Every finding on record at Colonial Vista Post-Acute & Rehab Center

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review [(PASARR)-an assessment used to identify people referred to nursing facilities with serious mental illness (SMI), intellectual disabilities (ID), and related conditions were not inappropriately placed in nursing homes for long-term care] had the required Level II referral sent when residents had a positive Level 1 PASARR and were an exempted hospital discharge (a process that allowed residents admission to a nursing facility from a hospital without undergoing the PASSAR screening when certain criteria were met) in the facility for more than 30 days for 4 of 7 residents (Resident 35, 64, 44 and 8) reviewed for PASARR. Additionally, the mental health diagnoses were not accurately documented on the PASARR Level I. These failures placed the residents at risk for inappropriate placement and not receiving timely and necessary services to meet mental health care needs. Findings included. Resident 35 Review of the medical record showed Resident 35 was admitted to the facility on [DATE] with diagnoses including a left leg fracture and anxiety. The 06/27/2025 comprehensive assessment showed Resident 35 had an intact cognition. Review of Resident 35's PASARR dated 06/20/2025, showed Resident 35 had a SMI for anxiety disorders and was an exempted hospital discharge. The PASSAR further showed a Level II must be completed if the scheduled discharge did not occur. Record review showed no PASARR Level II evaluation for Resident 35. Resident 64 Review of the medical record showed Resident 64 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (MDD –a mood disorder of persistent feelings of sadness, loss of interest, changes in sleep affecting how a person feels, thinks and behaves), Post-Traumatic Stress Disorder [(PTSD) a mental health condition that's caused by an extremely stressful or terrifying event], and anxiety. The 07/24/2025 comprehensive assessment showed Resident 64 had an intact cognition. Review of Resident 64's PASARR dated 07/18/2025, showed Resident 64 had a diagnosis of anxiety disorders and depression and was an exempted hospital discharge. The PASSAR further showed a Level II must be completed if the scheduled discharge did not occur. Review of the medical record showed no PASARR Level II evaluation completed for Resident 64. Resident 44 Review of Resident 44's medical record showed they were admitted to the facility on [DATE] with diagnoses which included a right femur (hip) fracture, dementia (a decline in cognitive ability) and depression (a mood disorder which causes sadness). The comprehensive assessment dated [DATE], showed the resident was severely cognitively impaired. Review of Resident 44's PASARR Level I, showed the assessment was completed by hospital staff on 07/14/2025 prior to admission to the facility. The assessment indicated the resident had an anxiety disorder, however, did not accurately reflect the resident's diagnosis of depression. Additionally, the PASSAR showed the resident was exempt from further screening as it was expected they would be discharged from the facility in 30 days or less. It was noted as of 08/22/2025 that the resident was already five days past the 30-day exempted stay and required a Level II screening. Record review showed no PASARR Level II evaluation for Resident 44. Resident 8 Review of the medical record showed Resident 8 was admitted to the facility on [DATE] with diagnoses including cardiac disease and PTSD. The comprehensive assessment dated [DATE], showed Resident 8 was cognitively intact. Review of Resident 8's PASARR Level I dated 05/28/2025, showed they had no mental health diagnoses and a Level II PASARR was not indicated. A second PASARR Level I was completed on 06/23/2025 by facility staff stating the 05/28/2025 completed PASARR Level I was incorrect and was updated to reflect the diagnoses of a depressive mood disorder and PTSD, though the PASARR still stated that no Level II evaluation was indicated for this resident. Record review showed no PASARR Level II evaluation for Resident 8. During an interview on 08/22/2025 at 10:33 AM, Staff D, Social Services Director, stated residents admitted to the facility had their PASARR's reviewed for accuracy of mental health diagnoses and 30-day hospital exempted discharges upon admission to ensure accuracy and if additional assessments such as a PASARR Level II was required for residents. Staff D stated the process was not followed. Reference WAC 388-97-1915(1)(2)(-c)

Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities for 6 of 6 residents (Resident 74, 14, 66, 57, 15, and 69) reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom. Findings included. Resident 74 Review of the medial record showed Resident 74 admitted to the facility on [DATE] with diagnoses including poliomyelitis (an infection that affects nerves, brain and spinal cord and can result in loss of muscle functions), diabetes (a disease that results in excess sugar in the blood), and obesity. The comprehensive assessment dated [DATE], showed Resident 74 required total assistance of one to two staff members with activities of daily living (ADLs) and was cognitively intact. Resident 14 Review of the medical record showed Resident 14 admitted to the facility on [DATE] with diagnoses including diabetes and kidney disease. The comprehensive assessment dated [DATE], showed Resident 14 required extensive assistance of one to two staff members with ADLs and was cognitively intact. Resident 66 Review of the medical record showed Resident 66 admitted to the facility on [DATE] with diagnoses including a stroke (a medical emergency that occurs when blood flow the brain is disrupted and deprives the brain of oxygen, leading to brain damage, disability or death) and diabetes. The comprehensive assessment dated [DATE], showed Resident 66 required total assistance of one to two staff members with ADLs and was cognitively intact. Resident 57 Review of the medical record showed Resident 57 admitted to the facility on [DATE] with diagnoses including kidney disease and heart disease. The comprehensive assessment dated [DATE], showed Resident 57 required extensive assistance of one to two staff members with ADLs and was cognitively intact. Resident 15 Review of the medical record showed Resident 15 admitted to the facility on [DATE] with diagnoses including cerebral palsy (a brain disorder that affects body and muscle coordination and movements) and kidney disease. The comprehensive assessment dated [DATE] showed Resident 15 required extensive assistance of one to two staff members with ADLs and was cognitively intact. Resident 69 Review of the medical record showed Resident 69 admitted to the facility on [DATE] with diagnoses including heart disease and kidney disease. The comprehensive assessment dated [DATE] showed Resident 69 required extensive assistance of one staff member for ADLs and was cognitively intact. During a Resident Council meeting (a group of residents that meet regularly to improve the quality of life and care in the nursing home) on 08/20/2025 at 10:10 AM, Resident 74 stated they were not happy with the activities that were provided by the facility anymore. Resident 74 stated in the past year since they have had a new Activities Director, they had not gone outside of the facility on any outings. They stated they used to get on the facility bus and go shopping or just out for drives but all that had stopped. Resident 74 stated they had brought it up before in Resident Council meetings, but were told they did not have anyone in the facility that could drive the bus anymore or that there was not enough help to take them out of the facility, so basically we are stuck in here unless we have family who can provide the appropriate transportation and assistance. During the same Resident Council meeting at 10:15 AM, Resident 14 stated they missed going on facility outings and when they complained about it, they had been told that there were not enough staff or volunteers to safely take them out anywhere. Resident 14 stated they did not understand that since the other Activities Director took a few different residents on outings at least once a week. This ensured everyone had a chance to go out once a month, even if they could not accommodate a large group. During the same meeting at 10:18 AM, Resident 69 stated the group used to go on outings called a Tour of Washington that were drives to interesting places, mostly within an hour of the facility. Resident 69 stated residents did not get off of the bus once they were loaded, as they did not require much care. Resident 69 stated not being able to go out and visit the world outside of the facility was depressing. During the same Resident Council meeting at 10:22 AM, Resident 15 stated they had a different problem about not going out of the facility on outings. Resident 15 stated they had been told their wheelchair was too large to fit in the facility bus. Resident 15 stated they used to be able to take the community bus and meet up with other residents for shopping or a meal, but that option had not been offered to them in over a year. Resident 15 stated they were told the facility bus was broken and that was why they were unable to go out of the facility unless they took the community bus. During the same meeting at 10:26 AM, Resident 57 stated they were also unhappy with the limited activities in the building and not being able to go out of the facility. Resident 57 stated they especially missed being able to go to the local apple festival and the annual [NAME]. They stated it used to be a big deal, and the residents would look forward to it and the staff would help take the residents to these events since they were close to the facility. During the same meeting at 10:30 AM, Resident 66 stated they agreed with all the other residents attending the meeting and would like to see more interesting activities both in and outside of the facility as they were frequently bored. During an interview on 08/20/2025 at 3:26 PM, Staff P, Activities Director, stated the residents had shared in past Resident Council meetings that they would like to go on facility outings again, but they had limited ability to do so since most of the residents were in wheelchairs, and it was difficult to load and unload them by themselves. Staff P stated the facility bus had been broken but was now fixed and they mainly used the facility van for appointments only. During an interview on 08/21/2025 at 9:15 AM with Staff A, Administrator and Staff K, Regional Nurse, stated they were aware the residents were requesting outside of facility outings and were working on arranging more outings with the activities department now that their bus was repaired. Reference WAC: 388-97-0940(1)(2)

Based on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for 2 of 5 residents (Resident 6 and 15) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity, respect and embarrassment. Findings included . Review of the policy titled Activities of Daily Living dated 03/2021, showed residents would be provided with care, treatment, and services to ensure their ADLs were maintained and did not diminish. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently in accordance with the care plan including appropriate support with assistance with elimination (toileting), hygiene (dressing) and eating. Resident 6Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain) and Alzheimer's Disease (a progressive brain disorder where brain cells are damaged and die, leading to a gradual decline in memory, thinking, and the ability to perform daily tasks). The 04/10/2025 comprehensive assessment showed Resident 6's cognition was severely impaired and required the assistance of two staff for ADLs including toileting hygiene and lower body dressing. During multiple observations from the hallway on 08/19/2025 at 3:18 PM, Resident 6 was visible from the hallway unclothed from the waist down lying in bed without an incontinent brief in place, there was a urine-soaked incontinent brief on the floor to the right of the bed. The resident's bottom and bed linens were soiled with bowel movement (BM), and urine saturated the bedding. A strong odor of BM was noted radiating into the hallway. At 3:27 PM, the resident was unclothed from the waist down, with BM on their bottom and linens. Four different staff members walked past the resident's doorway without providing assistance. At 3:31 PM, Staff J, Nursing assistant, NA, looked into the resident's room, observed the resident partially unclothed, and continued down the hallway without providing assistance to Resident 6. At 3:48 PM, the resident remained lying on their back, soiled with BM, attempting to pull their shirt down to cover themselves. At 3:54 PM, the resident continued to lie on the soiled mattress without a call light in use. The BM remained dried on the resident's bottom and linens. During an interview on 08/19/2025 at 3:55 PM, Staff J, stated they observed Resident 6 exposed when they looked into the resident's room. Staff J stated they did not notice the brief on the floor or the BM on both the resident and linen. Staff J stated they did not enter the room or provide the care that was needed at that time. Staff J stated they were told by other NAs to wait until it was the scheduled time to do cares on Resident 6 because he was restless. Staff J further stated they should have entered the room immediately to provide the necessary care. During an interview on 08/21/2025 at 4:02 PM, Staff A, Administrator, stated they would expect a NA to provide care immediately upon observing a resident who was exposed, and the correct process was not followed for Resident 6. Resident 15 Review of Resident 15's medical record showed the resident was admitted with diagnoses which included cerebral palsy (a disease due to abnormal brain development which effects movement and muscle tone), depression (a mood disorder which causes sadness) and dysphagia (difficulty swallowing). Review of the comprehensive assessment dated [DATE] showed Resident 15 was cognitively intact and was able to independently feed themselves after their meal was set up by staff. During an observation on 08/18/2025 at 11:55 AM, Resident 15 was sitting at a table in the dining room with another resident who had been served their meal and was eating. At 12:21 PM, Resident 15 stated to the Surveyor Can someone please go and find my lunch I am hungry. Resident 15 further stated This happens quite a bit. During a continued observation on 08/18/2025 at 12:25 PM, the resident sitting with Resident 15 stated to dietary staff She doesn't have a tray, and I am almost done. At 12:30 PM, Resident 15 received their tray, 30 minutes after the other resident had been served their meal and were done eating. During an additional observation on 08/20/2025 at 12:07 PM, Resident 15 was waiting for their meal after the other resident had been served and was eating. At 12:17 PM, Resident 15 was served their meal (10 minutes after the other resident). During an interview on 08/20/2025 at 12:20 PM, Staff L, NA, stated Resident 15's tray was usually sent out on the hall cart and placed in the resident's room instead of the dining room, which was why their meal was late every day. During an interview on 08/21/2025 at 10:31 AM, Staff K, Regional Nurse, stated it was an expectation that residents were served their meals at the same time to ensure their dignity was maintained. REFERENCE: WAC 388-97-0180(1-4).

