Every finding on record at Colfax Health and Rehabilitation of Cascadia

Based on interview and record review, the facility failed to timely identify and address a decline in condition for 1 of 3 residents (Resident 1) started on a new medication. Resident 1 experienced harm when they had a decline in condition as evidenced by nausea/vomiting, change of level of consciousness, were difficult to arouse, and became unresponsive after starting a new partial opioid (buprenorphine-naloxone (suboxone) - a central nervous system depressant used to treat opioid addiction) medication. Findings included .Review of Resident 1's electronic medical record (EMR) showed they were admitted to the facility on [DATE], at the age of 54, with diagnoses of diabetes, bilateral below knee amputations, and chronic kidney disease (inability of the kidneys to filter waste effectively).Resident 1's EMR showed on [DATE] at 1:00 PM they saw Collateral Contact 1 (CC1), community primary medical doctor, in their office and were prescribed buprenorphine-naloxone to help with their report of unrelieved nerve pain. The dose was documented in the medical provider summary note, dated [DATE] at 1:13 PM, to be 8 milligram (mg) -2 mg sublingual film (placed under the tongue to dissolve): place 0.5 film under the tongue every 12 hours.Review of Resident 1's [DATE] MAR (Medication Administration Record) showed an order, entered during the night shift on [DATE] into [DATE] by Staff D, Registered Nurse (RN), dated to start [DATE] at 6:00 AM, which stated: Alert charting: Medication change-adverse side effects r/t (related to) start of Buprenorphine-Naloxone for 3 days. Stop medication if [they have] severe nausea, confusion, disorientation, or other significant symptoms and contact [CC1]. The box for [DATE], on the [DATE] MAR, was then checked off by Staff E, RN, for day shift on [DATE], indicating they had followed the ordered direction to monitor for and report adverse side effects related to starting the new medication. Review of Resident 1's [DATE] MAR showed an order, entered on the night shift of [DATE] into [DATE], by Staff D, dated to start on [DATE] at 8:00 AM, for buprenorphine-naloxone 8 mg -2 mg sublingual film: give 1 film every 12 hours. The box for [DATE] was then checked as given by Staff E, in the AM on [DATE]. Further review of Resident 1's MAR showed no order for an antiemetic (a medication used to treat or prevent nausea and vomiting) nor any other narcotic pain medication since their admission.Review of Resident 1's nursing progress notes, showed a note written by Staff E on [DATE] at 9:43 AM which stated, Resident initial dosed N.O. (new order) suboxone (buprenorphine-naloxone is generic drug name for the commercial drug name suboxone) sublingual this morning. Resident had c/o (complained of) moderate to severe n/v (nausea/vomiting) and stated that [they]no longer wanted to take the medication. Nurse educated resident on the expected side effects of the medications and offered PRN (as needed) antiemetic medication. Resident accepted the PRN and stated that [they] will try the dose again tomorrow to allow [their] body to adjust to the new medication.On [DATE] at 4:58 PM, Staff E documented in the nursing progress notes, F/U (follow-up) to resident initial dosing of N.O medication suboxone. After resident c/o nausea, [they] stated that [they were] going to lay down. Resident could be heard snoring from the hallway ongoing from 11:00-13:00 (1:00 PM). After which resident cont. (continued) sleeping. Resident did not awake for lunch or oral medications.Review of staffing documentation, for [DATE], showed Staff F, Nursing Assistant (NA) was assigned to work from 6:00 AM until 6:00 PM, on the hallway where Resident 1 resided. Staff G, NA, was assigned for the same shift to assist with resident showers, and another NA who was assigned to work on the same hallway, was marked as no show.During an interview on [DATE] at 11:45 AM, Staff C, Staffing Coordinator, stated that an NA had called off early on the morning of [DATE]. They stated that they called around but could not find coverage. They stated that they did not communicate with the remaining building staff to adjust the resident assignments related to one staff not being in the building. Staff C stated that Staff F would have been responsible for the care of about 17 residents and that Staff G should have moved into the open NA spot instead of focusing on showers, but that they did not communicate the need to adjust assignments to the nursing staff the morning of [DATE].During an interview on [DATE] at 3:00 PM, Staff G, stated that they had worked with Resident 1 on multiple occasions but were not assigned to work with Resident 1 on [DATE] and that day they helped residents with showers and kind of floated around. Staff G stated Resident 1 was friendly, outgoing, and would often take time to talk with staff and other residents in a friendly manner. They stated Resident 1 normally snored when sleeping and would often take a nap before lunch. Staff G stated on [DATE], Resident 1s snoring was different, that it was really loud and could be heard all the way to the main nurses' station (about 150 feet away). Staff G stated they brought Resident 1 their lunch tray about 12:30 PM and that Resident 1 was really drowsy and did not talk to them as they typically did. Staff G stated that they needed to assist with continuing to pass out lunch trays to other residents and left the room before Resident 1 started eating. Staff G stated that they did not know that Resident 1 had started a new medication that day and they did not notify the nurse related to Resident 1 being really drowsy or acting differently than was normal.During an interview with Staff F, Nursing Assistant on [DATE] at 9:57 AM, they stated they had worked with Resident 1 on multiple occasions. They stated Resident 1 was usually very active, would leave the facility to self-propel in their wheelchair across the street to get snacks, sometimes several times a day, talked loudly, laughed a lot, was friendly and social with other residents and staff. They stated the day shift on [DATE] had been a very busy day, due to one NA staff not showing up for their shift. They further stated that they did not remember being assigned to work with Resident 1 on [DATE] and had not provided direct care assistance to Resident 1 on that shift. They stated that during lunch time on [DATE], they could not remember the exact time, but thought it would have been about 1:00 PM, another resident stopped them in the hallway and asked them to go check on Resident 1 as they could hear them snoring very loudly and were concerned. Staff F stated upon entering Resident 1s room, they were snoring really loudly and their lunch tray was untouched on their bedside table. Staff F stated Resident 1 was hard to rouse. Staff F stated that Resident 1 snored normally but the snoring that day was different and really loud. Staff F stated they thought snoring was a sign the resident could be Od'ing (overdosing) or that their blood sugar might be high or low but that they did not tell the nurse of their concerns. Staff G further stated that it was very busy that day and in retrospect they should have told the nurse about their concerns.During an interview with Staff E, on [DATE] at 3:00 PM, they stated that [DATE] was the second shift they had worked in the facility. Staff E stated that they were not very familiar with any of the residents and relied on the staff who knew the residents to notify them if there was anything different or unusual happening. Staff E stated that Resident 1 had started a new pain medication that morning ([DATE]) and that Resident 1 had approached them at the main nurses station a little before 10:00 AM and told them they were very nauseous. Staff E then stated they borrowed Zofran (a prescription antiemetic medication used to prevent nausea and vomiting) from another resident and had given it to Resident 1, after which Resident 1 went to their room and slept for most of the remainder of the shift. Staff E stated they checked the resident's blood sugar prior to lunch, about 11:00 AM, and gave them insulin (a medication used to help turn sugar into energy and manage blood sugar levels). They stated the resident had been snoring very loudly and they had to reposition the resident so their face was not in the mattress. Staff E stated that they again checked the resident's blood sugar at about 4:00 PM, again administered the prescribed insulin, noticed the resident was still sleeping on their stomach, moved pillows to keep the resident's face off of the mattress and went about their other assigned duties. Staff E stated that they did not receive any kind of notification, from any staff, that Resident 1's behavior was not typical or abnormal. Staff E stated that they did not call any medical provider to notify them of the need for medication to treat Resident 1's complaint of nausea or signs/symptoms of sedation. They stated that after dinner, probably about 6:00 PM, a NA had come out of Resident 1's room and started yelling for help. When they got to the room, they realized that Resident 1 was not breathing, assisted other staff to turn the resident onto their back and started cardiopulmonary resuscitation (CPR) as they did not know the resident's code status (a medical directive indicating a resident's preference for life-saving interventions - specifically CPR).During an interview on [DATE] at 12:26 PM, Staff H, NA, stated that they came into work at 2:00 PM on [DATE]. They stated that they brought Resident 1 their dinner tray that day, probably a little after 5:00 PM, and thought it was weird when they noticed the resident's lunch tray, on their bedside table, was untouched, as they usually ate well. Staff H stated that Resident 1 was very drowsy, was difficult to rouse and did not speak to them but only grunted. Staff H stated they thought Resident 1 was awake when they grunted and left the room to go assist another resident to eat. Staff H stated they then returned to pick up Resident 1's dinner tray, at about 6:00 PM, and found them laying on their stomach, their dinner tray was untouched. Staff H stated they approached Resident 1 and noticed they had visibly voided their bladder in bed, which was not normal. Staff H stated when they tried to rouse Resident 1, they were unresponsive and not breathing. Staff H stated they yelled out into the hallway for help and then tried to turn Resident 1 onto their back to start CPR, as they did not know the resident's code status During an interview with CC1, on [DATE] at 3:59 PM, they stated they had been Resident 1's medical provider for awhile and that on [DATE] Resident 1 had an appointment with them, in their office, where they had discussed Resident 1's level of unrelieved pain and different methods for controlling the pain. After discussion with Resident 1, CC1 decided to start Resident 1 on suboxone to try and control the resident's pain to tolerable levels, without the side effects caused by typical narcotics (addiction). CC1 stated that they did not receive any calls from staff at the facility until they were notified of Resident 1's death on the evening of [DATE] in a voicemail and then of the medication error on [DATE]. CC1 stated that they were surprised by the notification, as they had just seen Resident 1 the day before and they had reviewed their lab results. During that visit, Resident 1s lab results showed improved numbers indicating better control of their diabetes which also indicated they were making better lifestyle choices and CC1 was cautiously hopeful the resident would continue to improve.During an interview with Staff B, Chief Nursing Officer, they stated that they had been made aware of the short facility staffing on [DATE] but had not called to provide directions to staff for changing resident assignments. Staff B stated they thought that Staff C would have provided direction. They stated that they did not think nursing staff had notified Resident 1's medical provider of any side effects of the newly started medication. Staff B stated nursing staff should have notified either CC1 or the facility on-call medical provider, who worked on the weekends, of the nausea and sedation as directed on the resident's MAR. They stated they had become aware of the medication error affecting Resident 1, on [DATE], after they had passed away, and that their death had been unexpected. Staff B stated that it looked like Staff D had incorrectly entered the dose of the new medication, on the night shift of [DATE] into [DATE], for Resident 1 to have 1 full strip versus the actual order to give 0.5 a strip, . Staff B stated Staff D had not had a second nurse check the accuracy of the order prior to administration, as was facility policy.During an interview on [DATE] at 2:00 PM, Staff A, Administrator, stated that Staff C would be responsible for calling nursing staff to adjust assignments when a staff called off and another staff could not be found to cover the shift. They further stated that it was the expectation that nursing staff follow facility policy for checking orders for accuracy, administer medical orders as written, and notify medical providers when directed to do so.See citation for F 760 dated [DATE]Reference: WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), received medications as ordered and were free from significant medications errors. This failure placed residents at risk for adverse medication side effects, and worsening condition. Findings included . Review of Resident 1's electronic medical record (EMR) showed they were admitted to the facility on [DATE] with diagnoses of diabetes, with bilateral below knee amputations and chronic kidney disease (inability of the kidneys to filter waste effectively). Further review of Resident 1's EMR showed on 03/13/2026 they saw their community medical provider and were prescribed buprenorphine-naloxone (prescription medication primarily used for the treatment of opioid dependence. It is not intended for pain management) to help with their report of unrelieved pain. The dose was documented in the medical provider summary note to be 8 milligrams (mg) - 2 mg sublingual film (placed under the tongue to dissolve): place 0.5 film under the tongue every 12 hours. Review of Resident 1's March 2026 Medication Administration Record (MAR) showed an order, dated to start on 03/14/2026 at 8:00 AM, for buprenorphine-naloxone 8 mg-2 mg sublingual film: give 1 film every 12 hours. The box for 03/14/2026 was then checked as given by Staff F, Registered Nurse (RN), in the AM on 03/14/2026. Further review of Resident 1's MAR did not show an order for an antiemetic medication (a medication used to treat or prevent nausea and vomiting). Further review of the same MAR also showed an order dated 03/14/2026 at 6:00 AM which stated: Alert charting: Medication change-adverse side effects r/t (related to) start of Buprenorphine-Naloxone for 3 days. Stop medication if [they have] severe nausea, confusion, disorientation, or other significant symptoms and contact [Staff C]. The box for 03/14/2026 was then checked off by Staff F, Registered Nurse, for day shift on 03/14/2026. Review of Resident 1's nursing progress notes, located in their EMR, found a note written by Staff F, on 03/14/2026 at 9:43 AM which stated, Resident initial dosed N.O. (new order) suboxone (buprenorphine-naloxone is generic drug name for the commercial drug name suboxone) sublingual this morning. Resident had c/o (complained of) moderate to severe n/v (nausea/vomiting) and stated that [they] no longer wanted to take the medication. Nurse educated resident on the expected side effects of the medications and offered PRN (as needed) antiemetic. Resident accepted the PRN and stated that [they] will try the dose again tomorrow to allow [their] body to adjust to the new medication. Further review of nursing progress notes found another nursing note written by Staff F on 03/14/2026 at 4:58 PM, which stated, F/U (follow-up) to resident initial dosing of N.O medication suboxone. After resident c/o nausea, [they] stated that [they were] going to lay down. Resident could be heard snoring from the hallway ongoing from 11:00-1300 (1:00 PM). After which resident cont. (continued) sleeping. Resident did not awake for lunch or oral medications. Nurse has frequently had to turn resident on [their] side to prevent [them] from sleeping face down in [their] mattress. At the time of this note, resident cont. to sleep and snore loudly. During an interview with Staff F, on 03/25/2026 at 3:00 PM, they stated that they worked for a staffing agency and the shift they worked on 03/14/2026 was the second shift they had worked in the facility. They further stated that they gave Resident 1 the new order for suboxone on 03/14/2026 a little after 8:00 AM and the resident came back to tell them they were nauseous a little before 10:00 AM. Staff F stated that they then offered Resident 1 a medication called Zofran (antiemetic), that was prescribed for another resident. Resident 1 took the medication and went to lay down after which they were heard snoring loudly and slept most of the day. Staff F stated that they did not notify the medical provider, Staff C, of Resident 1's sedation or nausea and only found out the next day that the resident had received double the dose of suboxone that they should have been administered. During an interview on 03/18/2026 at 12:45 PM, Staff B, Chief Nursing Officer, stated that on 03/15/2026 they were made aware that Resident 1 had experienced a significant medication error when they were administered a full strip of suboxone, instead of the ordered half a strip. They stated that they did not think that the RN who administered the drug notified the medical provider of side effects from the medication error until after the resident was found unresponsive, after dinner, on 03/14/2026. See citation for F 684 dated 04/07/2026. Reference: WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to consistently provide wound care treatment and address refusal of care for 1 of 7 residents (Resident 4), failed to obtain wound supplies timely for 2 of 7 residents (Resident 5 and 6), and failed to enter orders for wound care for 2 of 7 residents (Resident 3 and 7) reviewed for non-pressure skin conditions. This failure placed residents at risk for worsening skin conditions.Findings included: <Resident 4> According to Resident 4's admission Minimum Data Set (MDS-a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 08/15/2025, they admitted to the facility on [DATE] with five ulcers (open wounds) on their lower legs, were at risk for development of further skin issues and had scheduled wound care. According to Resident 4's care plan, dated 08/14/2025, they had actual wounds to bilateral [NAME]'s (lower extremities) and left front thigh folds and rash. Interventions included to administer medications and treatments as ordered. Monitor /document for side effects and effectiveness. No care plan focus was found to address Resident 4's documented refusal to accept wound care. Further review found an additional care plan focus was found to be added on 12/24/2025, [Resident 4] has infection of the bilateral lower extremity wounds. Wound culture + (positive) for Staph (Staphylococcus-bacteria commonly found on the skin, most of the time does not cause harm but can sometimes causes infections) and Pseudomonas (a bacteria commonly found in the environment, particularly in water and soil). According to Resident 4's MAR's (medication administration record) for November and December 2025 and January 2026, the resident refused dressing changes or dressing changes were coded as not completed. November 2025 MAR:Apply [NAME] boot (a specialized, non-elastic, gauze bandage with medication impregnated into the gauze used for treating leg ulcers) to bilateral lower extremities with light compression. cleanse legs after removal with wound cleanser and pat dry. Apply Unna wrap (same as [NAME] boot), apply kerlex (brand of sterile woven gauze) and coban (a brand of light weight, self-adherent cohesive bandage that sticks to itself) or ace wrap (a compression bandage). Every day shift, every Monday, Wednesday, Friday. Dated 11/07/2025 through 12/02/2025.11/12/2025 marked as NN (other/progress note).an associated progress note, dated 11/12/2025 at 5:09 PM stated, Dressings change held today, unna wrap ordered today, dressing to be changed on Friday.no associated order or medical provider note was found with an order to hold the wound dressing. No indication was found that the medical provider was aware of the dressing not being completed. December 2025 MAR:12/01/2025 box is blank. This order ended on 12/02/2025.A new wound care order was entered and effective from 12/03/2025 through 12/15/2025 and was written as follows: xeroform (brand name of a medicated wound dressing) to [NAME] wound, followed by compression wrap and light Ace bandage over it. Every day shift every Monday, Wednesday, Friday.12/03/2025 box was blank, 12/08/2025 was marked as NN, 12/10/2025, 12/12/2025 and 12/15/2025 were all marked as MR (medication refused).no associated progress notes for 12/08/2025 was found. A new wound care order was entered on 12/21/2025 (6 days after last order ended) with an end date of 12/24/2025 and was written as follows: Cleanse wound cleanser and pat dry, alginate () to open areas, cover with abdominal pads () and cover with stockinet (). Twice weekly with one time being done a wound clinic. Every day shift, every Sunday.12/21/2025 box was marked as refused. A new wound care order was entered on 12/28/2025 and was effective through 01/12/2026 and was written as follows: Cleanse with wound cleanser and pat dry, absorptive silver to open areas, cover with kerlix and cover with stockinet. Twice weekly with one time being done at wound clinic. Every day shift, every Sunday. An antibiotic order was entered on 12/25/2025 to continue through 01/05/2026 for wound infection BLE (bilateral lower extremities). January 2026 MAR:-boxes to document wound care were marked as refused for 01/04/2026 - 01/11/2026. No other scheduled wound care for resident 4's lower extremities were found through 01/15/2026. The order for an antibiotic for the bilateral lower extremity infection shows a blank box on 01/04/2026. During an interview on 12/30/2025 at 12:20 PM with Resident 4, they stated that they were worried about the wounds on their legs, that the dressings were not being done regularly, and they thought their legs were starting to smell bad. During an interview with Staff B, Resident Care Manager, on 01/28/2026 at 10:56 AM, they stated that Resident 4 had been admitted with a lot of wounds and that there had been challenges finding a wound care provider to treat the wounds. They stated that they were now being seen at a local wound clinic and that they had an infection in the wounds in their legs. They stated that the resident would often refuse wound care and that there were no interventions in the resident's care plan for how to address refusals, nor was there a risk versus benefit discussion documented related to the possible consequences of refusing wound care. <Resident 5> According to hospital discharge orders, dated 11/06/2025, Resident 5 was discharged to the facility on [DATE] with an infection in their right anterior (front) lower leg that had required surgical debridement (medical procedure where dead or infected skin tissue is removed) leaving an open surgical wound that required treatment with a wound vac (Vacuum-Assisted Closure therapy -uses controlled suction to remove fluid, reduce swelling, and promote healing in open wounds) for the wound to heal. Orders on the discharge summary included details for the frequency the wound vac needed to be changed (Monday, Wednesday, Friday), gave the settings for the machine and indicated that the device would be discontinued by recommendation of the surgeon. According to Resident 5's care plan they admitted to the facility on [DATE], had cellulites (infection in the skin) of their right lower limb. A care plan intervention indicated the resident had an infection of the right lower extremity, but did not detail anything related to the wound vac order. The care plan also did not describe any interventions to address the Resident's refusal to accept wound care. According to Resident 5's December 2025 MAR they had an order started on 11/07/2025 for NPWT (negative pressure wound therapy - wound vac) dressing change three times a week and PRN (as needed). Clean wound bed with normal saline (a sterile solution of water and salt), apply skin prep (a liquid impregnated pad used to prepare intact skin for medical adhesive devices) to surrounding tissue. Apply adaptic or mepitel (non-adherent, mesh-structured wound dressing designed to protect wounds) to wound bed if fragile and indicated. Cut sponge to wound size and place in wound. Cover with transparent dressing. Every day shift Mon, Wed, Fri. Further review of the November 2025 MAR found entries for 11/7/2025, 11/10/2025, 11/12/2025, 11/14/2025 and 11/17/2025 all with code NN (other/progress note). Review of Resident 5's progress notes showed a progress note on 11/07/2025 at 5:09 PM, that stated, Resident is ordered to have wound vac in place. Resident did not arrive from hospital with wound vac in place. Therefore resident has a wet to dry dressing (packing saline-moistened gauze into the wound bed, allowing it to dry completely and then removing it to take away dead tissue) in place on right lower leg. Further review found a progress note for 11/10/2025 at 5:23 PM that stated, Resident is ordered to have wound vac in place. Resident did not arrive from hospital with wound vac in place. Therefore resident has a wet to dry dressing in place on right lower leg. Further review found a progress note for 11/12/2025 at 5:41 PM that stated, Resident is ordered to have wound vac in place. Resident did not arrive from hospital with wound vac in place. Therefore resident has a wet to dry dressing in place on right lower leg. Further review found a progress note for 11/14/2025 at 6:24 PM that stated, Resident is ordered to have wound vac in place. Resident did not arrive from hospital with wound vac in place. Therefore resident has a wet to dry dressing in place on right lower leg. Further review found a progress note for 11/17/2025 at 11:52 PM that stated, Resident went to wound clinic today. Returned from clinic with new dressing clean, dry and intact. Review of Resident 5's December 2025 MAR shows the same order as the November MAR with a blank box on 12/01/2025 and 12/03/2025. Additionally 12/08/2025 and 12/29/2025 were marked as refused and 12/10/2025 was marked as held. Review of Resident 5's progress notes found a progress note on 12/05/2025 at 8:10 PM, Wound vac was not suctioning today. This LN (licensed nurse) found res wound vac canister full and wound vac dressing dripping with fluid. On 12/10/2025 at 11:38 a progress note indicated Has routine dressing changes with wound vac but using wet to dry as awaiting supplies. Review of Resident 5's January 2026 MAR through January 21,2026, showed the same order as the November and December MAR with a blank box on 01/05/2026. Additionally, 01/09/2026 was marked with NN and 01/19/2026 was marked as refused. During an interview with Staff B, Resident Care Manager, on 01/28/2026 at 10:56 AM, they stated that Resident 5 did not come from the hospital with a wound vac and it took a little while to get one. Then we were running out of supplies because the staff were not telling me when the supplies were running low and it would take about seven days to get a new supply delivered. <Resident 6> According to Resident 6's December 2025 MAR they admitted to the facility on [DATE] with diagnosis including laceration of their small intestine. The same MAR had an order, started on 08/08/2025 and stopped on 01/06/2026 that stated, Negative pressure wound therapy (wound vac) to abdominal wound: black foam to be placed in cavity. Run at 125 mmHg (millimeters of mercury-pressure setting for the machine) continuously. Every day shift Mon, Wed, Fri related to laceration of unspecified part of small intestine. On the same MAR the boxes indicating if treatment was completed for 12/01/2025, 12/10/2025, 12/17/2025 and 12/29/2025 were blank. 12/08/2025 was marked as NA, and 12/24/2025 and 12/31/2025 were marked as refused. Review of the Resident's January 2026 MAR showed a blank box for 01/05/2026 and then the order was discontinued the next day. During an interview with Staff B, Resident Care Manager, on 01/28/2026 at 10:56 AM, they stated that Resident 6 did have a wound vac for a large open wound on their abdomen. They stated that we were running out of supplies because the staff were not telling me when the supplies were running low and it would take about seven days to get a new supply delivered. <Resident 3> According to hospital discharge orders, Resident 3 underwent a left below knee amputation (LBKA) related to an infection on 11/05/2025. No wound care orders were found on the hospital discharge document. According to a facility admit assessment, dated 11/11/2025, a comment was found on page 9, left bka with surgical wounds/sutures. Resident removed shortly after admission stating it was itchy. Some bleeding noted to incision site. Redressed with sterile gauze and ace wrap, educated resident on the importance of not removing dressing. Review of Resident 3's care plan, initiated 11/11/2025, found no focus or interventions for wound care for the resident's surgical wound related to their left BKA. Review of Resident 3's November 2025 MAR found an order for some wound care on 11/22/2025 (11 days after admission), without a specifically stated site to perform the wound care and without a specific strength for the solution to be applied. Documentation of the order being completed showed the entry NN for 11/22/2025, 11/23/2025, 11/28/2025, 1129/2025 and 11/30/2025. Review of progress notes for the period showed the order was not clear and needed to be clarified. It is unclear if wound care was performed during this period or how it was performed. Review of Resident 3's December 2025 MAR shows that same order as the November MAR with boxes blank on 12/03/2025 and 12/05/2025 and the order discontinued on 12/05/2025. The next order for wound care for the same surgical site was found as entered 12/16/2025 (11 days after the last order was discontinued) to include details for the strength of the solution to be applied to the wound and direction for how to perform the dressing. During an interview with Staff B, Resident Care Manager, on 01/28/2026 at 10:56 AM, they stated that Resident 3 came from the hospital with unclear surgical wound care instructions. They further stated that wound care was performed by them the day Resident 3 admitted but that they did not know why there were no orders entered for wound care for the resident's LBKA surgical incision until 11 days after admission. <Resident 7> According to hospital discharge orders, Resident 7 experienced a fall at home with a fractured right hip that required surgical repair on 12/27/2025. The resident was then discharged to the facility on [DATE] without clear surgical wound care instructions. According to Resident 7's admission MDS, dated [DATE], the resident admitted to the facility on [DATE], had a surgical wound and required surgical wound care. Review of Resident 7's December 2025 MAR showed no surgical wound care or monitoring of the surgical wound site was ordered to occur. Review of Resident 7's January 2026 MAR showed no surgical wound care or monitoring of the surgical wound site was ordered to occur. Further review of the Resident's medical record showed they were discharged from the facility on 01/02/2026, with their family, and were admitted to another facility. During an interview with Staff B, Resident Care Manager, on 01/28/2026 at 10:56 AM, they stated that Resident 7 came from the hospital with unclear surgical wound care instructions and they were not sure if wound care was performed during their stay at the facility. Reference: WAC 388-97-1060(1)

