment documented Resident 50 admitted to the facility from the hospital. Review of nursing progress notes documented on 07/10/2025, Resident 50 was sent to the hospital to be evaluated after experiencing difficulty breathing despite using supplemental oxygen. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital, as required. <Resident 2> Review of the record documented Resident 2 was initially admitted on [DATE]. The 05/24/2025 admission comprehensive assessment was not completed. The 06/05/2025 discharge assessment documented Resident 2 had diagnoses that included hip fracture and dementia and was severely cognitively impaired. A review of nursing progress notes documented the following: On 06/05/2025 at 7:00 AM, a nursing assistant notified the nurse that they heard Resident 2 call out and found the resident on the floor on their left side. Resident 2 was assessed and then transferred to the bathroom for toileting. Once finished, Resident 2 complained of left hip pain, was unable to bear weight and unable to stand from the toilet. Emergency Medical Services was called, and Resident 2 was transferred to the hospital at 7:30 AM. The resident remained at the hospital for surgical repair of a hip fracture then returned to the facility on [DATE]. There was no documentation in the record that the Ombudsman had been notified of Resident 2's discharge to the hospital as required. In an interview on 08/18/2025 at 1:27 PM, Staff B was asked if the Ombudsman was notified when residents were transferred to the hospital or discharged from the facility. Staff B stated the facility was not aware that notification needed to be sent to the Ombudsman and confirmed it had not been. <Resident 7> In a review of Resident 7's records, it was documented that they were admitted to the facility on [DATE] from the hospital. Review of the 08/08/2025 Transfer-Discharge report documented Resident 7 was discharged home for meeting their rehabilitation goals. In an interview on 08/18/2025 at 1:27 PM, Staff B, Director of Nursing, explained that no notification to the Ombudsman was sent for discharges because there was a confusion about who was responsible for sending the notifications. Reference (WAC) 388-97-1020(2)(a-d)

Based on interview and record review, the facility failed to ensure 3 of 5 sampled residents (Residents 34, 4, and 2), reviewed for Pre-admission Screening and Resident Review (PASRR, an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services) was completed prior to admission, accurately, and if indicated, a referral for a PASRR Level II (a more in-depth screening assessment) had been made. Failure to ensure PASRR was completed accurately for Residents 34 and 4, and failure to ensure a PASRR was completed for Resident 2 after their decision to reside at the facility following an exempted hospital stay (being admitted to the facility directly from the hospital after receiving acute inpatient care, and an expected length of stay at the nursing facility of 30 days or less), placed the residents at risk for a diminished quality of life and unidentified care needs related to their mental health. Findings included.<Resident 4> Review of the record documented Resident 4 was admitted on [DATE]. The 06/18/2025 comprehensive admission assessment documented Resident 4 had diagnoses that included depression and anxiety. On 06/05/2025, a Level I PASRR screening was completed, and incorrectly documented Resident 4 had no serious mental illness and that a Level II evaluation to determine what behavioral health needs the resident might need once a resident at the facility was not indicated. <Resident 2> Review of the record documented Resident 2 was admitted to the facility on [DATE]. A Level I PASRR screening completed on 05/23/2025 documented that Resident 2 had a serious mental illness but was exempt from having a Level II evaluation because the resident was expected to remain at the facility for less than 30 days. On 08/11/2025 at the beginning of the recertification survey, Resident 2 still resided the facility. Further record review found no notes from the facility management or from the Social Worker that a referral for a Level II evaluation was sent after the resident continued to reside at the facility past the 30-day exemption period. <Resident 34> The 06/11/2025 quarterly assessment documented Resident 34 had diagnoses that included depression and received medication to treat the symptoms of depression. Review of the progress notes from 02/27/2024 through 08/18/2025 documented Resident 34 admitted to the facility on [DATE] and on 01/11/2025 was sent to the hospital for evaluation due to increased confusion. The resident was readmitted to the facility on [DATE]. Review of Resident 34's record found a Level I PASRR had been completed prior to the resident's initial admission to the facility. An updated Level I PASRR was completed on 02/14/2025 after changes were made to the prescribed psychotropic medications. Section 1A of the form documented Resident 34 had serious mental illness indicators and a mood disorder, however, Section IV documented Resident 34 did not show any indicators of serious mental illness, and no Level II evaluation was indicated. In an interview on 08/18/2025 at 10:07 AM, Staff C, Assistant Director of Nursing, stated a Level I PASRR needed to be completed prior to a resident's admission to the facility, and if positive for serious mental illness indicators, a referral for a Level II evaluation needed to be made. Staff C acknowledged that Resident 2 should have had another PASRR completed after their stay extended past 30 days. In an interview on 08/18/2025 at 12:13, Staff B, Director of Nursing, confirmed the PASRR assessment needed to be completed as stated by Staff C. After discussion and review of Resident 34's record, Staff B acknowledged a Level II PASSR referral should have been completed. Reference: WAC 388-97-1915(1)(2)(a-c)

Based on observation, interview and record review, the facility failed to consistently follow care planned supervision interventions and fully evaluate the effectiveness of the fall prevention interventions in place for 1 of 3 sample residents (Resident 2) reviewed for accidents/hazards. This failure placed residents at risk for accidents and diminished quality of life.Findings included . Review of the facility policy titled, dated 01/20/2024, Fall Prevention Program policy documented each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse will indicate in the electronic medical record the resident's fall risk and initiate interventions on the resident's baseline care plan. Residents assigned low/moderate risk will have universal interventions implemented including clear pathways to the bathroom, bed lowered and locked, call light and frequently used items in reach, adequate lighting and assistive devices in good repair, and implement routine rounding schedule. For residents at high risk, low/moderate interventions were to be implemented, and additional interventions were to be provided including assistive devices, increased frequency of rounds, a sitter, if indicated, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting, family/caregiver education or therapy referral. Resident 2 was admitted on [DATE] and had diagnoses that included dementia, history of falls, and fracture of the left femur greater trochanter (the ball of the upper portion of the thigh bone) that did not require surgery. The 05/24/2025 comprehensive admission assessment was not completed.A 05/24/2025 nursing progress note documented Resident 2 arrived at the facility at 11:30 AM from the hospital for physical therapy related to a non-operative left femur fracture. The resident was oriented only to self and the current situation. The resident stated they had occasional back pain from their history of falls. They were oriented to their room and call light. The 05/24/2025 initial Personal Care Plan documented Resident 2 had confused cognition (mental action and understanding thoughts) and was a fall risk. Staff were to keep the bed in low position, call light in reach, and the resident needed frequent checks. The resident could bear weight as tolerated and required assistance of one staff and a two-wheeled walker to move in the room. Review of admission assessments, showed no individualized assessment of Resident 2's fall risk was completed on admission. A late entry progress note, Staff C, Assistant Director of Nursing/Resident Care Manager progress note effective 05/25/2025 at 7:33 AM documented they were notified Resident 2 attempted to transfer without assistance, that staff placed a floor mat, and that the care plan was updated.A 05/26/2025 at 6:58 PM nursing progress note documented staff notified the licensed nurse that Resident 2 fell in the Activities area. The fall was not witnessed; activity staff noticed when they saw the resident raising their arm up from the floor. The resident was on their bottom and no injuries were found. The 05/26/2025 Incident Report completed by Staff G, Licensed Practical Nurse (LPN), documented Resident 2 had an unwitnessed fall in the Activity area and Activity staff noticed when they saw the resident raising their arm. The resident was confused, had impaired memory, and was not injured. There were no investigation notes and no staff statements regarding the events.On 05/27/2025, after the resident fell, the Care Plan was updated to include Resident 2 was at risk for falls related to deconditioning and recent fall with hip fracture prior to admission. Interventions added on 05/27/2025 included anticipate and meet Resident 2's needs, be sure the call light was in reach and encourage the resident to use it, ensure the resident wears appropriate footwear when ambulating, fall mat at bedside for safety, ensure a safe environment, even floors free of clutter and spills, bed in low position and personal items in reach and toilet every two hours.On 06/02/2025, a late entry Staff C progress note effective 05/28/2025 at 10:43 AM was entered that documented they spoke to Resident 2 regarding the fall in the Activity area and the resident was unable to recall the events that took place; staff had already placed a fall mat at the bedside. The note stated that although activity staff were present, they did not witness the fall, but abuse and neglect were ruled out. The care plan was updated to include increased hourly supervision and toileting assistance. The resident had been toileted within one hour of their fall. On 06/05/2025 at 11:45 AM nursing progress note documented that the nurse went to the transitional care unit (TCU, where Resident 2 resided) at 7:00 AM and was informed that the resident fell. Staff had obtained Resident 2's vital signs at 6:40 AM, then the resident stated they wanted to sleep. Staff heard the resident call out at 6:55 AM and found the resident on the floor. The resident stated they had moved their fall mat that had an alarm pad on it and had not used their walker to go to the bathroom. The resident was able to move their legs and had no pain at that time. Staff assisted the resident up and walked with the resident and their walker to the bathroom. By the time the resident finished toileting, they complained of hip pain, and was unable to bear weight and stand from the toilet. Two staff assisted Resident 2 to their wheelchair, 911 was called, and Emergency Medical Services took the resident to the hospital at 7:30 AM. The 06/05/2025 Incident Report completed by Staff J, LPN, documented staff had obtained Resident 2's vital signs at 6:40 AM, then the resident wanted to sleep. At 6:55 AM, the staff heard the resident call out and found the resident on the floor with the fall mat moved. Resident 2 reported they moved the fall mat and was going to the bathroom. Staff J documented Resident 2 stated they hurt their left hip but was able to move their legs with no pain, so staff walked the resident to the bathroom. After finished toileting, Resident 2 was unable to stand and was in too much pain. The Incident Report did not include an investigation or staff statements regarding the fall.The 06/05/2025 at 2:18 PM Staff C progress note documented Resident 2 required surgery to repair their left hip that was re-injured in that day's fall. Staff stated they had just been in and the resident denied needing assistance to the bathroom. The bed was low, the fall mat was in place and the call light was in reach. When staff re-entered the room, the fall mat had been moved and Resident 2 stated they moved it. Staff C documented Resident 2 had a history of kicking their fall mat away from their bedside. Abuse and neglect were ruled out as staff had just rounded, the resident had poor safety awareness and was impulsive. Other interventions were to be explored upon the resident's expected return to the facility. The Staff G Nursing progress notes documented Resident 2 returned from the hospital on [DATE] at 2:30 PM, was provided their call light and transferred to bed. A 06/10/2025 at 11:55 AM Staff C progress note documented Resident 2's care plan was updated to include increased supervision to every 15 minutes for safety and that a task was entered to offer the resident to get up at 7:00 AM to begin their morning routine as the fall occurred at that time. On 06/16/2025, a comprehensive Fall Risk Assessment was completed by Staff I, LPN, and documented Resident 2 was assessed to be high risk for falls. A 06/30/2025 Staff G progress note documented that at 1:00 PM, they heard a resident yelling man down and responded to see Resident 2 in their room on the floor. The resident was sitting on their buttocks on the floor with their legs bent in front of them. The fall mat had been scooted away from the bedside, and the resident stated they attempted to get out of bed on their own. There was a reddened area on the resident's tail bone, and no other injuries. The 06/30/2025 Staff G Incident Report documented a resident yelled man down and responded to find Resident 2 on the floor in their room. Their fall mat had been scooted away and the resident stated they attempted to get up on their own. The resident sustained a red area on their tailbone that was sore to touch, but no other injuries. The Incident Report did not contain any staff or resident statements, and no notes regarding an investigation. A review of the June 2025 Nursing Assistant (NAC) task documentation of 15-minute checks showed omissions in 15-minute checks on 06/11/2025, 06/23/2025, 06/24/2025, 06/25/2025 and for the entire nightshift on 06/30/2025. The resident had been checked at 12:45 PM prior to the time they fell. A 07/01/2025 Interdisciplinary Care Team Conference form documented Resident 2's care plan was reviewed. Resident 2's family representative discussed adding nicotine lozenges to the resident's care. They felt Resident 2 had agitation from nicotine withdrawal. Staff C documented they would notify the provider. There was no documentation that falls were discussed. Those in attendance were Staff C, and Resident 2's representative.A 07/01/2025 Provider progress note documented Resident 2 was prescribed a muscle relaxer, Robaxin, to be used as needed. The medication was used little and was to be discontinued given the resident's fall. The 07/02/2025 Staff C progress note documented Resident 2 was unable to recall the events prior to their fall. The resident had been checked within 15 minutes of falling. The family representative thought the resident might be having nicotine cravings, and nicotine lozenges were ordered. Resident 2 was able to move their fall mat/alarm out of the way prior to getting out of bed. Nursing was to offer hip protectors when lying in bed to prevent injury, as preventing falls was difficult with the resident's impulsiveness. On 07/02/2025, Resident 2's care plan was updated to include applying hip protectors (brief-style pull-on garments that had extra padding in the hip areas) when the resident was in bed for naps or at bedtime. A 08/02/2025 at 3:31 PM nursing progress note documented Resident 2 had been irritable lately per report from the nursing assistant (NAC). The resident did not eat breakfast or lunch and did not get up.A 08/02/2025 at 9:36 PM progress note documented Resident 2 continued to be impulsive and non-compliant with staff stand-by assistance. Then at 6:45 PM, the resident was observed lying on their back four feet from their bed. The fall mat/alarm mat was moved towards the foot of the bed. Resident 2 stated Hello, I think I broke my arm. The resident would not stay put while staff went to get the nurse, so they were assisted to their bed and were resistive to assessments. Resident 2 was sent to the hospital at 7:25 PM. The 08/03/2025 at 5:00 AM nursing progress note documented Resident 2 was returning to the facility and had a broken wrist that was splinted and in a sling. The 08/04/2025 at 1:59 PM Staff C progress note documented they spoke with Resident 2 regarding their fall. Resident 2 stated they did not fall and did not know what their splint was and did not remember the events prior to the fall. The floor nurse was notified that an incident report needed to be filled out. The nursing assistant had checked the resident within five minutes of the incident. Abuse and neglect were ruled out as the care plan was followed. The resident's cognition and impulsiveness made the resident's falls unavoidable, and they were going to recommend the resident be moved to a facility with a memory care unit. On 08/11/2025, Resident 2 was observed lying on their back in bed. The resident had a brace on their right forearm and their fingers were varying shades of light and dark purple bruising. The resident was able to wiggle their fingers. Resident 2 stated they did not know what happened to their hand and did not know if they had fallen. A fall mat and alarm mat was observed next to the resident's bed, and the resident's bed was in low position. The resident's call light was near their feet. 08/13/2025 9:17 AM Resident 2 was asleep in bed. Their fall mat was in place and the bed was in low position. Their right arm was in the brace. From 9:17 AM until 11:23 AM, Resident 2's room was continuously observed. At 10:06 AM, a staff member later identified as Staff H, NAC, was in and right back out of Resident 2's room. Staff H entered Resident 2's room again and was immediately back out at 10:41 AM. At 10:49 AM, an unidentified staff member entered the resident's room, was overheard stating they left the resident a menu, then left the room. Until the observation ended at 11:23 AM, there had been no other staff in or around the resident's room. Incident Reports requested on 08/11/2025 during the survey entrance conference had no entry documented for the fall with fracture that Resident 2 sustained on 08/02/2025. A review of August 2025 NAC task documentation of 15-minute checks showed omissions in 15-minute checks on 08/02/2025, 08/03/2025, 08/06/2025, 08/09/2025, 08/10/2025 and 08/11/2025, most on the evening shifts. The resident was checked on 15 minutes prior to the time they fell on [DATE]. On 08/13/2025 during the times continued observations of Resident 2's room were conducted, the 15-minute checks were documented as completed when only three checks had been completed. On 08/20/2025 at 8:38 AM, Resident 2 was observed in their bed with Staff H, NAC, and Staff K, NAC. Resident 2's bed was in low position and the fall mat/alarm mat were next to the bedside. Staff H and Staff K were able to remove the resident's covers when requested so the resident's hip area was able to be observed. Resident 2 was wearing pajamas and an incontinence brief. There were no hip protectors in use. Staff H and Staff K looked in the resident's closet and drawer and did not locate any hip protectors. When asked, they were unsure if or when Resident 2 was to wear the hip protectors. They suggested the hip protectors might have been sent to the laundry. During an interview on 08/20/2025 at 8:42 AM, Staff H stated they could locate instructions they needed to care for the residents in their computer. Staff H stated Resident 2 was a fall risk and would forget to use their call light if they wanted to get up. Staff H stated they used a fall mat, and the black mat on top of the fall mat was an alarm mat. Staff H stated they were not present when the resident broke their arm, but the resident moved their fall mat and had also moved their mat when they fell and broke their hip. Staff H stated Resident 2 was supposed to have hip protectors on any time they were lying in bed. Sometimes the hip protectors went to the laundry so they might be gone for several hours. They stated Resident 2 only had one pair. Staff H stated they thought Resident 2 was on 15-minute checks, which meant they were to look at the resident and offer them toileting and then document that. Staff H stated if 15-minute checks were not completed, the resident was at risk for more falls. Staff H stated the alarm mat would alarm if anything touched the mat. Staff H stated the alarm going off could mean that something touched the mat, or that the resident was already on the floor. Staff H stated if 15-minute checks were not documented, they were not done. During an interview on 08/20/2025 at 9:03 AM in the laundry area, Staff L, Housekeeping/Laundry Supervisor, produced two pair of hip protectors that were in a bin marked for Resident 2. Staff L stated staff would bring the hip protectors to the laundry at night, they were laundered in the morning, and then the clean laundry done in the morning was delivered back to the resident rooms the same day.During an interview on 08/20/2025 at 10:23 AM, Staff I, LPN, Minimum Data Set (the comprehensive assessment that documented a resident functional abilities) Assessment Coordinator, stated they reviewed a resident's History and Physical documents prior to admission so a new resident's cognition, mobility issues, or fall risks were known as early as two or three days before a new resident arrived at the facility. The floor nurse did the physical assessment once a new admission arrived. An initial safety care plan was completed by the Resident Care Manager, Staff C, and new residents were checked every two or three hours for the first 72 hours. Staff I stated they were responsible for completing the fall risk assessment. Staff I stated the fall risk assessment was part of the comprehensive admission assessment, which had to be completed within 14 days of the resident's admission. Staff I stated the only fall risk assessment they saw in the documentation was completed on 06/16/2025, after the resident had returned from having their hip fracture repaired. Staff I stated they will visualize the residents when they complete their assessments, usually by day three, four or five of their admission. They stated Resident 2 might know what their call bell was for off and on, maybe.During an interview on 08/20/2025 at 11:13 AM, Staff G, LPN, stated the nurses were responsible to ensure the NACs completed their tasks. Staff G stated there was a tab in the electronic medical record where changes to a resident's care or updates were communicated. Alerts were also placed in the documentation. Staff G stated Resident 2 required quite a bit of monitoring; staff did not sit with the resident one to one, but staff G stated they guessed Resident 2 was to be checked and changed every two hours. They were unsure if the resident required 15-minute checks but stated they could observe the resident when they were at their medication cart and they could tell if the resident started to get antsy. Then they attempted to distract the resident and kept a closer eye on them. Staff G stated Resident 2 did not use their call bell, but yelled out, and the reisdent also moved their fall mat. Staff G was uncertain what hip protectors were. Staff G stated they assumed management re-evaluated a resident's interventions. During an interview on 08/20/2025 at 12:30 PM, Staff C stated a basic care plan was developed within the first 48 hours of an admission and that is what the staff used for the first 48 hours until they got to know residents more, and more is added to the plan of care by all disciplines. Staff C stated Resident 2 was admitted on a Friday on 05/24/2025. If residents arrived late in the day, then additional care areas would be added to the basic care plan on Monday. In Resident 2's case, the next Monday was a holiday, so Staff C stated they worked on the care areas on Tuesday. By then, Resident 2 had already fallen on 05/25/2025 so Staff C added a fall mat to the resident's plan of care. Staff C reviewed the initial safety care plan interventions and stated they were unsure what was meant by frequent checks. Staff C stated interventions were reviewed quarterly. Resident 2 was impulsive, so Staff C added other interventions to the plan of care such as ensuring the resident had appropriate footwear on. Staff C stated the resident fell again and broke their hip, so the supervision was increased to check the resident every 15 minutes. Staff C was asked about the initial fall in the Activity area with staff present. Staff C stated the staff were in the small office located in the activity room and acknowledged there were many areas of the Activity room that were not visible from the office and Staff C was unsure if Resident 2 was visible from the office. Staff C acknowledged Resident 2 was able to move their fall mat. Staff C stated they assumed the NACs still checked on Resident 2 every 15 minutes, even though there were omissions in the documentation. Staff C was notified of the continued observation of the resident's room on 08/13/2025, but the documentation reflected the resident was checked every 15 minutes. Staff C was unable to explain but stated they felt all interventions had been exhausted and that was why they recommended a memory care unit. Staff C stated when an incident occurred, the nurse at the time was expected to complete the incident report. Staff C stated they documented their investigation in the Resident Progress Notes. Medical Records was responsible for entering the incidents on the Incident Log. During an interview on 08/20/2025 at 3:12 PM, Staff B, Director of Nursing, stated the fall risk assessment is part of the comprehensive assessment done on admission and they expected a new admission to be evaluated by the MDS Coordinator within five days of admission. Staff B acknowledged that after admission, Resident 2 fell twice and sustained a hip fracture before their fall risk assessment was completed, almost two weeks after their admission. They did not consider that timely. Staff B stated if a resident had hip protectors and 15-minute checks as part of their plan of care, they expected staff to complete those interventions. If staff were not documenting that the 15-minute checks were completed, Staff B stated they were not done. Reference: WAC 388-97-1060(3)(g)