Based on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed for safe administration of medications for 2 of 3 residents (Residents 35 and 79), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment placed the residents at risk for medication errors, adverse medication interactions, and complications. Findings included. Review of the policy titled, Self-Administration of Medications, revised 02/2021, showed residents had the right to self-administer medications when the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help people receive the care they need] determined it was safe and appropriate through an evaluation and assessment of the residents cognitive and physical abilities. The policy showed when a resident was identified as appropriate and safe to self-administer medications, it would be documented in the resident's medical record and care plan. Resident 35Review of the medical record showed Resident 35 was admitted with diagnoses including a left leg fracture, multiple sclerosis (a disease that damages the communication between the brain and body, leading to muscle weakness, vision changes and memory issues) and fibromyalgia (a long-term health disorder of widespread body pain, tenderness, and fatigue). The 06/27/2025 comprehensive assessment showed Resident 35 required one to two staff members for activities of daily living (ADLs) and had an intact cognition. Review of Resident 35's medical record showed the resident had not been evaluated by the IDT for self-administration of medications or documented on their care plan.An observation on 08/18/2025 at 3:07 PM, Staff G, Licensed Practical Nurse, LPN, brought a medicine cup with three unknown medications, two white pills and one yellow capsule, into Resident 35's room and placed them onto the bedside table and exited the room. Staff G did not identify the medications or ensure Resident 35 took the medications. During an interview on 08/20/2025 at 9:41 AM, Staff G stated there were no residents that were allowed to have any medications in their rooms. Staff G stated Resident 35 was care planned to take their potassium and Lasix [(diuretic) increase production of urine] after their physical therapy. Staff G stated they did not need to observe residents taking their medications. Staff G further stated Resident 79 was permitted to have a pain relieving cream in their room as they were able to administer to themselves. During an interview on 08/20/2025 at 10:38 AM, Staff F, Resident Care Manager, RCM, stated there were no residents on the South Hall, where Resident's 35 and 79 resided, that were approved to self-administer their medications. Staff F further stated nurses were not allowed to leave any medications at the resident's bedside.During a concurrent observation and interview on 08/21/2025 at 2:22 PM, Resident 35 lying in their bed, with two white medications (a potassium tablet and a diuretic) in a medication cup and a box of topical pain relief cream on their bedside table. Resident 35 stated the medications were provided to them during the morning medication pass, and they held them all day and took them after their therapy in the afternoon and the pain relief cream was brought in by their family and the nurses were aware of this. Resident 79Review of the medical record showed Resident 79 was admitted with diagnoses including endocarditis (a serious infection of the heart lining), high blood pressure and diabetes (a chronic disease that results in too much sugar in the blood). The 07/24/2025 comprehensive assessment showed Resident 79 required substantial/set-up assistance of one to two staff for ADLs and had an intact cognition. Review of Resident 79's medical record showed the resident had not been evaluated by the IDT for self-administration of medications or documented on their care plan.During a concurrent observation and interview on 08/21/2025 at 3:33 PM, Resident 79 was sitting in a wheelchair in their room with a family member. On their bedside table were two types of pain relief creams, eyedrops, a topical cough suppressant and sleep supplement. Resident 79 stated their family had brought all these medications and supplements from home and they took them when they wanted. During an interview on 08/21/2025 at 2:41 PM, Staff B, Director of Nursing, stated the process for residents to administer their own medications was, the residents needed to be evaluated by the IDT to ensure the residents were cognitive, able to identify the medications, and use appropriately and have a physician's order. Staff B stated unless a resident had this process in place, nurses were to observe the residents taking their medications and not leave at the bedside. Reference WAC 388-97-0440

Based on interview and record review, the facility failed to ensure adequate monitoring and indications for use was in place for psychotropic (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) medication management for 1 of 5 residents (Resident 10) reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and adverse side effects. Findings included .Review of the policy titled, Antipsychotic Medication [used to treat mental health symptoms], dated 08/2024, showed nursing staff would observe and document information regarding the effectiveness of any antipsychotic medications. It further showed that nursing staff would review for appropriate indications for use for the drug, monitor for and report to the attending physician, side effects and adverse consequences.Resident 10Review of the medical record showed Resident 10 admitted to the facility with diagnoses including dementia (a decline in mental ability, specifically affecting thinking, memory, and reasoning), depression (a serious, long-lasting medical illness that involves persistent sadness, a loss of interest or pleasure in daily activities, and a range of emotional and physical problems), post-traumatic stress disorder (PTSD- a mental health condition that can develop after experiencing or witnessing a life-threatening or terrifying event, like war, a serious car accident, or assault) and insomnia (when you consistently have trouble falling asleep, staying asleep, or waking up too early, leading to poor-quality sleep even when you have time and opportunity for it). The 05/23/2025 comprehensive assessment showed Resident 10 had an impaired cognition and required the assistance of one staff member with activities of daily living (ADLs).Review of Resident 10's physician's order dated 07/19/2025, showed an antipsychotic medication had been ordered for insomnia, which was not an approved indication for use. Further review showed no monitoring for side effects related to antipsychotic medication. During an interview on 08/21/2025 at 12:30 PM, Staff D, Social Service Director, stated the process for any resident on psychotropic medications was to ensure the indication for use was correct, and monitoring of the medication was in place. Staff D stated they had not been notified that Resident 10 had been placed on an antipsychotic medication therefore their process for Resident 10 was not followed. During an interview on 08/21/2025 at 12:45 PM, Staff B, Director of Nursing, stated residents prescribed psychotropic medications were expected to have monitoring of side effects documented in the physician's orders and on the medication administration record. Staff B further stated social services and the Resident Case Managers were responsible for reviewing all psychotropic medications to ensure the correct indication for use and monitoring was in place. Staff B stated insomnia was not the correct diagnosis for the medication prescribed and should not have been used. Staff B Further stated they were aware they had ongoing issues with psychotropic medication practices. Reference: (WAC) 388-97-1060 (3)(k)(i)(4)

Based on observation, interview, and record review, the facility failed to ensure residents were able to use personal possessions in their room, specifically a personal refrigerator, for 2 of 2 residents (Residents 74 and 69) reviewed for resident rights. This failed practice placed the residents at risk of feeling like their rights had been taken away and emotional distress. Findings included . Resident 74Review of the medial record showed Resident 74 admitted to the facility on [DATE] with diagnoses including poliomyelitis (an infection that affects nerves, brain and spinal cord and can result in loss of muscle functions), diabetes (a disease that results in excess sugar in the blood), and obesity. The comprehensive assessment dated [DATE], showed Resident 74 required total assistance of one to two staff members with activities of daily living (ADLs) and was cognitively intact.Resident 69Review of the medical record showed Resident 69 admitted to the facility on [DATE] with diagnoses including heart disease and kidney disease. The comprehensive assessment dated [DATE], showed Resident 69 required extensive assistance of one staff member for ADLs and was cognitively intact.During a Resident Council meeting (a group of residents that meet regularly to improve the quality of life and care in the nursing home) on 08/20/2025 at 9:50 AM, both Resident's 74 and 69 stated approximately one year ago their personal refrigerators that were in their rooms were taken away from them with no explanation other than they were not allowed to have them anymore. They stated they were told by the previous facility administrator, if they wished to own personal food and drink items that required refrigeration, the activities department would keep the items for them. They both stated they knew of other residents who had personal refrigerators and felt it was not right for some to be able to have them and others not with no explanation or facility policy explaining the reason behind their decision.During a concurrent interview on 08/20/2025 at 3:21 PM, Staff B, Director of Nursing and Staff K, Regional Nurse, stated they were looking into getting the residents who wanted their refrigerators back to them as they had no knowledge of the reasons they were taken from them last year. Staff K stated they understood it was a resident's right to have personal items in their rooms as long as they were properly maintained and would review policies to cover personal refrigerator use in the facility. Reference WAC 388-97-0560 (1)(a-c)