Based on interview, and record review, the facility failed to develop and implement measures to prevent skin breakdown for 1 of 7 residents (Resident 1), failed to address resident refusal of care and consistently provide wound care for worsening pressure ulcers for 1 of 7 residents (Resident 2), and failed to enter wound care orders timely and collect ordered wound cultures timely for 1 of 7 residents (Resident 3) reviewed for pressure ulcers. Failure to implement interventions timely resulted in the development of potentially avoidable pressure ulcers, failure to address refusal of care and provide consistent wound care resulted in worsening pressure ulcers and failure to enter wound care orders timely and collect wound cultures, as ordered, resulted in delayed care of pressure ulcers. Findings included: The website nih.gov - in which nih refers to national institute of health- described the revised National Pressure Ulcer Advisory Panel pressure injury staging system and showed a pressure injury is localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear.-Stage 1 pressure injury: intact skin with a localized area of non-blanching erythema (redness that does not disappear when pressure is applied to the area).-Stage 2 pressure injury: partial thickness (involving epidermis and/or dermis) loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.-Stage 3 pressure injury: full thickness (wound that extends below the epidermis and dermis into the subcutaneous tissue or deeper) skin loss, in which adipose (fat) or granulation (new connective tissue) tissue is visible in the ulcer.-Stage 4 pressure injury: full thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon (strong cords of tissue that connect muscle to bones), ligament (bands that connect bones and joints], cartilage (tough, flexible connective tissue that protects bones and joints, and provides structure to the nose and ears), or bone in the ulcer.- Unstageable pressure injury: full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead skin or tissue that can appear in a wound) or eschar (dead tissue that forms over healthy skin and eventually falls off). - Deep Tissue Pressure Injury (DTPI or DTI): intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation reveling a dark wound bed or blood filled blister <Resident 1>According to preadmission hospital notes, dated 11/30/2025, Resident 1 had a pressure injury to their right heel, without description of the size or depth of the injury.According to an admission skin assessment, dated 12/03/2025, inspection of the resident's feet revealed no issues.According to Resident 1's admission Minimum Data Set (MDS-a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 12/09/2025, showed the resident admitted to the facility on [DATE] with no pressure ulcers or injuries and no pressure ulcer or injury care, but were at risk for development of pressure ulcers.According to Resident 1's care plan, dated 12/03/2025, the resident had an actual unstageable to bilateral heels r/t (related to) decreased mobility and had on admission. Further direction dated 12/03/2025 states Assess/record/monitor wound healing ((FREQ (frequency)). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements or declines to the MD (medical doctor). Further direction, dated 12/03/2025 stated offload heels when in bed (keep pressure off of heels by elevating them above surfaces).Review of Resident 1's December Medication Administration Record (MAR) showed blank boxes for skin assessments on 12/10/2025, 12/17/2025 and 12/24/2025, indicating they were not performed. Further review showed the only wound care order was entered on 12/19/2025 (17 days after admission), to start on 12/20/2025 at 6:00 AM, and stated, cleanse bilateral heels with wound cleanser. Let dry, apply skin prep periwound (around edge of wound). Apply calcium alginate (a type of wound dressing used to absorb fluid from wounds) and cover with bordered foam dressings (sterile, adhesive backed, water resistant pad designed to manage moderate to heavy wound exudate). Every day shift for wound care. The associated boxes were found to be blank on 12/20/2025, indicating the wound care was not performed, and was marked as HS (hospitalized ) for 12/21/2025.Review of an order recapitulation (summary of orders during stay at facility) from 12/01/2025 through 01/31/2026 showed the same bilateral heel wound care entered on 12/19/2025, to start on 12/20/2025, as seen on the resident's December MAR. The only other order, pertaining to skin integrity/care, found was for a weekly skin check: evaluate skin impairments, skin health, nail and foot care. Document results on the evaluation scheduled, every day shift every Wed (Wednesday) for skin integrity.Review of the resident's progress notes during their stay at the facility did not show documentation of skin evaluations, or any other concerns with pressure ulcers/injury until a nurse note was written on 12/19/2025 at 12:05 PM, and then struck out on 12/24/2025 at 3:43 PM, Res (resident) has blisters measuring 10cm (centimeters) X (by) 10cm on bilateral heels. This LN (licensed nurse) cleansed with wound cleanser applied bordered foam bandage, placed bilateral feet in blue padded boots, elevated on pillow. [Collateral Contact] was present at the time this LN was informed of heels. RCM (resident care manager) of facility was notified. Provider notified with new orders for wound care as follows.Further review of Resident 1's progress notes showed another note from the same LN, dated 12/19/2025 at 7:03 PM, stated .Family was in several times during this shift to visit d/t (due to) blisters on bilateral heels found today.Further review of progress notes found that the resident discharged AMA (against medical advice), with their family, on 12/20/2025 and were taken, by wheelchair, directly across the street to the town's rural hospital emergency room.Further review of progress notes found a note written by Staff B, Resident Care Manager, on 12/21/2025 at 1:30 PM that stated, was notified on 12/19/2025 of wounds to heel by floor nurse. Looked at with CNO (chief nursing officer). Old appearing wound to left heel and right heel. Offloading with boots in place. Spoke with [family member] on 12/20/2025 who stated that they were like that prior to admission. Stated that [they were] taking resident home soon. Instructed to follow up with home health/PCP (primary care provider) for continued monitoring of heels and explained offloading process. No other progress notes were found.During an interview with Resident 1's primary caregiver and collateral contact, on 12/20/2025 at 9:28 AM, they stated that Resident 1's feet and legs were scaly and dry prior to their admit, but that resident had been walking and working with therapy while at the facility and they thought they would be ready to return home very soon. On 12/19/2025 they went to visit Resident 1 and were told by staff that they were not walking or wanting to work with therapy. They then observed a nurse to be removing wraps from the resident's legs, and they were screaming that it hurt. They then stated they asked the resident what was hurting them and Resident 1 stated that their feet hurt. The collateral contact then removed the resident's socks and found one heel to be black and blue with a large blister on their heel, and the other heel was covered in a large blister. The collateral contact stated that they then conferred with the other family members and decided to take the resident out of the facility and to the local emergency room for care the next day.Review of hospital records, requested on 12/30/2025, showed Resident 1 was seen by a medical provider on 12/20/2025 at 11:05 AM. They note a bruised area to the resident's left heel, and a fluid filled blister on the right heel. The chief complaint was then updated to show skin ulcer, and at 11:09 AM was entered into the resident medical record as, Wound 12/20/2025 1109 pressure injury left plantar (bottom) heel assessment, with further description of the periwound (edge of the wound) with redness, base of the wound as blistered and ecchymotic (dark purple), with the injury being unstageable. The right heel was described as being identified on 11/30/2025, with an assessment completed on 12/20/2025 at 11:11 AM describing the area as having a red periwound, with the base of the wound being blistered and reddened, with the wound being unstageable and the length of the wound being 8.5 cm.During an Interview on 01/28/2026 at 10:56 AM, Staff B stated that they were told by a floor nurse on 12/19/2025 that Resident 1 had pressure injuries to their heels. They stated that they were then told by one of the resident's family members that the pressure areas had been there upon admit. They further stated that they did not know why skin checks had not been completed or why there had not been any documentation of the condition of Resident 1's heels during their stay. They stated that the resident's heels looked like they had blisters covering them on 12/19/2025, prior to leaving AMA with their family on 12/20/2025.During a phone interview with Staff A, Chief Nursing Officer, on 1/28/2026 at 12:45 PM, they stated that they had been told Resident 1 had pressure injuries to their bilateral heels on 12/19/2025 and that they then understood that the pressure areas had been there since admission. They could not say why the resident's heels did not have any evidence of monitoring having been performed or any wound care orders prior to 12/19/2025. They, further, could not explain why the resident had not had skin checks documented during their stay at the facility. <Resident 2>According to Resident 2's admission MDS, they were admitted to the facility on [DATE] with two, Stage 3 pressure ulcers and two unstageable -DTI pressure wounds. The MDS further indicated that pressure injury care was being performed.According to a skin assessment, dated 07/28/2025 the resident had four pressure injuries.Right scapula (shoulder blade) that measured 5.9 cm by 4.7 cm.Left scapula that measured 7.5 cm by 13.1 cm.Left gluteus (buttock) that measured 6.9 cm by 5.7 cm.Left lateral calf that measured 2.3 cm by 4.2 cm.According to a wound assessment, dated 01/21/2026 the resident had four pressure injuries.Right scapula that measured 6.0 cm by 17.0 cm.Left scapula that measured 9.0 cm by 19.0 cm.Left gluteus (buttock) that measured 13.0 cm by 6.0 cm.Left lateral calf that measured 21.0 cm by 9.0 cm.According to Resident 2's MAR's for November and December 2025 and January 2026, the resident refused dressing changes or dressing changes were coded as not completed.November 2025 MAR:Cleanse Left gluteus pressure ulcer with wound cleaner, NS, or soap and water. Pat dry. Apply Collagen pad. cover with bordered super absorbent foam/silicone dressing. Change daily and as needed every day shift -blank boxes on 11/4, 11/25, 11/27, with four refusals documented.Cleanse left lateral calf DTI with wound cleaner, NS, or soap and water. Pat dry. Apply Collagen pad. May use Xeroform with excess bleeding. Cover with bordered super absorbent dressing. Wrap with kerlix then ace wrap with light compression. Change daily and as needed everyday shift.-blank boxes on 11/4, 11/25, 11/27, with three refusals documented.Cleanse Left scapula pressure ulcer with wound cleaner, NS, or soap and water. Pat dry. Apply Collagen pad. Cut to fit. cover with bordered super absorbent foam/silicone dressing. Change daily and as needed every day shift -Start Date-blank boxes on 11/4, 11/25, 11/27, with four refusals documented.Cleanse right scapula pressure ulcer with wound cleaner, NS, or soap and water. Pat dry. Apply Collagen pad. cover with bordered super absorbent dressing. Change three times weekly and as needed every day shift every Mon, Wed, Fri.-Two refusals documented.December 2025 MAR:Left gluteus: four blank boxes and five refusals documented.Left lateral calf: four blank boxes and five refusals documented.Left scapula: four blank boxes and five refusals documented.Right scapula: one blank box and two refusals documented.January 2026 MAR:Left gluteus: two blank boxes and one refusal documented.Left lateral calf: two blank boxes and one refusal documented.Left scapula: two blank boxes and one refusal documented.Right scapula: one blank box documented.Review of Resident 2's care plan, initiated 07/09/2025, indicated the resident had actual pressure ulcers of their left scapula: stage 3, right scapula: stage 3, left gluteal: DTI, and left lateral calf: DTI. No interventions for how to address refusals of care were found.Review of the resident's medical record did not show any risk versus benefit discussions related to the possibility of the resident's pressure ulcers/injuries worsening related to their documented refusal of care.During an Interview on 01/28/2026 at 10:56 AM, Staff B, stated that Resident 2 would frequently refuse wound care. They further stated that they thought there had been a discussion with the resident related to their wounds possibly worsening if they continued to refuse care. They further stated that they did not monitor the Resident's MAR to determine if wound care was consistently being provided, they were not sure why there would be blank boxes and blank boxes indicated that wound care was not performed.During a phone interview with Staff A, on 1/28/2026 at 12:45 PM, they indicated that they were unable to locate any risk versus benefit discussions with Resident 2. They further stated that they thought the resident's pressure injuries were improving. Further they stated that the resident did not have care plan interventions to address wound care refusals and blank boxes on the MAR indicated that wound care was not performed. <Resident 3>According to an admission skin assessment, dated 11/11/2025, Resident 3, had a pressure injury to their left hip that measured 11.0 cm by 5.4 cm, with a depth of 0.1 cm.According to Resident 3's MDS, they were admitted to the facility on [DATE] and had one, Stage 3, pressure ulcer and were provided with pressure ulcer wound care.According to the Resident's November 2025 MAR, an order for wound care for the resident's left hip pressure wound, identified as being present on admission, was not entered until 11/19/2025 (eight days after admission). Further review of the Resident's December 2025 MAR showed an order for a left hip wound culture (a lab test that takes a sample of fluid or tissue from a wound to identify infectious microorganisms like bacteria or fungi) to be completed between December 4-7, with a signed box on 12/04/2025, indicating the resident was out of the facility, and all other boxes were blank. Another wound culture order was then entered on 12/09/2025 and was signed off as having occurred.According to Resident 3's wound culture result, dated as having been collected on 12/09/2025 (five days after the initial order), and resulted on 12/10/2025, showed the resident had mixed bacteria in their wound and antibiotics were then prescribed to treat the infection.During an Interview on 01/28/2026 at 10:56 AM, Staff B, stated that when Resident 3 was admitted to the facility there were not clear wound care instructions on the discharge orders from the hospital and orders were not entered until about a week later. They further stated that the original order for the left hip wound culture was not completed and had to be re-entered and therefore the results were delayed. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility repeatedly failed to ensure the facility had enough staff to answer resident call lights and attend to resident needs in a timely manner for 7 of 8 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life.Findings included . Review of the facility assessment, reviewed 09/04/2025, showed the facility had an average daily census of 40 and provided 24-hour nursing care including restorative, therapy, and behavior services. Staffing levels were based on the Washington State minimum standards and/or acuity levels. Daily staffing levels were reviewed daily to ensure sufficient staff were scheduled to meet licensed nurse coverage and meet the state requirement. Staff ratios were additionally reviewed to ensure care was provided to meet the needs of the current resident population. The facility utilized temporary contracted staff as needed.<Resident 1>According to Resident 1's Minimum Data Set (MDS-an assessment used in nursing homes to determine the level of care a resident requires) admitted to the facility on [DATE] with diagnoses including a surgically repaired abdominal aortic aneurysm (a life-threatening condition where the main artery in the abdomen becomes enlarged and weakened) and hypertension (elevated blood pressure). The assessment further showed Resident 1 required substantial assistance to move from lying to sitting, to move from their bed to their chair and to transfer on and off the toilet. They also were determined to be dependent with after-toilet hygiene, as well as having had major surgery just prior to admission. Resident 1 was cognitively intact and able to clearly verbalize their needs.Review of the 08/28/2025 through 09/04/2025 call light activation log showed Resident 1 activated their call light and experienced excessively long call light wait times on the following dates:- 08/28/2025 at 3:09 PM, 30-minutes- 08/30/2025 at 5:34 AM, 56-minutes; at 2:55 PM, 1 hour 2-minutes; 4:44 PM, 38-minutes- 08/31/2025 at 7:45, 34-minutes- 09/01/2025 at 9:08 PM, 37-minutes- 09/02/2025 at 6:45 AM, 28-minutes; 8:18 AM, 39-minutes.- 09/04/2025 at 4:56 AM, 28-minuteDuring an interview on 09/04/2025 at 11:55 AM, Resident 1 stated they had to wait around for staff, it seemed like the staff were very busy and that they had to wait a long time, sometimes over an hour for pain and nausea medication or to go to the bathroom.<Resident 2>According to Resident 2's 08/15/2025 MDS, they were admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (a neurologic disorder related to exposure to toxins), bacteremia (bacteria in the blood) and multiple open wounds. The assessment further showed Resident 2 was dependent on staff for toileting, showers, upper and lower body dressing, moving in bed and transfers. Resident 2 was cognitively intact and able to clearly verbalize their needs.Review of the 08/28/2025 through 09/04/2025 call light activation log showed Resident 2 activated their call light and experienced excessively long call light wait times on the following dates:- 08/29/2025 at 3:19 PM, 21-minutes; at 9:20 PM, 1-hour and 20-minutes- 08/30/2025 at 3:19 AM, 1-hour and 25-minutes; at 5:05 AM, 35-minutes; at 6:36 AM, 33-minutes; at 11:55 PM, 38-minutes.- 08/31/2025 at 4:25 AM, 30-minutes.- 09/02/2025 at 1:15 AM, 25-minutes; at 4:03 AM, 1-hour and 44-minutes; at 6:01 AM, 38-minutes; at 1:05 PM, 24-minutes; at 3:10 PM, 30-minutes; at 6:24 PM, 1-hour and 9-minutes.- 09/03/2025 at 3:43 AM, 35-minutes.- 09/04/2025 at 5:00 AM, 39-minutes; at 6:29 AM, 28-minutes.During an interview on 09/10/2025 at 11:10 PM, Resident 2 explained that they had multiple large wounds on their back, left hip and leg, and that they needed assistance to reposition in bed to take pressure off those areas. They further stated that they needed assistance with toileting and had to wait over an hour after having soiled their brief and were worried that the bowel movement could have gotten into the wounds on their left leg. <Resident 3>According to Resident 3's 09/04/2025 MDS, they were admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra (infection in the bone in the spine) and infective endocarditis (an infection in the heart). The assessment further showed Resident 3 needed moderate assistance from staff to dress their upper and lower body, to move from sitting to standing and from chair to bed. The assessment also showed the resident had a central line (a tube placed into a large vein, typically near the heart, to administer medications) and required long-term antibiotics to treat their infections. Resident 3 was cognitively intact and able to clearly verbalize their needs.Review of the 08/29/2025 through 09/04/2025 call light activation log showed Resident 3 activated their call light and experienced excessively long call light wait times on the following dates:- 08/29/2025 at 1:01 PM, 30-minutes; at 3:17 PM, 48-minutes.- 08/30/2025 at 3:17 PM, 48-minutes; at 9:11 PM, 41-minutes.- 08/31/2025 at 4:25 AM, 30-minutes.- 09/01/2025 at 9:50 AM, 31-minutes; at 10:55 AM, 25-minutes; at 5:46 PM, 1 hour and 8-minutes; at 9:16 PM, 27-minutes.- 09/02/2025 at 7:44 PM, 51-minutes.- 09/04/2025 at 1:06 AM, 24-minutes.In an interview on 09/10/2025 at 10:50 AM, Resident 3 stated that they were mostly at the facility to receive antibiotics for an infection in their back and heart. They stated that they had to wait a long time, sometimes about an hour, because their antibiotic pump was beeping or they needed to be disconnected from the line carrying the antibiotic so they could go to the bathroom. They further stated that one time they had to get out of bed and push their beeping machine down the hallway to try and find a staff to fix their beeping antibiotic pump.<Resident 4>According to Resident 4's 08/14/2025 MDS, they were admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone), acquired absence of both lower extremities (amputation of both legs), and pressure ulcers (injury to the skin and underlying tissue caused by prolonged pressure). The assessment further showed Resident 4 had impairment of both of their lower extremities, and was dependent on staff for toileting, toileting hygiene, showers, dressing their lower body and transfers. Resident 4 was cognitively intact and able to clearly verbalize their needs.Review of the 08/28/2025 through 09/04/2025 call light activation log showed Resident 4 activated their call light and experienced excessively long call light wait times on the following dates:- 08/29/2025 at 5:38 PM, 36-minutes; at 7:54 PM, 48-minutes.- 08/30/2025 at 12:09 AM, 34-minutes; at 2:51 AM, 23-minutes; at 3:35 AM, 1-hour and 3-minutes; at 9:41 AM, 1-hourand 52-minutes; at 5:22 PM, 33-minutes; at 6:47 PM, 2-hours and 48-minutes.- 08/31/2025 at 3:42 AM, 30-minutes; at 4:47 AM, 1-hour and 11-minutes; at 6:51 AM, 27-minutes; at 9:15 AM, 1-hour and 8-minutes; at 10:27 AM, 31-minutes; at 6:01 PM, 26-minutes; at 7:08 PM, 23-minutes; at 9:04 PM, 32-minutes.- 09/01/2025 at 8:30 AM, 22-minutes; at 11:13 AM, 22-minutes; at 11:51 AM, 49-minutes.- 09/02/2025 at 3:09 AM, 37-minutes; at 7:45 AM, 30-minutes; 9:52 AM, 1-hour and 6-minutes; at 12:39 PM, 1-hour and 25-minutes; at 6:48 PM, 46-minutes; at 8:13 PM, 30-minutes.- 09/03/2025 at 3:59 AM, 26-minutes; at 4:54 AM, 23-minutes; at 8:15 AM, 2-hours and 7-minutes; at 12:22 PM, 23-minutes.- 09/04/2025 at 5:50 AM, 23-minutes.During an interview on 09/10/2025 at 10:45 AM, Resident 4 stated that it felt to them, sometimes, like there was no one in the facility and it took awhile for someone to come help them. <Resident 5>According to Resident 5's 08/12/2025 MDS, they were admitted to the facility on [DATE] with diagnoses including fractures of the left ribs, right elbow, left toe and multiple areas of their spine during a motor vehicle accident. The assessment further showed that Resident 5 was dependent on staff for assistance with toileting, dressing their lower body and their personal hygiene. They further required substantial assistance with showering and dressing their upper body. Resident 5 was cognitively intact and able to clearly verbalize their needs. Review of the 08/28/2025 through 09/04/2025 call light activation log showed Resident 5 activated their call light and experienced excessively long call light wait times on the following dates:-8/29/2025 at 5:39 AM, 40-minutes; at 11:19:19 AM, 24-minutes; at 6:31 PM, 24-minutes; at 8:55 PM, 56 minutes.-8/30/2025 at 10:25 AM, 23-minutes.-9/1/2025 at 6:38 AM, 26-minutes; at 4:15 PM, 32-minutes; at 4:58 PM, 22-minutes.-9/2/2025 at 5:43 AM, 26-minutes; 11:03 AM, 26-minutes; 2:55 PM, 25-minutes; 6:20 PM, 31-minutes.-9/3/2025 at 3:56 AM, 24-minutes; at 10:08 AM, 32-minutes; at 11:06 AM, 51-minutes; at 12:00 PM, 34-minutes; at 7:24 PM, 25-minutes; at 9:10 PM, 22-minutes.-9/4/2025 at 7:30 AM, 1-hour and 5-minutes.During an interview on 09/10/2025 at 11:40 AM, Resident 5 stated that the facility did not have enough staff, and they had to wait more than 40 minutes on a regular basis. They further stated that they preferred to use the toilet to urinate but sometimes they just had to pee in their bed while they waited for someone to come help them.<Resident 6>According to Resident 6's 06/20/2025 MDS, they were admitted to the facility on [DATE] with diagnoses including postpolio syndrome (a condition that affects polio survivors, typically appearing 15-40 years after the initial infection leading to significant muscle weakness, fatigue and muscle pain). Further review of the assessment showed that the resident had impairment of both of their legs and one of their arms, and was dependent on staff for toileting, showers, upper and lower body dressing and bed mobility. Resident 6 was moderately cognitively impaired, but able to clearly verbalize their needs.Review of the 08/28/2025 through 09/04/2025 call light activation log showed Resident 4 activated their call light and experienced excessively long call light wait times on the following dates:- 8/28/2025 at 11:24 AM, 48-minutes.- 8/29/2025 at 9:09 AM, 31-minutes; at 8:12 PM, 31-minutes; at 10:56 PM, 1-hour and 34-minutes.- 8/30/2025 at 3:10 AM, 1-hour and 11-minutes; at 10:43 AM, 24-minutes; at 3:16 PM, 58-minutes; at 7:06 PM, 24-minutes; at 9:36 PM, 33-minutes.- 8/31/2025 at 12:19 AM, 23-minutes; at 11:43 AM, 23-minutes; at 2:34 PM, 24-minutes.-9/1/2025 at 9:55 AM, 22-minutes; at 3:32 PM, 25-minutes.-9/2/2025 at 1:08 PM, 30-minutes.-09/03/2025 at 9:04 PM, 23-minutes; at 4:59 PM, 48-minutes.-09/04/2025 at 4:41 AM, 44-minutes; at 9:21 AM, 38-minutes.In an interview on 09/10/2025 at 11:30 AM, Resident 6 spoke about their life and stated that sometimes it took a while for anyone to come when they pushed their call light, and they sometimes had to sit in [their] pee for a while. <Resident 7 >According to Resident 7's 08/25/2025 MDS, they were admitted to the facility on [DATE] with diagnoses including a methicillin resistant staphylococcus aureus infection (MRSA-a bacteria that is resistant to many antibiotics) and pneumonia. Further review of the assessment showed that the resident had impairment of both of their legs, and required substantial assistance from staff for toileting, showers, lower body dressing and transfers. Resident 7 had minimal cognitive impairment but was able to clearly verbalize their needs.Review of the 08/28/2025 through 09/04/2025 call light activation log showed Resident 7 activated their call light and experienced excessively long call light wait times on the following dates:- 8/29/2025 at 11:23 AM, 51-minutes.- 8/30/2025 at 5:35 AM, 1-hour and 14-minutes; at 11:27 AM, 32-minutes.-09/03/2025 at 7:47 AM, 46-minutes; at 11:18 AM, 28-minutes; at 7:20 PM, 1-hour and 21-minutes.-09/04/2025 at 9:06 AM, 1-hour and 1-minute.Resident 7 was not available for an interview but an observation of their room on 09/10/2025 at 10:45 AM and again at 12:00 PM found their urinal, most of the way full of urine, on the resident's bedside table, with a strong urine odor in the room, and their bed unmade.In an interview on 09/04/2025, with Staff C, Medication Technician and Nursing Assistant, they stated that they worked as both a medication technician (pass out scheduled medications under the supervision of a nurse) and a nursing assistant in the facility for the last four years. They further stated that they were sometimes scheduled to work as a medication technician but then would sometimes be pulled to the floor if the nursing assistants were short staffed. They thought the goal for staffing was for there to be a medication technician, another nurse who worked on the second medication administration cart, as well as a registered nurse who would oversee the medication technician and help the nurse on the other cart, if they needed help. They further stated that if they were pulled to work as a nursing assistant that would just leave two nurses for the floor. They further stated that they felt there were times when there was not enough staff, that the goal was for there to be five nursing assistants for the 12-hour period of 6:00 AM to 6:00 PM, and that there were frequently four nursing assistants. They stated that the staffing coordinator tried to fill the open spots, but they were not always able to. They stated that when there are four nursing assistants, then the residents had to wait longer for assistance, they sometimes did not get out of bed when they wanted to and the nursing assistants did not get their breaks.In an interview on 09/04/2025 at 12:10 PM, Staff D, Registered Nurse, stated that she had been working at the facility for three weeks and there had been a shortage of nursing assistants on some of the days they worked. They stated that they had been supposed to have training on 09/02/2025 but that they had to work on the floor because the medication technician was pulled to work as a nursing assistant. They stated that that day it had just been them and another nurse and that they had to pass medications, do assessments, dressing changes and give intravenous antibiotics for 28 residents and that it was a big challenge, even though the Director of Nursing had helped them.In an interview on 09/10/2025 at 12:05 PM, Staff E, Nursing Assistant, stated that they worked for an agency and in the last month had worked about eight shifts. They stated that they thought staffing was okay, but that the 100 hallway was very busy and sometimes the residents complained they had to wait for assistance and that the residents were on their call lights all the time.In an interview on 09/10/2025 at 10:10 AM, Staffing Coordinator, stated that the facility had recently opened a wing that had been closed for several years. At that time, they had tried to staff five nursing assistants, instead of four but there had been a lot of challenges. They stated that they had at least three agency staff per day and on that day, there were six of the ten nursing assistant positions filled by agency staff. They further stated that agency staff would sometimes call off an hour prior to the start of a shift and then the spot was very difficult to fill. Staff B further stated that two agency staff had also recently had to be sent home because one was found sleeping and another was found in an empty resident room not answering resident call lights.In an interview on 09/10/2025 at 12:18 PM, Staff A, Director of Nursing, stated that the facility had recently opened a wing that had been closed for several years and there had been some challenges scheduling enough staff and then the agency staff who were scheduled, to follow the facility expectations. They stated that the expectation was that a resident call light be answered in 20 minutes or less. They further stated that the facility was trying to hire more permanent staff. Reference WAC 388-97-1080 (1), 1090 (1)