Based on observation and interview, the facility failed to label and date food products in 2 of 2 resident snack refrigerators. This failure placed the residents at risk for food borne illness and decreased quality of life. Findings included .During an observation on 08/15/2025 at 3:04 PM, the resident snack refrigerator in the nurses' main charting room, contained six hard-boiled eggs in a plastic bag which was not labeled with a name or date. During an observation on 08/15/2025 at 3:08 PM the resident snack refrigerator on the transitional care unit contained six hard-boiled eggs in a plastic bag, and a bottle of honey mustard dressing, which were not labeled with a name or date.In an interview on 08/20/2025 at 9:18 AM, Staff M, Dietary Manager, stated the resident snack refrigerators were checked daily by the prep cook for proper labeling of food items and expiration dates. Staff M stated it was important for food items to be labeled and dated so the staff knew how long the item had been in the refrigerator and to whom it belonged. They stated unlabeled/undated food items would be discarded.Reference: WAC 388-97-1100(3)

Based on observation, interview, and record review, the facility failed to ensure staff followed Contact Precautions, when indicated, for 1 of 1 sampled resident (Resident 1), during wound care. This failure placed the residents at risk for spread of infection, illnesses, and unintended health consequences. Findings included . Per the Center for Disease Control (CDC) guidelines, staff should wear a gown and gloves for residents on Contact Precautions. Additionally, if there is a chance for splashes or sprays of body fluid eye precaution and mask may be needed. According to a facility assessment, dated 03/02/2025, Resident 1 had a history of a stroke, anxiety and depression. The resident had some difficulty making their needs known. Review of a hospital discharge orders, dated 05/12/2025, showed the resident had abscesses that had been drained and tested positive for Methicillin-resistant Staphylococcus aureus (MRSA, a bacteria that is resistant to many antibiotics and highly contagious by skin to skin contact or contact with contaminated surfaces). Dressing changes were to be daily and Contact Precautions followed. During an observation on 05/22/2025 at 10:21 AM, Staff A, Registered Nurse (RN), and surveyor entered Resident 1's room for a dressing change. There was no signage on the door to show the resident was on contact precautions and no cart outside the room with Personal Protective Equipment (PPE's). When entering the room, a sign was seen on the resident's wall that showed they were on contact precautions and a tote was below. The sign was difficult to see due to the lighting in the room. Staff A donned their gloves, cleansed the wounds, and covered them with dressings. Staff A washed her hands in between putting on new gloves. The wounds appeared to be healing. Staff A did not place a gown on during the procedure. Staff A was interviewed at 11:12 AM and asked if Resident 1 was on contact precautions. Staff A looked at their work sheet and stated they should be, Resident 1 had MRSA. Staff A stated a gown should have been worn but they did not see a sign or cart to show they were on contact precautions. Staff A and the surveyor went into the room where the sign and tote were located. During an interview on 05/22/2025 at 11:50 AM, Staff B, Infection Preventionist, stated they had not been in the facility when Resident 1 returned from the hospital. Staff B stated the signage for residents on contact precautions, especially with MRSA, should have been on the outside of the door and the PPE cart so staff could don prior to entering the room. Staff B confirmed Staff A should have worn a gown at the time of the dressing change. Reference: WAC 388-90-1320(2)((B)

Based on observation, interview, and record review, the facility failed to assess, monitor, and notify the physician of a non-pressure related skin condition for 1 of 3 sampled residents (Resident 1), reviewed for skin integrity. This failure placed the residents at risk for potential worsening skin conditions and a decreased quality of life. Findings included . Review of the facility policy titled Wound and Skin, dated 07/23/2013, showed the facility policy was to identify all wound and skin issues upon admission, on an ongoing basis, and on the routine weekly skin check day using the skin assessment tool. Once a wound or skin issue was identified, the Licensed Nurse (LN) was to document the characteristics of the issue i.e. size, depth, color, drainage, and location in the chart and on an incident report. This information must be documented in the skin assessment on a weekly basis. The findings were to be reported to the MD and fax MD with plan for treatment. Staff were to record this on the electronic Medication Administration Record (eMAR) under treatments and was to be followed up on by the LN's. The Director of Nursing (DNS) was to be notified for all skin issues. According to a facility assessment, dated 03/02/2025, showed Resident 1 had a history of a stroke, anxiety and depression. The resident had some difficulty making their needs known. Resident 1 required substantial to maximal assistance with most Activities of Daily Living (ADL's). Review of a skin assessment, dated 04/26/2025, showed Resident 1 had 2 boils: 1 on the left bottom side of the scrotum and 1 on the right side. They measured 2 centimeter (cm) x 2 cm, and had hard lumps under the wounds. The left inner thigh had a blister that measured 2 cm x 2 cm and the blister was described as popped. Staff noted they covered all areas with barrier cream. Review of the resident's eMAR for April 2025 through May 3, 2025 showed no treatment in place related to the resident's skin issues. Review of progress notes showed no documentation on 04/26/2025 about the new skin issue or that the physician had been notified. On 05/01/2025 a progress note by Staff B, Infection Preventionist (IPC), showed a Nursing Assistant (CNA) reported Resident 1 had blood on their brief. Staff B assessed the resident's groin and found a small amount of blood from an excoriated (raw and irritated) area to the right side of the scrotum. On 05/03/2025 Staff C, Registered Nurse (RN) documented Resident 1 complained their pain had increased from their boils. The resident was no longer able to sit in their chair and wanted to lay down. Warm compresses where applied to the boils and the resident stated it only helped a little. The resident requested to go to the hospital and the on call provider agreed due to the increased pain and discharge from the resident's boils. Review of hospital records, dated 05/03/2025, showed the resident had scrotal cellulitis (a bacterial skin infection affecting the deeper layers of the skin and underlying tissue, often causing localized redness, swelling, warmth, and pain) and abscesses (a swollen area within body tissue, containing an accumulation of pus). The abscesses were drained and cultures taken which showed Methicillin-resistant Staphylococcus aureus (MRSA, a bacteria that is resistant to many antibiotics and highly contagious by skin to skin contact or contact and by contaminated surfaces). During an interview on 05/16/2025 at 11:03 AM, Staff D, Licensed Practical Nurse (LPN), stated if a new wound was identified, nurses would complete an incident report, notify Staff B, Infection Preventionist, and call the physician if a treatment was needed. When asked about Resident 1, Staff D stated they had taken care of the resident the evening before the resident went to the hospital. Staff D stated a nursing assistant asked them to look at the resident. The resident had boils - 1 on the inner thigh, the other on the side of their testicle, which looked ready to pop. The area was open, oozing and swollen. Staff D stated they didn't complete an incident report because the boils had been reported to them a couple of days prior and assumed it had already been done. Staff D stated they notified the physician in the provider book. During an interview on 05/21/2025 at 12:27 PM, Staff E, RN, stated they had completed the skin assessment on 04/26/2025 after a nursing assistant had notified them the resident had pain in their scrotal area. The resident had a popped blister on their left inner thigh and the resident's scrotum was swollen. Staff E assumed since the blister had popped, another nurse had identified the area, so didn't investigate further to see if a incident report had been done. On 05/21/2025 at 3:00 PM, Staff F, CNA, had noticed the skin issues for Resident 1 on the day the resident was sent out to the hospital. Staff F stated they went and told the nurse so they could assess it. On 05/22/2025 at 9:37 AM, Resident 1 was laying in bed. The resident stated they had boils on their scrotum and went to the hospital to have them drained. Resident 1 said they now had dressing changes and was told by staff the areas were healing. Resident 1 gave the surveyor permission to observe the dressing changes. At 10:21 AM, Staff A, RN, donned their gloves and removed the resident's brief. The wounds were without dressings and open to air. Staff A cleansed the resident's wound on the underside of the right testicle. Their was a small area open area which appeared to be healing. Staff A stated the resident had orders for the area to be packed but the wound had closed enough that packing wasn't needed. The area was cleansed, gauze was placed, and a border dressing was applied. The left inner thigh had a pink/red, closed area. The area was cleansed and a border dressing was placed. The resident tolerated the dressing change well. On 05/22/2025 at 11:23 AM, Staff C, RN, was contacted by telephone. Staff C stated the first they knew about the resident's boils was on the day the resident was sent to the hospital. The resident had been in their wheel chair and complained of increased pain so was put in bed. Staff C offered a warm compress and commented they were not sure what had been done for treatment prior to that. Later in the shift, Staff C was told by a CNA the resident had some blood and drainage. Staff C described the wounds as opened with a nickel size pus plug. The surrounding area was hard, like the size of an apple or orange. The other areas were harder to visualize. The resident was sent to the hospital. On 05/22/2025 at 11:50 AM, Staff B, IPC, stated the were not aware there was skin issues with Resident 1. When Staff E had identified the boils, they should have completed an incident report, placed the resident on alert, contacted the physician and Administration, and documented on a progress note. On 05/01/2025 a CNA told Staff B the resident had blood on their brief. When Staff B assessed the area, they found an excoriated area to the right of the resident's scrotum. Staff B stated the boils were under Resident 1's scrotum and were not visable at that time. Staff B stated the nurses should have followed the process for a new skin issue, which had not been done. In addition, Staff D, LPN, had notified the physician in the provider book but since it was a Friday evening, the provider should have been contacted directly. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASARR, a screening required to be completed prior to admission to a nursing home that looked for indicators that one may have a serious mental illness) were completed for 3 of 5 sampled residents (Resident 1, 3, and 7), reviewed for PASARR's. Resident 1 and 3 were not referred for a Level II evaluation (an assessment that made recommendations about specialized services needed to determine the best setting to meet a person's behavioral health needs) and Resident 7 did not have a PASARR completed prior to admission to the facility, as required. This failure placed the residents at risk for a decline in their mental health and a decreased quality of life. Findings included . <Resident 1> Review of the quarterly assessment, dated 11/20/2024, showed Resident 1 was admitted with a history of a stroke, anxiety and depression. The resident was able to make their needs known. Resident 1's mood assessment showed they had little interest in doing things, felt down, felt bad about themselves and thoughts they would be better off dead. The resident was admitted on an antidepressant and antianxiety medication. Review of the resident's PASARR dated 08/19/2024, indicated Resident 1 had indicators they had a serious mental illness and required a PASARR level II review. Further review of the Electronic Medical Record (EMR) had no documentation to show the facility requested a Level II review from the PASARR coordinator. On 01/29/2025 at 12:05 PM, Resident 1 was laying in bed with a hospital gown. The resident stated the facility was pushing him to violence and he had hit a staff member about a week ago with their back scratcher. The facility told them if they hit someone again, they would call the police. Resident 1 stated they were trying to not get angry. The resident was tearful during the conversation. <Resident 3> Review of the Admission assessment, dated 12/20/2024, showed Resident 3 was admitted with diagnoses which included a stroke, Parkinson's Disease (a progressive disorder that affects movement, balance, and coordination), and a history of suicide attempt. The resident had difficulty making their needs known. The mood assessment showed the resident had little interest in doing things, felt down and bad about themselves, and had thoughts they were better off dead. The resident was admitted on an antidepressant. Review of the PASARR, dated 12/13/2024, indicated Resident 3 had indicators they had an intellectual disability or related condition, and required a PASARR level II review from the Development Disability Administration (DDA). Further review of the EMR had no documentation to show the facility requested a Level II evaluation from the DDA PASARR coordinator, as required. On 01/29/2025 at 10:35 AM, Resident 3 was sitting in their wheel chair in their room. The resident mumbled during the conversation and was difficult to understand. During the interview, the resident often looked down, not making eye contact. <Resident 7> Review of the quarterly assessment, dated 12/11/2024, showed Resident 7 was admitted with fractures, a history of a stroke, and depression. The resident had difficulty making their needs known. The mood assessment showed the resident had little interest in doing things and felt bad about themselves. The resident was admitted on a antidepressant. Review of the resident's EMR showed the resident was admitted on [DATE], from home. There was no PASARR form found in the resident's EMR at the time of admission. In an interview on 02/13/2025 at 1:55 PM, Staff A, Director of Nursing (DNS), stated Admissions would look at the PASARR's and they would be given to the Social Services Director (SSD) if a Level II was required and the SSD would send the requests to the PASARR coordinators. Staff A stated the SSD left in September 2024. The facility recently hired someone into the position of SSD and the process would be looked at moving forward. Reference: WAC 388-97-1915(4)