Based on observation, interview and record review the facility failed to provide adequate supervision during meals consistent with resident needs for 1 of 3 residents (Resident 15) reviewed for accidents and supervision. This failure placed Resident 15 at risk for choking and adverse health outcomes. Findings included. Resident 15 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included cerebral palsy (a disease due to abnormal brain development which causes disorders of movement, muscle tone and posture), and dysphagia (difficulty swallowing). Review of the comprehensive assessment dated [DATE] showed the Resident 15 was cognitively intact and dependent on staff for dressing, grooming and personal hygiene however they were able to eat independently after their meal was set up. Review of a physician order dated 08/20/2025 showed Resident 15's diet was regular texture with soft bite sized pieces served with gravy or sauce to decrease choking risk and thin liquids with straws to maintain swallowing precautions. Resident 15's care plan updated on 08/12/2025 showed the resident had identified choking risks related to their diagnosis of dysphagia. The intervention outlined in their care plan was to provide monitoring and supervision during meals for choking, coughing and/or holding food in their mouth without swallowing. During an observation on 08/18/2025 at 12:36 PM, showed Resident 15 was sitting at a table in the activity room with another resident eating their meals. The residents were eating alone with no staff providing any monitoring or supervision during the meal. During an interview on 08/18/2025 at 12:50 PM, Resident 15 stated they ate most of their meals with the unidentified resident in the activity room as they enjoyed each other's company and were good friends. Resident 15 stated they needed the other resident when they ate because they were afraid of choking on their food and further stated the nursing staff did not monitor them or provide them with supervision during their meals. During additional observations of Resident 15's meals showed on 08/19/2025 from 12:18 PM to 12:51 PM no staff supervision, on 08/20/2025 from 8:10 AM to 9:00 AM no staff supervision and on 08/20/2025 from 12:17 PM to 12:55 PM there was no staff in the activity room providing supervision or monitoring Resident 15 for choking during their meals. During an interview on 08/20/2025 at 12:14 PM, Staff L, Nursing Assistant, (NA), stated the nursing staff did not provide supervision for Resident 15 during meals as they were not aware they had swallowing precautions. During an interview on 08/21/2025 at 10:20 AM, Staff K, Regional Nurse, stated nursing staff should be providing supervision for Resident 15 during meals as they had dysphagia and were at risk for choking when they ate. Reference WAC388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure a resident who was continent of bowel and bladder received services and assistance to maintain their continent status for 1 of 2 residents (Resident 19) reviewed for bowel and bladder function. Failure to identify the decline in bladder and bowel continence and assess/determine causative factors, left the resident at risk for continued decline, feelings of embarrassment, and a decreased quality of life. Findings included. Resident 19 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory disease, diabetes, obesity, kidney disease, and depression. Resident 19's comprehensive assessment dated [DATE], showed they required total assistance of two staff members for bed mobility and transfers with a mechanical lift and were cognitively intact. During a concurrent observation and interview with Resident 19 on 08/19/2025 at 10:40 AM, showed them lying in bed with only a gown and an incontinent brief on. Resident 19 stated they liked to use a bed pan (a shallow vessel used by bedridden persons for urination or defecation) or a bedside commode when they needed to go to the bathroom and were continent of both their bowel and bladder if they were toileted in time. They stated they put on their call light multiple times a day to either be placed on the bedpan or gotten up on a commode, but the staff rarely answered their call light timely, so they had accidents in their brief and needed to be changed. During the same interview Resident 19 stated it was embarrassing to be cleaned up after an accident, but they could only hold it for so long before they just went ahead and went in the brief. Resident 19 stated I feel like the staff ignore my call light a lot of the time, because due to my large size, it takes at least two people to turn me over and position a bed pan under me or get me out of bed, so I rarely even ask to get up anymore. Review of Resident 19's care plan for bladder incontinence dated 06/12/2024 showed, the resident has bladder incontinence related to weakness and decreased mobility with the interventions listed as, bladder: some control, wears briefs, clean peri area with each incontinence episode. Review of Resident 19's care plan for bowel incontinence dated 06/12/2024 showed, the resident has bowel incontinence with the interventions listed as, bowel: some control, provide bedpan/bedside commode, provide peri-care after each incontinent episode. Review of the nursing assistant documentation from 07/23/2025 to 08/21/2025 showed Resident 19 was continent of their bladder 19 times and 66 times of incontinence. Review of the nursing assistant documentation from 07/23/2025 to 08/21/2021 showed Resident 19 was continent of their bowel three times, 21 times of incontinence, and eight times with no bowel movement recorded. During an interview on 08/20/2025 at 9:20 AM, Resident 19 stated they had never been assessed by the nursing staff on their bowel and bladder function or placed on any type of scheduled toileting to monitor for continence when toileted on a regular basis since their admission to the facility. During an interview on 08/21/2025 at 4:07 PM, Staff M, Registered Nurse, stated Resident 19 would use their call light to use the bedpan, however by the time staff got into the room, they had already gone in their brief. Staff M stated Resident 19 rarely got out of bed anymore, even though they were asked daily if they wanted to get up. Staff M stated they did not know if Resident 19 had been evaluated for the reason of their incontinence or been trialed for a scheduled toileting program (a structured approach to help individuals with mobility or incontinence, use the bathroom at regular intervals). During an interview of 08/22/2025 at 11:45 AM, Staff K, Regional Nurse, stated Resident 19 should have been assessed for their ability to remain continent of bowel and bladder since they were known to request being toileted daily. Reference WAC 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to ensure Infection Prevention and Control Guidelines and standards of practices were followed; 1. During a facility COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) outbreak to mitigate the risk for transmission of COVID-19 on 1 of 3 halls (South Hall); 2. During a residents Peripherally Inserted Central Catheter [(PICC) a long thin tube inserted through a vein in an arm to the heart to administer fluids, medications, and blood draws] dressing change for 1 of 2 residents (Resident 79). These failures placed residents, staff and visitors at risk for exposure to cross contamination (harmful spread of diseases) and the transmission of infectious diseases. Findings included. Review of the 06/2025 Washington State Department of Health SARS-CoV2 Infection Prevention and Control in Healthcare Settings Toolkit, showed long term care facilities were to conduct unit-wide testing and continue testing all residents and staff on the affected unit who previously tested negative every three to seven days for a minimum of 14 days from the most recent positive result, or the Licensed Health Jurisdiction direction. COVID-19 Testing During an interview on 08/19/2025 at 10:47 AM, Staff C, Infection Preventionist, stated the facility had admitted a resident with COVID-19 in July 2025 to the South Hall and was placed in quarantine and placed on aerosol contact precautions. Staff C stated a resident tested positive on 07/22/2025 when they went to the hospital for an emergency visit unrelated to COVID-19. Staff C stated three additional residents tested positive on 07/23/2025, when they experienced a low-grade fever, weakness, and a sore throat. Staff C stated they notified the Department of Health (DOH) and informed them they had closed the South Hall unit to include the dining room, activities and to other residents and staff. Staff C stated on 07/25/2025 another resident tested positive for COVID-19 and a staff member after they had symptoms of a moist cough, scratchy throat and lethargy (lack of energy) and on 07/26/2025 a second staff member tested positive after working the night shift in South Hall. Staff C stated the facility did not perform COVID-19 testing for all residents and staff during the outbreak. Staff C stated the facility performed testing for symptomatic residents only. Staff C stated in total there were six residents and three staff members who were COVID-19 positive during the outbreak and the outbreak ended on 08/11/2025. During a follow-up interview on 08/20/2025 at 1:50 PM, Staff C stated they did receive the WA DOH Toolkit and did not review in its entirety, therefore did not complete the required COVID-19 testing. During an interview on 08/20/2025 at 11:43 AM, Collateral Contact, Communicable Disease Specialist from the Local Health Jurisdiction (CC), stated they had been in communication with the facility for the COVID-19 outbreak. The CC stated they provided guidance to the facility and the IP and emailed the [NAME] Department of Health Covid toolkit. The CC stated they had requested updates from the facility on the COVID-19 outbreak. The CC stated the information they were provided with showed a line listing of residents and staff when they tested positive. The information also showed on 07/24/2025, 07/28/2025, 07/29/2025, 07/30/2025, and 07/31/2025 the facility had no new COVID-19 positive residents or staff. The CC stated when they received the information showing no new positives, they believed they facility had been continuing COVID-19 testing per the guidance, and they were unaware the facility had not continued to test the residents and staff. The CC stated the facility should have conducted COVID-19 testing of all residents and staff in the affected unit to ensure there were no Covid-19 residents and staff identified. The CC stated the WA DOH Toolkit they provided did show the facility was required to continue testing of all residents and staff who previously tested negative every three to seven days for a minimum of 14 days from the most recent positive result. During an interview on 08/20/2025 at 2:02 PM, Staff K, Regional Nurse, stated they were not aware there were additional residents who tested COVID-19 positive and if they had been made aware the facility should have continued COVID-19 testing per the guidelines. PICC Review of the medical record showed Resident 79 was admitted with diagnoses including endocarditis (a serious infection of the heart lining), and a PICC line for antibiotic therapy. The 07/24/2025 comprehensive assessment showed Resident 79 required substantial/set-up assistance of one to two staff for activities for daily living and had an intact cognition. During an observation and concurrent interview on 08/21/2025 at 4:27 PM, Staff H, Registered Nurse, prepared to perform a PICC dressing change on Resident 79. Staff H performed hand hygiene, donned (put on) gloves and used a disinfecting wipe and cleaned Resident 79's bedside table. Staff H disposed of the used wipe and gloves and tossed into the trash and without performing hand hygiene, opened the dressing supply package and then washed their hands. Staff H placed a surgical mask on Resident 79 and themselves and donned gloves. Staff H removed the sterile drape from the kit and placed it under Resident 79's arm with the PICC line. Staff H proceeded to remove the used dressing from Resident 79's PICC line, upon removal Staff H tossed the used dressing and their gloves into the trash can. Staff H without performing hand hygiene, donned sterile gloves, measured the length of the PICC line and the circumference of Resident 79's arm and placed their right hand into their pants pocket and removed a pen and wrote down measurements on the drape and placed pen back into their pocket. Staff H proceeded to open the antiseptic swab and clean around the PICC opening on Resident 79's arm and outward. Staff H attached a PICC line holder to Resident 79's arm and placed their right hand back into their pocket and removed the pen and placed onto bedside table. Staff H proceeded to apply a barrier adhesive and a a clear dressing with a white adhesive bordered edge covering the PICC, used the pen to write the date and their initials on the PICC dressing, put their hand back into their pocket and removed an alcohol swab and removed the old PICC cap access device and attached a new one. When completed, Staff H gathered all used supplies and tossed them into the trash can and removed their gloves and washed their hands. Staff H stated they placed their hands into their pockets during the dressing change with their sterile gloves and they should not have. Staff H stated they were unaware they did not use hand hygiene between glove changes and when they opened the dressing supply package. During an interview on 08/22/2025 at 11:25 AM, Staff B, Director of Nurses, stated Staff H had not followed the steps for the PICC line dressing change and they were going to provide re-education on the proper technique. Reference WAC: 388-97-1320(1)(c)(2)(a)(5)(b)

Based on interview and record review, the facility failed to honor residents' right to refuse a room transfer when their payor source changed for 1 of 2 residents (Resident 1) reviewed for choices. This deficient practice placed residents at risk for feeling vulnerable, disheartened and powerless. Findings included . Review of the undated facility policy, titled Room Change/Roommate Assignment, showed residents had the right to refuse a room transfer if the purpose was to relocate a resident from a Skilled Nursing unit (a living unit with the focus of regaining strength, endurance and independence through the skilled services of nursing and therapy) to a Long-Term Care (LTC) unit [a living unit with the focus of being a home with staff assistance to complete Activities of Daily Living (ADLs) ongoing]. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of respiratory failure, diabetes (a condition that happens when the body can't use glucose [a type of sugar] normally), and chronic kidney disease (occurs when the kidneys are damaged and can't filter blood properly, which can lead to a buildup of waste in the body). Review of the comprehensive assessment, dated 09/04/2024, showed Resident 1 was cognitively intact and required the assistance of two people for dressing, toileting, transfers, hygiene, and bathing. Review of the care plan, dated 09/06/2024, showed Resident 1 was participating in skilled therapy services with the goal of regaining strength to discharge home with their family. Review of an insurance coverage notification document, dated 10/22/2024, showed Resident 1 no longer met the guidelines for inpatient coverage at the facility (insurance was no longer going to pay for their stay and/or services). Review of the Progress Note (PN), dated 10/22/2024 at 11:17 AM, showed facility staff notified Resident 1 of the insurance denial, and Resident 1 stated they wanted to appeal (a formal request that a decision be changed) the decision. The PN showed facility staff initiated this on Resident 1's behalf. Review of the PN, dated 10/23/2024 at 11:30 AM, showed Staff A, Administrator and Staff B, Social Services Assistant, met with Resident 1 to establish next steps, and Resident 1 stated they could not pay the private pay rate or discharge home safely. The PN showed Staff A and Staff B stated Resident 1 would need to move to a semiprivate room, which had a lower cost. The PN showed Resident 1 stated .due to a previous bad experience with a roommate on (the LTC hall), they did not want to move . Review of the PN, dated 10/24/2024 at 1:14 AM, showed Resident 1 .was very tearful tonight about having to move to other unit tomorrow . Review of the PN, dated 10/24/2024 at 10:18 AM, showed Resident 1 expressed being upset about room transfer and reported the situation to the state agency. The PN documented .we (the facility) are moving them to help avoid potential financial distress ., and Resident 1 stated they understood, .but I don't want to be on that side (LTC hall) . Review of the census tab in the Electronic Health Record (EHR) showed Resident 1 was moved on 10/24/2024, from a private room on the Rehabilitation Hall (Skilled Nursing) to a semiprivate room on the East Hall (LTC). During an interview, on 11/15/2024 at 12:30 PM, Staff B stated Resident 1 was very upset about having to move rooms, and the facility offered many other accommodations in an attempt to offset Resident 1's frustrations. Staff B stated due to the heightened emotions of Resident 1, their personal belongings were moved to the new room while Resident 1 was out at an appointment. Staff B stated they did not know who made that decision. During an interview, on 11/15/2024 at 1:15 PM, Resident 1 stated they wanted to wait until their appeal results of the insurance coverage declination came back before moving rooms, but the facility forced them to do it sooner. Resident 1 stated they did not have a choice in the matter as the facility moved their personal belongings to the new room while they were out at an appointment. Resident 1 stated they felt their rights were violated. During an interview, on 11/15/2024 at 1:45 PM, Staff A stated Resident 1 was going to accrue a large private pay bill, and their intention was to lessen the burden by putting them in a cheaper room. Staff A stated, after reading their policy on room changes, they realized Resident 1 had the right to refuse the room transfer, and the facility did not honor that. Reference: WAC 388-97- 0600 (1-3)