Based on observation, interview and record review, the facility failed to repeatedly ensure the facility had enough staff to provide care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 7 of 10 sampled residents (Resident 98, 195, 14, 20, 28, 10, and 2 ), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed 02/18/2025 showed the facility had an average daily census of 40 and provided 24-hour nursing care including restorative, therapy, and behavior services. Staffing levels were based on the Washington State minimum standards and/or acuity levels. Daily staffing levels were reviewed daily to ensure sufficient staff were scheduled to meet licensed nurse coverage and meet the state requirement. Staff ratios were additionally reviewed to ensure care was provided to meet the needs of the current resident population. The facility utilized temporary contracted staff as needed. <Resident 98> According to the 05/30/2025 admission assessment, Resident 98 admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement, muscle tone, and posture) and muscle weakness. The assessment further showed Resident 98 sustained falls within the last month prior to admission and had major surgery during the prior inpatient hospital stay that required skilled nursing level of care. Resident 98 was cognitively intact and able to clearly verbalize their needs. Review of the 05/27/2025 impaired mobility care plan showed Resident 98 was at risk for falls and instructed staff to keep the call light within reach, anticipate Resident 98's needs, and respond to resident requests timely. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 98 activated their call light and experienced excessively long call light wait times on the following dates: - 05/28/2025 at 10:27 AM, 32-minutes - 05/29/2025 at 6:56 AM, 39-minutes - 05/30/2025 at 3:55 AM, 51-minutes; at 7:59 PM, 31-minutes, at 9:09 PM, one hour and 18-minutes - 06/01/2025 at 1:11 PM, 57-minutes; at 5:33 PM, one hour and 10-minutes - 06/03/2025 at 6:41 PM, 30-minutes - 06/06/2025 at 8:32 AM, 50-minute; at 6:26 PM, 54-minutes - 06/07/2025 at 8:33 AM, 50-minutes; at 9:17 PM, 47-minutes - 06/08/2025 at 8:27 AM, 57-minutes; at 1:12 PM, 52-minutes; at 7:53 PM, 34-minutes - 06/09/2025 at 12:40 PM, 30-minutes - 06/11/2025 at 1:46 AM, 50-minutes In an interview on 06/10/2025 at 12:35 PM, Resident 98 stated staff did not want to work. Resident 98 explained they experienced excessively long call light wait times and sometimes waited over an hour. <Resident 195> According to the 05/29/2025 significant correction assessment, Resident 195 admitted to the facility on [DATE] with diagnoses including pelvis (bones at base of spine that make up the hips, buttocks and pubic area, between abdomen and thighs) fractures and muscle weakness. The assessment further showed Resident 195 underwent a major surgical procedure during the prior inpatient hospital stay that required skilled nursing level of care. Resident 195 was cognitively intact and able to clearly verbalize their needs. Review of provider orders showed an active 05/22/2025 order Resident 195 was not to bear weight on either leg. Review of the 05/22/2025 self-care performance deficit care plan showed Resident 195 was a pedestrian injured in a traffic accident resulting in fractures and instructed staff to provide maximal assistance for most of their activities of daily (ADL) needs including bed mobility, toileting, and transfers. The 05/23/2025 impaired mobility care plan showed Resident 195 was at risk for falls and instructed staff to keep the call light within reach, anticipate Resident 195's needs, and respond to resident requests timely. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 195 activated their call light and experienced excessively long call light wait times on the following dates: - 05/31/2025 at 10:57 AM, 1 hour and 24-minutes; at 2:02 PM, 1 hour and seven minutes - 06/02/2025 at 12:52 AM, 29-minutes; at 1:18 PM, 38-minutes In an interview on 06/09/2025 at 1:38 PM, Resident 195 explained they were involved in a car accident that resulted in a broken pelvis and numerous surgeries. Resident 195 stated they should not be bearing weight, but sometimes self-transferred because they experienced excessively long call light wait times, sometimes waiting over an hour for assistance. <Resident 14> According to the 05/01/2025 quarterly assessment, Resident 14 had diagnoses including quadriplegia (paralysis in all four limbs, meaning both arms and both legs were unable to move normally). The assessment further showed Resident 14 had range of motion impairments to bilateral (both sides) upper and lower extremities and was dependent on staff assistance to perform most of their ADLs. Resident 14 was cognitively intact and able to clearly verbalize their needs. Review of the 10/31/2023 care plan showed Resident 14 was at risk for falls related to quadriplegia and instructed staff to keep the call light within reach, anticipate Resident 14's needs, and respond to resident requests timely. The 10/31/2023 self-care deficit care plan instructed staff to encourage Resident 14 to utilize their pressure sensitive call light to request assistance. The 10/31/2023 skin care plan showed Resident 14 had pressure ulcers (wound caused by unrelieved pressure) and instructed staff to turn and reposition them every 2-3 hours, as per the individualized schedule, or as requested/allowed. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 14 activated their call light and experienced excessively long call light wait times on the following dates: - 05/14/2025 at 8:59 AM, 42-minutes - 05/15/2025 at 7:29 AM, 48-minutes; at 7:32 PM, 44-minutes - 05/16/2025 at 3:30 AM, 44-minutes; at 9:33 AM, 33-minutes; at 6:41 PM, 47-minutes; at 7:49 PM, 43-minutes, at 8:58 PM, 37-minutes - 05/17/2025 at 2:52 AM, 59-minutes, at 9:39 AM, 47-minutes, at 3:50 PM, 37-minutes - 05/18/2025 at 3:13 PM, 35-minutes - 05/19/2025 at 1:12 PM, 38-minutes; at 11:36 PM, 31-minutes - 05/20/2025 at 1:08 PM, 39-minutes - 05/22/2025 at 5:38 AM, one hour; at 6:55 PM, 42-minutes - 05/23/2025 at 10:50 AM, 50-minutes - 05/25/2025 at 11:54 AM, 34-minutes - 05/27/2025 at 8:03 AM, 40-minutes - 05/28/2025 at 6:20 AM, 52-minutes - 05/29/2025 at 7:47 AM, 31-minutes - 05/30/2025 at 3:46 AM, 36-minutes - 05/31/2025 at 12:41 PM, 31-minutes; at 1:45 PM, 31-minutes; at 9:31 PM, 40-minutes - 06/01/2025 at 7:11 AM, 51-minutes; at 10:17 AM, 52-minutes; at 3:07 PM, 58-minutes - 06/02/2025 at 1:58 AM, one hour and 17-minutes - 06/04/2025 at 5:54 AM, 33-minutes; at 1:26 PM, 41-minutes, at 2:22 PM, 44-minutes - 06/05/2025 at 9:58 AM, 51-minutes; at 1:16 PM, one hour and 11-minutes; at 10:03 PM, 31-minutes - 06/06/2025 at 12:51 AM, 49-minutes; at 7:55 PM, 33-minutes - 06/07/2025 at 2:02 AM, 37-minutes; at 6:59 AM, one hour and 30-minutes - 06/08/2025 at 6:03 AM, 46-minutes; at 9:07 AM, one hour and 38-minutes - 06/10/2025 at 4:24 PM, 47-minutes; at 7:04 PM, 34-minutes; at 9:23 PM, 44-minutes - 06/11/2025 at 7:12 AM, 33-minutes - 06/12/2025 at 2:55 AM, 37-minutes; at 11:31 PM, 49-minutes In an interview on 06/10/2025 at 9:13 AM, Resident 14 stated staff were often too busy to reposition them. Resident 14 explained they experienced excessively long call light wait times, waiting over an hour to have their needs addressed. <Resident 20> According to the 05/08/2025 admission assessment, Resident 20 admitted to the facility on [DATE] with diagnoses including stroke with weakness affecting their dominant side. Resident 20 was cognitively intact and able to clearly verbalize their needs. Review of the 05/02/2025 urinary incontinence care plan showed Resident 20 utilized incontinence products and instructed staff to check and change when soiled. The 05/02/2025 self-care deficit care plan instructed staff to provide cares with two staff and encourage Resident 20 to utilize their call light to request assistance. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 20 activated their call light and experienced excessively long call light wait times on the following dates: - 05/15/2025 at 11:25 AM, 44-minutes; at 3:31 PM, 38-minutes; at 7:57 PM, 45-minutes - 05/16/2025 at 11:47 AM, 30-minutes; at 7:21 PM, one hour and 18-minutes - 05/18/2025 at 5:55 AM, 37-minutes; at 7:55 AM, 56-minutes - 05/20/2025 at 12:28 PM, 36-minutes; at 3:50 PM, one hour and one-minute - 05/21/2025 at 8:09 AM, 34-minutes - 05/22/2025 at 11:43 AM, 33-minutes - 05/23/2025 at 8:22 AM, 35-minutes - 05/24/2025 at 12:38 AM, 35-minutes; at 6:18 AM, one hour and 12-minutes; at 9:07 AM, 36-minutes; at 10:41 AM, 53-minutes; at 1:20 PM, 39-minutes; at 3:49 PM, 36-minutes; at 4:47 PM, 34-minutes - 05/25/2025 at 12:10 PM, 34-minutes; at 2:31 PM, 48-minutes; at 6:39 PM, 34-minutes; at 11:49 PM, 32-minutes - 05/26/2025 at 8:49 AM, 41-minutes; at 1:31 PM, 49-minutes; at 5:11 PM, one hour and 24-minutes; at 8:30 PM, 41-minutes - 05/27/2025 at 8:11 AM, 40-minutes; at 9:43 AM, 51-minutes; at 4:11 PM, one hour and 11-minutes - 05/29/2025 at 1:11 PM, one hour and 22-minutes - 05/30/2025 at 8:11 AM, 58-minutes - 05/31/2025 at 5:38 PM, 40-minutes; at 8:33 PM, 49-minutes - 06/01/2025 at 8:01 AM, one hour and five minutes; at 12:55 PM, 38-minutes; at 6:15 PM, one hour and two-minutes - 06/02/2025 at 12:22 AM, 52-minutes; at 2:21 AM, 42-minutes; at 11:24 AM one hour and two-minutes; at 10:24 PM, 40-minutes - 06/03/2025 at 9:57 AM, one hour and two-minutes; at 7:27 PM, 58-minutes - 06/04/2025 at 6:25 AM, 51-minutes - 06/05/2025 at 6:05 PM, 48-minutes - 06/06/2025 at 12:47 AM, 49-minutes; at 8:21 AM, one hour and 18-minutes - 06/07/2025 at 8:34 AM, 51-minutes; at 12:04 PM, one hour and 24-minutes; at 5:57 PM, 47-minutes - 06/08/2025 at 12:40 AM, one hour and 15-minutes; at 12:55 PM, one hour and 10-minutes; at 3:44 PM, one hour; at 5:55 PM, 44-minutes - 06/09/2025 at 10:57 PM, 37-minutes - 06/10/2025 at 12:43 AM, 45-minutes; at 5:36 PM, 55-minutes; at 10:22 PM, one hour and 17-minutes - 06/11/2025 at 12:32 AM, 51-minutes In an interview on 06/09/2025 at 11:18 AM, Resident 20 stated the facility needed more staff. Resident 20 explained they experienced excessively long call light wait times and had waited over an hour to be changed; night shift was the worst. <Resident 28> According to the 04/04/2025 admission assessment, Resident 28 admitted to the facility on [DATE] with diagnoses including medically complex conditions and depression. Resident 28 had moderate cognitive impairment. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 28 activated their call light and experienced excessively long call light wait times on the following dates: - 05/14/2025 at 4:01 AM, 33-minutes - 05/16/2025 at 7:04 PM, 49-minutes - 05/17/2025 at 5:47 AM, 39-minutes - 05/18/2025 at 5:23 AM, one hour and 30-minutes - 05/22/2025 at 3:01 AM, 43-minutes - 06/03/2025 at 6:02 AM, 45-minutes - 06/08/2025 at 6:02 AM, 31-minutes In an interview on 06/09/2025 at 11:37 AM, Resident 28 stated the facility did not have enough staff which scared them. Resident 28 explained they experienced excessively long call light wait times; weekends were the worst. Resident 28 stated they suffered from really bad depression, they were surviving but they did not like to be rushed; it caused them to get frustrated and shut down. <Resident 10> According to the 05/08/2025 admission assessment, Resident 10 admitted to the facility on [DATE] with diagnoses including muscle weakness. The assessment further showed Resident 10 was frequently incontinent of bowel and bladder and was dependent on staff assistance for toileting hygiene. Resident 10 was cognitively intact and able to clearly verbalize their needs. Review of the 05/02/2025 urinary incontinence care plan showed Resident 10 utilized incontinence products and instructed staff to check and change when soiled. The 05/02/2025 impaired mobility care plan showed Resident 10 was at risk for falls and instructed staff to keep the call light within reach, anticipate Resident 10's needs, and respond to resident requests timely. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 10 activated their call light and experienced excessively long call light wait times on the following dates: - 05/14/2025 at 4:18 AM, one hour and 54-minutes; at 8:14 PM, 32-minutes - 05/15/2025 at 8:50 AM, 32-minutes; at 6:11 PM, 32-minutes; at 7:39 PM, one hour and three-minutes - 05/17/2025 at 8:29 AM, 54-minutes - 05/18/2025 at 6:42 PM, 46-minutes - 05/19/2025 at 7:09 PM, 36-minutes; at 11:36 PM, one hour and 24-minutes - 05/20/2025 at 12:27 PM, 37-minutes; at 2:07 PM, 32-minutes - 05/22/2025 at 3:13 AM, one hour and 14-minutes; at 11:42 AM, 33-minutes; at 4:45 PM, 43-minutes - 05/24/2025 at 12:59 AM, 38-minutes; at 1:37 AM, 57-minutes - 05/25/2025 at 2:38 PM, 41-minutes - 05/26/2025 at 8:33 PM, 38-minutes - 05/27/2025 at 9:48 AM, 46-minutes - 05/29/2025 at 1:17 PM, one hour and 16-minutes - 05/30/2025 at 4:04 AM, 50-minutes; at 11:48 AM, 53-minutes - 05/31/2025 at 8:13 AM, 58-minutes; at 9:45 AM, 40-minutes - 06/02/2024 at 11:23 AM, one hour and three-minutes; at 7:57 PM, 51-minutes - 06/03/2025 at 9:04 AM, 43-minutes; at 7:26 PM, 58-minutes - 06/05/2025 at 6:13 PM, 41-minutes; at 8:43 PM, 43-minutes - 06/06/2025 at 8:20 AM, one hour and 19-minutes - 06/07/2025 at 12:20 PM, one hour and seven-minutes - 06/08/2025 at 1:02 AM, 52-minutes; at 11:39 AM 49-minutes - 06/09/2025 at 3:48 AM, one hour and 20-minutes; at 9:23 PM, 37-minutes - 06/11/2025 at 12:32 AM, 51-minutes - 06/13/2025 at 5:16 AM, 58-minutes In an interview on 06/09/2025 at 11:49 AM, Resident 10 stated the facility did not have enough staff. Resident 10 explained they experienced excessively long call light wait times and had to wait a long time to have incontinence care provided when they were incontinent. <Resident 2> According to the 03/19/2025 quarterly assessment, Resident 2 admitted to the facility on [DATE] with diagnoses including spondyloepiphyseal dysplasia [rare genetic disorder that affected bone and cartilage (strong flexible connective tissue that protects bones and joints) development, leading to dwarfism and other skeletal abnormalities] The assessment further showed Resident 2 was always incontinent of bowel and bladder and was dependent on staff assistance for toileting hygiene. Review of the 02/12/2025 urine incontinence care plan showed Resident 2 utilized incontinence briefs and instructed staff to check and change when soiled. The 02/12/2025 care plan showed Resident 2 was at risk for falls and instructed staff to keep the call light within reach, anticipate Resident 2's needs, and respond to resident requests timely. The 02/12/2025 self-care deficit care plan instructed staff to provide cares with two staff and encourage Resident 2 to utilize their call light to request assistance. Review of the 05/14/2025 through 06/13/2025 call light activation log showed Resident 2 activated their call light and experienced excessively long call light wait times on the following dates: - 05/15/2025 at 1:43 PM, 42-minutes; at 7:21 PM, one hour and one-minute - 05/16/2025 at 7:08 PM, 57-minutes - 05/17/2025 at 3:31 PM, 51-minutes - 05/18/2025 at 6:21 PM, 48-minutes - 05/19/2025 at 9:48 PM, 39-minutes - 05/20/2025 at 12:08 AM, 53-minutes - 05/23/2025 at 7:02 PM, 42-minutes; at 8:17 PM, one hour and 10-minutes - 05/24/2025 at 9:07 PM, 36-minutes - 05/26/2025 at 9:24 AM, 38-minutes; at 12:58 PM, 34-minutes; at 9:23 PM, 37-minutes - 05/29/2025 at 2:10 PM, 37-minutes - 05/30/2025 at 9:34 AM, 37-minutes; at 7:09 PM, 38-minutes - 05/31/2025 at 9 AM, 35-minutes; at 7:08 PM, 37-minutes - 06/01/2025 at 1:38 PM, one hour and two-minutes - 06/04/2025 at 2:25 PM, 34-minutes; at 6:50 PM, 48-minutes; at 8:14 PM, 43-minutes - 06/08/2025 at 4 AM, 32-minutes; at 7:47 AM, one hour and 17-minutes; at 4:30 PM, 53-minutes; at 7:33 PM, 31-minutes In an interview on 06/09/2025 at 1:36 PM, Resident 2 stated they experienced excessively long call light wait times. Resident 2 explained they waited over an hour to have incontinence care provided; this happened in the last couple of days. In an interview on 06/10/2025 at 1:07 PM, the Resident Council stated the facility lacked staff. The Council explained they repeatedly and consistently experienced excessively long call light wait times, at times waiting an hour and a half for staff to respond to a call light when activated. The Council further stated staff would often place call lights out of their reach such as in a nightstand drawer and then close the drawer. In an interview on 06/13/2025 at 11:26 AM, Staff C, Resident Care Manager, was unsure if acuity was considered when staffing was determined but being out on the floor, it's doubtful acuity is considered. Staff C acknowledged residents, including Resident 195, had voiced concerns over lack of staffing and excessively long call light wait times. During observation on Saturday 06/14/2025 at 3:59 AM, a strong foul urine odor could be smelled on the 100-hall similar to that of an unclean urinal or porta potty (small, self-contained toilet that can be moved to different locations). The odor increased when nearing room [ROOM NUMBER] and approaching the conference room. The smell became significantly stronger and found to be emitted from room [ROOM NUMBER]. During observation and interview on 06/14/2025 at 4:03 AM, Staff U, Registered Nurse, and the surveyor walked down 100-hall and entered room [ROOM NUMBER]. Upon entering room [ROOM NUMBER], the only resident in room [ROOM NUMBER] was observed wearing a gown, with both legs hanging off the bed, the call light was under the resident's pillow, and a white pull up brief was on the floor at the foot of the bed. The brief appeared wet, thick, heavy, and odorous with discolored brown/dark colored urine. Staff U stated the resident was a heavy wetter and was to be checked on every two hours. Staff U further stated they tried to prioritize answering call lights. Staff U acknowledged waiting over an hour to answer a call light was not timely or safe, anything could potentially happen. In an interview on 06/14/2025 at 4:21 AM, Staff V, Nursing Assistant, stated excessively long call light wait times had been a concern recently. Staff V further stated waiting over an hour to answer a call light was not good, not safe, a resident could fall. In an interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, explained staffing was determined based on Washington State minimum standards and acuity. Staff A stated the facility currently had a resident population who exhibited increased behaviors which required more staff to care for them. Staff A stated they expected adequate staffing coverage to meet the needs of the facility resident population. Staff A further stated a call light wait time ranging from 30-minutes up to nearly two hours was not timely. Staff A explained they could not say the wait time was unsafe because some residents preferred to have the call light on until care was provided, but anything could happen during the wait. Staff A further stated they expected staff to respond to call lights and resident needs timely. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F919 and WAC 1080 for additional information.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure opened dates were placed on food items in the refrigerator and freezer, expired foods were discarded in 2 of 3 refrigerators and in 1 of 1 dry storage areas, and ensure refrigerator temperatures were monitored. In addition, the facility further failed to maintain a clean cooking environment. These failures placed residents at risk for food-borne illnesses. Findings included . <Expired/undated food> During an initial tour of the kitchen on 06/09/2025 at 9:52 AM, the dry storage area revealed two opened cake mixes, a package of opened gyro bread, and a bag of opened tortilla chips with no receive or expiration date, and a container of rice crispies and froot loops cereal that expired 05/07/2025. The first refrigerator in the main kitchen contained two boxes of baking soda that expired on 03/16/2025, a bowl of molded grapes, and a stalk of partially used celery that had no receive or expiration date. The second refrigerator had a large container of opened salsa with no open or expiration date. The freezer contained opened bags of Salisbury steak, hashbrowns, tater tots, Texas toast, sausage patties and a partially eaten peach pie with no open or expiration dates. In an interview on 06/09/2025 at 10:14 AM, Staff S, Cook, stated all food items needed to be labeled with an opened and use by date so staff knew how long the food was good for. <Food Temperatures> During observation of tray line on 06/13/2025 at 11:36 AM, Staff T, Dietary Aide, pulled cottage cheese out of the refrigerator, the temperature was 42.4 degrees. Cold foods needed to be less than 41 degrees. Staff T placed the cottage cheese on a meal tray and was going to serve it to the resident. When Staff T and Staff S were asked about the temperature of the cottage cheese, Staff S stated the cold food items needed to be below 40 degrees. Staff T then removed the cottage cheese from the tray. Staff T obtained a canister of cottage cheese out of the refrigerator, and it was 42.9 degrees. He obtained a third canister of cottage cheese out of the refrigerator, and it was 40.9. On 06/13/2025 at 12:09 PM, Staff T placed a cooked hot dog on a plate and was going to serve it to a resident. Staff T was asked to take the temperature, and it was 128 degrees. Hot foods needed to be 140 degrees or greater. In an interview on 06/13/2025 at 1:11 PM, Staff T stated it was important to serve food items at the proper temperature to prevent food borne illness. <Hand Hygiene> In an observation of the tray line service on 06/13/2025 at 12:18 PM, Staff T was plating food when a nursing assistant walked into the kitchen and asked for ice cream for a resident. Staff T opened the refrigerator with their gloved hands they used to plate food, grabbed ice cream, and without removing their gloves or performing hand hygiene, continued plating food. Staff T grabbed a utensil that was touching the potatoes and then touched the rolls. In an interview on 06/13/2025 at 1:11 PM, Staff T stated gloves needed to be changed after opening the refrigerator door because there could be germs from others touching it. <Sanitary Environment> During an observation on 06/09/2025 at 9:56 AM, the floor in the dry storage area was unclean with food debris. In an observation on 06/09/2025 at 10:14 AM, the toaster had thick crumbs in the bottom, the stand that held the serving utensils had spilled food and splatter, the floor and edges of the floor near the kitchen sink had dirt and debris, the third refrigerator was unclean with spilled juices inside and splatter on the outside it, and the coffee machine had thick brown matter where the spouts were located. On 06/13/2025 at 1:02 PM, the cleaning schedules for April and May 2025 were requested from Staff T. Staff T stated they had no idea where the logs were and gave a copy of June's cleaning schedule. Review of the cleaning schedule provided showed multiple omissions. In an interview on 06/13/2025 at 1:11 PM, Staff T stated cleaning was done when staff were not cooking. Staff T stated it was important to keep the kitchen clean to prevent illness. In an observation on 06/13/2025 at 1:19 PM, the refrigerator at the nurse's station was unclean with spilled brown liquid on the bottom. The refrigerator had a temperature log with multiple omissions. In an interview on 06/13/2025 at 1:42 PM, Staff C, Resident Care Manger, stated the refrigerator needed to be cleaned weekly and the night shift nurse was supposed to keep track of refrigerator temperatures. Staff C stated the refrigerator needed to be kept clean, and it was important to monitor the refrigerator temperature so food did not spoil. Reference: WAC 388-97-1100 (3), 2980