Based on interview and record review, the facility failed to provide a bed-hold notice (a notice to inform residents of their right to pay the facility to hold their room/bed while they were hospitalized ), to the resident and/or their representative at the time of discharge, or within 24 hours of transfer to the hospital, for 4 of 4 sampled residents (Resident 1, 3, 6, and 7), reviewed for hospitalization . This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included . <Resident 1> The 11/20/2024 quarterly assessment documented Resident 1 was admitted with a history of a stroke, anxiety and depression. The resident was able to make needs known. Review of nursing progress notes, dated 09/16/2024, showed Resident 1 was transferred to the hospital due to complaints of increased numbness to their lower legs and pain in their hand. Additional record review showed no documentation the resident had been provided a bed-hold notice. <Resident 3> The 12/20/2024 admission assessment documented Resident 3 was admitted with Parkinson's Disease (a progressive disorder that affects movement, balance, and coordination) and a history of a stroke. The resident had difficulty making their needs known. Review of nursing progress notes, dated 02/03/2025, showed Resident 3 was screaming, swinging their cane in the air, and would not calm down. The facility was concerned about safety of staff and other residents and transferred the resident to the hospital for an evaluation. Additional record review showed no documentation the resident had been provided a bed-hold notice. <Resident 6> The 11/30/2024 assessment documented Resident 6 was admitted with history of a stroke, anxiety, and depression. The resident was able to make their needs known. Review of nursing progress notes, dated 01/01/2025, showed Resident 6 continued to exhibit confusion, had diarrhea, vomiting and unstable vital signs. The resident was transferred to the hospital for an evaluation. Additional record review showed no documentation the resident had been provided a bed-hold notice. <Resident 7> The 12/11/2024 quarterly assessment documented Resident 7 was admitted with fractures and depression. The resident had difficulty making their needs known. Review of nursing progress notes, dated 01/11/2025, showed Resident 7 had confusion, was lethargic (feeling tired, sluggish), and had tremors (involuntary shaking movement). The resident was sent to the hospital for an evaluation. Additional record review showed no documentation the resident had been provided a bed-hold notice. On 02/13/2025 at 11:34 AM, Staff C, Licensed Practical Nurse (LPN), stated they did not give the bed-hold policy to residents transferred to the hospital. Staff C stated it would be something the Resident Care Manager (RCM) or Social Services Director (SSD) would give the residents. On 02/13/2025 at 1:55 PM Staff A, Director of Nursing (DNS) and Staff B, Resident Care Manager (RCM), were interviewed. Staff A stated the residents received their first copy of a bed-hold during the admission process. If a resident was transferred to the hospital, a second notification should be given to the resident or their representative. Currently the facility didn't have a clear process and residents were given the information verbally. Reference: WAC 388-97-0120(4)

Based on observation, interview, and record review, the facility failed to ensure behavioral health needs were identified and met for 2 of 4 sample residents (Resident 1 and 3), reviewed for behavioral-emotional health. Failure to assess residents behavioral needs, identify individual resident responses to stressors and develop person-centered interventions placed residents at risk for unidentified behavior triggers, unmet behavioral needs, and diminished quality of life. Findings included . <Resident 1> According to the admission assessment, dated 08/23/2024, Resident 1 had diagnoses to include a stroke with left sided weakness, anxiety and depression. Resident 1 had difficulty making their needs known. The resident had hallucinations (where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind). The resident's mood assessment showed they felt bad about themselves, felt down, depressed, or hopeless, and had little interest in doing things. The resident took antidepressant and antianxiety medication. Review of the Pre-Admission Screening and Resident Review (PASARR, a screening required to be completed prior to admission to a nursing home that looked for indicators one may have a serious mental illness), dated 08/19/2024, indicated Resident 1 had a serious mental illness and required a PASARR level II review (an assessment that made recommendations about specialized services needed to determine the best setting to meet a person's behavioral health needs). Additional review of the record showed no Level II assessment had been completed. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2024, the resident was taking an antidepressant twice a day and an antianxiety medication every 8 hours as needed. The resident had antianxiety and antidepressant side effect monitors to be done each shift. A progress note was to be written if side effects were observed and an intervention included. There was nothing to show non-medication interventions were attempted prior to medicating the resident, no target behaviors identified, and no person-centered interventions in place. Review of the provider notes, dated 09/09/2024, documented the resident was on the maximum dose of medication for their depression. The provider requested a referral be placed for mental health counseling. On 09/13/2024, the provider again documented the resident needed outside psychiatric follow up due to being on the maximum antidepressant dosage and requested a referral for mental health counseling. Review of Social Services Director (SSD) notes, dated 09/10/2024 to 09/16/2024, showed contact was attempted to an outside mental health provider but the facility was waiting for a call back. There were no further notes found to show a mental health provider had been reached. Review of the 11/20/2024 quarterly assessment documented Resident 1 had delusions (false beliefs that are held with strong conviction, despite evidence to the contrary) and resisted care. In addition to the resident's mood assessment on admission, the resident now had thoughts they would be better off dead and felt bad about themselves. Review of Resident 1's comprehensive care plan identified the following care areas: -On 12/05/2024 - Mood and Behavior: Resident had been diagnosed with depression and anxiety with psychoactive medications (substances that affect the brain and alter perception and cognition) to treat. Interventions included attempt Gradual Dose Reduction (GDR, an assessment to show if a resident's dose could be lowered) per protocol and monitor side effects of the medications every shift. -On 01/09/2025 - the care plan was revised due to a history of holding down their call button to keep it on continuously, especially during the night, and not needing help. Interventions included 30 minute checks. It was documented the resident was made aware if they pushed the call button in between checks, staff may not be able to answer it. -On 01/23/2025 - the care plan was revised due to a history of physical aggression toward staff such as hitting with objects and using racially insensitive dialogue. Interventions included redirecting the resident when hitting or using insensitive statements and notify the nurse or SSD. There was nothing found to show target behaviors had been identified for the resident and no person-centered interventions in place. A review of nursing progress notes from 09/02/2024 to 11/30/2024 showed the resident had reported they were anxious on several occasions. The nurses documented the resident frequently used the call light and was inpatient. On 10/13/2024 it was documented the resident's dog had passed away and the resident was very emotional but had stabilized. On 11/11/2024, a note was written by Staff A, Director of Nursing (DNS). Staff A met with the resident related to a comment they had made about a nursing assistant the night before. The resident had reported they felt they had a stroke and according to the resident, the nursing assistant responded the nurses are too busy, and the hospital won't do anything for you. The nurse was interviewed and stated they had gone in and evaluated the resident for a stroke and there was no signs of one. The nurse reported to Staff A the resident got very anxious in the evenings and would work themselves up to thinking they were dying. Staff A contacted the provider. On 11/15/2024 the provider visited Resident 1 and documented to continue the current antianxiety medication because the resident stated it controlled their anxiety. On 01/06/2025, Staff A met with family to discuss Resident 1's continued anxiety. The family member reported the resident's anxiety had been an ongoing issue for Resident 1 due to traumatic events that had occurred in their life: divorce, loss of their farm, and loss of a farming career. Review of the resident orders showed the resident was started on a different antianxiety medication on 01/09/2025. The medication was slowly being increased as the prior medication was being decreased. During record review, there was no document to show an interdisciplinary team (IDT) had assessed the resident for their response to stressors, develop person-centered individualized interventions or evaluate the effectiveness of the resident's medication regimen. On 01/29/2025 at 12:05 PM, Resident 1 was laying in bed with a hospital gown on. The resident stated he felt staff were pushing them into violence. When asked, the resident stated about a week ago two staff members came in their room. Resident 1 stated at one point one of the staff member's put their fists up, so Resident 1 hit them with their back scratcher. The resident stated they were told if they hit another staff member again, the police would be called. The resident stated they felt bad they hit the staff member and was trying to be calmer. The resident was tearful during the conversation. The resident was asked about their antianxiety medication and they stated they were recently started on a new one but it hadn't helped their anxiety yet. During an interview on 02/13/2025 at 11:10 AM, Staff F, Certified Nursing Assistant (CNA), stated they had worked at the facility quite a while and knew most of the residents and their behaviors. They would also be told about behaviors at shift change or by the nurse. As far as interventions, they would try different things like reapproaching or making sure the residents needs were being met. Staff F stated they didn't take care of Resident 1 but assisted in answering the call light since it was on a lot and could be overwhelming for the resident's CNA. On 02/13/2025 at 12:20 PM, Staff E, Licensed Nurse (LN), stated there was an area in the computer they would chart on behaviors for residents on psychotropic or antidepressant medication. Staff E stated resident care plans would have the target behaviors and individualized interventions. Staff E said Resident 1 would make different types of statements and when Staff E would talk with the resident, the resident would say no one paid attention to them, or no one loved them. On 02/13/2025 at 12:55 PM, Staff G, CNA, stated they knew about resident behaviors from the residents care records, reported from the nurse or report from the CNA at the start of their shift. Interventions would depend on type of the behavior like redirecting. Staff G stated they had a good relationship with Resident 1 and didn't see a lot of behaviors, mostly call light use, and they would reassure the resident. At times Resident 1 would be teary or down and Staff G would report it to the nurse. <Resident 3> Review of the Admission assessment, dated 12/20/2024, showed Resident 3 was admitted with diagnoses which included a stroke, Parkinson's Disease (a progressive disorder that affects movement, balance, and coordination), and depression. The resident had difficulty making their needs known. Resident 3's mood assessment showed the resident had little pleasure in doing things, felt down, depressed, and hopeless, had trouble falling asleep, and thoughts of being better off dead. No behaviors were identified. Review of the PASARR, dated 12/13/2024, showed Resident 3 had indicators they had an Intellectual Disability and required a PASARR level II review. Additional review of the record showed no Level II assessment had been done The resident's care plan, dated 12/16/2024, identified the resident was diagnosed with depression and had a history of a suicide attempt. The resident was taking psychoactive medication for depression. Staff were to attempt GDR per protocol, monitor side effects of the anti-depressant, and do hourly supervision for safety. There was no target behaviors or person-centered interventions found in the care plan. The resident's MAR and TAR's were reviewed for December 2024 and January 2025. The resident was taking an antidepressant and was on medication for insomnia. There was an antidepressant monitor and staff were to put a +/-. A progress note was to be written only if the resident had a side effect observed and an intervention they tried. There was no monitors that non-medication interventions were in place, no target behaviors identified, and no person-centered interventions. During record review, there was no document to show an interdisciplinary team (IDT) had assessed the resident for their response to stressors, develop person-centered individualized interventions or evaluate the effectiveness of the resident's medication regimen or interventions. During an interview on 01/29/2025 at 10:35 AM, Resident 3 was sitting in a wheel chair in their room. The resident did not make eye contact during the interview. Resident 3 stated they had recently gone out to visit with their wife and they fought. The resident said they ended up walking to their brother's house. The police found the resident and brought them back to the facility. On 02/13/2025 at 11:30 AM, Staff D, CNA, stated they would be told about a resident's behaviors during report at the start of their shift and there would be behaviors on the resident care record. Staff D was asked about interventions for behaviors and stated if a resident refused care or was hitting they would reapproach them later. Staff D stated the only behavior they had seen for Resident 3 was when they had an outburst and was swinging their cane and yelling. Prior to the incident, the resident was pleasant. On 02/13/2025 at 11:34 AM, Staff C, LN, stated residents on psychotropic medication would have their behaviors monitored in the computer. If there was a behavior outside of what they were charting on for medication, like loss of a loved one, they would put the resident on alert and chart on them for 3-5 days. A new behavior from a resident would be placed in progress notes and the Resident Care Manager (RCM) would be notified. Staff C stated Resident 3 would often have their phone on speaker and would be fighting with their wife, they would both be yelling at one another. After those phone calls, the resident would be agitated and would stand at their door yelling for things. Staff C stated they would keep their distance from Resident 3 and calmly ask what they needed. On 02/13/2025 at 1:55 PM, Staff A, Director of Nursing (DNS) and Staff B, RCM were interviewed. Staff A stated social services was responsible for coordinating behavioral health services and would complete trauma informed assessments on admit. Social services also sent PASARR Level II's to the evaluator. Staff A stated the facility had not had a social worker for the last 6 months, which was about the time Resident 1 had been referred to a mental health provider. Staff A and B were asked if residents had target behaviors in place with individualized interventions and they stated they were in the residents care plans. When asked how Resident 1 was provided behavioral or emotional support, Staff B stated staff remained positive with the resident and would encourage the resident to get out of their room to walk. Some staff provided a fidget device for the resident, which helped them to not push the call light so often when the resident didn't need anything. When asked about how behavioral or emotional support was provided to Resident 3, Staff B stated they didn't have a full background on the resident but because they had attempted suicide prior, they were put on increased supervision. Staff B stated activities tried to engage the resident to help with socialization and they made sure the resident went to church in the community, when they wanted. Staff A was asked about documentation from an IDT team to show residents behaviors were being discussed, person-centered care plans developed, and an evaluation of the effectiveness of medications or interventions in place. Staff A stated there had been a period of time without psychoactive meetings since there hadn't been a SSD. Staff A stated they had been doing a more informal meeting and residents were discussed in the morning meeting. The pharmacist also reviewed resident medications and would let them know if a GDR was needed. An order would then be obtained and the team would be updated as well as the care plan. Reference: No associated WAC