Based on observation, interview, and record review, the facility failed to maintain safe food holding temperatures for 1 of 2 meal preparations (lunch meal on 9/26/2024) reviewed for safe and sanitary kitchen. This failed practice placed all residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]). Findings included . Review of a policy titled Food Preparation and Service dated 11/2022, showed the danger zone for food holding temperatures is below 135 Farenheit (F, a unit of temperature measurement) and the longer food sits below 135 F the higher the risk for the growth of harmful pathogens. A lunch meal preparation observation and concurrent interview on 09/26/2024 at 10:55 AM, showed the prepared food had been stored in the steam table at 11:05 AM for a serve out time of 11:45 AM. The temperatures of the food were as follows; Baked Chicken was at 119 F, ground chicken 134 F, brown gravy 132 F, carrots 127 F. Further temperature checks of the pureed (a texture of food that is soft and pudding like) foods were as follows; green beans 125 F, rice 120 F, and chicken 125 F. Staff Z, Cook, stated the food had been placed in the warmer for about 20 minutes but the pureed and bite sized food was placed about 45 minutes prior to testing the temperatures. Staff Z stated they only checked the food temperatures upon removing them from the oven to ensure the correct cooking temperatures had been reached but did not check the temperatures of the food prior to serve out after they had been sitting in the steam table. During an interview on 09/26/2024 at 11:17 AM, Staff AA, Food Service Manager, stated the food temperatures should have been checked prior to serve out to ensure proper temperatures. Staff AA stated the prepared food should not be put in the steam tables until 20-30 minutes before serving the food out. Staff AA stated Staff Z did not follow the correct process for holding foods and rechecking temperatures of foods to maintain safe temperatures. WAC Reference: 388-97-1100 (2)(3)

Based on observation, interview, and record review, the facility failed to discard expired foods in 1 of 1 dry storage and 1 of 1 walk in refrigerator reviewed for safe and sanitary kitchen. This failed practice placed all residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]). Findings included . During the general tour of the kitchen on [DATE] at 10:31 AM, showed expired foods in the dry storage room of the kitchen as follows; 1) three 46-ounce (oz, a unit of measure) containers of orange juice concentrate that expired on [DATE], 2) four 46 oz containers of thickened cranberry cocktail that expired on [DATE], 3) two packages of six-inch (in, a unit of measure) flour tortillas (24 tortillas to a bag) that expired on [DATE] and four packages that expired on [DATE], 4) four packages of eight-in flour tortillas (12 tortillas per package) that expired on [DATE], 5) two packages of 12-in flour tortillas (12 tortillas per package) that expired on [DATE], 6) two packages of yellow corn tortillas (five pound packages) that expired on [DATE], 7) a one gallon (a unit of measure) of Worcestershire (a sauce used for food flavoring) sauce that expired on [DATE], and 8) 20 boxes of 16 oz baking soda (a white powdery substance used in cooking and cleaning) that expired on [DATE]. Additionally, in the walk-in refrigerator, was a box of more than 25 oranges that had a use by date of [DATE]. During an interview on [DATE] at 11:04 AM, Staff BB, Cook, stated it was the responsibility of the dietary staff to ensure foods were monitored and discarded when expired. During an interview on [DATE] at 10:25 AM. Staff AA, Food Service Manager, stated we are all responsible for monitoring the food and the discarding of expired foods. Staff AA stated when we got an order and put it away, the other foods should have been checked for expiration dates, and apparently we have not been doing that. WAC Reference: [DATE] (3)

Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 3 residents (Residents 62 and 214) reviewed for hospital transfers. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and monetary charges associated with the bed hold while in the hospital. Findings included . Review of a policy titled, Bed Hold - [NAME], dated 08/01/2024, showed when a resident was transferred or discharged , the nursing department would provide the resident and/or their representative with a copy of the bed hold policy. If nursing was unable to provide the notice at the time of transfer or discharge, the Social Services Director or designee would contact the resident and/or their representative to notify them of the facility policy and obtain a decision on bed hold. <Resident 62> Review of the medical record showed Resident 62 was admitted to the facility with diagnoses including a stroke, dizziness and giddiness, and a heart attack. The 06/24/2024 comprehensive assessment showed Resident 62 was able to make their own decisions and was independent with all ADLs. Review of a nursing progress note dated 06/29/2024 at 11:35 PM, showed Resident 62 complained of chest pain radiating to their neck and arm. Resident 62 was transferred to the hospital for evaluation on 06/30/2024 at 12:10 AM . The medical record showed no documentation that a notice of bed hold had been given to the resident and/or their representative. <Resident 214> Review of the medical record showed Resident 214 was admitted to the facility with diagnoses including aftercare for surgery on the digestive system, severe protein-calorie malnutrition (a lack of available nutrients in the body that leads to changes in body composition and function), and diabetes (a group of diseases that result in too much sugar in the blood). The 09/17/2024 comprehensive assessment showed Resident 214 required substantial/maximum assistance of one staff member for ADLs. The assessment also showed Resident 214 had a moderately impaired cognition. Review of the medical record showed Resident 214 complained of abdominal pain and was transferred to the emergency room for evaluation on 08/10/2024 at 3:00 PM. There was no documentation that a notice of bed hold was given to the resident and/or their representative. During an interview on 09/26/2024 at 4:40 PM, Staff B, Director of Nursing Services, stated the notice of bed hold should be given to the resident and/or their representative when they were transferred out of the facility. They stated it was the responsibility of the nurse on duty at the time of transfer to provide the resident and/or their representative with the notice of bed hold. During an interview on 09/27/2024 at 10:15 AM, Staff A, Administrator, stated it was their expectation that a notice of bed hold was completed for residents that transferred to the hospital. Staff A further stated the process for bed hold, effective August 1, 2024, was for the Business Office Manager to fill out the notice of bed hold form and contact the resident and/or their representative to complete the form. Reference: WAC 388-97-0120(4)