Based on observation and interview the facility failed to maintain a resident call light system that was functionable and audible, as required. This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . During observation on 06/09/2025 at 11:21 AM, a call light was visibly lit up above a resident room but not audible in the hallway. Similar observations were made at 11:29 AM and 1:34 PM, on 06/10/2025 at 10:58 AM, 12:53 PM, and 2:36 PM, on 06/11/2025 at 8:48 AM, 8:59 AM, 9:07 AM and 9:32 AM. During an interview on 06/10/2025 at 1:07 PM, the Resident Council stated they experienced excessively long call light wait times, sometimes waiting over an hour. During observation and interview on 06/12/2025 at 12:04 PM, Staff F, Maintenance Director, the call light above room [ROOM NUMBER] was lit up as activated outside the resident room but no sound was heard. The call light above room [ROOM NUMBER] was activated, lit up above the resident room but again no sound was heard. Staff F acknowledged no sound was emitted when the call lights were activated. Staff F explained that the call light system would typically verbally announce what room number had the call light on. Staff F assessed the call light computer system. Staff F acknowledged the call light sound had been turned off by night shift staff to avoid disturbing the residents. Staff F was asked if the call light computer system could be locked to prevent unintended access or adjustments made to the system. Staff F was unsure if the call light computer system had the capability to limit or restrict access. Staff F acknowledged call lights needed to be audible at all times. In a follow-up interview on 06/12/2025 at 12:23 PM, Staff F stated they fixed the call light system, they were now audible. Staff F further stated they locked staff out of the system, and Staff F was now the only staff that could adjust the call light volume. During an interview on 06/12/2025 at 3:46 PM, Staff A, Administrator, stated they expected the call light system to be functionable and audible, as required. During observation and interview on 06/14/2025 at 4:03 AM, with Staff U, Registered Nurse, the call light above room [ROOM NUMBER] was visibly lit up as activated but was again not audible in the hallway. Staff U stated they were unsure why the call light above room [ROOM NUMBER] was not audible. During an interview on 06/14/2025 at 4:13 AM, Resident 195, the only occupant of room [ROOM NUMBER], stated staff turn the call lights down, so they are not audible whenever night shift comes on. During observation and interview on 06/14/2025 at 4:21 AM, Staff V, Nursing Assistant, acknowledged the call lights were audible when they started their shift last night, was unsure when the sound stopped, and acknowledged the call light above room [ROOM NUMBER] was visibly on but not audible. Staff V was asked how they ensured resident safety if and/or when the call lights were not functioning properly or audible. Staff V stated they did not leave the unit often. During observation and a follow-up interview on 06/14/2025 at 5:51 AM, Staff A, Administrator, a call light was visibly lit up above a resident room but again not audible in the hallway. Staff A acknowledged the call lights were not audible again and maintenance was headed to the facility. Reference WAC 388-97-2280 (1)(a) Refer to F725 for additional information.

Based on interview and record review, the facility repeatedly failed to ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, what information was conveyed to the receiving provider, bed hold offered upon transfer, and notification to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes who protected and promoted resident rights under federal and state law and regulations) of discharges and/or transfers, as required for 3 of 4 sampled residents (Resident 28, 195, and 44), reviewed for hospitalization . This failure placed residents at risk of potential delays in emergent hospital treatment, potential medical complications, and precluded the residents and/or their representatives to participate in decisions regarding their right to return to the same facility upon hospital return. Findings included . Review of the facility policy titled, Discharge and Transfer revised April 2025 showed, a resident's medical record should reflect the basis for transfer and/or discharge and should be documented before or as close as possible to the actual time of transfer or discharge. In the event the discharge or transfer was necessary for the resident's welfare and the facility could not meet the resident's needs, documentation should include specific needs that could not be met, facility efforts to meet those needs, specific services the receiving facility would provide to meet the needs of the resident which could not be met at the current facility. Information provided to the receiving provider should include a minimum of the practitioners responsible for care of the resident, resident advocate information, advanced directive information, special instructions and/or precautions for ongoing care as appropriate, the resident's comprehensive care plan goals, and all information necessary to meet the resident's needs to include the resident's status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs, diagnoses, allergies, medications (including when last received), and the most recent relevant blood work or diagnostic tests. The Ombudsman office was to be notified of transfers and/or discharges on a monthly basis. <Resident 28> According to the 04/04/2025 admission assessment, Resident 28 admitted to the facility on [DATE] with diagnoses including medically complex conditions. Resident 28 had moderate cognitive impairment. Review of April 2025 through May 2025 nursing progress notes showed Resident 28 was transferred to the hospital three times. -On 04/03/2025 Resident 28 was transferred to the hospital to have their buttock wound assessed. -On 04/10/2025 Resident 28 was transferred to the hospital after they cut their left hand with a dinner knife. -On 05/31/2025 Resident 28 was transferred to the hospital related to abdominal pain. No documentation was found to show what information was provided or communicated to the receiving facility, as required. Additional record review showed no documentation a bed hold was offered upon hospital transfer on 04/10/2025 or 05/31/2025. During an interview on 06/09/2025 at 11:37 AM, Resident 28 stated they had been transported to the hospital three times, since their admission to the facility. In an interview on 06/13/2025 at 10:17 AM, Staff C, Resident Care Manager (RCM), stated staff should document a detailed progress note if and/or when a resident was transferred to the hospital. Staff C acknowledged staff had not been completing hospital documentation, as required and it was often a scavenger hunt trying to find information. Staff C stated they expected staff to document as required. <Resident 195> According to the 05/29/2025 significant correction assessment, Resident 195 admitted to the facility on [DATE] with diagnoses including fractures. Resident 195 was cognitively intact and able to clearly verbalize their needs. Review of May 2025 through June 2025 nursing progress notes showed Resident 195 was transferred to the hospital four times. -On 05/25/2025 Resident 195 was transferred to the hospital for pain management. -On 05/26/2025 Resident 195 was transferred to the hospital after they sustained a fall out of bed. -On 06/01/2025 Resident 195 was transferred to the hospital related to blood-tinged urine. -On 06/07/2025 Resident 195 was transferred to the hospital for unrelieved bladder pain. No documentation was found to show what information was provided or communicated to the receiving facility, as required. In an interview on 06/09/2025 at 1:54 PM, Resident 195 stated they had been transported to the hospital a couple of times, since their admission to the facility. <Resident 44> According to the 03/29/2025 admission assessment, Resident 44 admitted to the facility on [DATE] with diagnoses including fractures. Review of March 2025 nursing progress notes showed Resident 44 admitted to the facility on [DATE] around 6:00 PM. On 03/29/2025 at 9:47 AM, Resident 44 was transferred to the hospital for chest pain. No documentation was found to show what information was provided or communicated to the receiving facility or that a bed hold was offered upon hospital transfer, as required. Ombudsman transfer and/or discharge notifications, September 2025 through current, were requested from Staff A, Administrator, on 06/12/2025 at 3:32 PM and again on 06/13/2025 at 1:09 PM. No documentation was provided. In a follow-up interview on 06/13/2025 at 10:25 AM, Staff C, RCM, reviewed Resident 44's medical record. Staff C stated Resident 44's record did not show sufficient documentation related to their 03/29/2025 hospital transfer to include a documented resident assessment or interventions attempted with effectiveness or results. Staff C acknowledged no documentation was found to show what information was provided or communicated to the receiving facility, as required. In an interview on 06/13/2025 at 10:30 AM, Staff E, Social Services, explained they had only notified the Ombudsman of discharges against medical advice because they were unaware the Ombudsman was to be notified of hospital transfers and normal discharges. In an interview on 06/13/2025 at 10:55 AM, Staff B, Director of Nursing, stated when a resident was transferred to the hospital, they expected staff to document a resident assessment, interventions attempted, and what information was conveyed to the hospital. In an interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, stated they expected staff to document what information was conveyed to the hospital, offer a bed hold upon transfer, and notify the Ombudsman of transfers and/or discharges as required. No associated WAC Refer to F842 for additional information.

Based on observation, interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR, a two-part screening; Level I determined presence of a Severe Mental Illness [SMI] or Developmental Disability. If present, a Level II evaluation by a specialized evaluator determined if nursing home placement was the appropriate level of care, and if behavioral health or other community services were recommended. A Level II was required to be completed prior to nursing home admission) were completed correctly, PASSR Level II were referred for evaluation when indicated, and Level II evaluation recommendations were incorporated into the plan of care, as required for 4 of 6 sample residents (Resident 18, 28, 6, and 30), reviewed for PASRR. This failure placed residents at risk of behavioral health needs not being met and diminished quality of life. Findings included . Review of the facility policy Behavioral Health Services, revised April 2025, documented if a resident met criteria for facility admission, the facility initiated a plan of care to meet the resident's behavioral health needs at the time of admission. The PASRR was to be reviewed for specialized services a resident needed and to assist with implementing a plan as indicated. If a resident did not qualify for specialized services but required more intensive behavioral health services such as individual counseling, the facility demonstrated reasonable attempts to provide services. Residents were assessed and monitored for signs and/or symptoms of depression, adjustment difficulties, and suicidal tendencies to identify and address reversible and treatable causes promptly. If a resident was identified as having a mental health disorder, the care plan was to address the individualized needs a resident had related to the disorder. <Resident 18> A review of the record showed Resident 18 was admitted on [DATE] and had diagnoses that included major depressive disorder, delusional disorder (false beliefs not based in reality), and suicidal ideation. The 05/30/2025 quarterly assessment documented Resident 18 was cognitively intact and had an assessment for depression that showed the resident had thoughts they would be better off dead, had trouble concentrating, felt bad about themselves, felt down, depressed or hopeless, and had little pleasure doing things. Resident 18 received antidepressant medications daily. A PASRR Level II Notice of Determination dated 01/29/2025 documented Resident 18 had a mental health diagnosis, met criteria for nursing facility level of care, and may benefit from specialized behavioral health services. A PASRR Level II Initial Psychiatric Evaluation Summary, the detailed findings of the Level II evaluation, was not included in Resident 18's record. Further record review found no assessments or behavioral health provider notes in Resident 18's record. During an interview on 06/12/2025 at 9:04 AM, Resident 18 was in their room eating breakfast. They stated they had admitted themselves to a locked psychiatric unit in January of 2025 to get help adjusting their antidepressant medications. Resident 18 was unable to finish the process there after being admitted to the hospital. Resident 18 stated they were agreeable to behavioral health services because it had helped them through a dark period in their past but had not seen anyone yet. During an interview on 06/12/2025 at 1:20 PM, Staff E, Social Services, stated a referral had been sent to the behavioral health provider in April of 2025, but did not see in the resident's record that Resident 18 had been seen yet. During an interview on 06/14/2025 at 6:27 AM, Staff A, Administrator, stated if the summary of the PASRR Level II evaluation was not received by the facility, they would not know what interventions or recommendations needed to be incorporated into Resident 18's plan of care as required. <Resident 6> According to the 05/12/2025 quarterly assessment, Resident 6 had diagnoses including dementia and was administered antipsychotic (medication that affected the brain, emotions, and behaviors) medications. The assessment further showed Resident 6 had moderate cognitive impairment. Review of the 08/21/2024 PASRR showed Resident 6 exhibited indicators of having a mood disorder and a level II evaluation referral was required to assess for a serious mental illness. Review of the 03/10/2025 psychosocial evaluation showed Resident 6 had a PASRR level I and no further action was needed. The assessment further showed Resident 6 received antipsychotic medications. Review of August 2024 through June 2025 nursing progress notes showed no documentation Resident 6's PASRR was sent to a PASRR level II evaluator, as required. During an interview on 06/12/2025 at 1:20 PM, Staff E, Social Services, stated they reviewed PASRRs prior to admission to ensure accuracy, if a PASRR was found to be incorrect the hospital was contacted for PASRR correction. Staff E further stated a resident would not be admitted without a PASRR or with an inaccurate PASRR. Staff E reviewed Resident 6's medical record. Staff E acknowledged Resident 6's 08/21/2024 PASRR had not been referred for evaluation yet and this was not timely. <Resident 28> According to the 04/04/2025 admission assessment, Resident 28 admitted to the facility on [DATE] with diagnoses including depression. Resident 28 had moderate cognitive impairment. Review of the 03/21/2025 PASRR level I screen showed Resident 28 exhibited indicators of having an anxiety and mood disorder. A Level II evaluation referral was required to assess for a serious mental illness. Review of the 03/25/2025 hospital progress notes showed on 03/19/2025 Resident 28 attempted to stab themselves with a butterknife, while hospitalized . Resident 28 was evaluated by psychiatry and Resident 28's behavior was likely largely driven by an underlying personality disorder and would benefit from focused outpatient therapy. Review of the 03/24/2025 PASRR level II psychiatric evaluation summary showed determinations including plan of care were made based on diagnosis and need for treatment. The evaluation showed Resident 28 made a suicide attempt during hospitalization by attempting to stab [themselves] in the abdomen with a butter knife. Resident 28 endorsed persistent depression at baseline and indicated they intended to die from the attempt due to the distress of feeling helpless about [their] medical conditions. The evaluation further showed given Resident 28's report of depressive symptoms throughout their life and multiple suicide attempts, seeking ongoing psychiatric consultation would be useful and offering counseling/therapy was recommended. Resident 28 would likely benefit from an additional psychiatric assessment for diagnostic clarification and medication evaluation to explore efficacy of medications. The summary included numerous recommendations for Resident 28's plan of care to include staff approaches, behavioral supports, activities, environmental adjustments, mental health services, and other medical services. Review of the 03/30/2025 psychosocial evaluation completed by the facility showed Resident 28 had a PASRR level I and materials were sent to the State Agency. The assessment further showed Resident 28 did not show indicators of a serious mental illness but received psychotropic medications. Review of the 04/07/2025 care plan showed Resident 28 had adjustment issues related to admission and instructed staff to adjust Resident 28's routine to imitate home routines and provide them the opportunity to communicate their feelings. A 04/07/2025 depression care plan instructed staff to administer medications as ordered, help Resident 28 with constructive ways to manage feelings, monitor/document depressive symptoms, watch for indicators of suicidal ideation, and ensure Resident 28 did not have sharp objects close to them. No documentation was found to show the 03/24/2025 PASRR level II psychiatric evaluation recommendations for Resident 28's plan of care were incorporated into the care plan, as required. Review of March 2025 through May 2025 nursing progress notes showed Resident 28 was anxious and agitated. On 03/29/2025 Resident 28 expressed feelings of depression stating, I want to die. Resident 28 denied having any suicide plans or intent stating, it's only up to God and nothing could help them. On 04/10/2025 911 was called at approximately 6:30 PM because Resident 28 had a dinner knife, superficially cut their left hand, attempted to stab staff when they approached to discuss the situation, and Resident 28 then took the knife like [they] were going to stab [their] stomach. Resident 28 was accompanied to the hospital by law enforcement. The hospital emergency room doctor stated Resident 28 has a long standing [history] of these behaviors and requested Staff M, Medical Doctor, call them to discuss Resident 28. On 04/29/2025 staff were asked to look into Death with Dignity but Resident 28 would not qualify unless they had six months or less to live. On 05/19/2025 Resident 28 was seen and assessed by the facility mental health counselor, 52 days after admission and 39 days after the suicidal gesture with a dinner knife. No documentation was found to show the 03/24/2025 PASRR level II psychiatric evaluation recommendations for Resident 28's plan of care were incorporated into the care plan, as required. During a follow-up interview and record review on 06/12/2025 at 2:03 PM, Staff E, Social Services, stated when a PASRR level II evaluation with recommendations was received, the findings were reviewed, interventions implemented, and evaluation filed a binder. Staff E acknowledged they were behind on referring PASRR Level II's for evaluations as required and had a to do list. A copy of the list was requested. Review of the list showed 11 residents needed to be referred for PASRR Level II evaluations, including Resident 6 and Resident 30. Staff E reviewed Resident 28's medical record. Staff E acknowledged Resident 28's care plan did not incorporate the Level II evaluation recommendations. Staff E further stated if behavioral health services would have been implemented timely Resident 28 might not have experienced the 04/10/2025 suicidal ideation with a suicidal gesture or requested death with dignity. <Resident 30> According to the 05/28/2025 quarterly assessment, Resident 30 had diagnoses including depression, bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels), and a psychotic disorder (mental illness where a person's thoughts and perceptions are significantly disturbed, leading to a disconnect from reality). The assessment further showed Resident 30 was cognitively intact. Review of the 06/13/2024 hospital discharge summary showed Resident 30 started a sentence and forgot their thoughts mid-sentence. Resident 30 was paranoid and suspicious of health care systems. Psychiatry (doctor that specialized in understanding, diagnosing, treating, and preventing mental, emotional, and behavioral disorders) was consulted and Resident 30 was identified as having a possible personality disorder (mental health condition characterized by long-term patterns of thinking, feeling, and behaving in a manner that significantly deviated from expectations and cause distress or impairment in daily life). Review of the 06/06/2024 PASRR showed Resident 30 did not exhibit indicators of having a personality disorder or other indicators of a serious mental illness and a Level II evaluation was not indicated. Review of the 05/26/2025 psychosocial evaluation completed by the facility showed Resident 30 had a PASRR level I and no further action was needed. The assessment further showed Resident 30 showed indicators of a serious mental illness and did not receive psychotropic (medication that affected the brain, emotions, and behaviors) medications. A summary showed Resident 30 was apprehensive to cares and sometimes refused to help themselves. Review of the 06/14/2025 psychosocial evaluation completed by the facility showed Resident 30 had a PASRR level I and no further action was needed. The assessment further showed Resident 30 showed indicators of a serious mental illness and did not receive psychotropic medications. In a follow-up interview on 06/12/2025 at 2:23 PM, Staff E, acknowledged Resident 30's PASRR had not been sent off for a Level II evaluation yet. In an interview on 06/12/2025 at 3:46 PM, Staff A, Administrator, stated they expected staff to review a PASRR for accuracy prior to admission, redo a PASRR if and/or when a resident had a change or when indicated, refer PASRR Level II for evaluation when indicated, and implement PASRR Level II recommendations into a resident's plan of care, as required. Reference WAC 388-97-1915 (4) Refer to F740 for additional information.