Based on interview and record review, the facility failed to consider re-admission for 1 of 4 sampled residents (Resident 3), reviewed for hospitalization . This failure placed the resident at risk for increased anxiety related to being placed in an unfamiliar environment, and a diminished quality of life. Findings included . Review of a facility form titled Transfer and Discharge ., revised on 12/24 documented emergency transfers/discharges were initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. The resident will be permitted to return to the facility upon discharge from the acute care setting. In a situation where the facility initiates discharge while the resident is in the hospital following emergency transfer, the facility will have evidence that the resident's status at the time the resident seeks to return to the facility . Review of the Admission assessment, dated 12/20/2024, showed Resident 3 was admitted with diagnoses which included a stroke, Parkinson's Disease (a progressive disorder that affects movement, balance, and coordination). The resident had difficulty making their needs known. Review of Nursing Progress notes, dated 02/03/2025, showed the resident was at their doorway screaming and began swinging their cane at Staff A, Director of Nursing (DNS). Resident 3 was asked to calm down and continued to scream unintelligibly and swinging their cane. Staff A was fearful of immediate safety for staff and residents. Resident 3 walked down the hallway, swinging their cane and yelling, and exited the front of the building. The police and Emergency Medical System (EMS) came to the facility and transferred the resident to the hospital. Staff A informed EMS the facility could not manage the resident' aggression and would not take them back. During an interview on 02/13/2025 at 1:55 PM, Staff A stated the resident was sent to the hospital because they were a threat to staff and residents. Staff A informed EMS they were not taking the resident back. A discharge notice was sent to the hospital at the time of discharge. Reference: (WAC) 388-97-0120(4)(b)