Based on observation, interview, and record review, the facility failed to ensure the provision of ongoing assessments and monitoring in accordance with professional standards of practice for 5 of 5 residents (Residents 7, 23, 25, 122 and 1) reviewed for quality of care. The failure to assess and monitor for impaired skin integrity, edema, (swelling caused by presence of excess fluid in the body tissues) and bowel management placed the residents at risk for unmet care needs and negative health outcomes. Findings included . <Skin> Review of a facility policy and procedure document titled Skin at Risk/Skin Breakdown last revised on 09/2020 showed .A full body skin evaluation is completed on admission and weekly by the licensed nurse. Updates of current non-pressure areas coincide with the weekly full body skin audit and monitors bruises, skin tears and abrasions on the resident's Treatment Administration Record (TAR). All other skin impairment concerns are documented on the 'Skin-Wound Form' (an electronic health record form in the assessment section of the resident's medical record). The policy further stated to document on the skin impairment forms to include the measurements of size, color, presence of odor, exudate (wound fluid), pain associated with the skin impairment, and the current type of treatment used. <Resident 7> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include peripheral vascular disease (a condition in which in which narrowed blood vessels outside the heart cannot deliver enough oxygen and nutrients to the body and could cause chronic wounds to the limbs). The 07/14/2024 comprehensive assessment showed the resident's cognition was intact and could make their own decisions. The assessment also showed Resident 7 had venous/arterial ulcers to their lower extremities. A concurrent observation and interview on 09/23/2024 at 1:53 PM, showed Resident 7 lying in bed, both legs were wrapped from below the toes to below the bend in the knees with brown elastic compression (ace bandages) bandages. There was a foul smell, the smell of rusty wet coins, while standing at the bedside talking to the resident. Resident 7 stated their dressings on their legs had not been changed since the day prior. The date on the dressings on both legs showed 09/22/2024. Resident 7 stated the facility utilized traveling nurses and when they worked, the bandages would not get changed. Resident 7 stated they would normally get changed every third day but were supposed to be changed daily. An observation on 09/24/2024 at 9:58 AM showed the bilateral leg dressings were still the same dressings that were dated 09/22/2024. Review of Resident 7's September 2024 TAR, showed an order on 07/24/2024 for dressing changes to both leg wounds daily. The wounds were to be cleansed with wound cleanser, followed by an oil emulsion dressing (a dressing that keeps draining wounds flowing without sticking to the wound bed), followed by super absorbent pads, and finally, covered with the ace bandages. The order showed the dressing changes had not been completed on seven of the 25 opportunities for the dressing change, in addition to two documented refusals. The order also showed on 09/23/2024, it was documented the dressing had been changed, even though the same dressings were on from 09/22/2024 until 09/25/2024. Additionally, the TAR showed an order on 10/11/2023 for weekly skin checks to be completed and document a (-) for no new skin impairment and a (+) for new skin impairment. Three of the four opportunities for skin checks had not been completed and showed no documentation. A concurrent observation and interview on 09/25/2024 at 10:44 AM, showed the dressings on both legs were still the same dressings dated 09/22/2024. Resident 7 stated they smelled horrible and had asked the nurse to change their dressings before they left the facility for a same-day procedure and was informed by the nurse they did not have time and would have to wait until they returned from their procedure. Resident 7 stated they would be embarrassed if they had to go to their procedure smelling as bad as they did. Resident 7 was being provided incontinent care by Staff L, Nursing Assistant, and the resident had dried areas of dark black/green bowel movement on the top portion of the absorbent pads that were sticking out of the top of the ace bandages along with a new area of wet bowel movement the size of a softball. Also, the middle of the left leg, was a baseball sized, brownish/black leakage that had leaked through the dressings and dried on the outside of the ace bandage. Staff L stated they were leaving the room to go report the bowel movement on the dressings to the nurse and see if that would get them to change the dressings. An observation on 09/25/2024 at 11:06 AM, showed Staff R, Registered Nurse (RN), changing Resident 7's dressings to their lower legs, along with Staff S, Licensed Practical Nurse/Resident Care Manager (LPN/RCM). Staff R and Staff S each used a bottle of wound cleanser to soak the dressings to soften them up for removal and as bandages were being removed, they were saturated with stringy, green and brown slough (a mass or layer of dead tissue separated from the surrounding or underlying tissue) skin. The room was filled with the smell of rusted wet coins. Wounds were cleansed and new dressings placed as ordered. Staff R dated the dressings 09/25/2024 with their initials. An observation on 09/26/2024 at 2:20 PM, Resident 7 was observed lying in bed sleeping, had returned earlier in the day from their same-day procedure on 09/25/2024. Dressings to both legs are still dated 09/25/2024 with Staff R's initials. An observation on 09/27/2024 at 9:00 AM, showed Resident 7 was lying in bed eating breakfast. Resident 7 stated the dressings had not been changed since 09/25/2024 and while standing at the foot of the bed, the same wet, rusty coin smell was present. The dressings were dated 09/25/2024 and had Staff R's initials. During an interview on 09/27/2024 at 10:58 AM, Staff B, Director of Nursing Services, along with Staff K, Regional RN, stated their expectations were for the nurses, including travel/agency nurses to follow the physician orders and change the dressings daily. Staff B stated the nursing staff should have completed weekly skin checks and weekly wound assessments, and they failed to follow that process. <Resident 23> Review of Resident 23's medical record showed the resident admitted to the facility with diagnoses to include cirrhosis (a condition in which the liver is scarred and permanently damaged) and diabetes (a chronic disease that occurs when the body can not properly regulate blood sugar levels). The 06/17/2024 comprehensive assessment showed Resident 23 required the assistance of one staff member for activities of daily living and had an intact cognition. During an observation and concurrent interview on 09/24/2024 at 1:03 PM, showed Resident 23 sitting in their wheelchair, with multiple scattered bruises to their lower arms, wrists and hands. All the bruised areas were yellow/brown/green in color and were in various stages of healing. Resident 23 was noted to have a band aid on an area to their lower right forearm and stated they got a skin tear yesterday from hitting it on a door frame. Resident 23 stated they got bruises on their arms and hands all the time from hitting them on the door frame trying to get outside to the smoking patio. During an observation on 09/26/2024 at 8:48 AM, showed Resident 23 lying in bed with an open skin tear 1 centimeter (cm, a unit of measure) by 0.5 cm to their right lower forearm. Review of the September 2024 Medication Administration Record (MAR) showed Resident 23 was to have weekly skin assessments each Monday and showed no monitoring or skin assessments of the bruised areas, or skin tear to right lower forearm. Review of the September 2024 TAR showed no monitoring of the bruised areas or skin tear. During an interview on 09/26/2024 at 1:08 PM, Staff B stated their expectations for the Licensed Nurses was that all skin issues, including bruises, were to be documented on the weekly skin assessment and were to be monitored until resolved. Staff B further stated that the nursing staff did not follow the correct process for Resident 23's skin issues. <Resident 25> Review of the medical record showed Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes, bilateral heel ulcers, congestive heart failure (a condition when the heart cannot pump blood well enough to keep up with the body's need), lymphedema (a condition in which lymph fluid builds up in tissue causing swelling, discoloration and hardening of the skin), obesity, and depression. The 09/04/2024 comprehensive assessment, showed Resident 25 required substantial assistance of one to two caregivers for activities of daily living (ADL's) and was cognitively intact. A concurrent observation and interview on 09/24/2024 at 8:49 AM, showed Resident 25 lying on their bed, both of their lower legs were swollen with edema, and pressure relief soft boots were in place on both feet. Resident 25 stated they had deep wounds on the bottom of both heels caused by poor circulation that were being treated by the facility nurses. Review of a provider visit note, dated 09/16/2024, stated the resident had unstageable (a full thickness wound that is covered by a layer of dead tissue that prevents the stage of the wound from being determined) bilateral diabetic ulcers to the heels and three plus edema [a full and swollen extremity that leaves an indentation in the skin when pushed on, that is six millimeters (mm, a unit of measure) deep and takes up to 60 seconds to rebound]. Pictures of the wounds were present in the providers documentation though no size or definitions of the wounds were present. Review of Resident 25's physician orders, dated 08/29/2024, showed the resident was receiving medication to assist with removing fluid from the lower extremities, was on a daily fluid restriction to decrease the amount of fluid intake, and daily weights to assure fluids were not increasing weight in the body. Review of Resident 25's TARs for August and September 2024, showed they received daily monitoring and every three-day dressing changes to the bilateral wounds on the heels by the licensed nursing staff though there were no sizes or condition of the wounds present. Review of Resident 25's nursing progress notes, skin assessment forms, and wound documentation forms from 08/29/2024 through 09/26/2024 , showed no documentation of the size or condition of the wounds to evaluate if the treatments ordered assisted in healing the wounds or if the wounds were worsening. In addition, no documentation was found describing the edema or if measurements were taken to evaluate if the medication and treatments provided to decrease the fluid in the lower extremities was effective. <Resident 122> Review of the medical record showed Resident 122 was admitted to the facility on [DATE] with diagnoses including diabetes, infection of a right foot ulcer, chronic venous stasis (a condition in which veins in the leg have problems moving blood back to the heart causing leg swelling, skin changes and ulcers), severe lymphedema, obesity, and stasis ulcers to the bilateral lower legs. The 09/10/2024 comprehensive assessment showed Resident 122 required substantial assistance of one to two caregivers for ADLs and was cognitively intact. A concurrent observation and interview with Resident 122 on 09/23/2024 at 1:05 PM, showed the resident sitting up on the side of their bed with a wound vac (a treatment that uses negative pressure suction to help heal wounds) in place on the right foot and both legs wrapped from the foot to the knee in dressings. Resident 122 stated they had a wound on the bottom of their right foot and multiple ulcers on both of their lower legs that became infected, and they were currently receiving intravenous (medications administered through a vein) antibiotics four times a day in the facility. Resident 122 further stated that they had their dressings changed by the facility nurses twice a week to all their wounds on their shower days and as needed in between. An observation on 09/24/2024 at 1:50 PM, showed Staff C, (LPN/RCM), changing dressings to Resident 122's bilateral lower leg ulcers and the wound vac treatment to the right foot. Their right side of the foot from mid foot to the heel showed a large unstageable wound. The wounds to both the left and right lower legs were difficult to assess due to excessive appearance of wood like, raised keratosis (a condition of excessive overgrowth and thickening of the skin) on all parts of the lower legs and feet from severe lymphedema. Staff C stated they had not in the past completed any measurements or assessments of the wounds during the dressing changes but would get the size of the wounds during this dressing change and document the results in a nursing progress note. Review of Resident 122's September 2024 TARs from 09/04/2024 through 09/26/2024, showed they received daily monitoring and twice a week dressing changes to the right heel wound and both lower leg ulcers by the licensed nursing staff though there were no sizes or condition of the wounds present in the documentation. Review of Resident 122's nursing progress notes, skin assessment forms, and wound documentation forms from 09/04/2024 through 09/23/2024 , showed no documentation of the size or condition of the wounds to evaluate if the treatments ordered assisted in healing the wounds or if the wounds were worsening. In addition, no documentation was found describing the lymphedema or if measurements were taken to evaluate if the medication and treatments provided to decrease the fluid in the lower extremities was effective. Review of a nursing progress note by Staff C dated 09/24/2024 at 4:17 PM, showed .Residents right lateral (side of foot) plantar (the thick tissue on the bottom of the foot) foot wound had the wound vac replaced today. Wound was cleansed with wound cleaner and patted dry. Wound has granulation tissue (new tissue that forms in wounds during the healing process) present in wound bed, serosanguinous drainage (thin, slightly yellow or pink tinged fluid). Wound this week measures 4.6 cm by 3.2 cm by 0.3 cm. Black foam (a foam used to seal the wound vac treatment) was fitted and bridged created for vac placement on top off foot. Foam secured in place and suction obtained. During an interview on 09/25/2024 at 2:07 PM with Staff C stated the facility was not currently completing wound assessments for skin impairments including what the wounds looked like when a resident was admitted , if a resident developed a skin problem while in the facility, or when assessed at dressing changes. Staff C stated when the current owner of the facility took over on 08/01/2024 they no longer had an assessment form in their electronic medical record to document their assessment of skin conditions on. Staff C stated they would expect the nurses to document their skin assessments in the progress notes if there was no actual assessment form available to document on, like the one they wrote on 09/24/2024 describing the size and condition of the wound and what treatment was used. During an interview with Staff B on 09/27/2024 at 11:30 AM, they stated the facility had not been doing wound assessments on admission, when a skin issue was found, or following dressing changes. Staff B stated documentation to assess if the skin conditions were improving or deteriorating was expected on all skin impairments including edema monitoring. Staff B stated they would expect the licensed staff to document their findings in a progress note if the forms they were accustomed to using were no longer present in the medical record. During an interview with Staff K on 09/27/2024 at 11:35 AM, they stated they were unaware the facility no longer had skin and wound assessment forms or edema monitoring forms in the facility's electronic health record. Staff K stated they were working closely with the new corporation's electronic health records team to assure all needed assessments for resident care were put into practice. <Bowel Management> Review of a policy titled Bowel Protocol dated 09/2024, showed the nurses were to identify residents who had not had a bowel movement (BM) in three days then review the MAR for use of the as needed bowel medication that had been given the shift prior. The policy showed if a resident went greater than four days without a BM, the nurse would complete an abdominal assessment and notify the physician for further orders. <Resident 1> Review of Resident 1's medical record showed they admitted to the facility with diagnoses to include functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). The 07/16/2024 comprehensive assessment showed Resident 1's cognition was intact, was dependent upon staff for their toileting hygiene, and experienced constipation (hard, dry bowel movements or passing stool fewer than three times a week). During an interview on 09/23/2024 at 12:05 PM, Resident 1 stated they had issues with constipation and had not had a BM in at least seven days. Resident 1 stated they received daily medication for their constipation, but it had not worked very well and they would have to sit on a bed pan (a container used as a toilet by a person who is too ill to get out of bed) for an extended length of time waiting to have a BM which was uncomfortable and felt it caused them skin impairment to their bottom. Review of Resident 1's BM tasks (a record that nursing assistants document on every shift) from 08/28/2024 through 09/26/2024 showed as follows; 1) no BM from 09/15/2024 day shift through 09/24/2024 evening shift (greater than nine days with 3 shifts no documentation, 2) no BM from 09/05/2024 night shift through 09/11/2024 night shift (greater than five days with three shifts having no documentation), 3) no BM from 08/28/2024 day shift through 09/01/2024 evening shift (greater than 4 days with two shifts having no documentation). Review of Resident 1's September 2024 MAR showed the resident had seven as needed medications ordered for the bowel protocol with specific directives to allow different routes of administration for constipation management. The record showed the Milk of Magnesia, an as needed medication, was used once on 09/24/2024 (greater than nine days with no BM), no other as needed medications were utilized. Review of Resident 1's 08/07/2024 care plan, showed the resident was at risk for constipation with an intervention to monitor for side effects of constipation and to keep the physician informed of any problems (the record showed no notification to the physician had been made when the resident went greater than 4, 5, and 9 days without a documented BM and the record showed no bowel assessments had been completed to monitor for side effects of the constipation). During an interview on 09/26/2024 at 9:49 AM, Staff V, NA, stated they documented BMs at the end of every shift and if the computer showed the resident had not had a BM in three to four days they would inform the nurse if the resident did or did not have a BM during that shift. Staff V further stated Resident 1 consistently had issues with constipation. During an interview on 09/27/2024 at 8:41 AM, Staff W, LPN, stated they checked their bowel list daily and if a resident did not have a bowel movement within 72 hours they would initiate their standing orders (as needed medications) starting with Metamucil (a brand of medication used for increasing fiber to increase BMs, and was not an as needed medication ordered) and then if that did not work they would go to the enema or suppositories. Staff W stated the residents should not go greater than 72 hours without a BM and after 72 hours they would complete bowel assessments (listen and check for bowel tones and feel for pain or distention in the abdomen) and notify the physician for further directions. Staff W stated they would document in the resident's record any medications given and notification to the physician. During an interview on 09/27/2024 at 10:18 AM, Staff C, stated they did not believe Resident 1 went 10 days without a BM, the most I have ever seen is four to five days. Staff C stated Resident 1 would often refuse their daily bowel meds and Resident 10 would tell Staff C they did not feel they had a problem with constipation (the MAR showed the Miralax (a brand of medication used for bowel management) was the only daily medication the resident refused on 14 days out of 28). Staff C stated they had notified the physician of the constipation, and they had changed the medications but did not see the physician had been updated on the no BM from 09/15/2024 through 09/24/2024 and had seen no new orders. Staff C felt the issue was not with the resident experiencing constipation but with the staff not accurately documenting (even though the resident could say they knew it was at least seven days they had gone without a BM). Staff C additionally did not see documentation of bowel assessments that had been completed and stated they should have done bowel assessments if Resident 1 went that long without a BM. WAC Reference: 388-97-1060 (1) 35676 48368