Based on observation, interview, and record review, the facility failed to provide care-planned restorative interventions and do periodic evaluations of current programs for 2 of 3 sampled residents (Residents 14 and 23), reviewed for restorative services (interventions developed to promote the resident's ability to achieve and maintain optimal physical, mental, and psychosocial functioning). The facility further failed to assess the need for restorative services for a resident (Resident 2). This failure placed the residents at risk for a decline in mobility and a decreased quality of life. Findings included . Review of the Facility assessment dated [DATE] documented services offered were based on resident needs. Services regarding mobility and fall prevention included transfers, ambulation, restorative nursing, contracture prevention, and supporting resident independence in doing as much of these activities by themselves. <Resident 14> In an interview on 06/10/2025 at 9:24 AM, Resident 14 stated staff did not have time to do exercises with them. The resident stated therapy showed two nursing assistants how to put their splint on and they were to show the others how to apply it, but one nursing assistant left the facility and the other felt it was not their job to do so. Resident 14 stated they were told by therapy that they had done as much as they could and it was the nursing assistants' job to do the programs. The 05/01/2025 quarterly assessment documented Resident 14 had diagnoses which included traumatic spinal cord dysfunction with quadriplegia (paralysis to arms and legs). The resident was cognitively intact and required total assistance with activities of daily living (ADL's). The assessment showed the resident was bed bound. The 05/16/2025 comprehensive care plan had the following care areas: -Resident required a splinting and ROM (range of motion) restorative nursing program related to limited ROM (quadriplegia). -Restorative program; left wrist splint to be worn at night (up to 10 hours) after ROM was completed to prevent contractures (the abnormal shortening of muscle, tendons, ligaments, or skin, leading to reduced ROM and joint stiffness). Passive ROM to right and left upper extremities from shoulders to fingers, one set of 10 ROM to each joint. The restorative program was to be reviewed routinely to validate its effectiveness and to adjust the program as indicated. A review of the Restorative task documentation completed by nursing assistants showed from 05/16/2025 to 06/13/2025, Resident 14 was not offered the passive ROM program on 05/20/2025, 05/29/2025 and 06/10/2025. The splint program showed no documentation that it was offered on 05/25/2025 through 05/26/2025, 05/31/2025, 06/06/2025 through 06/07/2025 and 6/13/2025. <Resident 23> The 04/15/2025 quarterly assessment documented Resident 23 had diagnoses which included dementia and muscle weakness. The resident was cognitively impaired, required set up to touching assistance with ambulation and used a walker. The 05/16/2025 comprehensive care plan had the following care areas: -Resident required a restorative program related to ability to ambulate. -Restorative program; walk to dine, ambulate with walker with one person assistance, keep resident's wheelchair behind them. The restorative program was to be reviewed routinely to validate its effectiveness and to adjust the program as indicated. A review of the Restorative task documentation completed by nursing assistants showed from 05/14/2025 through 06/11/2025, Resident 23 was not offered their ambulation program on 05/14/2025, 05/19/2025, 05/31/2025, 06/01/2025 and 06/02/2025. In an observation on 06/12/2025 from 11:24 AM through 12:47 PM, Resident 23 self-propelled their wheelchair toward the dining room, up and down the hall, and then entered the dining room at 11:39 PM. The resident finished eating and wheeled themselves out of the dining room. During this continuous observation, Resident 23 was not offered to ambulate to or from the meal service. The documentation showed the resident had refused to ambulate. In an interview on 06/12/2025 at 3:55 PM, Staff J, Nursing Assistant (NA), stated nursing assistants completed the restorative programs with the residents and refusals were documented in the computer. Staff J stated it was hard to complete the restorative programs when staff called off for work. In an interview on 06/14/2025 at 6:23 AM, Staff I, NA, stated Resident 23 refused the ambulation program at times. Staff I stated they walked Resident 23 from their bed to their bathroom instead of in the hallway because the hallway distracted the resident. In an interview on 06/13/2025 at 10:26 AM, Staff C, Resident Care Manager, stated restorative programs were completed daily and documented in the plan of care. Staff C added refusals were also documented. Staff C stated it was important to do the restorative programs to maintain muscle tone, their ability to ambulate, and to prevent contractures. In an interview on 06/14/2025 at 7:49 AM, Staff O, Registered/Restorative Nurse, stated they assessed restorative programs monthly to see if they were effective and had just started documenting this in the progress notes about a month ago. Staff O stated the restorative program was not being well followed. <Resident 2> In an interview on 06/10/2025 at 9:52 AM, Resident 2 stated they used to work with therapy, and nobody was doing exercises with them. The 03/19/2025 quarterly assessment documented Resident 2 had diagnoses which included chronic obstructive lung disease (COPD, a group of lung diseases that made it difficult to breathe), neuralgia (nerve pain) and depression. The resident was cognitively impaired and required total assistance for most ADLs. The 02/12/2025 comprehensive care plan had the following care areas: -Resident has an ADL self-care performance deficit related to reduced mobility, and pain, amongst others. -The goal was for Resident 2 to improve their current level of functioning in bed mobility, transfers, dressing, eating, bathing, toileting, personal hygiene, oral care, ambulation and wheelchair locomotion. -There were no interventions to assist Resident 2 in obtaining these goals. In an interview on 06/14/2025 at 6:29 PM, Staff I stated Resident 2 did as much as they could for themselves and would benefit from a restorative program because it brought them quality of life, helped them with mobility and depression. In an interview on 06/13/2025 at 10:54 AM, Staff C, Resident Care Manager, stated restorative programs were placed when therapy was completed. In an interview on 06/13/2025 at 3:18 PM, Staff P, Physical Therapist, stated residents were placed on restorative programs when they met their goals and needed a functional maintenance program. Staff P stated Resident 2 was appropriate for a restorative program but the facility did not have the staff to do the restorative programs. Reference: WAC 388-97-1060(3)(d)

Based on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 3 of 11 sampled staff (Staff EE, U, and FF), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed 02/18/2025 showed the facility had an average daily census of 40 and provided 24-hour person-centered direct nursing care including restorative, therapy, and behavior services. The facility utilized temporary contracted staff as needed. Staff competencies were reviewed and determined annually to meet the needs of all residents. The facility additionally provided just in time training for conducting one-on-one training, read and signs, small groups or all staff in-services. Competencies could be verified by skills return demonstration or post training quizzes. All staff training, competencies, and skill sets required were tracked via a computerized training system. <Staff EE> Review of Staff EE's, Nursing Assistant (NA), personnel file showed they were hired on 03/14/2025. Review of Staff EE's training records showed no documentation of training or competency on file. <Staff U> Review of Staff U's, Registered Nurse, personnel file showed they were an agency staff member. Review of Staff U's training records showed no documentation of training or competency on file. <Staff FF> Review of Staff FF's, Licensed Practical Nurse, personnel file showed they were hired on 04/25/2025. Review of Staff FF's training records showed no documentation of training or competency on file. In an interview on 06/10/2025 at 1:22 PM, the Resident Council stated the facility utilized agency staff but they don't care. The Council explained staff had been observed visiting at the nurses station, while residents experienced excessively long call light wait times. In an interview on 06/12/2025 at 11:45 AM, Staff A, Administrator, stated Staff U was an agency staff member and would have to reach out to the staffing agency for trainings and competencies because they had nothing on file. Staff A explained the previous Staffing Coordinator had not saved agency employee files. No documentation was provided. In an interview on 06/13/2025 at 11:26 AM, Staff C, Resident Care Manager, stated they were unsure of the facility process to ensure agency staff had adequate training, skills, and competencies to provide care to the facility resident population. In an interview on 06/14/2025 at 4:21 AM, Staff V, NA, stated they were an agency staff member and did not receive training, orientation or had their skills and/or competencies evaluated, they were only given a quick tour of the building. In an interview on 06/14/2025 at 4:34 AM, Staff GG, NA, stated they were an agency staff member and this was the first shift they had worked for this facility. Staff GG further stated they did not receive training, orientation or had their skills and/or competencies evaluated. In an interview on 06/13/2025 at 1:59 PM, Staff G, Human Resources/Staffing Coordinator, stated they were new to the role. Staff G stated they were unaware they needed to train and evaluate agency staff to ensure they had adequate skills and/or competencies and acknowledged this had not been done. In a follow-up interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, stated they expected staff to receive adequate training in order to have adequate skills and/or competencies to meet the need of the facility resident population. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F725 and F947 for additional information.

Based on interview and record review the facility failed to routinely complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 5 sampled nursing assistants (Staff I, L, and N), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life. Findings included . <Staff I> Review of Staff I's, Nursing Assistant (NA), personnel file showed they were hired on 07/16/2021. No documentation of a performance evaluation was found on file. <Staff N> Review of Staff N's, NA, personnel file showed they were hired on 02/01/2022. No documentation of a performance evaluation was found on file. <Staff L> Review of Staff L's, NA, personnel file showed they were hired on 04/04/2023. No documentation of a performance evaluation was found on file. In an interview on 06/13/2025 at 1:54 PM, Staff C, Resident Care Manager, stated they were unsure how often or who completed staff performance evaluations. In an interview on 06/13/2025 at 1:59 PM, Staff G, Human Resources, stated they were unsure how often performance evaluations had to be completed. In an interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, stated they expected staff to complete performance evaluations yearly, as required. Reference WAC 388-97-1680 (1), (2)(a-c) Refer to F726 for additional information.

Based on observation and interviews, the facility failed to maintain an appropriate temperature in 1 of 1 medication storage rooms, ensure expired medications were removed from inventory and insulin vials were dated when opened for 1 of 2 medication carts, observed for medication storage. In addition, bottles of a liquid oral narcotic were not monitored for loss or diversion as required. This failure placed residents at risk of receiving less than the optimum dose of their medications, placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion. Findings included . Review of the 11/28/2017, last revised 10/15/2022, policy titled, Medication Management showed medications were discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner, labeled in accordance with facility requirements and State and Federal regulations and stored under proper conditions of sanitation, light, ventilation, segregation, and security. Narcotics were logged into a narcotic declining balance accountability system. <Medication Room Temperature> On 06/13/2025 at 8:56 AM, an observation of the medication room was conducted with Staff D, Corporate Nurse. The temperature of the medication room was 80 degrees. Staff D agreed the room was hot and asked Staff F, Maintenance Director, if something could be done. Staff F adjusted something outside of the medication room and stated that it would probably help. The Medication Room Temperature log for June 2025 showed the following temperatures: 06/05/2025 80 degrees 06/06/2025 80 degrees 06/08/2025 80 degrees 06/09/2025 80 degrees 06/10/2025 82 degrees 06/12/2025 80 degrees 06/13/2025 82 degrees In an interview on 06/14/2025 at 6:01 AM, Staff B, Director of Nursing, stated it was important to maintain the proper temperature of the medication room to ensure medications did not break down. In an interview and observation on 06/14/2025 at 4:30 AM, Staff U, Registered Nurse (RN), opened the medication room and the temperature was 80 degrees. Staff U stated it was important to maintain an acceptable temperature in the medication room to ensure medications were kept in stable zones and did not deteriorate. <Narcotics in Medication Room> During an observation of the medication room on 06/13/2025 at 9:09 AM, there was an emergency kit that was locked in the bottom drawer of the refrigerator. The emergency kit had a zip tie from the pharmacy and contained two injectable vials of Ativan and three bottles of oral Ativan (a medication used for anxiety). Staff D stated the nurses counted the Ativan once it was opened. In an interview on 06/14/2025 at 4:30 AM, Staff U, Registered Nurse, stated the Ativan in the medication room was not accounted for. Staff U stated it was important to count the Ativan because it was a narcotic and diversion could occur. In an interview on 06/14/2025 at 7:12 AM, Staff B stated they spoke to Staff D and was told they did not have to count the Ativan. Staff B stated they were told they only had to verify the emergency kit was there and sealed with the pharmacy zip tie. In an interview and observation on 06/14/2025 at 8:23 AM, Staff B observed the emergency kit and stated they had not been counting the Ativan and acknowledged it needed to be tracked to prevent diversion. <Expired/Undated Insulin> In an observation on 06/13/2025 at 9:27 AM of the 200-hall medication cart with Staff AA, Licensed Practical Nurse, there was a Lispro insulin pen and a Glargine insulin pen that was opened on 05/14/2025, past the use by date of 28 days, and an opened Novolog insulin pen that was undated. In an interview on 06/13/2025 at 9:44 AM, Staff C stated it was important to discard expired insulin because it could impact the effectiveness of the medication. Reference: WAC 388-97-1300 (2), 2340

Based on interview and record review, the facility failed to ensure bedtime snacks were offered to 6 of 6 sampled residents (Resident 18, 26, 7, 11, 20 and 1), interviewed during Resident Council. This failure placed residents at risk for hunger and potential weight loss due to the gap between meals. Findings included . In an interview on 06/09/2025 at 11:18 AM, Resident 20 stated snacks were not being stocked. Resident 20 explained they would request a snack around 10:00 PM but staff would tell them the refrigerator was empty. During the Resident Council meeting on 06/10/2025 at 1:07 PM, Resident 18 stated they went without snacks at times. Resident 18 stated the dietary manager had been making snacks but was on vacation. The resident stated applesauce, peaches, and mixed fruit were offered but none were available in the evenings. Residents 26, 7, 11, and 1 all agreed with this information. In an interview on 06/14/2024 at 4:16 AM, Staff U, Registered Nurse, stated they ran out of snacks, but it was much better than it was two months ago. Staff U stated they did not have access to the kitchen at night. When asked what they would do if a diabetic needed a snack, Staff U stated they had the same concern and it would be helpful to have access to the kitchen to get snacks. In an interview on 06/14/2025 at 6:03 AM, Staff B, Director of Nursing, stated the nurses did not have access to the kitchen at night. Staff B stated refrigerators were stocked with snacks for use at night. Staff B stated the facility had diabetic residents and needed to have snacks available when needed, including bedtime. Staff B added they had residents who ate a lot of snacks. Reference: WAC 388-97-1120 (1)

Based on interview and record review the facility failed to ensure resident records were complete, accurate, readily accessible, and systematically organized for 3 of 4 sampled residents (Resident 28, 42, and 195), reviewed for transfer and discharge. This failure placed residents at risk of having an incomplete medical record, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Discharge and Transfer revised April 2025 showed, a resident's medical record should reflect the basis for transfer and/or discharge and should be documented before or as close as possible to the actual time of transfer or discharge. <Resident 28> According to the 04/04/2025 admission assessment, Resident 28 admitted to the facility on [DATE] with diagnoses including medically complex conditions. Resident 28 had moderate cognitive impairment. Review of April 2025 through May 2025 nursing progress notes showed Resident 28 was transferred to the hospital three times, once on 04/03/2025, 04/10/2025, and on 05/31/2025. Additional review of Resident 28's medical record showed no documentation of the hospital encounter details to include the resident's status, assessment, testing, treatment, and/or plan of care. <Resident 195> According to the 05/29/2025 significant correction assessment, Resident 195 admitted to the facility on [DATE] with diagnoses including fractures. Resident 195 was cognitively intact and able to clearly verbalize their needs. Review of May 2025 through June 2025 nursing progress notes showed Resident 195 was transferred to the hospital four times, once on 05/25/2025, 05/26/2025, 06/01/2025, and on 06/07/2025. Additional review of Resident 195's medical record showed no documentation of the hospital encounter details to include the resident's status, assessment, testing, treatment, and/or plan of care. In an interview on 06/13/2025 at 10:23 AM, Staff C, Resident Care Manager, stated hospital records should be scanned into a resident's electronic medical record to ensure the doctor had information to refer to and ensure a complete and accurate medical record. In an interview on 06/13/2025 at 10:56 AM, Staff B, Director of Nursing, stated they expected staff to scan and enter hospital visit notes into the medical record to ensure a complete and accurate medical record. In an interview on 06/13/2025 at 11:15 AM, Staff R, Medical Records, stated hospital encounter notes should be placed into a resident's medical record to ensure a complete and accurate medical record. Staff R acknowledged it was important to ensure information was readily available so the provider could review it and make pertinent treatment decisions. In an interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, stated they expected staff to ensure facility residents had a complete and accurate medical record. <Resident 42> A 02/05/2025 Quarterly assessment documented Resident 42 had diagnoses that included stroke that affected the left side of their body. The resident was severely cognitively impaired and was dependent on staff for most of their activities of daily living. A review of nursing progress notes documented on 03/28/2025, Resident 42's spouse was notified that the resident had declined, yelled out randomly, and was eating and drinking very little. Medications to provide for Resident 42's comfort were ordered. On 04/14/2025, Resident 42 had declined to get out of bed for the previous two weeks, and their decreased food intake and fluid intake continued. On 04/15/2025, Resident 42's spouse was updated on the resident's condition, their decreased intake and that the resident slept more. On 04/18/2025 at 12:47 PM, the resident's spouse was notified of further resident decline and labored breathing. The progress note documented the resident had periods of apnea (lack of breathing), and at 6:44 PM, death appeared imminent, the resident groaned, had labored breathing, and received two doses of morphine. There were no other progress notes that documented the final events that led up to the time the resident passed, who assessed the resident to verify cessation of vital signs or determined the time of death for Resident 42 or who was notified of the resident's passing. A Record of Death document, scanned into Resident 42's record, documented Resident 42 passed away on 04/19/2025 at 8:10 AM and their body was released to the mortuary at 11:05 AM. When interviewed on 06/14/2025 at 8:04 AM, Staff A, Administrator, stated that as part of a complete medical record, they expected a progress note to be written that included the events regarding the resident's passing. Reference WAC 388-97-1720 (1)(a)(i-iv)(b) Refer to F628 and F740 for additional information.

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 when providing high contact types of care for residents with drains, tubes, or colonized with antibiotic resistant bacteria) were implemented when indicated for 4 of 5 sampled residents (Residents 14, 195, 96, and 11) reveiwed, and that hand hygiene and EBP were implemented during 2 of 2 medication administration observations and 1 of 1 wound treatment observations. These failures created risk that antibiotic resistant bacteria were spread from resident to resident, and created potential risk of illness. Findings included . The Centers for Disease Control and Prevention (CDC) 07/12/2002 Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended the use of EBP as an infection control intervention. EBP recommended the donning (to put on) of gowns and gloves during high contact resident care activities when other types of precautions did not apply for residents with wounds or indwelling medical devices, such as feeding tubes or catheters. High contact care activities included dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting. The facility policy Hand Hygiene reviewed 06/02/2025 documented hand hygiene was the single most important procedure for preventing the spread of infection. Opportunities for hand hygiene included before starting work, before donning gloves, entering a resident room, or before moving to a clean body site after caring for a soiled body site, and after contact with any objects in the immediate vicinity of the resident. MEDICATION ADMINISTRATION AND WOUND CARE/HAND HYGIENE <Staff AA observation> The 04/30/2025 annual assessment documented Resident 3 had diagnoses that included multiple sclerosis (MS, nerve damage that disrupted communication between the brain and the body) and obstructive sleep apnea (OSA, muscles in the throat relaxed during sleep which blocked the airway). Resident 3 was dependent on staff for most of their activities of daily living and had a urinary catheter in place (a tube inserted into the bladder that allowed urine to drain into a collection bag). On 06/13/2025 at 8:30 AM, Staff AA, Licensed Practical Nurse (LPN), was observed passing medications to Resident 3. A red sign was on the door that instructed staff to stop and check with the nurse before entering. Under the red sign was a white sign that indicated Resident 3 required use of EBP related to their catheter. Inside the door was a cart filled with PPE. Once inside the room, Resident 3 was observed lying in bed. Resident 3 wore their CPAP mask (continuous positive air pressure, pushed air into the airway that kept the airway open while sleeping) over their nose. Resident 3's urinary catheter collection bag was without a dignity cover and was on the floor. Without donning a gown and gloves, Staff AA placed a medicine cup of pills on the resident's overbed table, removed Resident 3's CPAP mask and placed it on their nightstand then bent over, picked up the urine collection bag and hung it on the bedframe then did not sanitize their hands. A nursing assistant (NA) entered the room and both staff donned disposable gloves only. Resident 3 was slumped down in their bed. Pillows were repositioned, the resident was pulled up in bed, and their covers were adjusted. The NA removed their gloves and exited the room. Staff AA gave Resident 3 the medicine cup wearing their same gloves and assisted the resident to take their pills. Staff AA removed their gloves, did not clean their hands, and returned to their medication cart and removed additional medications from their cart. When interviewed concurrently, Staff AA stated it was their understanding that they were to don a gown only when there was a chance they could be splashed by body fluids, such as when they emptied Resident 3's urine collection bag. Staff AA reviewed the EBP sign on Resident 3's door, and acknowledged that they should have worn PPE, as they had been in contact with a lot of the resident's environment. Staff AA acknowledged they should have completed hand hygiene after handling the resident's catheter before giving the resident their medications. <Staff X observation> During observation on 06/13/2025 at 9:02 AM, Staff X, Registered Nurse (RN), did not perform hand hygiene and dispensed medications for Resident 23. Staff X entered Resident 23's room, adjusted their bed and administered medications to Resident 23. Without performing hand hygiene, Staff X dispensed, and administered medications to Resident 35. Without performing hand hygiene, Staff X dispensed and administered medications to Resident 11. In an interview on 06/13/2025 at 9:42 AM, Staff X, acknowledged they did not perform hand hygiene when they dispensed and administered medications and should have. In an interview on 06/13/2025 at 11:03 AM, Staff B, Director of Nursing, stated they expected staff to perform hand hygiene when indicated. In an interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, stated they expected staff to perform hand hygiene when indicated. <Wound Care> The 05/01/2025 quarterly assessment documented Resident 14 had diagnoses that included quadriplegia and traumatic spinal cord dysfunction. Resident 14 was cognitively intact, bed bound and required total assistance for activities of daily living such as dressing and mobility. The assessment further showed Resident 14 had two Stage 4 pressure ulcers (extensive tissue damage that extended into muscle, tendon and sometimes the bone), and had dressing changes. On 06/11/2025 at 2:48 PM, wound care was observed with Staff Q, RN, and Staff J, NA. Resident 14 was noted to have a Stage 4 pressure ulcer to their tailbone and right hip. Staff Q and Staff J put on a gown and two pairs of gloves each. Staff Q then sanitized the table with a bleach wipe, emptied the resident's garbage, put a new garbage bag in the can, removed their top pair of gloves, sanitized the first pair of gloves they had on and put a second pair of gloves on. Staff J removed phlegm from the resident's mouth, removed their top pair of gloves and put a second pair of gloves on. Staff J removed more phlegm from the resident's mouth, removed their top pair of gloves, sanitized the first pair of gloves they had on, and placed a second pair of gloves on. Resident 14 looked at Staff J and stated you look better like that, referring to the gown they wore, and asked if they had to throw it away after each use and Staff J said yes. Staff Q adjusted the catheter tubing, removed their top pair of gloves, sanitized the first pair of gloves they had on, applied a second pair of gloves, removed the old dressing to the right hip and removed their top pair of gloves. Staff Q then pulled up a syringe full of iodine and saline and flushed the wound, cleansed the wound with gauze and then removed their top pair of gloves, placed a second pair on, applied skin prep to the surrounding tissue of the wound, removed both pair of gloves and sanitized hands. Staff Q put on two pairs of gloves, applied more skin prep to the surrounding tissue of the wound, put on a new dressing, removed their gown and gloves and washed their hands. At 3:15 PM, the same day, Staff Q and Staff J put on new gowns and two pairs of gloves. Staff Q removed the dressing from Resident 14's tailbone, removed their top pair of gloves, sanitized their first pair of gloves, and put on a second pair of gloves. Staff Q cleansed the wound with normal saline, removed their top pair of gloves and put on a second pair of gloves, applied skin prep to the surrounding tissue of the wound and covered the wound with a dressing. In an interview on 06/13/2025 at 9:59 AM, Staff D, Infection Preventionist, stated the nurses should not have worn two pairs of gloves and it was not appropriate to sanitize gloves. Staff D stated after a pair of gloves were removed, hand hygiene should have been performed, and this was important to prevent the spread of infection. ENHANCED BARRIER PRECAUTIONS <Resident 14> The 05/01/2025 quarterly assessment documented Resident 14 had diagnoses that included quadriplegia and traumatic spinal cord dysfunction and was cognitively intact. Resident 14 had two Stage 4 pressure ulcers and received wound care. In an observation on 06/10/2025 at 9:08 AM, Resident 14 had an EBP sign on their door and a cart outside of their room that contained PPE. On 06/11/2025 at 9:05 AM, two nursing assistants were observed entering Resident 14's room with no PPE on. In an interview on 06/11/2025 at 9:10 AM. Staff J and Staff BB, Nursing Assistant, stated they had just repositioned Resident 14. They stated they wore PPE when they worked with the resident's catheter or colostomy bag. When Staff J and Staff BB were shown the EBP sign they stated they should have worn gloves and that the staff had never had them do that. Staff BB stated it was important to wear PPE to prevent infections. During an observation and interview on 06/11/2025 at 12:17 PM, Resident 14 was lying in bed. The resident stated the nursing assistants were now wearing gowns when they repositioned them. <Resident 195> According to the 05/29/2025 significant correction assessment, Resident 195 admitted to the facility on [DATE] with diagnoses that included pelvis (bones at base of spine that make up the hips, buttocks and pubic area, between abdomen and thighs) fractures and muscle weakness. Resident 195 underwent a major surgical procedure during the prior inpatient hospital stay that required active skilled nursing care, had surgical wounds that required wound care, and had an indwelling urinary catheter. Resident 195 was cognitively intact and able to clearly verbalize their needs. Review of provider orders showed an active 05/22/2025 order for Resident 195 to be on EBP related to catheter placement. Gowns and gloves were required for high-contact care that included dressing, bathing, transferring, toileting, changing linens, or during device or wound care. Review of the 05/22/2025 care plan documented Resident 195 was to be on EBP related to a urinary catheter. Staff were instructed to use EBP to prevent infection by using a gown and gloves during high-contact care that included dressing, bathing, transferring, toileting, changing linens, or during device or wound care. During observation on 06/09/2025 at 10:40 AM, an EBP sign was posted on Resident 195's room door with a white three drawer tote outside the room. The tote contained gloves, goggles, and booties but no gowns were found. During observation on 06/09/2025 at 2:16 PM, Resident 195 requested their urine collection bag be emptied. Staff Y, NA, performed hand hygiene and put on a pair of gloves but did not don a gown before they emptied the urine collection bag. During observation on 06/10/2025 at 12:56 PM, Staff L, NA, was observed wearing a pair of gloves but no gown while they placed Resident 195's pillow in a pillowcase, at the bedside. During an interview on 06/11/2025 at 2:44 PM, Resident 195 stated staff had never put on a gown when they touched or manipulated their catheter, changed their linens, or performed high contact care activities. During an interview on 06/13/2025 at 9:51 AM, Staff W, NA, was unable to explain what EBP consisted of. Staff W stated staff should follow precautions when indicated to prevent the spread of infection. Staff W acknowledged Resident 195 had an indwelling catheter and staff should wear stuff when dealing with bodily fluids and/or their bedding. During an interview on 06/13/2025 at 10:04 AM, Staff C, Resident Care Manager, explained EBP included the use of a gown and gloves when dealing with wounds, invasive (into the body) devices such as catheters, or performing high-contact care activities to prevent the spread of infection. Staff C stated Resident 195 had a catheter and staff should follow EBP with them. During an interview on 06/13/2025 at 11:02 AM, Staff B, Director of Nursing, stated they expected staff to follow EBP when implemented or indicated to provide proper infection control measures. <Resident 96> A record review documented Resident 96 was admitted on [DATE]. The comprehensive assessment was incomplete. Resident 96 had diagnoses that included a right below the knee amputation site infection and obstructive uropathy (blockage of urine flow). A review of provider orders documented Resident 96 had a peripheral inserted central catheter (PICC, a catheter inserted in the arm that extended into a major blood vessel near the heart and allowed for long-term administration of intravenous [IV] medications) and received IV antibiotics. Additionally, Resident 96 had a urinary catheter. On 06/09/25 at 11:26 AM, Resident 96 was observed asleep in bed. An IV pump with an empty bag of antibiotic and tubing hung on the pole. A urine collection bag for a urinary catheter was observed hanging on the bedframe. There was no EBP signage observed on the entrance to Resident 96's room, and no PPE at the entrance or in the resident's room. Additional observations of lack of EBP signage and PPE were made on 06/10/2025 at 10:12 AM. On 06/11/2025 at 9:26 AM, EBP signage and a PPE cart were positioned at the entrance of Resident 96's room, nine days after their admission. During an interview on 06/13/2025 at 2:58 PM, Staff D, Infection Preventionist, stated when a resident was admitted , the admission nurse reviewed the records from the hospital then posted EBP signage if indicated, but acknowledged that any of the nurses could implement EBP. <Resident 11> A 05/13/2025 five-day assessment documented Resident 11 had diagnoses that included sepsis (infection throughout the whole body) and cellulitis (infection of the skin and the tissues beneath the skin). On 06/10/2025, an order was given to provide wound care to the back of Resident 11's left thigh. Staff were to cleanse the area with normal saline, pat the area dry, apply calcium alginate (a type of dressing used to treat wounds that have moderate to heavy drainage), and cover with border-gauze every Monday, Wednesday and Friday and as needed. Resident 11's room was observed to have no EBP implemented (signage alerting staff to wear PPE) and no PPE in the vicinity available for use on 06/11/2025 at 2:32 PM, 06/12/2025 at 8:51 AM, and 06/13/2025 at 1:17 PM. During an interview on 06/13/2025 at 2:58 PM, Staff D reviewed Resident 11's orders and stated Resident 11 should have had EBP implemented related to their wound care. They notified Staff B, Director of Nursing, that EBP needed to be implemented. During an interview on 06/14/2025 at 6:10 AM, Staff A, Administrator, stated they expect staff to implement and follow EBP when indicated. Reference WAC 388-97-1320(1)(c)

Based on interview and record review the facility failed to repeatedly ensure nursing assistants received a minimum of 12 hours of in-service training per year, as required to include dementia management, abuse prevention, and caring for individuals with cognitive impairment for 2 of 5 sampled staff (Staff I and L), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, unmet care needs, and diminished quality of life. <Staff I> Review of Staff I's, Nursing Assistant (NA), personnel file showed they were hired on 07/16/2021. Review of Staff I's training records showed no documentation they received a minimum of 12 hours of in-service training per year as required to include dementia management, abuse prevention, and caring for individuals with cognitive impairment. <Staff L> Review of Staff L's, NA, personnel file showed they were hired on 04/04/2023. Review of Staff L's training records showed no documentation they received a minimum of 12 hours of in-service training per year as required to include dementia management, abuse prevention, and caring for individuals with cognitive impairment. In an interview on 06/12/2025 at 11:54 AM, Staff A, Administrator, acknowledged some staff did not have the minimum required training. Staff A explained the computerized training system did not automatically schedule trainings when due or required. In a follow-up interview on 06/14/2025 at 6:10 AM, Staff A, stated they expected staff to receive adequate training in order to have adequate skills and/or competencies to meet the needs of the facility resident population. Reference WAC 388-97-1680 (2)(a-c) Refer to F726 for additional information.