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), admitted without pressure ulcers, and at increased risk for skin integrity breakdown, was consistently monitored and assessed weekly, to prevent development of pressure ulcers. This failure caused harm to Resident 1, when they developed an unstageable pressure ulcer which worsened on their coccyx (tailbone area) requiring hospitalization . Findings included . Record review showed that Resident 1 was readmitted to the facility on [DATE] with diagnoses of right above the knee amputation (surgical removal of the leg at the level just above the knee) and dementia (degenerative disease where memories and the ability to care for oneself declines). Resident 1's comprehensive assessment dated [DATE] showed the resident had severe cognitive impairment, required the extensive assistance of two staff to reposition in bed, was at risk for pressure ulcer development, and did not have a pressure ulcer. Record review and interview showed that Resident 1 had resided at the facility prior to a scheduled above the knee amputation (01/24/2023), but fell during a staff assisted transfer and fractured their right upper leg bone on 01/20/2023, and was sent to the hospital for evaluation. On 01/21/2023 Resident 1 had their right leg amputated above their knee. The resident returned to the facility on [DATE]. Upon their return, the facility admission skin assessment did not describe any areas of pressure injury. The assessment did describe a fissure (a crack in the skin) on the resident's coccyx (tailbone area) measuring 6.0 x 0.1 centimeters (cm.) without any descriptive unit of measurement. A review of the resident's care plan showed the resident had a potential for skin breakdown and had a history of open areas to their feet and coccyx. Interventions included weekly skin checks, to be completed by a licensed nurse. The 02/03/2023 Braden Scale for predicting pressure sore risk evaluated Resident 1 as high risk for development of pressure sores. Record review showed a progress note written by Staff A, Registered Nurse, on 01/31/2023, showing that Resident 1 had a non-blanchable area to the coccyx which was 2.0 cm. x 1.0 cm. When the same nurse was interviewed on 03/06/2023 at 1:00 pm, they stated that they had done a skin check on the resident that day, but did not remember the exact circumstances other than what was written in their progress note. The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer (Injury) Stages include: * Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate at risk persons. * Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed. * Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. On 02/02/2023, an order for a dressing to treat a coccyx wound was entered into Resident 1's treatment administration record. Per a review of the resident's record, there were no medical provider or nursing notes describing the size, condition or assessment of the area found until 02/16/2023, when a nursing note showed that the resident was seen by an outside wound provider and their coccyx wound was debrided (dead tissue was removed). The outside wound provider note dated 02/16/2023 described Resident 1's coccyx wound as an unstageable pressure wound (see above definition), measuring 7.0 cm. x 4.0 cm., with more than half of the wound covered in slough (dead tissue). On 02/20/2023 the resident was found to have abnormal lab results along with a decreased level of consciousness, and was sent back to the hospital for evaluation. Upon the resident's admission to the hospital the resident was noted to have an unstageable sacral (the area about mid buttock where the pointed bone of the pelvis comes closer to the skin surface) pressure wound, with eschar present. On 02/21/2023, a hospital wound nurse evaluated Resident 1's posterior wound which was then measured at 14 cm. x 14 cm. with eschar, skin peeling and slough, with a slight odor present. The resident was admitted to the hospital and did not return to the facility, so the wound could not be visualized. On 03/16/2023 at 12:25 pm, Staff B, Resident Care Manager, stated that Resident 1 had skin checks documented on 02/01/2023, 02/08/2023 and 02/15/2023 all with a negative (-) sign documented, indicating no new or worsening skin impairment. They further stated they could not explain what happened with the wound between the resident admission on 01/27/2023 and 02/16/2023. On 03/16/2023 at 12:30 pm, Staff C, Infection Control and Wound Care Nurse, stated that usually when wound orders were started, they would have consulted with the medical provider and put a note in the resident's medical record. They further stated that there was documentation of the nurses changing the wound dressing, but Staff C did not see documentation of why the treatment was started for the coccyx wound, or what happened with the wound between 02/02/2023 - 02/16/2023, when the outside wound care provider saw the resident and measured the pressure wound. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to ensure there was a system in place that would effectively address the nutritional needs of 11 of 13 sample residents (1, 3, 6, 7, 8, 9, 10, 12, 13, 14, 15) who experienced significant weight loss or declines in wounds. Resident 6 was harmed when their pressure ulcer worsened to Stage IV (deep tissue, muscle, and possible bone involvement). The facility Registered Dietician (RD) did not assess or oversee the nutritional status of the residents, including those with significant weight loss, (only reviewing the initial assessment), did not initiate or develop nutrition care plans, or implement interventions, supervise the tasks delegated to a Dietetic Technician (DT), or review the menus for nutritional soundness as required. Weights were not consistently monitored, and medical professionals in charge of resident care (providers) were not notified when a resident had significant weight loss to determine if it was unavoidable. The lack of a system where nutritional declines were followed up timely and were addressed by qualified individuals placed all residents at risk of serious harm. On 07/27/2022 at 4:00 PM, the facility was notified that Immediate Jeopardy (IJ) was identified related to CFR 483.25 F692 Maintaining Nutritional Status. The facility was also put into Stop Placement at that time. On 07/28/2022 at 12:19 PM, the removal of the immediacy was validated by ensuring residents had been weighed, residents had been assessed in person by the Registered Dietician, the providers had been notified of resident weight loss, and staff education was begun. On 07/28/2022 at 02:53 PM, the facility was informed the immediacy was removed, and they were no longer in Stop Placement Findings included . Per the record, Resident 6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/07/2022 admission nursing assessment showed the resident had a surgical incision on their hip and a Stage I pressure ulcer on the coccyx (tailbone). The 06/08/2022 care plan did not contain care areas, goals, or interventions, related to the resident's nutritional status or prevention of pressure injury to their skin. The 06/14/2022 admission assessment showed the resident was severely cognitively impaired, required extensive assistance of one for eating, and weighed 100 pounds. The resident had one Stage I pressure ulcer (redness of the upper layers of skin that does not turn white when pressed). The 06/14/2022 Staff H, Diet Technician (DT) admission nutritional assessment showed the resident had poor meal intake - averaging 36%, and was tolerating the mechanical soft diet without difficulty. The recommendation was to add nutritional enhanced meals (NEMS, added calories such as protein powder, butter or brown sugar for example) and a liquid supplement twice a day to their medication pass. The assessment was countersigned by Staff G, RD. The following weights were recorded for the resident: -06/17/2022 100.6 pounds (lbs.) -07/08/2022 83.6 lbs. -07/13/2022 85.6 lbs, a 14.9% loss. A 07/13/2022 Staff H Nutrition at Risk (NAR) progress note showed the resident had variable intake, weighed 85.6 lbs., and suspected the weight was erroneous (incorrect). A re-weight was recommended; none was completed. There were no entries in the resident's record by Staff G, and no documentation the provider was notified of the 14.9% weight loss on 07/13/2022. On 07/14/2022, the wound care Physician Assistant (PA) progress note showed the resident was noted to have redness and an open area on their coccyx the week prior, and was started on an air mattress and referred to an outside wound agency. The PA showed the treatment would consist of offloading (removing) pressure to the area, and encouraging the resident to improve their nutrition and protein intake. Per the note, a factor impacting healing was the resident's severe malnutrition. On a follow-up visit on 07/21/2022, the PA documented the resident's wound was a Stage IV pressure ulcer (deep muscle involvement, possibly to the bone). On 07/27/2022 at 10:15 AM, the resident's coccyx was observed during a dressing change with Staff E, Registered Nurse (RN) and Staff F, Nurse Aide (NA). A reddened area similar in size to the palm of a hand was observed over the tailbone area. A deep slit similar in length to the end of a thumb was observed. When separated open by Staff E, underlying muscle was observed - the wound was not measured at that time. During an interview on 07/22/2022 at 3:04 PM, Staff H was familiar with Resident 6, and had recommended the staff get a re-weight on 07/13/2022, but the resident had not been reweighed. Staff H was not aware Resident 6 had a Stage IV pressure ulcer, or that the wound care provider noted the resident's severe malnutrition would impact healing of the wound. Staff H stated they would not have consulted with Staff G regarding Resident 6. After the concerns regarding care of residents at nutritional compromise was raised with the facility, Resident 6 was reweighed and determined to be at 79 lbs. Resident 9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 05/24/2022 assessment showed the resident was severely cognitively impaired, required extensive assistance of one staff for eating, weighed 178 lbs., and had weight loss of 5% in one month or 10% in 6 months, and was not on a physician prescribed weight loss program. The resident's record showed the resident had been hospitalized from 04/26/2022 to 05/05/2022, and again from 05/17/2022 to 05/19/2022. The 02/23/2020 comprehensive care plan, updated 04/29/2022 showed the resident was risk for alteration in nutritional status related to diabetes, Alzheimer's, and frequent refusal of meals, and risk for dehydration related to a history and poor fluid intake. Interventions included to provide a diet as ordered, a one ounce protein supplement in juice at breakfast and lunch, consume three liters (L) of fluids daily until changed or discontinued, encourage fluid intake frequently, and popsicles after meals. The following resident weights were recorded: -03/22/2022 202.6 lbs. -04/14/2022 193.4 lbs. -05/22/2022 178.2 lbs. -07/12/2022 165.8 lbs., a 10% weight loss compared to 01/25/2022. A 03/22/2022 Staff H Nutrition at Risk (NAR) progress note showed the resident had lost 11.6 lbs., a 5.4% loss. Per the note, the resident had recently had a urinary tract infection ([CONDITION(S)]) and ate only their soup at lunch that day, but the weight loss was overall beneficial. The Registered Dietician, Staff G, did not assess the resident at that time, or put any additional interventions in place. Per review of the record during that period of time, there was no documentation to show the provider was made aware of the resident's weight loss. A 04/12/2022 Staff H nutritional assessment showed the resident's current weight was 192.4 lbs., an approximate loss of 8% in one month. Per the assessment, the resident ate well at breakfast and lunch, but frequently refused dinner. Per the record, the resident's weight trended down since they were ill with a septic [CONDITION(S)] (a potential life-threatening infection), but as noted in their 03/22/2022 NAR note, the weight loss overall was beneficial. There were no other nutritional assessments in the record, and no indication Staff G or the provider were aware and/or involved in the nutritional status of the resident. A 05/31/2022 Staff H NAR progress note showed the resident weighed 178 lbs., and had been ill in the hospital with a septic [CONDITION(S)], and also an ulcer that caused nausea and vomiting. The provider had ordered a protein supplement three times daily with medication passes. Staff H recommended nutrition enhanced meals (NEMS, extra protein powder and calories such as butter, extra gravy, or brown sugar for example). There were no notes from the Staff G. The 06/14/2022 Staff H NAR note showed the resident refused to be weighed, and a new weight was to be obtained for further evaluation. During an interview on 07/22/2022 at 3:04 PM, Staff H stated they did a comprehensive assessment for Resident 9 on 04/12/2022. Staff H stated they did not reassess the resident after they had been ill in the hospital twice. Staff H saw Resident 9 on 05/31/2022. Then the resident refused to be weighed on 06/14/2022, so they were waiting for another weight. The resident was weighed again on 07/12/2022 and showed a 13 lb. weight loss - 165.8 lbs. Staff H stated Resident 9 should have been discussed at the 06/28/2022 NAR meeting but was not, saying the resident was missed. Per Staff H, the NAR meeting was held every two weeks, so the weight loss recorded on 07/12/2022 would have been discussed at the next meeting at the end of July. Resident 9's weight loss resulting from illness was not desirable as they had documented previously, as they were referring to the resident's obesity. Staff H also stated this was not a case they would have consulted with Staff G about. Per the record during July 2022, it did not show contact with the physician. On 07/26/2022, after the concern regarding the care for residents with weight loss was discussed with Staff H, Resident 9 was weighed on 07/26/2022, and weighed 156.8 (an additional loss). Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 03/22/2022 admission assessment showed the resident was moderately cognitively impaired, required set-up help for eating, had three unstageable pressure ulcers, and weighed 232 lbs. The following resident weights were recorded: -03/31/2022 194.2 lbs. -04/18/2022 205.6 lbs. -05/18/2022 202.0 lbs. -07-08-2022 195.2 The 03/22/2022 Staff H admission dietary assessment reported the resident had a hospital weight of 232 lbs., and the resident stated they normally weighed 220 lbs. A significant other noted the resident weighed 195 lbs. upon hospital admission, but Staff H was unable to find supporting documentation. Recommendations were to provide a collagen promoting (a substance that aids wound healing) powder in drinks twice daily, 1.5 servings of protein with meals, and a supplement drink with lunch and dinner. The assessment was signed by Staff G. Review of the Staff H NAR progress notes showed that on 04/05/2022, the resident weighed 194 lbs., and they suspected the weight was not accurate. A re-weigh was recommended. On 04/19/2022, the resident weighed 205 lbs., the gain was deeemed beneficial by Staff H, and the wounds were healing. On 05/03/2022, a new weight was to be obtained for further evaluation. On 05/17/2022, the resident weighed 207 lbs., and one of the supplement drinks was discontinued. On 05/31/2022, the resident weighed 202 lbs., and this loss was attributed to increased therapy. The 06/14/2022 note showed they were waiting for a new weight to be obtained for further evaluation, and that on 06/28/2022, the resident was not weighed because they had COVID-19. There were no entries in the resident's record by Staff G, aside from an initial signature on the admission dietary assessment. During an interview on 07/22/2022 at 3:04 PM, Staff H stated Resident 1 was followed in the NAR meetings. The resident was admitted on [DATE], and weighed 232 lbs. Their weight on 03/31/2022 was 194 lbs., so on 04/01/2022 Staff H recommended the resident get re-weighed. Staff H initially assessed the resident on 03/22/2022, so that assessment would have included hospital weights. Staff H stated they were told not to use hospital weights. Staff G signed off on the admission assessment. Staff H. had provided supplements and extra protein at meals; their weight stabilized, the the wounds improved so they stated they would not have done anything different for Resident 1. During an interview on 07/20/2022 at 3:14 PM, Staff G stated they oversaw the clinical components of the facility's nutrition program. Staff H was also contracted and was not Staff G's employee. Per Staff G, they reviewed Staff H's initial nutrition assessments and signed off on them. Staff H then did any other quarterly assessments, headed the Nutrition at Risk meeting, did any follow-up from that meeting, and was capable of assessing nutritional needs when a resident developed a pressure ulcer or needed different nutrients such as potassium for example. Staff G stated they had visited the facility twice; once to introduce themselves to staff, and once when Staff H was unavailable. Staff G did the vast majority of their work remotely. Staff G stated they had not been involved in the care of Resident 1. During an interview on 07/22/2022 at 3:04 PM, Staff H stated they completed the initial and quarterly resident nutritional assessments, and ran the Nutrition at Risk meetings. Per Staff H, Staff G signed off on the initial assessments only. Staff H might also consult with Staff G on difficult cases such as residents receiving tube feedings, but they did not meet to discuss resident care or concerns. Staff H ran a report from the electronic record that showed every resident that had a significant weight change. Staff H acknowledged that if weights were not done, however, those residents did not show on the report. On 07/20/2022 at 3:51 PM, a Current Weights and Vitals report was generated from the facility electronic resident records. Of 48 current residents, 10 residents (Residents 3, 6, 7, 8, 9, 10, 12, 13, 14, 15) had warnings of weight losses of 5% in one month, 7.5% in 3 months, or 10% in 6 months from their previous weight recordings. Resident 1 had discharged and was not on the report. The sample related to weights and nutrition was expanded and record reviews were completed for the residents on the 07/20/2022 Current Weights and Vitals report that had significant weight loss warnings. Similar patterns of care were noted: -Resident 3 had diabetes and a wound that required wound vacuum treatments (a type of therapy to help wounds heal). Per the record, Resident 3 had an 8.7% weight loss from 04/20/2022 through 05/18/2022. The provider Registered Nurse Case Manager 07/19/2022 progress note showed they requested a weight for the resident, as none had been done since 05/2022. There were no entries in the resident record by Staff G. -Resident 7 had Alzheimer's dementia and a compression fracture. Resident 7 had an 8.7% weight loss from 05/09/2022 through 07/07/2022. The resident did not have a nutritional care plan that established goals or interventions for their nutritional needs. There were no entries in the resident's record by Staff G, RD. -Resident 8 had [CONDITION(S)] and malnutrition. The resident had an 8% weight loss of 13.95 lbs. from 04/06/2022 through 07/08/2022. The resident did not have a nutritional care plan that established goals or interventions for their nutritional needs. There were no entries in the resident's record by Staff G, RD. -Resident 10 had dementia and dehydration. The resident had an initial nutritional assessment on 04/20/2022. From 04/06/2022 through 04/14/2022, the resident's weight dropped from 153.0 lbs. to 125.8 lbs. On 05/17/2022, Staff H wrote that the resident's weight stabilized, and they would no longer follow the resident in the NAR meetings. The resident was not weighed from 06/15/2022 until 07/22/2022, and had lost 15 lbs. There had been no Registered Dietician assessments after 04/2022, and no entries in the record by Staff G, RD. -Resident 12 had dementia, mild protein-calorie malnutrition and history of a pressure ulcer. From 05/28/2022 to 05/31/2022, the resident lost 5.2 lbs - from 121.4 lbs. to 116.2 lbs. The resident was followed on 06/14/2022, and 07/13/2022, but had not been weighed since 05/31/2022, and on 07/13/2022, had an additional weight loss (now weighing 110.0 lbs.). It was unclear from the documentation if the resident had a pressure ulcer. Their skin was observed on 07/27/2022 with Staff C, Resident Care Manager. The resident stated their bottom was sore, and a 0.7-centimeter (cm) x 0.4 cm. non-blanchable red area was observed to the left of the tailbone. Staff C stated this red area was new and they would follow-up. There were no entries in the resident's record by Staff G, RD. -Resident 13 had dementia and a stroke. From 05/25/2022 through 06/21/2022, the resident lost 9.6 lbs., a 5.8% loss. There was a provider order 07/13/2022 for weekly weights. There were no other weights in the record since 06/21/2022. There were no entries in the resident's record by Staff G, RD. -Resident 14 had dementia and diabetes. The resident lost 10.0 lbs. from 05/05/2022 to 05/23/2022, an 8.7% weight loss. The 05/31/2022 Staff H NAR note showed the resident's weight continued to decline, and they received supplements the resident's family brought in. The resident was seen by the provider on 06/21/2022 when they were ill with COVID-19. There were no entries in the resident's record by Staff G. -Resident 15 had a stroke and mild protein-calorie malnutrition. From 05/01/2022 through 07/14/2022, the resident lost 17.2 lbs., or 13.8%. The resident had not been followed in the NAR meeting since 03/22/2022. When next discussed in the NAR meeting on 06/14/2022, Staff H showed no medical changes except possible progression of dementia. The record during that time showed the resident refused meals, but ate snacks and a chocolate drink the daughter brought in. The 06/28/2022 NAR note stated the resident could not be weighed because they had COVID. The 07/13/2022 Staff H NAR note showed they were waiting for a current weight for further evaluation. There were no entries in the resident's record by Staff G. On 07/20/2022, a review of the facility menus showed the menus were from a national food service provider and were labeled Spring-Summer 2022. The menus were grouped by week and day, and there were five weeks of meals included. There were no staff signatures or dates that showed the menus had been reviewed by the registered dietician to determine their nutritional value. When interviewed on 07/20/2022 at 10:15 AM, Staff I, Director of Nursing Services (DNS) stated Staff G was contracted, Staff I did not know their last name, and had never seen them in person. When interviewed on 07/20/2022 at 11:50 AM, Staff C, Resident Care Manager, stated they did not know who the RD was or who oversaw the kitchen. Staff C stated they met with Staff H when residents lost weight or had nutritional needs. When interviewed on 07/20/2022 at 3:14 PM Staff G, Registered Dietician stated the facility purchased their menu program from a vendor, and someone else approved the menus. Staff G assumed it was a RD. Staff G confirmed menus had to be approved by an RD. When interviewed on 07/20/2022 at 3:32 PM Staff J, Administrator, stated Staff G approved the menus. Staff J also stated they did not have a contract, that Staff L, Dietary Manager, created the menus and Staff G approved them. When interviewed on 07/21/2022 at 11:48 PM, Staff L stated they used a product from a national vendor for the menus. Staff L stated they did not have a contract, but Staff G was aware of and approved of the vendor, and then Staff H approved the menus. Per Staff L, previously, the RD and Staff L both signed a document showing the menus had been reviewed, but that stopped when the facility changed vendors just prior to the pandemic. Staff L liked the signature sheet and inquired about it when they changed vendors, but stated no one got back to them. When interviewed on 07/22/2022 at 3:04 PM, Staff H stated menus had to be approved by an RD, and Staff G approved the menus. Staff H stated nursing was responsible for obtaining missing weights. Staff H had not notified the providers of resident weight loss, they just wrote their notes. They thought nursing notified the providers of weight loss. When interviewed on 07/27/2022 at 12:00 PM, Staff Q, Nurse Practitioner (NP) stated they were told about declines of residents in general, but not about weight loss. Staff Q stated they might be told by nursing about weight loss, or they might look at trends, but how it should work was if they were notified of the significant weight loss, they would probably see the resident, assess them, then document if the loss was avoidable. The Medical Director was not available for interview. When interviewed on 07/27/2022 at 1:41 PM with Staff C and Staff J, Staff C stated if resident weights were not done and entered in the electronic medical record, they were not being captured in the weight loss report. Nursing would notify providers in general if a resident was not eating, but not for weight loss. Staff C stated nurses did not look at the big picture of resident weights, and thought it was the responsibility for Staff H to follow up on weights not done. Staff J was not aware that Staff G and Staff H did not confer, that Staff G did not review the menus, and stated the providers should be notified of weight loss. Staff J stated they would absolutely want RD involvement when residents had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Reference: WAC 388-97-1060(3)(h)