Based on observation, interview, and record review, the facility failed to prevent accidents by not ensuring residents who smoked were assessed for safety and kept their smoking paraphernalia stored in a locked area not accessible to other residents for 3 of 3 residents (Residents 23, 30, and 164) reviewed for smoking. Additionally, the facility failed to store a portable oxygen tank in a safe manner for 1 of 3 oxygen storage rooms (oxygen storage room [ROOM NUMBER]). This failure placed all residents at risk for avoidable accidents, injuries, and the potential risk of fire. Findings included . <Smoking> Review of the Smoking policy dated 08/01/2024, showed residents who smoke independently or require supervision would be evaluated for their ability to smoke safely upon admission or at the time they decide to smoke, and the policy would be signed prior to them smoking. The policy showed residents would be reassessed at least quarterly or with significant changes in condition and that all smoking paraphernalia (cigarettes, electric cigarettes, and lighters) would be locked up. <Resident 23> Review of Resident 23's medical record showed the resident admitted to the facility with diagnoses to include tobacco use. The 06/17/2024 comprehensive assessment showed Resident 23 required the assistance of one staff member for activities of daily living and had an intact cognition. Review of a document titled Smoking Safety Evaluation, showed Resident 23 knew how their smoking materials were to be stored and could demonstrate proper storage of smoking materials. An observation on 09/23/2024 at 10:48 AM, showed Resident 23's coat laying over the back of an unused wheelchair next to the edge of the empty bed in room [ROOM NUMBER] close to the door. Further observation showed a pack of cigarettes and a lighter in the front pocket of their coat. An observation and concurrent interview on 09/27/2024 at 10:32 AM, showed Resident 23 siting up in their wheelchair next to their bed by the window. Resident 23's coat was laying over the back of the unused wheelchair next to the bed closest to the door with a pack of cigarettes and a lighter in the front pocket. Resident 23 stated they put their coat there because no one was using that space or wheelchair, and they did not have anywhere to lock up their cigarettes and lighter. During an Interview on 09/26/2024 at 1:50 PM, Staff A, Administrator, stated they would expect all residents who smoke to have their smoking materials properly stored in a lock box provided for them. Staff A stated they were aware Resident 23's lock box was missing. 44922 <Resident 30> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain). The 08/30/2024 comprehensive assessment showed Resident 30's cognition was moderately impaired and was independent with wheelchair mobility. During an interview on 09/24/2024 at 10:10 AM, Resident 30 stated they were an independent smoker, smoked several times a day, and kept their cigarettes and lighter in their bedside nightstand drawer. Resident 30 refused to answer any additional questions. An observation and concurrent interview on 09/24/2024 at 1:35 PM, Resident 30 was observed under the gazebo patio outside of the day room, which was the designated smoking area. Resident 30 removed their pack of cigarettes from the front pocket of their shirt along with their lighter and lit their cigarette. Resident 30 stated they had a locked drawer in their room where they kept their cigarettes and lighter locked up but also would just keep them in the pocket of their shirt. Review of a 04/21/2023 smoking evaluation, showed Resident 30 was safe to smoke independently and would ask for their smoking equipment and returned the smoking equipment when finished. There were no other smoking evaluations after 04/21/2023 (17 months since the last evaluation). An observation on 09/26/2024 at 9:42 AM, showed Resident 30 sleeping in bed, they would not arouse when attempted to speak with them. The nightstand to the left side of the bed had an unlocked top drawer that was ajar and Resident 30's cigarettes and lighter could be seen. An observation on 09/27/2024 at 9:08 AM, showed Resident 30 sleeping in bed, does not arouse when spoken to. Their top nightstand drawer is unlocked and ajar and Resident 30's lighter and cigarettes could be seen. <Resident 164> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include asthma (condition in which your airways narrow and swell and may produce extra mucus). The 09/12/2024 comprehensive assessment showed the resident's cognition was moderately impaired and was dependent on one staff member for transferring and wheelchair mobility. An observation and concurrent interview on 09/23/2024 at 3:33 PM, showed the resident sitting under the gazebo on the patio outside of the day room, unattended. A Nursing Assistant (NA) exited to the patio and assisted Resident 164 back to their room. On their bedside table, in a clear plastic, food storage container there was a black lighter and an electric cigarette in a box (brand named [NAME]). Resident 164 stated they smoked two to three times a day and had a pack of cigarettes and a lighter in their purse that was sitting on their nightstand to the right side of their bed. Review of Resident 164's care plan on 09/23/2024 showed no smoking care plan had been formulated. Review of Resident 164's smoking assessments on 09/23/2024, showed no smoking assessment had been completed. An observation and concurrent interview on 09/26/2024 at 9:23 AM, Resident 164 was sitting up in bed, bedside table over the top of the bed, placed in front of the resident, and the same plastic food container with the same contents was on the bedside table as previously seen on 09/23/2024. An observation on 09/27/2024 at 9:13 AM, Resident 164 was assisted outside to the smoking area and left to smoke unattended. During an interview on 09/27/2024 at 10:37 AM, Staff C, Resident Care Manager, stated residents who want to smoke should have been assessed on admission for safety and signed the smoking policy. Staff C stated the resident's cigarettes should be kept locked up on the nurse's medication carts and given to the residents prior to smoking. Staff C stated residents should not have smoking paraphernalia out in the open and should be locked up until discharge, if not in use. Staff C additionally stated residents who smoke would get re-assessed annually for safety. <Oxygen> An observation on 09/24/2024 at 3:25 PM, in an unlocked room that was previously used as an oxygen storage room (oxygen storage room [ROOM NUMBER]), was a small portable oxygen tank, half full, in a black oxygen bag, propped up against the wall behind the door, unsecured. During an interview on 09/24/2024 at 3:34 PM, Staff B, Director of Nursing Services, stated the unlocked storage room had been previously used as the oxygen storage room and had recently been moved to the other end of the hall. Staff B stated they needed to ensure all staff had been in-serviced on the new location of the oxygen storage room. During an interview on 09/25/2024 at 11:44 AM, Staff L, NA, stated the unlocked storage room was previously used as an oxygen storage room and was changed to a Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) room. Staff L stated they were not provided education on the room changes. During an interview on 09/26/2024 at 8:46 AM, Staff Y, Registered Nurse, stated the unlocked storage room used to be the oxygen room and did not know when that changed. Staff Y stated the storage room was now being used as a storage for PPE and oxygen tanks should not be stored there. Staff Y did not recall being provided education on the room changes. During an interview on 09/26/2024 at 3:31 PM, Staff A stated the unlocked storage room had been an oxygen storage room and was previously moved the week prior. Staff A stated they had provided education to staff of the room changes but apparently needed to provide more. WAC Reference: 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were implemented for hand hygiene/handling medications during medication administration for 1 of 5 staff (Staff M), and use of personal protective equipment when entering a contact precautions (safety measures used by healthcare workers to prevent the spread of infectious agents that can be transmitted through direct or indirect contact) room for 1 of 3 resident rooms (room [ROOM NUMBER]) reviewed for infection control. These failures placed residents, staff, and visitors at risk for exposure to cross contamination of infectious disease. Findings included . Review of a policy titled, Hand Hygiene, dated 08/01/2024, showed hand hygiene was the primary means of preventing the transmission of infection and should be performed as soon as possible after contamination such as before/after direct contact with a resident. Review of a policy titled, Transmission Based Precautions (a set of infection control measures used when a resident may be infected with a certain infectious agent), dated 08/01/2024, showed contact was the most common and most significant mode of transmission of infection and occurred by directly touching the resident and/or their environment. Staff that had contact with the resident should wear gloves and a gown. <Medication Administration> During an observation on 09/25/2024 at 8:21 AM, Staff M, Registered Nurse (RN), was standing at their medication cart. Staff M removed a card of pills from the medication cart and pushed the pill through the foil backed card. The pill fell on to the medication cart. Staff M picked up the pill with their bare hand and placed the pill into a medication cup. Staff M removed a bottle of vitamins from the top drawer of the medication cart, poured three tablets into their bare hand, and placed the tablets into the same medication cup. Staff M added five additional medications to the medication cup, put on gloves, and took the medications, in the cup, into a resident room. Staff M placed the medication cup on the resident's breakfast tray on the over the bed table and assisted the resident to a seated position at the side of the bed. Staff M handed the medication cup to the resident, rearranged a cup and food items on the resident's breakfast tray, handed the resident their water cup, and watched the resident take their medications. Staff M removed their gloves, picked up the empty medication cup, and exited the resident's room. Staff M went to their medication cart, threw away their gloves and medication cup and proceeded to prepare medications for the next resident without performing hand hygiene . During an interview on 09/25/2024 at 2:22 PM, Staff P, Infection Preventionist, stated the expectation was for all staff to use alcohol-based hand rub, at the minimum for, hand hygiene, before and after entering a resident room, between glove changes, before and after administering medications, and before moving on to the next resident when administering medications. During an interview on 09/27/2024 at 9:57 AM, Staff B, Director of Nursing Services, stated when preparing medications, there should always be a barrier between the medication and the nurse's hands. Staff B further stated the staff needed to perform hand hygiene between each resident when administering medications. During an interview on 09/27/2024 at 10:35 AM, Staff A, Administrator, stated Staff M was an agency nurse. Staff A stated they had high expectations for the agency staff and would have expected them to be trained in hand hygiene practices. <Contact Precautions> An observation on 09/24/2024 at 8:55 AM, showed Staff N, Nursing Assistant (NA), enter resident room [ROOM NUMBER] that had a Contact Precautions sign posted on the door. The sign instructed providers and staff to put on gloves and a gown before entering the room and discard gloves and gown prior to leaving the room. Staff N entered resident room [ROOM NUMBER] and picked up a plate cover that was on the foot of the resident's bed and put it on their meal tray. They picked up the meal tray that was on the over the bed table and exited the room. Staff N did not have on a gown or gloves. During an interview on 09/24/2024 at 12:48 PM, Staff N stated they did not need to wear a gown or gloves in the contact precautions room unless they were going to provide hands on care for the resident in room [ROOM NUMBER]. They stated they were told that was the process by both the charge nurse and the infection preventionist. During a concurrent observation and interview on 09/27/2024 at 8:42 AM, showed Staff O, Social Services Director, enter resident room [ROOM NUMBER] without wearing a gown or gloves. Staff O shut the door and met with the resident in their room. At 8:48 AM, Staff O opened the door to resident room [ROOM NUMBER], exited the room, and proceeded to walk down the hall. At 8:49 AM, Staff O stated they did not need to wear a gown or gloves if they were not doing cares on the resident in room [ROOM NUMBER]. Staff O then read the contact precautions sign and stated the sign showed they should have been wearing a gown and gloves, they made a mistake, and they would talk to the infection preventionist about what personal protective equipment was needed in the contact precautions room. During an interview on 09/27/2024 at 10:44 AM, Staff A stated they expected all staff to follow precautions that were posted on resident rooms. Reference: WAC 388-97-1320(1)(c)(2)(b)