Based on observation, interview and record review, the facility failed to honor residents' choices regarding having the hoyer sling (a sling used for a full body mechanical lift transfer) left under them after being transferred into their wheelchairs, for 2 of 4 sampled residents (Residents 10 and 20), reviewed for choices. This failure placed residents at risk for not receiving resident specific care, not having their preferences honored, and a diminished quality of life. Findings included . <Resident 10> The 05/08/2025 assessment documented Resident 10 had diagnoses which included heart failure, diabetes, and chronic pain. Resident 10 was cognitively intact, able to make their needs known, and required total assistance with transfers. In an observation and interview on 06/09/2025 at 11:49 AM, Resident 10 was observed sitting in their wheelchair with a hoyer sling underneath them. The resident stated they did not like having the sling underneath them because it was uncomfortable and caused pain. A similar observation of Resident 10 with the hoyer sling underneath them was made on 06/11/2025 at 12:05 PM. The resident stayed in bed during further observations made during the survey. <Resident 20> The 05/08/2025 assessment documented Resident 20 had diagnoses which included a stroke, hemiplegia (paralysis on one side of the body), and chronic pain. Resident 20 was cognitively intact, able to make their needs known, and required total assistance with transfers. In an observation and interview on 06/09/2025 at 11:18 AM, Resident 20 was observed sitting in their wheelchair with the hoyer sling underneath them. The resident stated the sling was very uncomfortable. Resident 20 stated the staff told them they had to leave the sling underneath them because they did not have enough staff to take it out and put it back on later. A similar observation of Resident 20 with the hoyer sling underneath them was made on 06/11/2025 at 12:06 PM. In an interview on 06/12/2025 at 3:38 PM, Staff H, Nursing Assistant (NA), stated hoyer slings were left underneath the residents. Staff H further stated it was important to remove hoyer slings from under the residents to prevent ulcers (wounds caused by unrelieved pressure). In an interview on 06/14/2025 at 6:34 AM, Staff I, NA, stated hoyer slings were kept under the residents because it was safer and easier. Staff I added they did not ask the residents if they wanted the hoyer slings left under them because they have compromised mobility. In an interview on 06/13/2025 at 2:24 PM, Staff B, Director of Nursing, stated hoyer slings created pressure on the resident's skin and should not be left underneath residents. Reference: WAC 388-97-0900(1)-(4) Refer to F725 for additional information.

Based on interview and record review, the facility failed to inform and provide written information regarding the right to formulate an advance directive (legal document that outlined wishes for medical care if a person was unable to make decisions for themselves) for 1 of 4 sampled residents (Resident 195), reviewed for advanced directives. This failure placed residents at risk of not being able to exercise their rights, not having their wishes honored, and a diminished quality of life. Findings included . Review of the facility policy titled, Advanced Directives/Health Care Decisions dated [DATE] showed, the facility would determine if a resident had executed an advanced directive or had given other instructions to indicate what care he or she desired in case of subsequent incapacity, upon admission. If the resident or their legal representative executed one or more advanced directives, copies would be obtained, incorporated, and maintained in the resident's medical record to be readily retrievable by any facility staff. If the resident had not executed an advanced directive, the facility would advise the resident and/or family of the right to establish an advanced directive and document in the resident's medical record discussions regarding advanced directives and any healthcare decision that resident executes. If the resident wished to formulate an advanced directive, a nurse or social worker provided the resident with written information concerning the right to make decisions regarding medical care, including the right to specify ahead of time whether a health care provider begins or continues life-sustaining treatment. The policy further showed the facility identified, clarified, and periodically reviewed, at least quarterly, after a life altering event, and after return from a hospitalization, as part of the comprehensive care planning process, the existing care instructions and whether the resident wished to change or continue these instructions. According to the [DATE] significant correction assessment, Resident 195 admitted to the facility on [DATE]. Resident 195 was cognitively intact and able to clearly verbalize their needs. Review of the [DATE] care plan showed Resident 195 chose to have cardiopulmonary resuscitation (CPR) in case of a medical emergency if and/or when their heart stopped beating. Interventions instructed staff to review advanced directives, CPR code status, scope of treatment with the resident and/or their appointed health care representative upon admission, change of condition, and at least quarterly. No documentation was found to show Resident 195 was informed and/or provided with written information regarding the right to formulate an advanced directive, as required. Review of the [DATE] care conference evaluation showed Resident 195 participated in an admission care conference held on [DATE]. The evaluation showed Resident 195 did not have an advanced directive. No documentation was found to show Resident 195 was informed and/or provided with written information regarding the right to formulate an advanced directive, as required. Review of [DATE] through [DATE] nursing progress notes showed no documentation that Resident 195 was informed and/or provided with written information regarding the right to formulate an advanced directive, as required. In an interview on [DATE] at 9:26 AM, Resident 195 stated the facility only reviewed their CPR status with them and did not inform and/or provide them with written information regarding their right to formulate advanced directives. In an interview on [DATE] at 10:29 AM, Staff C, Resident Care Manager, stated social services offered and provided residents with information on the right to formulate advanced directives upon admission and during care conferences. Staff C explained advanced directives were important because they allowed staff to know what a resident's healthcare wishes were. In an interview on [DATE] at 12:58 PM, Staff E, Social Services, stated information on advanced directives was offered upon admission and during care conferences. Staff E stated an information packet on formulating advanced directives would be provided during care conferences and documented in the care conference evaluation. Staff E reviewed Resident 195's medical record. Staff E acknowledged they were unable to find documentation Resident 195 was informed and/or provided with written information regarding the right to formulate an advanced directive, as required. In an interview on [DATE] at 3:46 PM, Staff A, Administrator, stated they expected staff to provide residents with information on the right to formulate advanced directives. Refer to WAC 388-97-0280 (3)(c )(i-ii), 0300 (1)(b), (3)(a-c)

Based on observation, interview and record review, the facility failed to ensure that 4 of 4 residents who were assessed to smoke independently (Resident 30, 31, 24, and 20) had a designated safe location to smoke, fire-safe receptacle for disposal of cigarette butts, and a system in place to ensure smoking supplies were stored safely. In addition, the facility failed to ensure smoking evaluations were done timely for 1 of 1 sampled resident (Resident 22) reviewed for smoking. These failures, which were exacerbated by hotter than normal temperatures during fire season, placed the facility at risk for fire and all residents at risk for serious injury, harm or death and constituted an immediate Jeapordy (IJ). On 07/10/2024 at 1:58 PM, the facility was notified IJ was identified related to F689 CFR S483.25 Free of Accident Hazards/Supervision/Devices. The facility removed the immediacy on 07/10/2024 with an onsite verification by surveyours ensuring all residents that smoked had a smoking assessment completed, education was provided on the safe disposal of cigarette butts to staff and residents, and a receptacle for the disposal of the cigarette butts were provided. Findings included . According to the facility policy titled Smoking Campus Policy, dated 11/28/2017 and updated 7/10/2024, residents were unable to smoke on the facility premises. It documented at the time the facility went tobacco free, if there were current residents still smoking, the current residents were allowed to use tobacco or tobacco products in a designated area outside, weather permitting. These residents were required to have a smoking assessment completed to determine the level of supervision to be provided and interventions to mitigate the risk of injury. Additionally, a smoking assessment was not required if a resident did not smoke and the policy would be enforced by asking residents to immediately comply, assessing for distress, and storing any tobacco products or lighting material at the nursing station with the resident's consent. During the entrance conference meeting on 07/08/2024 at 9:04 AM, with Staff A, Interim Administrator, and Staff B, Director of Nursing (DON), when asked if the facility had residents who smoked, Staff B stated the facility was a non-smoking campus and residents who smoked were assessed on admission to ensure they were safe to smoke independently, and there were no designated smoking areas or times, since residents had to be independent to smoke. The facility had four residents who smoked (30, 31, 24, and 20). Record review showed the following residents all had smoking assessments completed on 05/30/2024. Additional information is as follows: *Resident 30, admitted [DATE], no admission smoking assessment completed, the only smoking assessment found was the assessment on 05/30/2024 *Resident 31, admitted [DATE], first smoking evaluation 01/03/2024 *Resident 24, admitted [DATE], no admission smoking assessment completed, the only smoking assessment found was the assessment on 05/30/2024 *Resident 20, admitted [DATE], no admission smoking assessment completed, first smoking assessment completed on 01/03/2024. <Observations> On 07/10/2024 at 8:28 AM, Resident 31 was observed leaning up against the telephone pole at the top of the facility driveway smoking. On 07/10/2024 at 11:15 AM, dry vegetation was observed at the end of the facility asphalt driveway, multiple cigarette butts were on the ground around the area, and a plastic garbage bin located by the facility front door contained paper, surgical masks, and approximately 50 cigarette butts. At 12:18 AM, discarded cigarette butts were observed lying in brown, brittle, dry grass in the facility front yard. At 12:18 PM, 3 cigarette butts were observed lying in brown, dry, grass by the facility sign, 2 cigarette butts were lying on the ground by the fence along the facility driveway (where resident 31 was observed smoking), and 5 cigarette butts were lying on the ground under a facility window in the garden area parking lot. Resident 20 was also observed at this time sitting on their walker on the sidewalk at the end of the facility driveway smoking. Review of the AccuWeather Forecast showed the outside temperature was 97 degrees Fahrenheit on 07/10/2024 and an extreme heat warning was in place. In addition, the Washington State Department of Natural Resources website, (https://fortress.wa.gov/dnr/protection/firedanger/) advised the risk of fire was high. In an interview on 07/10/2024 at 1:58 PM, with Staff A, Staff B, Staff C (Clinical Resource Nurse), and Staff O, Corporate Nurse, when asked about the lack of safe disposal of cigarette butts and potential risk for fire, Staff B stated residents needed to dispose of cigarettes safely and stated they did not have a means to do that. <Resident 22> Per the 07/09/2024 assessment Resident 22 was cognitively intact and able to direct their own care. They required assistance for transfers, and supervision when using their wheelchair, and had diagnoses which included stroke, and hemiplegia (one-sided weakness or paralysis). Review of Resident22's current physician orders, dated 01/23/2024, showed Varenicline Tartrate daily to decrease tobacco craving. Review of the care plan dated 7/10/2024, showed Resident 22 wished to smoke, was determined to be dependent and unsafe to smoke, and could not smoke while at the facility. A smoking evaluation dated 07/10/2024 by Staff B, documented Resident 22 had no independent smoking privileges allowed off premises due to safety concerns. A Progress note by Staff E, Social Services Director, dated 3/11/2024 documented Resident 22 was found outside smoking a cigarette and had already been advised by Staff B that smoking wasn't allow on the property. Additionally, the note documented Resident 22 wouldn't give their lighter to Staff E for safe keeping. A progress note by Staff B, dated 03/12/2024, documented on 3/11/24 Resident 22 was provided education regarding smoking. Staff B explained to Resident 22 the facility policy at that time, informed them they were not safe to take themself off the property to smoke, and that they would need to be evaluated to make sure were safe to smoke independently. Staff B then let Staff E know Resident 22 was not safe to have a lighter in their possession. Additional review of Resident 22's care plan found no documentation that a smoking evaluation had been completed. During an interview on 07/10/2024 at 9:55 AM, when asked if they smoked Resident 22 stated the last time, they smoked was about one month ago at a doctor's appointment. They stated they kept their cigarettes and lighter in their bag and proceeded to remove a lighter and sealed pack of cigarettes from their bag. During an interview on 07/16/2024 at 03:50 PM with Staff A, Staff O, and Staff C, Staff C stated they talked to Resident 22 about surrendering their cigarettes the prior week and Resident 22 became upset and stated they would keep them in their purse. When asked what process was place in ensure safety since the resident refused to give the facility their cigarettes and lighter Staff O stated it should have been added to the care plan for nurses to check each shift. In an interview on 07/22/2024 at 04:49 PM, Staff B stated a smoking evaluation and safety plan for Resident 22 should have been completed on 03/11/2024 when Resident 22 was identified as a smoker. Reference (WAC): 388-97-1060 3(g)

Based on observation, interview, and record review the facility failed to protect a resident's right to be free from physical and psychological abuse by another resident for 1 of 2 sampled residents (Resident 28) reviewed for abuse. Resident 28 experienced psychological as evidenced by a change in behaviors, being up at night, pacing and fear. This failure placed residents at risk for physical and psychological abuse, and a diminished quality of life. Findings included . Review of the facility policy Abuse Prevention, Identification and Reporting and Investigating, dated 10/31/2017, directed protocol for Protection of a Patient during an investigation if resident to resident abuse occurred. The policy stated . Residents are separated and supervised to prevent additional contact until the investigation is completed and an intervention plan implemented. Examine of the alleged victim for any signs of injury, including a physical examination and psychosocial assessment as needed. Protect the alleged victim from retaliation . Statements are collected immediately from those with knowledge of the event. The investigation starts immediately, maintains integrity . Review of Resident 28 comprehensive Minimum Data Set Assessment (MDS) dated [DATE], showed Resident 28 was cognitively intact. Diagnosis included mental illness with delusions of grandeur (impressive, especially of appearance). During an observation on 07/08/2024 at 8:45 am, Resident 28 was observed sitting in the hallway by the nursing station, not engaged with other residents talking incoherently to themself. During an interview on 07/08/2024 at 9:37am, Resident 28 stated staff and clients mock me. A resident slapped me on the a** [butt] I filed a police report. Resident 28 reported Resident 14 who slapped them lived two doors down the hallway. Resident 28 had the last room at the end of the hallway. Resident 28 stated they would have to pass by Resident 14's room every time they left their own room. During an interview on 07/16/2024 at 2:00 pm, Staff J stated Resident 28 was talking to me about her television and they walked into the hallway. Staff J observed Resident 28 walking by Resident 14's room and Resident 14 reached out and smacked Resident 28 on the butt. Staff J said they were in shock. Staff J said Resident 14 can be nasty, but never thought they would put their hands on Resident 28. Staff J said they believed Resident 14 was planning as they were behind the door and when Resident 28 walked by [NAME] it was quite shocking. Staff J added that they reported the incident of Resident 14 smacking Resident 28 to Staff N, Staffing coordinator. During an interview on 07/11/2024 at 2:30 pm, Staff B, Director of Nursing (DNS), stated Staff J, Maintenance Person, witnessed Resident 14 slap Resident 28 on the butt on 07/01/2024. Staff B stated there was no investigation initiated, no physical or psychosocial assessment completed. Staff B stated they came to the facility on [DATE] and saw the police at the facility. Staff B asked Staff M, Charge Nurse, to make a report, but that did not happen. Staff B thought Staff M would initiate the abuse protocols. Staff B stated to investigate allegations of abuse in the facility, guidelines from the Center for Medicare and Medicare would be followed, the Purple Book (DSHS abuse protocol guidance) and the policies and procedures of the facility corporation. Staff B stated none of this was done at the time. The abuse was not called in and an investigation needed to have been done and is being done now. Staff B stated Resident 14 was being moved to a different room on a different hall today [ten days after the physical abuse]. Staff B acknowledged Resident 28 would probably feel vulnerable, anxious, fearful, and probably would be upset if another resident slapped them on the butt. Review of progress note from 07/01/2024 to 07/03/2024 showed: - Staff B arrived at the facility and noted the presence of a police cruiser in the parking lot. After speaking with Staff M, Licensed Nurse, regarding the police presence, Staff B was aware Resident 28 called them due to a male resident smacking her bottom yesterday. Police took her statement and did speak to the male resident accused of smacking Resident 28's bottom. - Resident appeared to become more manic in her behaviors the last two days. - Resident 28 was placed on alert due to changes in behavior. - Resident 28 decided to go down the hall and yell at another female resident in a wheelchair. - Resident 28 was upset that the other resident said hello to the activity director. She was quick to become agitated over what she perceives others to be doing. - Resident 28 has been to the kitchen over 10 times since lunch requesting multiple food items. - Staff B discussed whether there was a possibility of resident having a Urinary Tract Infection (UTI.) Resident would not agree to having a Urinary Analysis (UA) with her increased mania at this point in time. - Resident tested negative for Covid-19 (infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) test yesterday. Continued review of 07/02/2024 progress noted, Resident 28 was out in the hallway at the nurses station mostly all shift. Made rude comments to other pts [Residents]. Pt [Resident] became agitated when other people talk or talk over her. Stomping her feet and wailing her arms around. Is constantly asking staff for things. Resident wanted to talk with Staff A, Administrator. Review of progress note dated 07/02/2024, showed Resident 28 came out onto the 200 hallway at approximately 2000 [08:00 PM], demanding all the televisions to be turned down and the rooms that had televisions on to have their doors shut. Review of progress note dated 07/03/2024, showed Resident 28 was up three times during the night, pacing, looking around like she was counting the staff, nodding her head then walking away, no contact with others resident on this shift. Per record review over three days (7/01/2024-07/03/2024). It revealed Resident 28's increased agitation was documented. There was no documentation of the resident being assed for psychosocial well-being to rule out behaviors that may have been related to the abuse. There was no documentation of interventions or investigation regarding the incident that occurred on 07/01/2024. During a follow up interview on 07/10/2024 at 11:00 am, when asked if they were feeling safe in the facility, Resident 28 stated, Everyone knows (in reference to the abuse) everyone who has been here is aware of it, they laugh and I feel preyed upon, that's preyed with an e in the facility. Reference WAC 388-97-0640 (1)