Based on interview and record review, the facility failed to provide necessary care and services for one of three sample residents (4), reviewed for non-pressure skin wounds. Failure to consistently assess and monitor surgical wounds resulted in harm to Resident 4, when the resident required hospitalization for worsening of the wounds related to not receiving required treatment; and placed residents at risk of not receiving required treatment and care to prevent harm. Findings included . A discharge note from the hospital, dated 01/14/21, documented the resident's sacral area (at the base of spine) and perineal area (from the groin to the anus - the opening where stool is evacuated) were fragile and macerated (had softening skin and breakdown due to prolonged exposure to moisture), and had been draining. Per the note, the resident had fluff gauze as needed to contain and keep the drainage away from the skin. The resident's inner thighs had incisions intact with steri strips (thin adhesive bandages). It was also noted the left inner thigh had non-blanchable (skin that doesn't turn white when pressed) redness, and a blister was on the right inner thigh. An abdominal incision was described as clean and intact. The resident had two Jackson-[NAME] (JP) drains (often placed in wounds during surgery to prevent the collection of fluid underneath the incision site) on the right thigh, three JP drains on the left thigh, and a left sided [CONDITION(S)] (when the colon is diverted to the outside of the body through the abdomen). Per record review, Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had surgery on the perineum, using skin from the inner thighs for reconstruction. The resident was alert, oriented, and able to make her needs known. Discharge orders from the hospital, dated 01/14/21, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no specific instruction to show where the cream was to be applied. Per review of the admission skin assessment, dated 01/14/21, facility nursing staff documented that the resident had a [CONDITION(S)], the left and right thighs had JP drains, and the resident's coccyx was excoriated (a raw, irritated area of skin). There was no documentation to show the location, condition, or size of the resident's several surgical incisions, upon admission to the facility. Review of the resident's admission care plan, dated 01/15/21, showed the resident had skin impairment related to surgical wounds. Staff were directed to document the location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 01/15/21 progress note by Staff D, Nurse Practitioner, requested facility staff to contact the plastic surgeon to clarify wound care orders. Review of facility progress notes showed the following: - 01/14/21, admission, incision closed but open to air to inner thigh. Resident with 3 JP drains to left thigh and 2 drains to right thigh. Excoriation to gluteal fold (crease at bottom of buttocks). - 01/17/21 (the next entry related to skin) showed surgical incisions were approximated (when edges of a wound are together). No further description of the multiple incisions were found. - 01/18/21 showed the incision to the buttocks had a small amount of thick bloody drainage observed. The physician was notified. It was also documented a small nonblanchable pressure wound to extra skin on posterior upper thigh was observed. There was nothing to identify which thigh incision was affected. - 01/19/21 showed surgical incisions were starting to show signs of infection. Per the note, the left upper thigh incision was oozing purulent drainage (consisting of or discharging pus). - On the same day (01/19/21), there was an entry from Staff B, Director of Nursing, documenting a conversation with the plastic surgeon. It was noted Staff B was able to clarify wound orders to the right medial thigh (five days after admission). Review of the plastic surgeon's notes, dated 01/19/21, showed the resident's right medial thigh had impending necrosis (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) to the inner incision. Per the note, the perineum incision was intact with the exception of a 1.0 centimeter (cm.) dehiscence (wound separation) on the posterior area. The note also showed there were multiple areas of breakdown to the coccyx and buttocks, probably Stage I pressure related (affecting the upper layer of skin). Wound care orders were given to the facility to place dry gauze to the right thigh incision and to change it twice a day. The resident had an appointment with the colorectal surgeon on 01/22/21, was directly admitted from the appointment to the hospital, and did not return to the facility. During an interview on 04/09/21 at 2:10 PM, Staff B, Director of Nursing, stated after the resident had arrived to the facility they realized the complexity of the multiple wounds. Staff B stated there was nothing on discharge orders related to wound care, other than [MEDICATION(S)] cream to be applied. When asked about specifically where the cream should be applied, Staff B stated it was interpreted as to be placed on all of the resident's incisions. Staff B stated on 01/17/21 a licensed nurse reported the resident's incisions appeared to be dehiscing and slightly more macerated (see previous definitions), however, according to the documentation in the resident's chart, on the same day, the incisions were intact. When the surveyor asked why wound care orders were not clarified upon admission, Staff B stated the facility was not sure who the plastic surgeon was, until their office contacted the facility for a follow-up appointment. Staff B stated staff should have been charting on the incision/wounds each shift, and confirmed all the incisions should have been identified upon admission. Reference (WAC) 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure one of three sample residents (#1), reviewed for use of an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine), received appropriate care and services related to the catheter. This failure resulted in harm to Resident #1, who became septic (a life threatening condition in which the body is fighting a severe infection), and required hospitalization , after a previously used catheter was reinserted. Findings included . According to a [DATE] annual assessment, Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was alert and oriented, and able to make his needs known. The resident had a suprapubic catheter (a permanent catheter inserted through the abdomen into the bladder to drain urine). Per the record, Resident #1 was also taking a blood thinner. According to the resident's care plan for the suprapubic catheter, it was placed on [DATE]. The size of the catheter was a 16 (the diameter of the tube) french (FR). The catheter was to be changed every 30 days, and flushed (a procedure to unplug a catheter to allow urine to flow), if it became blocked. During an interview on [DATE] at 2:30 PM, Resident #1 was in bed on his right side. During the interview, Resident #1 stated he almost died recently, due to issues with his catheter. He stated staff went to change it, and the correct size was not available, so a larger catheter was placed. Resident #1 stated the catheter was too tight and had to be removed stating, blood was everywhere. Resident #1 went on to say since the correct size was not available, the old catheter was put back in. Resident #1 then stated he had to be sent to the hospital. A [DATE] progress note showed Resident #1's catheter was not draining, and could not be flushed. The resident requested a catheter change, and Staff A, Registered Nurse, documented a 16 FR was not available; the only size was a 20 FR (2 sizes larger than a 16 FR). Staff A inserted the 20 FR, and noted there was some bleeding around the insertion site, but no urine returned once the tube was inserted into the bladder, and the catheter would not flush. Staff A then documented she cleaned the previously used 16 FR with [MEDICATION NAME] (a product used to treat minor wounds like cuts, scrapes, burns), and reinserted it. The next facility progress note related to the urinary catheter was on [DATE]. Staff B, Registered Nurse, documented the resident's abdomen was firm and distended, requiring Staff B to replace the catheter. Staff B documented about an hour later, Resident #1 was restless, had body tremors, with speech showing anxiety and stuttering. Per the note, the resident's skin was mottled (discolored), and his lips mildly cyanotic (blue in color, due to lack of oxygen). The resident's blood pressure was low at ,[DATE] (normal blood pressure is approximately ,[DATE]), and the oxygen level in his blood was 85% (normal is ,[DATE]%). The resident was sent to the hospital. Review of hospital notes, dated [DATE], showed the resident was brought to the hospital for significant blood in the urine. Per the notes, when he arrived at the hospital his temperature was 100.7 (normal is 98.6), his heart rate was elevated, and the blood pressure was ,[DATE]. The hospital diagnosed Resident #1 with a complicated UTI with gross hematuria (a large amount of blood in the urine), probably caused by poor sterile practices during catheter replacement (the old catheter had to be placed back), today catheter changed for a new one, caused trauma and bleed. In addition, it was documented based on the above findings, the patient has evidence [MEDICAL CONDITION] based on the presence of a UTI, elevated temperature, and increased heart rate. The resident remained at the hospital until [DATE]. On [DATE] at 3:20 PM, Staff B, Registered Nurse, stated if the correct size of catheter was not available for a resident, he would contact the physician before using it. Staff B recalled Resident #1's catheter would not flush on [DATE], so Staff B replaced it with a new 16 FR. The resident started to decline, and he was immediately sent to the hospital. During an interview on [DATE] at 3:30 PM, Staff A stated there had been an issue in the past with having adequate supplies of 16 FR catheters. Staff A stated when Resident #1 needed to have his catheter changed on [DATE], there was only a size 20 FR. When asked if the physician needed to be contacted prior to inserting a larger size, she stated no. Staff A went on to say there was some blood around the suprapubic site when inserting the larger catheter, not a large amount, and once inserted there wasn't drainage of urine. Staff A then stated she removed the 20 FR, the previously used catheter was cleaned with [MEDICATION NAME], and reinserted. On [DATE] at 2:10 PM, Staff C, Director of Nursing, stated if the correct size catheter was not available, then the physician should be contacted before using a different size. She confirmed a previously used catheter should not be reinserted. Staff C stated she was aware of the incident, and had re-educated the nurses. WAC Reference: [DATE](3)(c)

Based on interview and record review, the facility failed to provide care and services according to professional nursing standards, for one of three sample residents (#1), with an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). The failure occurred when Staff A, Registered Nurse, unsuccessfully inserted a cather using a larger size (with no physician order), then re-inserted the previously used urinary catheter. This resulted in harm to Resident #1, who develped a urinary tract infection [MEDICAL CONDITION], and then became septic (having an infection already present which spread throughout the body, which could be life threatening), requiring hospitalization . Findings included . Record review showed Resident #1 had a suprapubic catheter (a tube inserted into the bladder through the abdomen) placed on 11/01/19. The catheter size was 16 FR (FR = French, and the number would indicate the diameter of the tube - the higher the number the larger the tube). There were physician orders to change the catheter every 30 days, and flush it if it became blocked. Progress notes written 12/01/2020 showed Resident #1's catheter was not draining, and was noted to be clogged. Staff A, Registered Nurse, attempted to flush the catheter without success. The resident requested the catheter be changed, however, the only size catheter available was a 20 FR (2 sizes larger). The documentation showed Staff A inserted the 20 FR, some bleeding occurred at the insertion site, but no urine drained into the catheter bag. Staff A tried to flush the larger catheter, without success. The 20 FR was then removed, and the previously used 16 FR was wiped off with [MEDICATION NAME] (a product used to treat minor wounds like cuts, scrapes, burns), and reinserted. Review of hospital records, dated 12/05/2020, showed the resident had a complicated urinary tract infection [MEDICAL CONDITION] with blood in his urine. Per the record, the probable cause was poor sterile practices during catheter replacement (the old catheter had to be placed back). It was also noted the resident had evidence [MEDICAL CONDITION], due to the UTI, to include a temperature and fast heart rate. During an interview on 01/25/21 at 3:30 PM, Staff A stated Resident #1 needed to have his catheter changed on 12/01/2020, and there was only a size 20 FR available. When asked if she contacted the physician prior to inserting a larger size, she stated no. Staff A went on to say there was some bleeding around the site when inserting the larger catheter, and once inserted there was no drainage of urine. Staff A then sterilized the old catheter, due to the facility having no other 16 FR catheters, and reinserted it. When asked how the old catheter was sterilized, Staff A stated by cleansing it with [MEDICATION NAME]. On 01/29/21 at 2:10 PM, Staff C, Director of Nursing, stated if the correct size of catheter was not available, she expected staff to try to obtain the correct size, and if not found, contact the physician before inserting a larger size catheter. Staff C confirmed the used catheter should not have been reinserted. WAC Reference: 388-97-1620(2)(b)(i)(ii), (6)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure three of three sample residents (#43, 37, 22), reviewed for urinary tract infections (UTIs) and indwelling urinary catheters (a flexible tube inserted into the bladder to drain urine), received appropriate care and services to minimize the risk of associated urinary tract infections. This failure led to actual harm for Resident #43, when staff did not follow-up on a change in condition, and delayed physician notification and treatment, which led to the resident having acute [MEDICAL CONDITION] (a term used to indicate altered brain function related to an infection). In addition, the facility failed to identify [MEDICAL CONDITION] (difficulty urinating and completely emptying the bladder) for Resident #37, when he did not void, despite having an indwelling urinary catheter in place, for greater than 24 hours, which resulted in him having discomfort and a severe urinary tract infection. The facility also failed to ensure Resident #22, who admitted to the facility with an indwelling urinary catheter, had physician orders [REDACTED]. Findings included . 1. According to a 12/28/19 quarterly assessment, Resident #43 had [DIAGNOSES REDACTED]. The assessment further showed the resident was assessed to be moderately impaired in memory, was frequently incontinent of bladder, and required extensive assistance of one person for transfers and toileting. A bladder incontinence care plan, revised on 07/12/18, showed that staff were to monitor/document for signs or symptoms of a UTI, which included a change in the resident's behavior (no specific behaviors were listed). A 12/14/19 progress note showed Staff C, Medication Aide, documented the resident was hitting and attempting to bite staff. Per the note, the resident had slapped one aide in the face, causing redness. The note further showed that Staff D, Registered Nurse, was notified of Resident #43's behaviors. Per an interview with the resident's family member (see below), these were behaviors typically exhibited when the resident had a urinary tract infection. A 12/14/19 nursing progress note showed Staff D, Registered Nurse, documented that the resident had become aggressive towards an aide. The note further showed the resident had not been feeling well, and had to use the toilet several times, and that Staff C had come to the nurse, concerned that the resident might have a UTI. In addition, on the same day, the resident had several bouts of diarrhea, and was coughing and sounded congested. When Staff D asked the resident if she was feeling ill, the resident stated she was. Staff D indicated (in the note) that she would continue to monitor the resident's behaviors. A review of the progress notes from 12/15/19 through 12/23/19 (nine days) showed no monitoring of the resident's behaviors, and no indication that the resident's physician had been notified, in order to obtain a urinalysis test (to see if the resident had a UTI). A nursing progress note dated 12/23/29 at 7:23 AM, by Staff E, Licensed Practical Nurse, showed the resident had been up and down in her room all night, and had an unsteady gait. Per the note, the resident was trying to lock the bathroom door and push night stand against hall door. The resident was given pain medication without a problem, but became agitated when staff tried to give her something to drink. In addition, the resident was able to walk towards the toilet independently, but slapped at staff attempting to help her complete personal hygiene and change a soiled brief. The note showed that upon inspection, the brief contained urine that was dark and odorous (foul smelling). Staff [NAME] obtained a urine sample to rule out a UTI, and placed the resident on alert charting (every shift documentation) to monitor for possible UTI related behavior changes. Per record review, no physician notification or order were found, prior to the sample being obtained. A review of the progress notes from 12/23/19 through 12/31/19 (when antibiotics were started), did not show any further follow-up or monitoring of resident behaviors related to a UTI, or notification to the resident's representative, related to the resident's change in condition. (For more information, refer to F-580: Notification of Changes.) A laboratory test result showed the urine sample was collected on 12/23/19, and the results were reported to the facility on [DATE]. The test showed the resident had a urinary tract infection, which would require antibiotics. Per the record, from 12/27/19 through 12/31/19, the physican had not been notified of the results of the urine test. On 12/31/19, the physician assessed the resident, and a note showed Resident #43 had acute [MEDICAL CONDITION], due to the UTI. The note showed antibiotics were ordered on that day. In an interview on 01/24/2020 at 11:30 AM, Staff B, Director of Nursing, was asked what the expectation was, with regard to abnormal laboratory tests. She stated that the expectation was that the physician would be called and orders obtained, especially for abnormal tests, however, she believed in this instance, that staff had just put the results in the physician folder and did not call the physician, until 12/31/19. In an interview on 01/27/2020 at 10:10 AM, Staff C, Medication Aide, stated that the resident's daughter had come in to see her mother around 12/14/19, and was told about the urinary frequency and agitation. Staff C stated the resident's daughter told her that her mother may have a UTI, because of the behaviors that the resident was exhibiting. Staff C further stated that she had told Staff D about the possiblity of the resident having a UTI at that time, but was not aware if the nurse had followed up on the information. In an interview on 01/28/2020 at 1:08 PM, Staff D, Registered Nurse, was asked when she was informed by Staff C regarding the resident's behavior and possible UTI, and what she did when she was given the information. Staff D stated that she probably put a note in the physician communication book, but confirmed she did not call to get an order for [REDACTED]. 2. Per the record, Resident #37's 12/10/19 annual assessment showed he had [DIAGNOSES REDACTED]. The assessment further showed the resident was dependent on staff for all activities of daily living. An indwelling urinary catheter care plan, dated 04/11/19, showed staff were to monitor, record, and report signs and symptoms of urinary tract infections to the physician, which included: burning, blood tinged urine, cloudiness, no output of urine, foul smelling urine, fever, chills, or altered mental status. Per the Centers for Disease Control (CDC) Guideline for Prevention of Catheter-associated Urinary Tract Infections 2009, Catheter tubing must be placed in a manner to promote unobstructed flow of urine from the bladder into the collection bag. The CDC also stated, that the collection bag should always be below the level of the bladder, but not resting directly on the floor. In an observation on 01/22/2020 at 9:33 AM, the resident was in his wheelchair propelling himself down the hallway; the catheter was attached below his wheelchair, and the tubing had a dependent loop (a U shaped loop, that prevents urine from flowing into the collection bag), which contained cloudy urine. On 01/23/2020 at 9:53 AM, the resident was in the dining room; the tubing of the catheter had a dependent loop, and contained dark cloudy urine. Review of the (MONTH) 2020 catheter care task sheet (a documentation tool for nursing assistants) showed that staff had documented the resident had zero output for 24 hours, on 01/22/2020. Review of the (MONTH) 2020 Treatment Administration Record (TAR), which records catheter output every shift, showed on 01/22/2020, zero output had been recorded for three consecutive shifts. No documentation was found to show the physician had been notified, to report signs and symptoms of a UTI (as directed on the 04/11/19 care plan), or documentation to show other interventions attempted, to ensure the catheter was working properly. On 01/23/2020 at 4:07 PM, the surveyor spoke with Staff B, Director of Nursing, regarding the resident's lack of output. Staff B stated she was not aware that his catheter was not draining, and would check for patency (the process of assessing the catheter to ensure the tubing was not kinked, or blocked, preventing urine flow. A blocked catheter should be flushed via the catheter tubing.) Review of Staff B's nursing progress note the same day showed, Resident has order to flush catheter if not draining - see order for details. Catheter output for day shift on 01/23/2020 was 660 ml. (milliliters) verified by NAC who drained catheter. No indication of an assessment of the resident's condition was included in the note. On 01/24/2020 at 10:46 AM, the resident was lying in bed, with the catheter bag on the floor, next to the bed. Staff R, Nursing Assistant, when asked if the catheter bag was supposed to be on the floor, stated it should not be, and placed it in the privacy bag, which was attached to the side of the bed. On 01/24/2020 at approximately 10:45 AM, Staff L, Advanced Registered Nurse Practitioner (ARNP), was at the resident's bedside. When asked if she was aware of the resident having recent [MEDICAL CONDITION], she stated she had not been notified. When asked if the facility had the ability to scan the bladder, she stated she did not know. Staff M, Registered Nurse, also present during the interaction, confirmed the facility had a bladder scanner (an ultrasound machine that measured the amount of urine in the bladder). Staff L gently pressed on the resident's bladder, and found it to be distended and painful. In an interview on 01/24/2020, at 1:12 PM, Staff M stated she performed the bladder scan on the resident, and approximately 1500 cc's (cubic centimeters) of urine remained in his bladder. Staff M stated the catheter was replaced at that time, and approximately 800 cc's of thick pus (a thick fluid caused by infection) and cloudy/sediment and blood, were observed in the urine. Staff L was notified of the findings, ordered a urine sample to be sent to the lab, and started the resident on antibiotics. In an interview on 01/24/2020 at 1:48 PM, Staff O, Registered Nurse, stated she expected the nursing assistant to report to her if there was no urine output from a catheter. She stated she would then scan the resident's bladder, and call the physician for orders. In an interview on 01/24/2020 at 1:55 PM, Staff N, Nursing Assistant, stated she would report to the nurse if there was nothing in the catheter to empty, or if a resident hadn't gone to the bathroom all day. In an interview on 01/24/2020 at 2:03 PM, Staff B, Director of Nursing, stated it was her expectation that the nurse be notified if a resident had zero urine output. She then reviewed the catheter care charting and the treatment administration record documentation, and confirmed there was no documented output on 01/22/2020. She further confirmed there was no progress note which showed the resident had been assessed, or that the physician had been notified. On 01/24/2020 at approximately 9:00 AM, the surveyor asked Staff M, Registered Nurse, about the lab results; she was unable to locate them in the chart. Staff B, also present during the interaction, looked through the nursing station and the physicians' box, and was unable to locate the results. Staff B stated she would call the lab for the results. As of 01/30/2020, no lab results had been provided. On 01/30/2020 at 9:14 AM, when asked about the lab results, Staff B stated they called the laboratory for the urinalysis results, and the lab stated the sample had been mistakenly sent to Seattle, so they did not have the results. 3. According to the 11/18/19 admission assessment, Resident #22 had an indwelling urinary catheter, and her [DIAGNOSES REDACTED]. Review of an 11/14/19 admission medication list showed the resident's urinary catheter size was #14 (the larger the number, the larger the tubing). Per the Centers for Disease (CDC), www.cdc.gov/infectioncontrol/guidelines, proper catheter sizing is an essential part of successful urinary management. If the catheter is too small, then urine will pass too slowly. If the catheter is too big, it could cause pain or even damage to the urethra (a duct which transports urine from the bladder to outside of the body). Per the CDC information, the catheter size is part of the prescription, and cannot be changed unless a doctor provides a new prescription with a different size Review of a nursing progress note by Staff DD, Registered Nurse, showed the resident admitted directly to the facility with the urinary catheter. The note did not show information regarding the size of the catheter. In addition, review of Resident #22's physician orders [REDACTED]. The baseline care plan, dated 11/14/2019, showed no specific care plan was developed for care of the resident's urinary catheter, but rather general information which showed catheter care every shift, which was assigned to the nursing assistants. A care plan was not developed to include monitoring the resident for signs of a urinary tract infection, frequency of cather changes, size of cather (i.e. specific directions for the nursing staff), or interventions to prevent a urinary tract infection. Review of the (MONTH) and (MONTH) 2019 Medication Administration Record [REDACTED]. A nursing progress note on 11/16/2019 at 11:03 PM by Staff D, Registered Nurse, showed the resident pulled out the catheter, and Staff D immediately replaced the catheter with a new one. The note showed no information on the size of the catheter replaced, if the resident experienced any site trauma, or how she tolerated the procedure. Additionally, the note did not reflect notification of the physician by nursing regarding the catheter change, or showed orders were obtained after the incident for catheter reinsertion. According to the nursing progress notes dated 11/29/2019 by Staff E, Licensed Practical Nurse, the resident's catheter was again replaced without physician orders. In an interview on 01/30/2020 at 2:03 PM, Staff B, Director of Nursing, acknowledged nursing staff failed to timely obtain physician orders, or appropriately obtain person-centered catheter care orders for Resident #22, including determining the appropriate catheter size. She verified the nursing staff needed more education on urinary catheter care and catheter infection control practices. (See F880 for further information). Reference WAC 388-97-1060(3)(c)