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services related to enteral feedings [(EF) the delivery of nutrients through a tube directly into the stomach to provide nutrition for those who cannot obtain nutrition by mouth, were unable to safely swallow, or need nutritional supplementation] for 1 of 1 resident (Resident 214) reviewed for EF. This failed practice placed the resident at risk for receiving expired and/or inaccurate enteral nutrition, adverse consequences, and complications of tube feeding. Findings included . Review of a policy titled, Enteral Feeding Tubes, dated [DATE], showed the Registered Dietician (RD) calculated the nutritional value of the EF and made recommendations as needed. Upon admission or initiation, the licensed nurse (LN) obtained a physician's order for the recommended EF formula. Additionally, when the EF bag and tubing was hung, the LN labeled the enteral feeding container/bag with the resident's name, date, time, and initials (of the LN). The EF bag and supplies were to be changed every 24 hours to prevent excessive microbial growth. Review of nursing professional standards guidance from Lippincott Nursing Procedures 8th Edition titled, Tube Feedings, dated 2019, showed the enteral formula container was labeled with the patient's identifiers; formula name (and strength if diluted); date and time the formula was hung; administration route; rate of administration; administration duration; initials of who prepared, hung, and checked the enteral formula against the order; expiration date and time; and notation enteral use only. Label the enteral administration set with the date and time that it was first hung. The administration set and tubing could be used continuously for a maximum of 24 hours. <Resident 214> Review of the medical record showed Resident 214 was admitted to the facility with diagnoses including presence of a gastrostomy (an artificial opening in the stomach), aftercare for surgery on the digestive system, and severe protein-calorie nutrition (a lack of available nutrients in the body that leads to changes in body composition and function). The [DATE] comprehensive assessment showed Resident 214 required substantial/maximum assistance of one staff member for activities of daily living. The assessment also showed Resident 214 had a moderately impaired cognition. An observation on [DATE] at 10:14 AM, showed Resident 214 was reclining in their bed. There was an EF pump on a pole next to their bed. There was a container of Jevity 1.2 EF (a high-protein, fiber-fortified formula that provides complete, balanced nutrition of enteral feeding) hanging on the pole. The EF pump was not running and there was residual EF in the tubing. There was no label on the container or tubing that showed the date, time, and initials of the LN that hung the EF. There was an empty container of Jevity 1.2 formula on the bedside table. An observation on [DATE] at 8:45 AM, showed Resident 214 in bed, a clear bag labeled Kangaroo (a brand of bag used for EF) was hanging on the pole next to the bed. The tubing from the bag was fed through the EF pump and there was residual EF visible in the tubing. The pump was not running, and the bag was empty. The bag label showed a date and time. There was no labeling showing what was in the Kangaroo bag or initials of the LN that hung the bag. An observation on [DATE] at 7:55 AM, showed Resident 214 reclined in bed watching television. There was a Kangaroo bag hanging on the pole next to the bed that was empty, dated and timed. There was residual EF in the tubing. There was no documentation on the bag to identify what EF had been delivered. Review of a physician's order dated [DATE], showed Resident 214 was prescribed Vital AF 1.2 formula (an EF formula for residents that require tube feeding and experience absorption and digestion problems, or have impaired gastrointestinal function) for severe protein-calorie malnutrition. Additional orders dated [DATE], showed Enteral feed, every 24 hours, change gravity bag every 24 hours, label with date/time/resident name. During an interview on [DATE] at 8:59 AM, Staff J, Registered Dietician, stated they were not aware that Resident 214 had not received the prescribed Vital AF 1.2 formula. They stated they were not aware that the facility had substituted the Jevity 1.2 formula (a lower protein dense formula than Vital AF 1.2) since the facility had the Vital AF 1.2 in stock. They stated Resident 214 should have been receiving what was ordered. During an interview on [DATE] at 10:50 AM, Staff A, Administrator, stated they expected the licensed nurses to follow the physician's orders for the EF. If the EF was unavailable, the process would be to call the physician for a substitution. Staff A stated they expected the nursing staff to follow professional standards of practice and label the EF bags appropriately. Reference: WAC [DATE](3)(f)

Based on observation, interview, and record review, the facility failed to assess, monitor, or treat skin to prevent the development of facility-acquired pressure injuries (PIs) for 1 of 3 residents (Resident 1) reviewed for PIs. This failed practice placed residents at risk for worsening or new pressure injuries, pain, and unmet care needs. Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). <Resident 1> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include diabetes (a chronic disease that affects how the body uses insulin and glucose) and functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). The 07/16/2024 comprehensive assessment showed the resident's cognition was intact and required substantial/maximal staff assistance for bed mobility, toileting, and hygiene. The assessment additionally showed at that time, Resident 1 was being treated for one Stage 3-PI. During an interview on 09/23/2024 at 11:55 AM, Resident 1 stated they had been treated for two PIs to their bottom for greater than a year and one had resolved. Resident 1 stated they received a barrier cream to the remaining PI due to the PI had nearly resolved. Review of Resident 1's 02/07/2024 revised care plan for skin integrity showed the resident had a potential for skin impairment and that the resident was at risk for skin impairment. The care plan showed nursing staff were to monitor and document the location, size, and treatment of the injury, refer to the Medication Administration Record (MAR) and Treatment Administration Records (TAR) for interventions, and weekly skin checks would be completed. Additionally, the care plan showed there would be weekly treatment documentation (length, width, depth, and type of tissue and/or exudate) of any areas of skin impairment and any changes to skin impairment. Review of the September 2024 TAR, showed orders as follows: 1) on 06/29/2024 for Triple Paste (a brand of medication used as a barrier cream) to be applied to the buttocks every morning and at bedtime for skin care, 2) an order on 05/26/2024 to cleanse with normal saline and apply Triple Paste to a PI (did not identify the stage of the PI) to the coccyx (tailbone) daily and as needed until resolved (the order showed no treatment had been completed on 09/15/2024 and 09/22/2024), 3) an order on 05/28/2024 for weekly skin checks every Tuesday and document a (-) for no new skin impairment and a (+) for new skin impairment. The order also read if a new skin impairment was found, staff were to follow the Skin at Risk policy. A weekly skin assessment had been completed on 09/24/2024 with a (-) documented for no new skin impairments. Review of the 07/30/2024 weekly treatment documentation, showed the resident had a Stage 2-PI to their coccyx that measured 0.5 centimeters (cm, a unit of measurement) by 0.1 cm. There were no other weekly treatment documentation notes found as of 07/30/2024. An observation and concurrent interview on 09/26/2024 at 9:33 AM, showed Resident 1 being provided incontinent care by Staff L, Nursing Assistant. Resident 1 was observed to have two opened areas, one to their right buttock the size of a dime with partial thickness skin loss and one to their left buttock half the size of a dime with partial thickness skin loss and cracked opened skin in their gluteal fold (where the right and left buttocks form to create a crease) that had scant amounts of red drainage. Staff L stated the opened areas were not new areas and as far as they knew, the nursing staff were aware the sores were present. Review of a 09/23/2024 nursing progress note, showed sores to bilateral buttocks, treated per orders. The note showed the left buttock open sore was 0.5 cm by 0.5 cm and the right buttock open sore was 1.5 cm by 0.5 cm in size. No further notes or assessments had been completed for skin impairments and there were no ordered treatments or documentation showing the physician had been notified. During an interview on 09/27/2024 at 10:18 AM, Staff C, Resident Care Manager, stated nursing was responsible for completing the weekly skin checks and the NAs were responsible for reporting any new skin impairments they found during showers or care, to the nurses. Staff C stated the facility had a process to complete weekly wound assessments on any skin impairments with descriptions and measurements but when transferring over to their new medical record system, the assessment was not re-created so those assessments had fallen through the cracks. Staff C stated Resident 1 had a history of skin impairments to their bottom off and on and was unaware of the current skin issues observed during care. Staff C stated the nursing staff should have followed the process, notified the physician, obtained treatment orders, and completed assessments. During an interview on 09/27/2024 at 10:58 AM, Staff B, Director of Nursing Services, also present was Staff K, Regional Registered Nurse, stated their expectation was that nursing staff completed weekly skin checks with weekly assessments documented on residents with skin impairments. Staff B stated they would also expect the care plans to be updated to reflect the current status of the resident and for the physician to be notified and orders obtained if needed. WAC Reference: 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer are able to make decisions for themselves because of illness or incapacity) for 2 of 3 residents (Residents 1 and 10) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include breast cancer (when abnormal breast cells grow out of control and form tumors) and diabetes (a chronic disease that affects how the body uses insulin and glucose). The 07/16/2024 comprehensive assessment showed Resident 1's cognition was intact and able to make their own decisions. During an interview on 09/23/2024 at 11:55 AM, Resident 1 stated they had an AD in place and if they had been sent to the hospital, the facility would know what to do. During a follow-up interview on 09/26/2024 at 9:33 AM, Resident 1 stated the only end-of-life care treatment that had been discussed with them during quarterly care conferences were on a green Physician's Orders for Life Sustaining Treatment [POLST, a form that lets you choose the types of medical treatment you want during serious illness] form that resident 1 had on their bedside table and handed to the Surveyor. Resident 1 stated they had not been talked to or offered any other information regarding their wishes for end-of-life care and as far as they understood, the POLST form was their AD. Review of a document titled Durable Power of Attorney for Healthcare (DPOA, authorizes an agent to make medical decisions on your behalf when you are unable to do so) dated 01/22/2015, showed Resident 1's wishes as expressed in my Living Will would be followed but may not cover all aspects of care so they were designating a DPOA. Review of Resident 1's medical record showed, there were no documents titled Living Will. Review of Resident 1's 08/07/2024 care plan, showed the resident had a DPOA on file for their healthcare needs. The care plan additionally showed Resident 1's POLST reflected their AD wishes. <Resident 10> Review of the resident's medical record showed the resident admitted to the facility with diagnoses to include respiratory failure and a stroke (when blood flow to the brain is interrupted, leading to brain damage) with left sided weakness. The 07/18/2024 comprehensive assessment showed the resident's cognition was severely impaired and unable to make their own decisions. During an interview on 09/25/2024 at 4:39 PM, Staff I, Social Services Director, stated the facility would offer AD forms they could print off the internet to residents or family members upon admission. Staff I stated the residents could then discuss their options with their medical provider and complete the forms. Staff I stated they readdressed the ADs quarterly at care conferences and would document in the quarterly assessment or in a progress note. Review of Resident 10's quarterly assessment dated [DATE], showed the AD had been reviewed and was still appropriate. The assessment showed no information to formulate an AD had been discussed or offered. Review of Resident 10's 07/25/2024 AD care plan, showed Representative stated that the orders on the POLST reflect the treatment wishes and Resident is unable to complete an AD. During an interview on 09/27/2024 at 9:18 AM, Resident 10's Representative stated the facility had gone over the POLST form with them during care conferences but formulating an AD had not been discussed in all the years Resident 10 had been at the facility, nor were they offered information on formulating an AD or how to formulate an AD. During an interview on 09/27/2024 at 10:50 AM, Staff A, Administrator, stated their expectations would be for Social Services to address ADs on admission and quarterly during care conferences, care plan the ADs, and document the outcome if ADs were refused. WAC Reference: 388-97-0300 (1)(b)