Based on interviews and record review the facility failed to ensure supervision was provided following a decline in function, recent fall from the toilet and recent unconscious episode to 1 of 3 residents (Resident 1) reviewed for falls with injuries. Despite Resident 1's changes in condition their plan of care was not revised to address the need for additional staff supervision with toileting. This failed practice resulted in actual harm to Resident 1 who fell from the toilet after being left unsupervised by staff. Resident 1 sustained multiple facial fractures, skull fracture and subarachnoid hemorrhage (SAH - bleeding in the space between the brain and the tissue covering the brain) and was hospitalized for nine days. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included stroke, unsteady gait, chronic fatigue, muscle weakness and history of falls. Review of Resident 1's comprehensive assessment, dated 08/31/2023, showed the resident had moderate cognitive impairment (difficulty remembering things, making decisions, concentrating and learning); required extensive assistance by two staff for turning in bed, transfers, dressing, toilet use and walking; limited assistance by one staff for personal hygiene and partial/moderate assistance by staff from a sitting to a standing position and toilet transfers. Review of physician's orders showed the resident received Plavix (medication to keep the blood from clotting) daily. Review of Resident 1's plan of care, initiated on 03/03/2022, showed they required extensive assistance by two staff for transfers. Review of a facility investigation report, dated 08/17/2023 at 12:35 PM, showed Resident 1 was found on the bathroom floor. They stated their wheelchair had rolled when they attempted to transfer after toileting. Resident 1 sustained a small skin tear to their left hand. The investigation report showed the resident had a history of falls due to impulsive behavior and confusion. The wheelchair anti rollback device (designed to prevent a wheelchair from rolling back and away from the resident as they attempted to sit down) was evaluated and education was given to the resident to lock the brakes prior to transfers to prevent further falls. Review of Progress Notes (PNs), dated 09/26/2023 at 6:02 PM, showed Resident 1 had increasing functional decline with their abilities. Review of the Physical Therapy (PT) Progress Report showed the following decline: Transfers - On 08/31/2023 Resident 1 required stand by assistance with 10% verbal cueing needed. On 09/28/2023 the resident required moderate assistance by staff with 35% verbal cueing needed. Sitting Balance - On 08/31/2023 the resident scored 35/44 and on 9/28/2023 they scored 22/44 Review of PNs, dated 10/02/2023 at 1:14 PM, showed Resident 1 had an unresponsive episode at 11:55 PM. The resident was engaged in a normal conversation when they became stiff in the wheelchair and unresponsive. The episode lasted only a few seconds and the resident was unable to recall the incident. The following day on 10/03/2023 at 3:15 PM review of a facility investigation report, showed Resident 1 was found by staff lying on their left side on the bathroom floor. There was stool present in the toilet and resident's disposable brief. Their left shoe was off and pants were down. There was blood coming from their nose and they had a swollen left eye. An indentation (dent) was observed to the forehead, and skin tears/lacerations (deep cuts) on the left arm. The resident was responsive but unable to state if they hit their head on the floor or bathroom sink. The investigation report showed Staff A, Nursing Assistant, had left the resident seated on the toilet while they attended to other residents down the hall. Upon finding the resident on the floor staff immediately transferred them by ambulance to the emergency room . Review of the 10/03/2023 hospital records showed Resident 1 sustained the following injuries: SAH, fracture of the nasal bone, fracture of the right side of the jaw, bilateral orbital fractures (break in one of the bones surrounding the eyeballs), large hematoma (occurs when an injury causes blood to collect and pool under the skin) to forehead, abrasions (break in skin that happens when the skin rubs off) to knees and face and skin tears to left hand and forearm. Review of the facility Event Summary Report, dated 10/6/2023, showed Resident 1 could be impulsive and not wait for assistance. They might attempt to transfer without calling for help. The report showed the bathroom door had been closed and the resident's wheelchair was not in the bathroom. Despite Staff A informing the resident to utilize the call cord in the bathroom to request assistance the call cord was never activated by the resident. Staff concluded the resident's functional abilities had declined, was unstable on their feet and impulsive. The resident was working with therapy with transfers at the time of the fall and required maximum assistance. The resident was unable to walk or stand without assistance due to being unstable on their feet. The resident had a history of being noncompliant with waiting for assistance with transfers. Staff A stated on 10/06/2023 at 02:45 PM, that Resident 1 had put on their call light to request to use the bathroom. Despite the plan of care showing the resident required two staff for transfers Staff A transferred the resident from their wheelchair onto the toilet by themselves. The resident's wheelchair was placed outside the bathroom door. Staff A then left the resident alone on the toilet while they attended to other residents down the hall. They stated they were gone for approximately 20 minutes. Prior to that day Staff A had only assisted the resident with the use of their urinal. The resident did not utilize the call cord to summon staff for assistance. Staff A stated they were unable to recall what the plan of care showed for staff assistance with transfers and toileting as they had not looked at it recently. During an interview on 10/06/2023 at 12:06 PM with Staff B, PT, they stated on 08/30/2023 Resident 1 had progressed to stand by assistance with transfers using a front wheeled walker. On 09/28/2023 the resident required moderate to maximum assistance by two staff for transfers. They were impulsive and Staff B frequently had to tell them to wait for the walker. The resident's cognition was higher two to three weeks ago than it was during the therapy session on 10/02/2023. Staff C, Registered Nurse/MDS Nurse, stated on 10/06/2023 at 12:20 PM, Resident 1 was not eating enough and was not doing as well in therapy. The resident was weaker and had vision issues. They were impulsive and that was why they had a lot of falls. Staff D, Nursing Assistant (NA), stated on 10/12/2023 at 2:15 PM, that Resident 1 had not been feeling good the past three weeks. The resident required two staff to assist with transfers as they were always wobbly, unsteady. The resident would try and stand up on their own, wanted to get up and go. Sometimes they would try and transfer from the wheelchair to the bed without assistance. The resident started on therapy and was doing well until the past three weeks, definitely weaker. Staff D stated they never left the resident seated on the toilet without staff present. Staff E, NA, stated on 10/16/2023 at 9:50 AM, that Resident 1 required two staff for transfers and they were not to be left alone on the toilet. Staff E stated the resident would self transfer and was not steady on their feet. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure safe transportation for 1 of 4 sample residents (1), reviewed for transportation to an appointment in the facility van, with a driver and accompanied by a second staff. The facility failed to ensure the safety belts in the vehicle were in good repair and functioning. These failures resulted in serious physical and psychosocial harm to one resident when they sustained a fall from the wheelchair during the transportation to the appointment, resulting in a fractured leg and subsequent amputation, and placed other residents at risk for serious injury, impairment, or death during transportation. The facility has corrected all the above deficiencies prior to the abbreviated survey. This constituted a past noncompliance immediate jeopardy. Findings included . Review of the facility policy and procedure titled Transportation Van, dated [DATE], showed the preventative maintenance checks were completed at least monthly and documented on the Preventative Maintenance Task sheets by the facility maintenance supervisor. The document showed the transportation van was to be kept in proper working condition, which included seatbelts being in good working order. Review of the User Instructions Form, for the use of the facility van (the one used at the time of the incident on [DATE]), showed the combination lap/shoulder belts needed to be placed through the opening of the wheelchair armrest, to ensure a proper belt fit around the resident. The form showed that lap/shoulder belts should not be held away from the resident's body by wheelchair components or parts such as armrests, panels, or frame. The lap/shoulder belt was to be connected to the rear tie-down belt, which was connected to the floor of the van. Resident 1. Review of the resident's current profile and diagnosis list showed they were admitted to the facility on [DATE] with diagnoses which included chronic [CONDITION(S)] (when leg veins don't allow blood flow back up to the heart, resulting in blood collecting in the legs), chronic kidney disease, [CONDITION(S)], diabetes, heart disease, and a left ankle sprain. Review of the [DATE] quarterly comprehensive assessment showed the resident had no cognitive deficits, required extensive assistance of one staff for turning in bed and personal hygiene, and extensive assistance of two staff for transfers (utilizing a mechanical lift system), dressing, and toilet use. Review of the resident's weight record dated [DATE] showed that Resident 1 weighed 305.4 pounds. Review of a facility investigation summary report dated [DATE] showed on [DATE], the resident fell from their wheelchair while being transported by the facility driver in the facility van to an eye appointment. Per the report, the resident fell forward from their wheelchair, landing on top of their left leg, while traveling down a steep hill. They were immediately taken to the emergency room by Emergency Medical Services (EMS), and x-rays revealed a fractured left leg. Review of the local hospital emergency room (ER) report, dated [DATE], showed the resident had an open fracture (the bone was exposed at the area of the fracture) of the end of the left tibia (the larger bone on the inside of the leg), and a closed fracture of the left fibula (the smaller bone on the outside of the leg). The ER report showed that the resident stated that they had slid forward out of the wheelchair, getting their legs pinned below them and under the chair. Per the resident, that occurred going down a hill, and the belt had broken (which secured them in the van). Due to the complexity of the fracture, the resident was then taken by an air ambulance service to a larger emergency room out of the area. Review of the second hospital's records showed the resident had surgery to repair the left leg fractures on [DATE], and five days later had an above the knee amputation to the left leg. Per the record, the resident was discharged back to the facility on [DATE]. Observation on [DATE] at 9:10 AM of a cell phone picture of the van, utilized during the incident on [DATE], showed there were two seats with a large opening in between the seats for wheelchair use. Staff A, Van Driver/Receptionist, stated on [DATE] at 12:05 PM and [DATE] at 12:20 PM, that they were the main van driver for the facility, and were in the process of transporting the resident to an appointment on [DATE], when the resident fell from the wheelchair. Per Staff A, the resident's wheelchair was positioned in the open space which was located between two regular seats (which had their own seatbelts). Staff A stated when placing the lap/shoulder belt on the resident, they were unable to place the belt through the armrest on the right side of the wheelchair, as the resident's body was pressed tightly against the sides of it, so they had to bring the belt across the front of the wheelchair armrests. Staff A stated when they went to connect the lap/shoulder belt to the belt attached to the floor and it was not latching properly, Staff A used one of the seat belts from the chair seat of the van located on the right side of the resident's wheelchair. Both actions taken by Staff A resulted in the lap/shoulder belt not being securely fitted against the body of the resident, to ensure safety of the resident. In addition, the lap/shoulder belt was not placed in accordance with the above user instructions. Staff A stated that they had only moved the van two feet in the driveway when the resident stated a feeling of slipping. They immediately stopped the van and obtained assistance from a nursing assistant to remove a blanket which was under the resident and repositioned them in the wheelchair. Per Staff A, as they drove the van down the hill and was starting to break at a stop sign, they heard the resident fall from the wheelchair. They further stated the resident was observed on their knees on the floor of the van, stating they thought they broke their ankle. Staff A stated they then called EMS for assistance, and stated the resident was in pain. Upon the assessment of EMS, the resident was transported to the emergency room . Staff A stated the malfunctioning belt from the floor of the van had been that way since they started work at the facility on [DATE]. They had not notified anyone about the belt as they assumed the new van, located in the facility parking lot, had been purchased due to the faulty equipment. Staff A stated in addition to Resident 1, they had transported nine other residents in wheelchairs using the malfunctioning belt. Staff A was aware that a second staff member was to accompany them to the appointment, but was told they did not have an available staff member. Staff A was also aware that if a staff member was not available, they were to call and reschedule the appointment. They stated the appointment was not rescheduled, as the resident had stated it was fine to go to the appointment without additional staff assistance. Staff A did not notify anyone regarding the lack of staff accompanying them. A telephone interview on [DATE] at 2:04 PM with the EMS Officer, showed when they arrived to the scene of the van on [DATE], the resident's wheelchair was positioned between two seats, and the resident was on the floor of the van in front of their it. Per the EMS staff member, the resident was very scared and very hurt, stating the resident had an open fracture of the left leg, and there was quite a lot of bleeding. During a telephone interview on [DATE] at 2:51 PM with the ER Nurse Practitioner, they stated that after they stabilized the resident in the emergency roiagnom on [DATE], the resident had stated the facility van had been going down a hill when their belt broke, causing them to go forward from the wheelchair to the floor. The resident stated their legs went backwards, and they ended up on their knees on the floor of the van. Staff C, Maintenance Supervisor at a sister facility, stated during a telephone interview on [DATE] at 2:05 PM, that when they did a maintenance check on the van on [DATE], there was a buckle on the belt coming from the floor of the van on the right side that was not latching; the belt on the left side was functioning properly. During an interview on [DATE] at 10:30 AM with Staff D, Administrator, they stated the facility had purchased a new van as the old van's (utilized during the incident on [DATE]) lease had expired, and it had to be returned to the owner by [DATE]. Following the maintenance check done on the old van on [DATE], it was never utilized for resident transport again by the facility following the incident. On [DATE] at 4:45 PM, Staff D stated the policy at the time of the incident was nursing staff were to accompany the resident, and if staff was unavailable, the appointment was to be rescheduled. On [DATE] at 2:20 PM, Staff D stated they were unable to locate any of the monthly preventative maintenance task sheets (to have been conducted by the maintenance supervisor), for the van used during the incident on [DATE]. Staff had no knowledge of when the last maintenance check had been done on the former van, as they were unable to obtain any documentation. Per Staff D, the previous maintenance supervisor had resigned their position from the facility on [DATE], and the new maintenance supervisor did not begin employment until [DATE]. Review of the Medical Transport Driver Competency form, dated [DATE] for Staff A; Staff E, Human Resources; and Staff F, Maintenance Supervisor; all designated van drivers, showed they completed the competency skills checklist on the new van with satisfactory results. Staff F stated during an interview on [DATE] at 2:15 PM, that the maintenance checklist was going to be an electronic form and performed every month, per facility policy. The facility implemented the following interventions on [DATE], which corrected the deficiencies: - Completed an audit of the residents that required facility van transportation and a second staff member to accompany them to the appointment. If a second staff member was not available, the facility would reschedule the appointment. - Provided staff education on safe resident transportation and use of safety belts and sending a second staff member to accompany the resident to the appointments. - All designated van drivers completed the competency skills checklist on the new van with satisfactory results. - Conducted monthly maintenance audits on the facility van. This was a Past Non-Compliance Immediate Jeopardy situation and is no longer outstanding. Reference (WAC) [DATE](3)(g) This is a repeat deficiency from the Statement of Deficiencies dated [DATE] and [DATE].

Based on interview and record review, the facility failed to ensure residents received the necessary care and services to promote healing and prevent worsening of pressure ulcers for 1 of 3 sample residents (1), reviewed for pressure ulcers. Additionally, the facility failed to notify the physician of the continued deterioriation of the resident's pressure ulcer. This failed practice resulted in actual harm to Resident 1, who was transferred to the emergency room , due to a significant change in condition as a result of an infected, worsening pressure ulcer. Findings included . Review of Resident 1's record showed they were admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes showed a round pressure ulcer measuring 0.5 centimeters (cm.) was initially observed on 12/03/2020, to the resident's upper coccyx (tailbone). Review of a wound consultant's report, dated 12/21/2020, showed the pressure ulcer was a Stage III (full thickness skin and tissue loss with exposed or directly palpable - i.e., could be felt - muscle, tendon, ligament, cartilage or bone in the ulcer) to the resident' sacrum (a triangular shaped bone located at the bottom of the spine), which measured 1.0 cm. by 0.5 cm., with a depth of 0.3 cm. The area continued to be monitored weekly by the wound consultant through 01/25/2021, at which time the wound consultant services were discontinued by the facility. Review of the resident's 11/02/2021 comprehensive assessment showed they required extensive assistance of two staff for turning in bed, transfers, dressing, and toilet use; extensive assistance of one staff for eating and personal hygiene; was frequently incontinent of bowel and bladder; and had moderate impairment of thinking, reasoning, and remembering. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 09/06/2021 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weekly Skin Evaluation, dated 09/29/2021, showed the pressure ulcer measured 1.5 cm. by 1.0 cm., with a depth of 0.1 cm. Per the evaluation, the wound bed was pink in color. Nine days later, on 10/08/2021, the measurements significantly increased to 3.0 cm. by 1.5 cm., with a depth of 1.0 cm., and a yellow wound bed (necrotic tissue that needed to be removed from the wound for healing to take place). Per record review, despite the worsening of the pressure ulcer, the physician was not notified, and no changes in treatment orders were obtained. Review of Weekly Skin Evaluations dated 10/21/2021, 10/29/2021, 11/04/2021, 11/11/2021, and 11/18/2021, showed the depth of the resident's Stage III pressure ulcer increased to 2.5 cm., 2.4 cm., 2.2 cm., 2.2 cm., and 2.1 cm. respectively, from the 1.0 cm. depth measured on 10/08/2021 - the record showed no physician notification/consultation, or a change in interventions. Review of progress notes in the resident's medical record documented by the Registered Dietician, dated 10/27/2021, showed the resident had an inadequate intake and an overall decline, due to muscle wasting. Review of the 11/18/2021 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician stated we have been trying everything we normally do - trying to improve nutrition status; changing position frequently - keeping weight off it [pressure ulcer]; dressing changes; it is just not healing. The plan was to consult with the wound clinic. Review of the 11/24/2021 Weekly Skin Evaluation showed the wound had worsened and was not responding to treatment, and a referral was requested for the wound clinic. The 12/01/2021 Weekly Skin Evaluation showed the Stage III pressure ulcer had worsened with measurements of 3.5 cm. by 2.5 cm., with a depth of 2.75 cm.; the wound bed was red and irritated, the surrounding tissue color was dark red/purple, and the surrounding wound edges were swollen. Per record review, despite the worsening pressure ulcer to the sacrum, the physician was not notified, and no changes in the treatment plan were made. On 12/04/2021, a progress note written by Staff C, Licensed Practical Nurse, showed at 6:40 PM, the resident exhibited abnormal excessive sweating, lethargy (sluggish), temporal body temperature (a body temperature obtained by scanning the thermometer across the forehead with a normal range of 97.4 to 100.1 degrees Fahrenheit) of 99.4 degrees, oxygen saturation level was 97% on two liters of oxygen (normal level is 95% of higher). Due to changes in the resident's condition, the resident was transferred to the emergency room (ER). Review of the 12/04/2021 ER report showed the resident had a rectal temperature of 104.6 degrees Fahrenheit (F) (normal rectal body temperature is 96.8 to 100.3 degrees F), was lethargic, and unable to give any history. The report also showed the resident had an 8.0 cm. by 5.0 cm., with a depth of 5.0 cm. of necrotic tissue (death of cells or tissue) ulcer over the sacrum, with foul smelling drainage. An area of redness measuring 5.0 cm. to 10.0 cm. extended from the wound in all directions. Per the record, the resident was given two antibiotics intravenously (in the vein). Review of a hospital Medical Records Consult report, dated 12/07/2021, showed there were no good surgical intervention options available for the resident's pressure ulcer. The decision was made to place the resident on comfort measures. Staff C stated during a telephone interview on 01/07/2022 at 11:03 AM, the resident's body temperature was 100.2 degrees temporal at 6:40 PM on 12/04/2021. Staff C administered Tylenol to the resident. Following the Tylenol, the resident's body termperature decreased to 99.4 degrees temporal. The resident was lethargic and had not eaten any of the dinner meal. Staff C notified the physician, and orders were obtained to transfer them to the ER. Staff A, Registered Nurse, stated on 12/29/2021 at 3:00 PM, that they had been off work for five weeks, and upon returning, had assessed the resident's pressure ulcer on 11/28/2021, which had been very small prior to their time off, and had increased in size with black eschar (dead tissue) in the middle of the wound bed. Staff A stated the surrounding skin around the wound bed was red and hard . not stageable, and purulent drainage (a sign of infection) with foul smelling odor was present. Staff A was told by another licensed nurse that a referral to the wound clinic was already in progress. Staff A stated they called the wound clinic on 11/28/2021, and was told they had received no information on the resident (despite the physician's visit ten days earlier on 11/18/2021, with a referral to the wound clinic). Staff A then completed a communication form to the physician, dated 11/28/2021, which showed the resident had a large, nonstageable wound with purulent drainge, and requested an order/referral to the wound clinic. The form was signed by the physician on 12/07/2021 (nine days later, with the resident already in the hospital), with orders stating to set up the appointment as soon as possible. Staff B, Administrator, stated on 01/03/2022 at 2:38 PM, that the above communication form to the physician was placed in a folder and sent to the clinic, for the physician to read and sign. Staff B stated the resident's physician was on vacation between 11/27/2021 to 12/17/2021, however, was still taking phone calls from the facility. Per a telephone interview on 12/29/2021 at 12:41 PM with the director of the wound clinic, they stated they never received a referral for the resident to the wound clinic until 12/06/2021. Per the director, the procedure was for a facility to call and give the resident's date of birth, and fax them the demographic form (including names, telephone numbers, insurance information), so they can then enter the resident into their system. The wound clinic would then call the facility to arrange an appointment time. The usual time was within a couple of days once the referral was sent. If the pressure ulcer was worsening, the resident would become a top priority to be evaluated. The resident's physician stated during a telephone interview on 01/05/2022 at 1:07 PM that they were aware the referral to the wound clinic was delayed. The physician stated the resident had been declining in their condition from the end-stage [CONDITION(S)] disease. Despite the worsening of the resident's pressure ulcer, there was no change in treatment since 09/02/2021. Additionally, the physician was not consulted in a timely manner, and had not observed the wound since 11/18/2021. Reference (WAC) 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to assess the effectiveness of the treatment, obtain a medical evaluation, perform thorough/accurate assessments, and develop preventative measures for 1 of 1 sample residents (2), reviewed for non-pressure related skin conditions. This failed practice resulted in actual harm to Resident 2 due to pain issues and worsening of the skin problems. Findings included . Resident 2. Review of the resident's medical record showed they were admitted to the facility on [DATE] from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital records showed on 11/07/2021, the physician ordered an antifungal medication (used to treat a skin infection which can appear as bright red in color, and can spread across a large area of skin), to be applied twice daily to breast and groin areas. The medication was applied on 11/08/2021 at 9:37 AM by hospital staff, prior to the resident's discharge from the hospital. Review of the resident's comprehensive assessment, dated 11/14/2021, showed they were totally dependent on two staff for transfers, required extensive assistance of two staff for turning in bed and use of the toilet, and required extensive assistance of one staff for dressing and personal hygiene. The resident had moderate impairment with thinking, reasoning, and remembering. Review of the resident's Admission Nursing Evaluation, dated 11/08/2021, showed their weight was 334 pounds, they had a urinary retention catheter, and an area of redness to the left buttocks measuring 0.6 by 0.5 centimeters. Despite the resident having an actual skin problem on admission, review of their 11/08/2021 plan of care, which was revised on 11/27/2021, showed they were at risk for skin impairment due to fragile skin, dry skin, use of blood thinning medications, decreased mobility, diabetes, oxygen therapy, and having a urinary catheter. The actual skin problem was not on the resident's plan of care. Interventions included weekly skin assessments, and use of a draw sheet or lifting device to move the resident. Despite the resident requiring two staff to assist with turning in bed, obesity, and decreased mobility, there were no interventions to reposition the resident at designated times. In addition, there was no designated treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes dated 11/16/2021, documented by Staff E, Social Services Director, showed the resident had concerns regarding a rash on their back turning into water blisters. Progress notes on 11/28/2021 and 11/30/2021 showed the resident's buttocks had excoriation (skin breakdown resulting from prolonged exposure to moisture), with multiple loose stools. Review of a progress note on 12/10/2021 at 5:17 PM, documented by Staff F, Director of Nursing, showed a skin assessment was done with the state surveyor present. The resident had redness to their pannus (an apron of lower abdominal skin - often present with obesity), groin, peri rectal area, and both buttocks. The note also showed tenderness was present upon touching the area, especially the left buttock/peri anal area. A dime-size macerated (skin in contact with moisture too long) area was present to the left buttocks. Barrier cream (protective skin cream)was in place over affected areas. Documentation showed the resident was admitted with the above skin alterations, and had been educated regarding turning, but was non compliant about being off their back. A urinary catheter was in place, but the resident's skin was extremely moist due to obesity. An order was obtained from the physician on 12/10/2021, following the skin assessment, for an anti-fungal medication to be applied to the perineal/coccyx area twice daily, until 12/23/2021. Despite the above documentation by Staff F on 12/10/2021, regarding the resident being admitted to the facility with the skin problems, and the resident's expressed concerns of skin problems on 11/16/2021, review of the progress notes between 11/09/2021 to 12/09/2021 (documented by eight different licensed nurses), showed there were 29 days where staff documented there were no non-surgical skin problems. Review of the resident's November 2021 Treatment Administration Record showed a skin audit was to be performed weekly, and if there were new skin impairments staff were to document with a yes, and if no new impairments staff documented no. Audits performed on 11/15/2021, 11/22/2021, and 11/29/2021 did not show a yes or no, but rather the staff's initials and a check mark. There were no assessments done regarding size of the skin alteration, color, location, and/or effectiveness of the barrier cream. Review of the resident's Weekly Skin Evaluation, dated 12/06/2021, showed redness with maceration to the peri anal, groin, pannus, buttocks, and surrounding skin. Barrier cream was being utilized, and the area was unchanged. Review of physician assessments, dated 11/11/2021 and 11/29/2021, showed no evaluation by the physician of the resident's skin problems. On 12/10/2021 at 3:00 PM, the resident's skin was observed with Staff F, Director of Nursing, following the resident's statement of their bottom hurting. There was a large area of bright red excoriation over both buttocks and perineal area. A dime-size, slightly open area was observed on the left buttocks. A white barrier cream was present over the areas. Upon slight touching of the resident's reddened areas, the resident called out in pain. Tenderness was present over all affected skin areas. The resident was able to partially turn to the side with difficulty, by placing their hands in the open slots of the headboard. The open slots were not designed to be used to assist with turning. There were no pillows observed in the resident's room for turning. The resident stated during a telephone interview on 12/08/2021 at 3:11 PM, that when they were first admitted to the facility they did not have any skin problems. The resident stated the staff were not turning them, stating it was not their job. The resident stated, I have so many sores on my back side I can hardly sit in a wheelchair. If I beg and plead I can get some ointment. Per record review, there were no treatments being done by licensed nursing staff. During a telephone interview on 12/08/2021 at 2:32 PM with the resident's representative, they stated the resident still had sores to their bottom, and the physician had not seen them. The representative stated they were doing the resident's treatment when visiting the resident, and staff was not turning the resident. Staff G, Physical Therapy Assistant, stated on 12/13/2021 at 11:10 AM, the resident would have pain if they sat on their bottom too long. Staff G stated when the resident was first admitted to the facility they were not able to get up in a wheelchair. Staff G stated the resident was only able to partially turn in bed, and can rotate some. Staff E, Social Services Director, stated on 12/13/2021 at 10:20 AM that the progress notes written on 11/16/2021 regarding water blisters was actually a concern voiced by the resident's representative, during the initial care conference (which was also attended by Staff F). Staff A, Licensed Practical Nurse, stated on 12/14/2021 at 11:39 AM, that when they observed the resident's skin the evening of 12/10/2021 the resident was pretty uncomfortable, and the skin was red and tender. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 02/25/2021.