Based on observation, interview, and record review, the facility failed to provide adequate supervision, and to ensure the care planned intervention of a two-person assist with transfers was followed to prevent a fall, for one of three sample residents (#1), reviewed for falls. This failed practice resulted in actual harm to Resident #1, who fell during a transfer, and sustained a significant injury to his leg, requiring treatment in the emergency room , and staples to close the wound. Findings included . Per an assessment, dated 09/11/19, Resident #1 had [DIAGNOSES REDACTED]. The resident had some memory impairments, and was moderately impaired for decision- making. The assessment also showed the resident required extensive assistance with transfers. The resident's care plan, dated 09/25/18, identified the resident was a high risk for falls related to balance, gait, and having a [MEDICAL CONDITION]. Per the care plan, the resident was to be transferred with two staff. Review of progress notes, dated 10/12/19, showed Staff A, Nursing Assistant, stated she had slowly dropped Resident #1 to the floor. Upon assessment after the fall, the resident had an L shaped deep laceration, with moderate bleeding. The provider was notified, and the resident was sent to the hospital for treatment. Review of the facility investigation, dated 10/14/19, showed the nurse was called to the resident's room on 10/12/19, due to Staff A transferring the resident by herself, and having to lower the resident to the floor. Per the investigation, Staff B, Director of Nursing (DNS), was asked to assess the resident by another nurse, who felt he needed treatment in the emergency room . When she arrived at the resident's room, she found him alone on the floor, with the wheelchair pedal under his back. Documentation showed there was a pool of blood on the floor, and the resident had a large crescent-shaped laceration to his lower leg. The investigation showed the DNS yelled out why is the resident alone? Staff A then came back into the room; the resident yelled for her to leave, stating, she didn't know what she was doing. A pressure dressing was applied, the ambulance was called, and Resident #1 was transported to the hospital. Per the record, he received 20 staples to close the laceration. The conclusion was Staff A did not follow the care plan which directed two-person assistance with transfers, and as a result, Resident #1 sustained a significant injury. Staff A also left the resident unattended after the incident. After the resident returned from the hospital, a follow-up visit was done on 10/16/19 by the Staff D, Nurse Practioner, and a progress note written. Staff had reported concerns about Resident #1 having a possible infection. It was documented staff had observed redness, warmth, and slight swelling the night prior (10/15/19). On 10/16/19 Staff D was informed during a dressing change that morning, the nurse observed scant, purulent drainage (i.e., looked like pus), coming from the staple line. The resident did not have a fever, but he had a history of [REDACTED]. Per the note, upon physical examination, it was documented the staples were intact, there was minor swelling and redness at the staple line, and minor swelling in the area below the staples. The plan was to start the resident on antibiotics for seven days. On 11/05/19 at 9:25 AM, Resident #1 was sitting in the activity room, in his wheelchair, watching TV. Resident #1 stated a staff member was trying to get him up and dropped him, and his leg got cut on the way down. The resident stated, she didn't know what she was doing, and went on to say he received 21 stitches. During an observation on the same day at 1:18 PM, Staff C, Registered Nurse, assisted the resident to his room. Resident #1's pant leg was pulled up, and a large laceration was noted on the outer left leg, which appeared to be healing. Per Staff C, the staples had been removed the day before. During an interview on 11/05/19 at 1:25 PM, Staff C stated she had been in the facility when the fall occurred. She stated she entered the room, the resident's leg was filleted open (i.e., split), and blood was everywhere. Staff C stated she placed a pressure dressing on the resident's leg, knowing he would need stitches, and the resident was sent to the hospital. She went on to say Resident #1 told her he had explained to Staff A that it took two people to transfer him, but she did the transfer by herself anyway. On 11/05/19 at 2:15 PM, Staff B, Director of Nursing, confirmed the resident required two people when being transferred, and the care plan was not followed by Staff A, who then dropped Resident #1. Per Staff B, Staff A was an agency nursing assistant. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure necessary care and services were provided to prevent an avoidable, facility acquired, pressure ulcer for one of two residents (#47), reviewed for pressure ulcers. This resulted in actual harm to the resident, who developed an open pressure ulcer, after a toe separator was left in place between the resident's toes, for a prolonged period of time. Findings included: According to the facility's admission assessment dated [DATE], Resident #47 had [DIAGNOSES REDACTED]. The assessment showed the resident required total, two-person, physical assistance with bed mobility and dressing. The assessment also showed the resident was at risk for pressure ulcers, and did not have any pressure ulcers on admission. A review of a facility incident investigation dated 03/08/18, showed Staff F, Nursing Assistant, went to help Resident #47 with cares, when the resident complained of his right sock being too tight. The nursing assistant removed the sock, noted the resident had gunk coming out from between his toes, and alerted the nurse. Staff G, Licensed Practical Nurse, examined the resident's foot, and documented that upon assessment, the resident had a toe separator in between his toes. The nurse further documented she removed the toe separator, and discovered an open pressure ulcer on the inside of the resident's great toe. In a note dated 03/16/18, Staff B, Director of Nursing, documented the resident had a stage two (partial thickness skin loss/open wound) pressure area, caused by a toe separator that had been placed on the resident's foot by facility staff. A joint interview was completed on 05/01/18 at 5:21 p.m., with Staff B and Staff D, Licensed Practical Nurse. Staff D stated she was completing a skin check on the resident, a few weeks prior to the stage two pressure ulcer being discovered, when she noticed a reddened area between the resident's right great toe and second toe. She further stated a former employee went to a dollar store, got a toe separator that was used for pedicures, and placed it between the resident's toes. Staff B stated that the former employee (Staff S) did not have an order to place the toe separator on the resident, had not created a care plan for it, and had not completed skin checks on it, otherwise she would have seen it was getting worse. When asked how long the toe separator had been in place without being removed and/or checked on, Staff B stated between two to three weeks. Reference: (WAC) 388-97-1060(3)(b)

Based on interview and record review, the facility failed to provide necessary care and services to one of nine sample residents (#2), reviewed for care. The facility failed to monitor the resident's blood glucose levels as ordered by the physician, and nursing staff failed to obtain a physician's order, prior to increasing the resident's oxygen flow. This resulted in actual harm to the resident, who experienced a low blood sugar, received too much oxygen, and fell out of a wheelchair, requiring hospitalization in the intensive care unit. Findings included: Per the comprehensive assessment dated [DATE], Resident #2 admitted on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a progressive lung disease which destroys lung tissue, and makes patients prone to CO2 (carbon [MEDICATION NAME]) retention (American Lung Association, 11/01/16). A review of the resident's 08/09/17 admission orders [REDACTED]. In addition, the resident had an order for [REDACTED]. BLOOD GLUCOSE MONITORING The resident's medication administration and treatment administration records (MAR/TAR) for August 2017 showed the order for the glucose checks was not started until 08/19/17, after the resident readmitted from the hospital (see below). A review of the resident's blood sugar summary also showed daily glucose checks had not been completed for the resident during her intial stay at the facility, between 08/09/17-08/14/17. In an interview on 09/07/17 at 5:00 p.m., Staff A, Director of Nursing, confirmed blood glucose monitoring was not present in the resident's record, as ordered by the physician. OXYGEN ORDERS In addition, the MAR and TAR for August 2017 showed the physician order for [REDACTED].{oxygen} via N/C {nasal cannula} to maintain sats {a measurement of oxygen in the blood} above 90%. A review of Resident #2's progress notes, between 08/09/17 and 08/14/17, showed on 08/10/17 at 2:41 p.m., the resident was on 3 liters of oxygen; on 08/12/17 at 3:54 p.m., 4 liters; and on 08/13/17 at 10:45 p.m., 4 liters. A progress note dated 08/14/17 at 11:29 p.m. showed the resident was on 5 liters of oxygen at the time of the fall (see below). A review of physician orders and the physician's contact log (to document when the physician was called) showed no order was given to increase the resident's oxygen, prior to the increases noted above. In an interview on 09/07/17 at 2:53 p.m., Staff C, Resident Care Manager, stated the way the oxygen order was transcribed onto the MAR, it would indicate to a nurse they could titrate the oxygen up or down, depending on the resident's needs, without needing to contact the physician for an order. Staff C confirmed the order was transcribed incorrectly onto the MAR. A review of the facility's incident log showed on 08/14/17, the resident had a fall in her room. The facility's incident investigation showed at 4:30 p.m., the resident was found on the floor face first, bleeding profusely from her nose. The resident's oxygen was noted to be at 5 liters per minute. At 4:40 p.m., the resident's oxygen saturation level was documented at 46 % (normal levels are above 90%), and paramedics were called. At 4:50 p.m., paramedics arrived and checked the resident's blood glucose level, which was at 37 (blood glucose normal range is 80-120). An IV was started, and the resident was transported to the hospital by ambulance. There was no documentation the resident's blood sugar had been taken that day, prior to the accident, even though there were physician orders to do so. In addition, there was no physician's order to increase the resident's - the order was for 2-3 liters per minute. The 08/14/17 hospital admission records showed the resident was admitted to the intensive care unit (ICU), with excessive carbon [MEDICATION NAME] in the bloodstream, and low blood sugar. The resident remained in the ICU for 2 days. See F 281 for additional information. Reference: (WAC) 388-97-1060(1)

Based on record review and interview, the facility failed to provide services in accordance with professional standards of quality for one of nine sample residents (#2), reviewed for care. Failure to monitor blood glucose levels as ordered by the physician, and failure to administer oxygen as ordered by the physician, resulted in actual harm to the resident, who experienced a low blood sugar, low oxygen/high carbon [MEDICATION NAME] levels, and a fall, which required hospitalization in the intensive care unit. Findings included: Per review of the 08/14/17 comprehensive assessment, Resident #2 had [DIAGNOSES REDACTED]. According to Lippincott's Manual of Nursing Practice (Lippincott, Williams & Wilkins, 2014, pages 239 and 313), nursing staff should assess risk of CO2 (carbon [MEDICATION NAME]) retention, because increased oxygen administration in patients prone to CO2 retention (including those with [MEDICAL CONDITION]) could cause further elevation of CO2, resulting in reduced oxygen levels and other medical complications. The American Diabetes Association 2016 Guidelines for blood glucose monitoring indicate blood glucose levels should be checked, for people taking insulin, before meals, at bedtime, and when low blood sugar is suspected. A review of the resident's 08/09/17 admission orders [REDACTED]. The resident had orders for a short-acting insulin, to be given three times daily, and a long-acting insulin, to be given every 12 hours. BLOOD GLUCOSE MONITORING The resident's medication administration and treatment administration records (MAR/TAR) for August 2017 showed the blood glucose checks were not done during her intial stay at the facility, between 08/09/17-08/14/17. Per record review, multiple nurses had cared for the resident, and had administered insulin during that time period. In an interview on 09/07/17 at 5:00 p.m., Staff A, Director of Nursing, confirmed blood glucose monitoring was not present in the resident's record, as ordered by the physician. OXYGEN ORDERS In addition, the MAR and TAR for August 2017 showed the physician order for [REDACTED]. A review of Resident #2's progress notes, between 08/09/17 and 08/14/17, showed nursing staff adjusted the oxygen multiple times, including up to 5 liters per minute, during that time period. A review of physician orders and the physician's contact log (to document when the physician was called) showed no order was given to increase the resident's oxygen, prior to the increases. In an interview on 09/07/17 at 2:53 p.m., Staff C, Resident Care Manager, stated the way the oxygen order was transcribed onto the MAR, it would indicate to a nurse they could titrate the oxygen up or down, depending on the resident's needs, without needing to contact the physician for an order. Staff C confirmed the order was transcribed incorrectly onto the MAR. A review of the facility's incident log showed on 08/14/17, the resident had a fall in her room. At the time of the fall, the resident was found to have a low blood sugar of 37 (normal 80-120), and a low oxygen level of 45% (normal above 90% on 5 liters. The resident was transported to the hospital by ambulance. There was no documentation the resident's blood sugar had been taken that day, prior to the accident, even though there were physician orders to do so. In addition, there was no physician's order to increase the resident's oxygen to 5 liters - the order was for 2-3 liters per minute. The 08/14/17 hospital admission records showed the resident was admitted to the intensive care unit (ICU), with excessive carbon [MEDICATION NAME] in the bloodstream, and low blood sugar. The resident remained in the ICU for 2 days. Facility nursing staff failed to follow professional standards of care related to monitoring blood glucose levels, when giving multiple daily doses of insulin, and providing the appropriate amount of oxygen to a resident who was at risk for increased carbon [MEDICATION NAME] levels. See F 309 for additional information. Reference: (WAC) 388-97-1620(2)(ii)

Based on observation, interview, and record review, the facility failed to address an outbreak of norovirus timely, when it was determined action was needed, and failed to implement infection control procedures to prevent additional spread. The illness started with 2 residents (#19, 39) and spread to 29 of 49 residents and 15 staff. The lack of an effective infection control program represented an Immediate Jeopardy. Findings include: Cheney Care Center is a 54 bed facility with 20 beds designated as a Special Support Unit (SSU) for dementia. The facility has a combination of private/semi-private rooms. Residents in semi-private rooms share a common bathroom. The facility is accessible through a main door and the SSU is accessible through a restricted egress door in the facility. The census at the start of the survey was 49. During the survey, several residents were ill with symptoms of vomiting/loose stool/diarrhea, first noted by the facility on 2/17/14 and first reported to the health district and the surveyors on 2/20/14. Between 2/17/14 and 2/25/14, the infection spread to include 29 residents in all areas of the facility. 3 residents (#22, 39, 49) had positive cultures confirming norovirus infection. On 2/20/14 at 11:20 a.m., Staff #C, the Infection Control Officer, informed the surveyors that 4 residents had symptoms of nausea and/or vomiting identified that same day. She notified the local health district and was in the process of informing nursing, housekeeping, and laundry staff. She stated she would post a sign on the entrance door to notify visitors that residents were ill. She stated staff was being informed to use gloves and wash hands in the rooms where residents were sick. The facility did not follow accepted infection control procedures to contain an outbreak, including inconsistent use of gloves and gowns when caring for ill residents, consistently isolating residents for a minimum of 48 hours after resolution of symptoms, minimizing resident movements within a unit during an outbreak, and suspend group activities and dining services for the duration of the outbreak. Examples are as follows: SOUTH/EAST UNIT. -Resident #39 resided on the south unit. Per record review, the resident was found dry heaving in a waste basket in her room on 2/17/14. On 2/20/14, the resident had an emesis (vomited) and a "large amount of liquid stool." In an interview on 2/20/14, the resident stated she currently had the dry heaves, but had thrown up last night (2/19/14). She had a basin at the bedside. Per record review, on 2/21/14 the resident was transferred to the hospital for treatment of [REDACTED]. -Resident #19 resided on the south unit. Per record review, on 2/17/14 the resident had 2 large emesis after breakfast and a large loose stool. He stayed in his room for lunch. On 2/18/14 at 11:30 a.m., Resident #19 was at a table in the common area, next to other residents. He was spitting up mouthfuls of clear fluid onto his shirt. He was served served lunch in the main dining room where Staff #E stated that the resident has had an upset stomach the last few days. On 2/19/14 at 9:00 a.m., the resident was again in the common area and not in his room. During observation of care for Resident #19 on 2/19/14 at 11:45 a.m., Staff #E and #D provided personal care for a large stool/urine incontinence. Staff wore gloves but not gowns during care. The resident stated he did not think he should go to the dining room because he was not feeling well. Staff #E fed the resident lunch in the common area. Having the resident eat in the common areas with evidence of illness and not feeding the resident (with symptoms of a possible contagious illness) in his room placed other residents/staff at risk. On 2/20/14 after lunch, Staff #G, who provided care for Resident #19 and other residents in the south unit, reported she was told to use gloves when caring for residents who were ill, but hadn't been given any direction about using masks or gowns. -Resident #17, who resided on the south unit (3 doors from Resident #39,) had an onset of vomiting on 2/20/14. On 2/20/14 at 1:25 p.m., Staff #R and #S were caring for the resident's roommate and did not wear gloves (as directed by Staff #C on 2/20/14) . They stated they didn't know Resident #17 was sick. They reported they were not told anything other than there were 3 people "throwing up." -Resident #10 resided on the east hall of the facility. Per record review, the resident vomited twice during the night shift on 2/19/14. During observation of lunch on 2/19/14, the resident ate in the dining room. Per record review, on 2/19/14 the resident threw up at dinner and was taken to his room to be cleaned up. The facility allowed the resident to eat in the dining room after earlier symptoms of vomiting, placing other residents and staff at risk for exposure to a contagious illness. In an interview on 2/20/14 at 2:25 p.m., Staff #C stated when she reported the outbreak to the health district, she received a telephone message response recommending the facility use contact precautions for ill residents. Staff #A stated gowns were used for residents on contact precautions but contact precautions were not required at this time and staff was not going to use gowns at this time. As a result of the above observations, interviews, and record reviews, the Field Manager was contacted on 2/20/14 at 4:00 p.m. The Field Manager directed the surveyors to obtain a safety plan from the facility related to the above concerns. In response, Staff #A stated the facility would provide gowns in 4 carts on the south and east halls immediately accessible to staff caring for ill residents. On 2/21/14 at 9:25 a.m., Staff #C informed the surveyors that 5 additional residents had developed symptoms of vomiting and/or diarrhea since 2/20/14 (#5, 15, 22, 49, 80.) This list included 4 more residents ill on the south hall, some of whom had shared bathrooms. In an interview on 2/21/14 at 10:50 a.m., Staff #A and #J stated that additional infection control interventions were not warranted to control the spread of infection. Per record review, on 2/24/14, 18 residents in all areas of the facility had become ill, as well as 10 staff. Residents were not restricted to their rooms and group activities were not suspended until 2/24/14. Per record review, on 2/26/14 the stool cultures for Resident #22 and #49 were positive for norovirus. Five more residents had symptoms of illness, including residents on SSU. The survey team re-entered the building on 2/27/14 at 1:40 p.m. Resident #84 was observed in the hallway near the facility entrance. Staff #A reported there were 3 residents (#17, 19, 22) on the south hall (where the illness began) who had been removed from isolation but isolated again due to recurrence of symptoms. Another resident (#7), who also resided on the south unit, had symptoms on 2/25/ and 2/26/14 and was also in isolation. -Per record review, resident #84 first developed symptoms of diarrhea on 2/24/14. On 2/26/14 the resident had a loose stool. Despite this fact, the facility removed the resident from isolation on 2/27/14 - less than 48 hours after the last symptom. He was sitting in an area of the facility where other residents, staff, and visitors could potentially be exposed to the contagious illness. Resident #22, who the facility identified with repeated symptoms, (positive culture for norovirus) shared a bathroom with Residents #2, #42, and #61 who were not currently ill. On 2/27/14 at 2:50 p.m., Resident #2 used the shared bathroom independently. There were no measures in place to have Resident #22 use a separate bathroom or bedside commode. In an interview with Staff #A on 2/28/14 at 1:30 p.m., Resident #2 developed repeated symptoms of illness on 2/28/14. The resident had continued to use the same bathroom as Resident #22, who was positive for norovirus, and still had symptoms of illness. During the visit on the afternoon of 2/27/14, residents were observed in group activities. The facility allowed residents to participate in group activities despite still having residents with symptoms of illness. SPECIAL SUPPORT UNIT: Lunch was observed on 2/20/14 at 11:45 a.m. Staff #P was feeding a dependent resident, and had gotten some food from the resident's mouth on her finger - she wiped it on the resident's shirt protector. Throughout the meal, the resident was observed spitting liquid back out of her mouth onto her shirt protector. Staff #P was then observed serving 2 other residents food. She also grabbed a plastic utensil from the medication cart for another resident. She completed these tasks without washing her hands or wearing gloves, potentially cross contaminating the residents she assisted. On 2/20/14 at 11:50 a.m., Resident #56's family member assisted her at lunch in the common area. The family member asked Staff #Q what the signs on the front door were about in regard to an illness. Staff #Q stated she did not know and she had "not heard anything about it ." There was no sign on the SSU door to notify staff, volunteers, or visitors to wash their hands prior to entering the SSU. When interviewed on 2/20/14 at 1:41 p.m., Staff #K reported she heard there were 4 to 5 residents on the other units that were ill and no one had gotten back to her or given her a report for clarification. She said it is "need to know" and she does "not need to know if it is not back here". On 2/21/14 at 10:25 a.m., Staff #O provided an activity on SSU in the common area with multiple residents. She then went to another activity outside of the SSU without washing her hands before she left the unit. On 2/21/14 at 10:25 a.m., Staff #P was taking the vital signs of several residents who were sitting in the common area on SSU. Staff #P went from resident to resident without cleaning the blood pressure cuff, finger oxygen sensor, and forehead thermometer. -Per record review, Resident #50 (roommate of #57 below) had diarrhea on 2/20/14, loose stool on 2/23/14, diarrhea on 2/24/14 and another loose stool on 2/27/14. Per record review, the facility reported the on-set of illness as 2/24/14, 4 days after initial symptoms occurred. The resident was transferred to a private room on another unit and given IV (intravenous) fluids on 2/24/14 for 48 hours for a [DIAGNOSES REDACTED]. The resident was taken off of quarantine on 2/27/14 even though she continued to have symptoms of the virus that day. This placed other residents at risk for contracting the contagious illness. -Per record review, Resident #57 (roommate of #50) had diarrhea on 2/20/14 and a loose stool on 2/22/14 with a temperature of 99.2 degrees. The resident had another episode of diarrhea on 2/25/14. The facility documentation reported the on-set of illness as 2/25/14 - 5 days after the first symptoms appeared. This delayed the placement of the resident in isolation, and potentially caused further spread of the illness. -Per record review, Resident #56 had diarrhea on 2/21/14 and 2/25/14 with a loose stool on 2/26/14 and 2/27/14. The facility documentation reported the on-set of illness as 2/25/14, which delayed the placement of isolation and precautions taken to prevent spread of illness. In addition, on 2/28/14 at 2:50 p.m., Staff #N confirmed the resident was taken off of isolation the morning of 2/28/14. This was less 48 hours since the last documented symptoms. -According to the facility record, on 2/24/14, Resident #41 was moved to a room off the SSU due to symptoms of the GI illness (diarrhea). On 2/25/14, the resident was identified as being potentially dehydrated (because of the fluid loss from diarrhea), and was started on IV fluids for 48 hours. The resident's need for additional IV fluids was a result of contracting the illness. The lack of adequate measure to isolate infected residents, and intervene timely to prevent the spread and contamination of infection constituted Immediate Jeopardy to 29 residents. Of the 29 residents, 3 were on the east hall, 20 were on the south hall and 6 were on the SSU.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable level for 1 of 3 residents (#1) related to assessment for latent injury after an incident. The facility failed to take action which delayed treatment and caused harm for Resident #1. Findings include: Resident #1, per record review, had [DIAGNOSES REDACTED]. She required limited assistance with activities of daily living (ADL's). The care plan directed staff to encourage the resident to call for assistance with transfers and toileting, but at times she would do independently. She was on narcotic pain medications at 8:00 a.m. and 8 p.m. and then got a non-narcotic pain medication at noon. Per review of the facility investigation dated 11/4/12, the resident reported that she transferred herself from her recliner to the bedside commode. She sustained a large bruise that measured 6 centimeters (cm) x 3 cm on her right ulna and 3 scratches. Staff were instructed to monitor the scratches for signs and symptoms of infection, monitor pain, and gave her a different commode with arm rests. Per record review, there was no documentation from 11/4/12 until 11/9/12 regarding range of motion, swelling, or pain to her right arm to indicate the staff were monitoring for latent injury.. During the investigation, Staff #C reported to the investigator that on 11/5/12 she noticed the resident "babied" her right arm. She said usually the resident was independent after she was dressed. She said the resident favored her right arm the entire shift. Staff C said she reported the resident complained of pain and that she was not using her right arm to the nurse and a nursing assistant. Staff #C said on 11/8/12 the resident expressed that she thought her arm was fractured. The resident told her she had previously had a fracture prior to her admission to the facility and the resident said this felt like it did when it was fractured before. Staff #C said on 11/8/12 the resident's arm was bruised and the swelling was so bad that her watch was embedded into her skin. On 11/19/12 at 3:10 p.m., Staff #E reported she evaluated the resident on 11/4/12 after she bumped her right arm on the commode. She said she had a large bruise on her right arm, but was able to move her arm and could also move her fingers on 11/4/12. She reported she did not use her right arm after that and asked for help, but thought it was because she was afraid to use it. During the investigation, Staff #F said on 11/5/12 the resident complained of pain and cried out when she used her walker or put weight on her right arm. She said on 11/8/12 her arm was more swollen and she had indentations on her skin where her watch had been. On 11/19/12 at 2:30 p.m., Saff #D reported on 11/8/12 the resident's right arm was swollen and bruised. She said she had a skin tear on her right arm so she dressed/covered the skin tear. She looked at her right arm the next day and noted her arm was still swollen and she continued to complain of pain so she got an order from the doctor to x-ray her right arm on 11/9/12. On 11/19/12 at 3:00 p.m., the resident described the incident as staff had indicated. She said her arm was painful when she moved it in certain directions. She reported it took the facility over 3 days to get an x-ray ordered. On 11/19/12 at 5:00 p.m., Staff A and B were unable to find any information to indicate the nurses monitored the resident after the incident on 11/4/12 to 11/8/12. The facility failed to provide the necessary care and services following an incident which resulted in delay of treatment. This resulted in harm for Resident #1.