Based on interview and record review, the facility failed to supervise to ensure staff followed the care plan with bed mobility (turning in bed), by not having two staff present for 1 of 3 sample residents (1), reviewed for activities of daily living. This failure resulted in harm to Resident 1 who fell out of bed while one staff person was assisting, experienced a significant change in condition shortly after the fall, necessitating emergency hospital transport, and expired at the hospital. Findings included Resident 1. Review of the resident's medical record showed they had diagnoses which included [CONDITION(S)] (paralysis from the neck down including the main part of body, arms, and legs). Review of the resident's [DATE] comprehensive assessment showed they were totally dependent on two staff for bed mobility, transfers, dressing, and use of the toilet. The resident was cognitively intact. Review of the resident's plan of care, dated [DATE], showed the resident required two staff to assist with turning and repositioning in bed. Review of a facility investigation showed on [DATE] at 3:00 PM Staff A, Licensed Practical Nurse, was called to the resident's room. The resident was lying on the floor on their right side, between the wall and bed. Prior to the fall Staff B, Nursing Assistant, was changing the resident's brief without additional staff to assist, as directed in the care plan. Upon Staff B turning the resident away from them towards the wall, Staff B lost their grip on the resident, causing the resident to roll out of bed onto the floor. The investigation concluded Staff B had not followed the resident's plan of care for bed mobility. Further review of the facility investigation showed with the exception of an abrasion to the resident's right forearm there were no other injuries observed by staff. Initially the resident refused to go to the hospital for an evaluation, stating they were fine. The resident became drowsy during the evening meal on [DATE], and only ate a few bites. The physician was notified at 7:45 PM regarding the resident's change in mentation and decline in blood pressure. Physician orders were received to transport the resident to the emergency room by ambulance, which was done at approximately 8:25 PM on [DATE]. Review of hospital records, dated [DATE], showed the resident was unresponsive; had cold, moist skin, and their blood pressure was low upon initial assessment in the emergency room . Cardiopulmonary resuscitation was performed without success. The resident expired at 10:39 PM on [DATE]. Staff B, Nursing Assistant, stated on [DATE] at 9:02 AM, they were aware the resident required two staff to assist with ADLs, and had performed care in the past without a second staff member assisting. Staff B stated having pulled the resident towards them to provide perineal care, and then rolled the resident in the opposite direction, towards the wall. Per Staff B the bed was not against the wall, and when Staff B lost grip of the resident, they fell between the bed and the wall. Staff B was unable to determine if the resident hit their head, as they were unable to visualize the resident. Staff B stated due to their height, the height of the resident's bed was adjusted to a high level so Staff B did not hurt their back during provision of care. Reference (WAC) [DATE](3)(g)

Based on interview and record review, the facility failed to timely or thoroughly evaluate and monitor a change in condition for three of seven sample residents (#1, 2, 3), reviewed for changes in condition. Failure to thoroughly or timely evaluate and monitor the residents prevented staff from determining changes in condition, which required physician notification, consultation, and additional medical treatment. This resulted in actual harm to Resident #2, who experienced a significant change in condition, the physician was not notified of the changes, and the resident then had a [MEDICAL CONDITION], which resulted in his unexpected death. In addition, the failed practice resulted in actual harm to Resident #3, who had a change in condition following a fall to the floor, and delayed treatment for [REDACTED]. Resident #2. Review of the resident's medical record showed he was admitted to the facility on [DATE] from the hospital, following surgery for [REDACTED]. Review of a fax sent to the resident's physician on [DATE] showed the resident's oxygen saturation level was low, between ,[DATE]% on room air (normal oxygen saturation level was ,[DATE]%). Per the record, raising the head of the bed, and having him take deep breaths only increased the saturation level to 88%. The resident's lung sounds were clear, and he had no respiratory complaints. Per the record, oxygen was started at 0.5 liters per minute, which increased his saturation level to above 90%. Review of the Daily Skilled Needs Evaluation, between [DATE] - [DATE] showed the following documentation: [DATE] - B/P-,[DATE], HR-65, RR-18, oxygen satuation of 93%, good appetite and fluid intake, oriented to person, place, and time. [DATE] - B/P- ,[DATE], HR-50, RR-18, oxygen saturation of 92% on two liters of oxygen, good appetite and fluid intake, oriented to person, place, and time. [DATE] - B/P- ,[DATE], HR-58, RR-18, oxygen saturation of 93% on two liters of oxygen. Review of the same form on [DATE] showed Staff E, Registered Nurse, documented the resident was having a change of condition, since the last evaluation was performed on [DATE]. The change in condition was documented as an elevated blood pressure with shortness of breath. The document showed the resident's blood pressure was ,[DATE], and no shortness of breath was noted. In addition, documentation showed the resident was not swallowing his medications and was chewing, had a decreased oxygen saturation level, refused breakfast, and had an elevated heart rate (showing it was 128 beats per minute - a normal rate being between ,[DATE] beats per minute), and his oxygen saturation level was 89% on room air. Per the record, when oxygen was applied at two liters per minute, the saturation level increased to 91%. Review of progress notes by Staff E, Registered Nurse, showed on [DATE] at 12:15 PM, a nursing assistant (NA) reported the resident was on the floor face down. The resident's POLST form (Physician Orders for Life-Sustaining Treatment) was checked, and Cardio [MEDICAL CONDITION] Resuscitation was initiated. The physician and 911 were then called, and when the Emergency Medical Technicians arrived, the resident was transported to the hospital where he expired at 12:45 PM on [DATE]. Staff E stated during a telephone interview on [DATE] at 3:01 PM, that the Daily Skilled Needs Evaluation form was filled out at approximately 10:00 AM on [DATE], when she entered the resident's room to give him medications, as he was the last resident on her medication schedule. Per Staff E, the resident's respiratory rate was less than 12 breaths per minute (normal is 15 -20 breaths per minute), and there was something unusual regarding his breathing. Staff E stated he usually took his medications whole without problems, but that morning he began chewing the first medication she gave him. She also stated he was not very talkative, just looked at her, and did not answer questions. Staff E stated the resident's HR of 128 beats per minute was taken by a nursing assistant before 8:00 AM, and the resident's breakfast tray was untouched. Staff E stated his oxygen saturation level was 88% to 89%, so she applied oxygen, which increased his saturation level to 91%. During a second interview with Staff E on [DATE] at 8:25 AM, regarding the observation of the resident at approximately 10:00 AM on [DATE], she stated it was not the resident's blood pressure that was elevated but rather his heart rate, and that his repiratory rate was 10 to 11 breaths per minute. Despite changes in the resident's condition, Staff E stated she did not check on the resident again until he was found at 12:15 PM by a nursing assistant lying unresponsive on the floor. Staff A did not contact the physician until after that time. Staff G, Nursing Assistant, stated during a telephone interview on [DATE] at 9:37 AM, on the morning of [DATE] at approximately 8:00 AM, the resident was not verbally responsive to her, as per his usual self. She stated, he wasn't the person (resident's name) I knew, didn't seem OK. Per Staff G, the resident was very weak, and was not able to reposition himself in bed as he normally did. He had not touched his breakfast, and usually would eat something on his tray. Staff G stated she thought the resident had his oxygen on at that time. She stated Staff E was in the hallway right by the resident's door passing medication, so she informed Staff E the resident was not OK .doesn't look so good and to check his vital signs. Staff G stated Staff E did not enter the resident's room right away. Staff H, Physical Therapist, stated on [DATE] at 3:50 PM, when the resident first admitted to the facility he was short of breath due to low activity tolerance. Staff H stated he was very alert and oriented, and they were starting to look at discharge planning. Resident #3. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders for [DATE] showed the resident received Tylenol twice daily at 8:00 AM and 6:00 PM for pain, and a narcotic pain patch every three days. Review of the resident's plan of care, dated [DATE], showed the resident had impaired cognitive function, required extensive assistance with one staff with toileting, transfers, dressing, turning/repositioning in bed, and locomotion using her wheelchair (w/c). Review of progress notes on [DATE] at 4:30 PM showed Staff I, Cook, reported to Staff E, Registered Nurse, that the resident was about to go down on the floor. When Staff E entered the resident's room, she found the resident had slipped out of the w/c, and the w/c cushion was halfway out of the chair. Per the note, the resident had her hands on the cushion behind her, with her buttocks just a few inches from the floor. Her left foot was against a transfer pole, which prevented her from falling completely to the floor. Staff E documented it appeared the resident was in the process of self-transferring from her w/c to the bed when the w/c cushion slipped, causing her to slide down. The resident was making sounds of discomfort, and was assisted to the floor by Staff E. Upon assessment (per the record), there were no signs of a fracture. Staff E documented range of motion was only partially assessed, as the resident was not cooperative, and was very combative during the assessment. The next documented assessment, relative to the resident's assisted fall, was on [DATE] at 6:00 AM (13.5 hours later), by Staff J, Registered Nurse, which showed there was no bruising, obvious injury. The resident had complained of generalized pain during the night, and was given Tylenol which showed effective results. Review of the resident's Medication Administration Record [REDACTED]. Documentation an hour later at 2:00 AM showed the medication was effective. Review of the [DATE] MAR indicated [REDACTED]. The next documentation was on [DATE] at 11:00 AM by Staff K, Registered Nurse, which showed the resident was transported to the emergency room (ER) for x-rays of her left hip due to a recent fall. Review of hospital records, dated [DATE], showed when the resident arrived to the ER she was crying out in discomfort with any movement, and immediately grabbed towards her left hip/groin area. Per the hospital record, any attempted movement of the left lower leg caused the resident discomfort; the left lower leg was externally rotated and shortened (often signs of a [MEDICAL CONDITION]). Staff I, Cook, stated during a telephone interview on [DATE] at 1:02 PM, that when he walked by the resident's room the afternoon of [DATE], the resident was completely on the floor, was sitting up. Her w/c was behind her and one leg was bent up. Staff I stated it appeared the resident had been seated in her w/c and fell out of it. Staff I immediately reported his observation of the resident to Staff E, Registered Nurse, who stated she would go and check on the resident. During an interview with Staff E on [DATE] at 8:55 AM, she stated she was told by Staff I that a resident was on the floor. Per Staff E, when she entered the resident's room, the resident was holding herself slightly up from the floor, and was afraid to let go of the w/c, so Staff E assisted her to the floor. Staff E and Staff M, Nursing Assistant, transferred the resident to her bed. With the resident in bed, Staff E attempted to do an assessment, and was unable to perform range of motion, as the resident was very combative. Staff M, Nusing Assistant, stated during a telephone interview on [DATE] at 9:38 AM, she had assisted Staff E in transferring the resident from the floor to her bed on [DATE]. Per Staff M, the resident did not express any complaints of pain until she was in bed. Staff M stated the resident was touching her groin area, tenderness in that area .wanted us to stop touching her, wouldn't let us touch her .refusing all care at that time. She was grabbing her crotch, I could see she was in pain when she was squeezing her face together like in pain. Staff M stated they just let her lay in bed with a blanket over her, and she slept for most of the evening shift. Staff J, Registered Nurse, stated during an interview on [DATE] at 10:50 AM, she worked from 6:00 PM on [DATE] to 6:00 AM on [DATE]. Staff J stated she received report from Staff E regarding the resident. Staff J stated the resident complained she had pain, but was unable to indicate where the pain was. She stated the resident was somewhat restless, so she gave her Tylenol for pain. Staff J stated the resident was combative with care that night and would not allow staff to reposition her, but her normal behavior was often to refuse repositioning. No bruising or skin problems were observed. During a telephone interview on [DATE] at 12:34 PM with Staff N, Nursing Assistant, she stated she was unaware the resident had fallen until the next day ([DATE]). Per Staff N, normally the resident used the bathroom at night, however the night following her fall she was not even trying to get up. She (the resident) was in a lot of pain, screaming out, couldn't even touch her. Staff N stated she asked Staff J if there was anything she could give the resident for pain, and Staff J responded the only thing available was Tylenol. She stated she told Staff J, this is not normal for her (the resident). Per the record, the physician had not been notified at that time. Staff O, Registered Nurse, stated during a telephone interview on [DATE] at 12:09 PM, that she had worked from 6:00 AM to approximately 10:15 AM on [DATE], at which time she left work due to illness. Staff O stated she was unaware the resident had fallen the day before, as staff on the night shift had not told her. The nursing assistants had gotten the resident up in a wheelchair, and informed her the resident was in pain during the transfer. Staff C, Nursing Assistant, stated during a telephone interview on [DATE] at 12:30 PM, that when she transferred the resident from her bed to the w/c between 6:,[DATE]:45 AM on [DATE], the resident did not grab the transfer pole like she normally did, but rather grabbed her hip and crotch areas, complaining of pain. Staff C stated the resident was fighting with Staff C when she attempted to pull her pants up. Staff C stated she reported her observations to Staff O, and that morning the resident did not eat breakfast like she normally did. At 9:40 AM the resident was grimmacing in pain. When Staff K, Registered Nurse, reported to work at 10:15 AM, Staff C stated she asked her to come and evaluate the resident, which she did. Staff K stated on [DATE] at 10:15 AM, she arrived to work on [DATE] at 10:00 AM. As soon as she walked out the door after speaking with Staff O, the Nursing Assistant came to her and told her the resident had fallen the day before and was in pain. Staff K assessed the resident at approximately 10:30 AM, and observed slight rotation of her right foot and shortness of her right leg. She stated the resident would hardly let her touch her leg/hip due to the pain. She called the physician and the resident was transferred to the ER. Staff L, Housekeeping/Laundry Supervisor, stated during a telephone interview on [DATE] at 11:33 AM, she was told by Staff E when they transferred the resident from the floor to her bed the afternoon of [DATE], the resident stated it hurts, pointing to her groin area. She stated the next morning the resident was seated in a wheelchair but, she wasn't herself, head tilted back, no verbal responses when Staff L said good morning to her. Resident #1. Review of the resident's medical record showed he was readmitted to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Clinical Functional Abilities form, dated [DATE], showed the resident required substantial/maximum assistance with toileting, transfers, dressing, and oral hygiene. A progress note dated [DATE], showed at 7:00 AM the resident was found unresponsive and expired at 7:05 AM. Staff D, Nursing Assistant, stated during a telephone interview on [DATE] at 10:25 AM, when she walked into the resident's room the morning of [DATE] he needed to use the bathroom, so she transferred him into a wheelchair and placed him on the toilet. Staff D stated she left the resident on the toilet to go find Staff C, Nursing Assistant. When she promptly returned, the resident was found unresponsive on the toilet. Licensed nurses were called, and determined the resident was without pulse or respirations. Review of the facility daily assignment sheet, dated [DATE], showed the resident's blood pressure (B/P) as ,[DATE] and his heart rate (HR) was initially 43 beats per minute (BPM), and when rechecked was 50 BPM (a normal heart rate is between ,[DATE] beats per minute). Review of the Daily Skilled Needs Evaluation forms between ,[DATE]-,[DATE] showed the following vital signs: ,[DATE] - B/P-,[DATE], HR-52 BPM. ,[DATE] - B/P-,[DATE], HR-60 BPM. ,[DATE] - B/P-,[DATE], HR-50 BPM. ,[DATE] - no vital signs documented. ,[DATE] - B/P-,[DATE], HR-50 BPM. ,[DATE] - B/P-,[DATE], HR-78 BPM. ,[DATE] - B/P-,[DATE], HR-60 BPM. ,[DATE] - B/P-,[DATE], HR-60 BPM. Review of physician's orders showed when the resident was readmitted from the hospital on [DATE], the dosage for [MEDICATION NAME] (a medication used to treat heart failure and irregular heartbeats with the side effect of slowing the HR) had increased from 125 micrograms (mcgs) to 250 mcgs per day. In addition, [MEDICATION NAME] (a medication used to treat high blood pressure and irregular heartbeats with the side effect of slowing HR) dosage was reduced from 80 milligrams (mgs) twice daily to 40 mgs twice daily. Prior to the resident's hospitalization , review of his vital signs betweeen ,[DATE]-,[DATE] at 7:00 AM showed an average BP of ,[DATE] and average HR of 72 BPM. Despite the changes in dosages of the medications on [DATE], and decreased B/Ps and HRs between ,[DATE]-[DATE], there was no nursing evaluation of the effects of the medication dosage changes, or contact with the physician regarding changes in vital signs. In addition, despite the low HR readings on ,[DATE], ,[DATE], and [DATE], [MEDICATION NAME] was administered to the resident on ,[DATE], and [DATE], and [MEDICATION NAME] was administered to the resident on ,[DATE], ,[DATE], and [DATE]. In addition, despite the resident's B/P on [DATE] being ,[DATE], [MEDICATION NAME] was administered. Both medications were administered to the resident on [DATE] in the absence of documented B/P and HR. There were no physician ordered parameters for the [MEDICATION NAME] and [MEDICATION NAME] following the resident's readmission to the facility on [DATE]. Reference (WAC) [DATE](1)

Based on interviews and record review, the facility failed to ensure one of four residents (#1), was treated in a dignified and respectful manner by a nursing assistant (Staff A). This failure resulted in actual harm to Resident #1, due to injuries he received when Staff A attempted to remove his watch in preparation for a shower, which he was refusing to take. Findings include: Resident #1. Review of the resident's 01/11/18 Care Directive Form (utilized by nursing assistant staff, which gives resident-specific directions for care), showed the resident required assistance with activities of daily living, was at risk for falls, and at risk for skin injuries, for which he was to wear geri sleeves (arm protectors for thin, fragile skin). Review of the resident's medical record noted a Progress Note (PN), dated 04/20/18 at 3:15 PM, which showed the resident was alert and oriented, and able to make his needs known. He angrily stated to staff, she (Staff A- Nursing Assistant) grabbed my arms when I said I don't want to take a shower; look what she did. I'm bleeding all over. I don't want her in my room. The resident was found with three skin tears on his left arm, one between his thumb and wrist, two by the left elbow, and another skin tear to the right wrist. Geri sleeves were then applied to the resident's arms, following treatment to the skin tears. Review of the facility investigation report, related to the above incident, showed an interview conducted by Staff B, Social Services, with Staff A, Nursing Assistant, on 04/20/18. Staff A stated she initially told the resident, I am going to give you a shower, to which the resident replied, no. Staff A then stated to the resident, it's time to take a shower - it's been three days, to which the resident again replied,no. Staff A then stated, here let me help you take your watch off, and get you ready for a shower. The resident stated, no, don't, I am not taking a shower. Staff A stated during the above exchange with the resident, she was holding his left hand in both of her hands, and attempting to remove his watch from his left wrist. She had demonstrated she was supporting the resident's left hand with her left hand, and with her right hand she had grasped the expandable band of his watch, and was attempting to pull it off. The resident was pulling back with his left arm, attempting to break free of her grasp. Staff A stated when the resident said he was not going to take a shower, he grabbed his watchband with his right hand, and pulled it back onto his wrist. It was at that point when Staff A looked down, saw the resident's skin tearing and bleeding, so she immediately let go of the resident's hand. When Staff B, Social Services Director, was questioned on 05/07/18 at 1:20 PM, relative to the above incident, she stated when she interviewed the resident he displayed fear immediately following the interaction with Staff A, but after staff talked with him throughout the day, his fear lessened. He initially made the comment it was a dangerous place. During an interview with the resident on 05/07/18 at 11:20 AM, he stated she (Staff A) had come into his room and wanted to give him a shower, which he refused to take. The resident stated, she was insistent, and she definitely heard him tell her no, he was not going to take a shower. Resident #1 also stated when she tried to remove his watch from his left wrist, that was when he sustained the injuries to his arms. He stated the geri sleeves were not on at the time of the incident. The resident denied any fear of Staff A, stated he didn't feel she intentionally caused the injuries, but rather was not listening, when he told her he did not want to shower at that time. Reference (WAC) 388-97-0180(1-4)

Based on observation, record review, and interviews, the facility failed to ensure adequate supervision and protective devices were provided to prevent accidents, for one of eight residents (#1), reviewed for falls. This deficient practice resulted in actual harm to Resident #1, who fell from the wheelchair in the facility van, after not being secured in the wheelchair during the transport, and sustained a fractured toe, facial injuries, and hematoma (blood collection outside of a blood vessel) of the scalp. Findings included: Resident #1: review of the resident's medical record revealed [REDACTED]. Review of Progess Notes (PNs), dated 05/11/17, showed the Physical Therapist (PT) requested two staff to assist with all transfers. Review of a facility investigation report and PNs showed on 06/13/17 at 12:16 p.m., the facility received a telephone call from Staff A, Maintenance Director, stating that during the transport of the resident, to an appointment outside the area, he had to slam on his brakes to avoid a collision with a delivery truck. That action resulted in the resident being flung forward from her wheelchair into a metal bar, and then onto the floor. The resident was quickly taken to the emergency room by ambulance, where x-rays revealed a fractured fifth toe of the right foot, swelling of the eyelid and right cheek, an abrasion (wound caused by superficial damage to the skin) to the top of the head, and a hematoma of the scalp. The above investigation showed Staff A had secured the resident's wheelchair with tie-downs prior to the transport, however, there were no protective devices (waist and shoulder straps) utilized, to secure the resident in the wheelchair. Staff A stated he had forgotten to attach the seat belt and shoulder safety harness on the resident, as he was rushed. Review of the Employee Safety: Authorized Driver form, included the following rule, The driver and passengers are required to wear seat belt and shoulder harness. Staff A had signed the above form on 03/24/17, noting that he had read and understood that rule. Staff A informed the administrator, during the investigation, that he had received previous training regarding the safety rules of the van from a former staff member. Per interview on 07/13/17 at 3:40 p.m. with Staff B, PT, noted the resident was becoming progressively weaker during therapy sessions, prior to the above incident on 06/13/17. Observation of the facility van on 07/14/17 at 9:35 a.m., accompanied by Staff C, Administrator, noted a metal bar, extending from the ceiling to the floor, was located behind the driver's seat. Appropriate protective devices were observed. Staff C stated at the time of the incident, the resident was seated directly behind the driver. When Staff A abruptly applied the van brakes, the resident was thrown from her wheelchair into the metal bar, and landed on the floor of the van. Reference: (WAC 388-97-1060(3)(g))

Based on interview and record review, it was determined the facility failed to provide consistent supervision to prevent a fall with fracture for 1 of 2 residents reviewed for accidents (#17) in a sample of 36. Failure to provide consistent supervision resulted in actual harm to Resident #17 who sustained a fractured right leg following a fall. Findings include: Resident #17 had [DIAGNOSES REDACTED]. Per record review, on admit the resident had some short-term memory problems, confusion, and required extensive assistance of 2 for bed mobility and transfers. The resident was impulsive, had poor safety awareness and judgment, and was at risk for falls. Care plan interventions to limit the risk of injury included a bed low to the floor and alarms that sounded when the resident was in bed or the wheelchair to alert staff to the resident getting up unassisted. Additional record review of nursing note dated 12/3/12 at 10:00 p.m. revealed the resident had progressed to requiring 1 person assist for transfers and bed mobility, was continent and using the toilet, and was using the call light to request assistance. Per record review, on 12/4/12 at 2:20 p.m., the resident was found on the floor in her room, holding the alarm that was still attached to her sweater and had not sounded. The resident appeared unharmed and stated she slipped out of the chair while trying to reposition herself. Additional record review revealed on the evening shift of 12/5/12, the resident was confused and tried to self-transfer approximately 17 times. The resident took the alarm off when in her room and also attempted to self-transfer to the toilet. Staff provided 1:1 for supervision and instruction about using the call light and leaving the alarm attached, and had the resident stay at the nurse's station for increased supervision. Per record review, on the evening shift of 12/6/12, staff noted the resident was "still self-transfering'" was confused, and had short-term memory loss. There was no information about measures the staff implemented to provide supervision. There was no evaluation in the clinical record of the symptoms of increased restless behavior, the inability to remember to use the call light to call for assistance, and the resident's supervision needs in light of her removing the alarm and self-transferring. Review of the facility investigation related to the fracture noted that on 12/8/12 during the dayshift, the resident was "up and down" and was found self-transferring to the bathroom. On the evening shift, the nursing assistant caring for the resident again found her removing the alarm and self-transferring. The nursing assistant placed the resident at the nurse's station while assisting other residents with dinner and explained the resident needed assistance with every transfer. At 7:30 p.m., the nursing assistant talked to the resident and made a plan to assist the resident to get ready for bed at 8:00 p.m. At 7:45 p.m., the nursing assistant reminded the resident she would assist her at 8:00 p.m. After 7:45 p.m., the resident repeatedly asked staff what her room number was and if she could go to her room. Staff advised her she could go to her room, but should not try to get ready for bed until someone helped her. At 8:00 p.m., staff heard the resident calling for help and found her partially undressed on the floor in the bathroom doorway with injury to her right leg. The alarm was on the wheelchair seat still attached to the sweater. The resident stated she was told she could use the bathroom if she needed to. The resident was transferred to the local hospital for surgery for [REDACTED]. Despite the resident's repeated incidents of self-transfer and the nursing assistant's plan to take the resident to her room to provide care with needed supervision, other staff allowed the resident to go to her room unsupervised; at which time the resident self-transferred and fell , sustaining a significant injury due to lack of staff supervision.

Based on observation, interview, and record review, the facility failed to develop measures to prevent pressure ulcer development, re-evaluate and implement new interventions to promote healing for 1 of 4 (#59) resident's reviewed with pressure ulcers in a sample of 37. This resulted in harm for Resident #59. Findings include: Resident #59 had [DIAGNOSES REDACTED]. The resident had memory problems and moderate impairment with making daily decisions. He required assistance with activities of daily living (ADL's) including bed mobility. Care planned interventions included weekly licensed nurse skin checks and directed the nursing assistants to monitor for red areas and report to the nurse if observed. Per record review, the resident was admitted to the facility on [DATE] and had no pressure ulcers. The facility assessed the resident as a moderate risk for developing pressure ulcers. Per record review, the resident developed a pressure ulcer on his left heel on 10/8/10. After the development of the pressure ulcer the resident received an order for [REDACTED]. Per record review, on 11/12/10 the facility documented there was another pressure ulcer on the left heel. The pressure ulcer was a stage 1 (intact skin with non-blanchable redness). After the pressure ulcer developed, the facility implemented an intervention to float the resident's heels. The interventions included wearing quilted boots and to apply cream to the heels. Per record review, on 11/19/10 the ulcer worsened to a stage 2 (shallow open ulcer) measuring 1 centimeters (cm) x 1 cm. The skin team recommended cleansing the left heel with a medicated cleanser and covering with a [MEDICATION NAME] dressing (a skin dressing to promote healing of wounds). The order was to change the dressing every 3 days or as needed. Per weekly skin assessments on 12/3/10 through 12/17/10, the left heel pressure ulcer worsened to a 3.5 cm x 2 cm ulcer and had 100% eschar (dead tissue). Per record review there was no information indicating the facility evaluated the effectiveness of the treatment at that time. Per record review on 12/17/10, the resident developed a right heel pressure ulcer. The right pressure ulcer was not discovered until it measured 5 cm x 6 cm with 100% eschar. There was no documentation of the right heel pressure ulcer being assessed again until 1/7/11 and at that time it worsened to 7 cm x 6 cm with black/brown tissue. The left heel pressure ulcer was measuring 3 cm x 4 cm with 100% eschar and it mentioned the resident had tissue swelling. Per record review, on 1/14/11 the wound on the left heel was the same size with drainage, a slight odor and the tissue was white/grey in color. The physician was not contacted with the status of the left heel pressure ulcer and the treatment remained the same from 11/19/10 to 1/14/11. The right heel pressure ulcer was evaluated after 2 weeks and the treatment was changed. The left heel pressure ulcer did not have a change in the treatment even though it worsened. Per interview on 1/24/11 at 3:15 p.m., Staff #A stated the skin team reviewed the residents with pressure ulcers weekly. She reported that the skin team determined what type of treatment would be used after consulting with the physician. She discussed that if in 2 weeks there was no improvement of the pressure ulcer then they would contact the physician to get further orders. Staff #A confirmed the physician had not been contacted on the status of the resident's left heel pressure ulcer. The facility failed to prevent, re-evaluate when the pressure ulcer was not improving, and did not implement new treatments for the left heel pressure ulcer. This resulted in harm for this resident.