Based on observation, interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for 1 of 5 residents (Resident 34) reviewed for trauma informed care. The facility failed to identify triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding Resident 34's history of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Record review of the facility policy titled Trauma-Informed Care, dated 08/01/2024, showed .The facility will recognize how trauma effects individuals through evaluation and identification of triggers during the admissions process. The facility will develop an appropriate plan of care and interventions based upon the residents' triggers and will modify the plan of care for any changes in behavior . <Resident 34> Review of Resident 34's medical record showed the resident admitted to the facility with diagnoses to include PTSD, anxiety (a feeling of fear, dread, or uneasiness) and depression (a prolonged feeling of sadness, hopelessness, or loss of interest in activities). The 08/21/2024 comprehensive assessment showed Resident 34 required the assistance of one staff member for activities of daily living and had an intact cognition. During an interview 09/23/2024 at 3:25 PM, Resident 34 stated they had PTSD stemming from being in the war and they had a father who was not a nice man, he was abusive. Resident 34 stated their triggers included, watching the news, loud noises, and they had a problem with men. During a follow up interview on 09/26/2024 at 2:54 PM, Resident 34 stated they got agitated, tearful, and anxious when they experienced these triggers. Record review of Resident 34's care plan, dated 08/22/2024, showed no trauma informed based plan of care that included Resident 34's triggers, behaviors, or interventions. During an interview on 09/25/2024 at 10:48 AM, Staff I, Social Service Director (SSD), along with Staff O, SSD, stated Resident 34's triggers should have been assessed and placed in the plan of care. Staff O stated Resident 34 did not have a trauma assessment completed that showed the details of their PTSD or their triggers. Staff O further stated they needed a better system in place to care for residents. During an interview on 09/27/2024 at 7:58 AM, Staff B, Director of Nursing Services, stated that trauma-based triggers and interventions were to be in the resident's plan of care so the staff knew how to care for the residents. WAC Reference: 388-97-1060 (3)(e)

Based on observation, interview, and record review, the facility failed to ensure two of two residents (37,5) were treated with dignity and respect when the facility delayed resolution and notification to Residents 37 and 5, the outcome of an investigation that revealed an unfounded allegation of sexual abuse. This failure placed both residents at risk for prolonged psychological distress and caused psychosocial harm to Resident 37 who experienced frustration, anger, increased sadness, and a diminished quality of life. Findings included . Resident 37. Review of the medical record showed the resident admitted in April of 2020. The 04/19/2022 comprehensive assessment showed the resident utilized a wheelchair to move about the facility, was cognitively intact with a Brief Interview for Mental Status (BIMS - a screen used to identify a resident's current cognition) of 14 (score ranges from 0-15, severe impairment to intact). On 05/23/2022 at 11:30 AM, a group meeting was conducted with six residents present. When the question was raised regarding resident rights, Resident 37 spoke up and stated they felt their rights were violated and that a friend was being accused of rape. The resident stated they would like to speak with the surveyors in detail following the meeting. During an observation and interview on 05/24/2022 at 9:04 AM, the resident was observed in bed watching television. The resident stated they felt their rights were violated by people here and that on the morning on 05/20/2022 the facility had told them their friend (Resident 5) was accused of being sexually inappropriate with Resident 37 and accused of rape and I said, are you kidding me . they did not ask me anything, they just told me. The resident stated that during the evening prior (05/19/2022), they (37 and 5) had asked the nurse if they could watch television together and the nurse said sure. Resident 37 said there was nothing going on . the only thing I can think is that (Resident 5) had put their arm around my shoulder. The resident further stated that Resident 5 was a good friend and they enjoyed activities together, spending time in the day room and that Resident 5 would push them in their wheelchair back and forth to meals I'm missing (5) . it's really bothering me and bothered (5) too. The resident stated that on that Friday morning (05/20/2022), a staff had called their Resident Representative (RR) and said that (37) needed to go to the hospital to be examined for rape. I'm not a kid, I'm [AGE] years old, I know what rape is . I spent four hours in the hospital with no reason. The resident stated that when they came back from the hospital, Resident 5 had left the facility. The resident stated they had not talked to their RR since and was very angry with them and the fact that they were involved and that it did not happen as the facility had told them. During the same interview Resident 37 stated that they were increasingly upset because the allegation was untrue and yesterday, 05/23/2022 they told their nurse of their anger and frustration. The nurse informed the resident to see someone in the social services department. The resident stated they self-propelled from their room to social services department and spoke of their frustration to that staff. The resident stated they had not heard from anyone since talking to social services and asked what this surveyor what they could do to get them help. Stated they worried about Resident 5. Review of a Social Services (SS) progress note dated 05/23/2022 at 4:47 PM showed Resident 37 came to SS for a visit . expressed frustration . Affect is flat, appears subdued and depressed . expresses sadness over loss of friend, concerned about [Resident 5] .shouldn't have had to leave like that. There was no rape. [Resident 5] was touching my shoulder, that's all . Stated not ready to speak with their RR yet . Review of the medical record showed Resident 5 admitted to the facility in November 2021 for aftercare following a surgical repair. Review of the 05/09/2022 comprehensive assessment showed the resident was cognitively intact with a BIMs of 15. Further review showed a progress note on 05/20/2022 at 9:00 AM that the resident was seen laying on (37's) bed and rubbing (37's) chest .[Resident 37] transported to ER (emergency room ) . for sexual assault exam. [Resident 5] ultimately left the facility AMA (against medical advice) at approximately 12:30. During an interview of 05/24/2022 at 9:22 AM, Staff S, Nursing Assistant (NA) stated they were familiar with both residents and provided care regularly to both. Staff S stated they had no concerns regarding sexual contact between the residents and that the residents sat together at lunch and would spend time in the day room. They seemed to enjoy each other's company. During an interview on 05/24/2022 at 9:29 AM, Staff Q, Registered Nurse (RN), stated they regularly provided care to both residents. Resident 5 regularly pushed Resident 37 to and from meals and they would eat lunch together. Staff Q stated they never saw anything inappropriate. Staff Q stated they were not happy about the situation and I know [Resident 37] is sad [Resident 5] is gone . we all need human contact. During an interview on 05/24/2022 at 3:04 PM, Staff G, RN/ Resident Care Manager stated that when they came to work on Friday, 05/20/2022, they heard in passing, from a night shift nurse who was leaving shift, that Resident 5 was laying down in 37's bed caressing the resident's breasts. Staff G then informed Staff B, Director of Nursing Services (DNS) who instructed them (Staff G) to make phone calls to the other staff who had worked with the two residents to determine what they had observed. Staff G stated that on 05/20/2022 someone else (unknown staff) approached Resident 5 who stated they had done nothing inappropriate to Resident 37, became mad and left AMA. Staff G said that they made phone calls as directed by Staff B and that no staff reported seeing any contact between the residents. Staff G stated they had not had time to document the staff interviews and that it very well could have been misconstrued . I believe [Resident 37] . in all honesty, I did not think it was as important as everyone has made it out to be . I do not think anything went on . Staff G further stated, that when a resident connects with another resident here, it's magical. Review of the hospital's 05/20/2022 discharge summary showed the resident was seen in the emergency department for concerns of possible sexual assault and when the resident was asked what happened they stated nothing. The resident told the hospital staff that [Resident 5] had their arm around the resident's shoulder and that it was consensual and was adamant no sexual assault occurred. The summary showed a hospital nurse spent nearly an hour talking to different staff members at the facility and was unable to get a clear history of what may have happened. The practitioner summary indicated that because the resident provided a clear and coherent history, was answering questions and was consistent with their story. I do not think [Resident 37] needs to have a pelvic exam or forensic exam against their will. The summary showed the resident was discharged back to the facility on the same day. During an interview on 05/24/2022 at 9:00 PM, Staff T, Registered Nurse stated they regularly worked the night shift and had worked the evening of May 19th, 2022 and was assigned to Resident 37, their shift ended on the morning of the 20th. Staff T stated that they regularly provided care to Resident 37 and had never seen any inappropriate behavior between Residents 37 and 5. I was aware that there was a friendship, and nothing happened on the night of the allegation. No NA staff reported any concerns to Staff T. I think it was people talking and talking, but nothing happened. They did watch television together in Resident 37's room with the door open. Staff T stated on the morning of the 20th, prior to leaving their shift, they had mentioned to another staff that the residents had been together watching television and somehow that was misconstrued [Resident 5] was touching her breast . that did not happen! Staff T stated that Resident 37 is very alert and that the resident is very sad and upset. On 05/25/2022 at 8:20 AM, Staff A, Administrator, stated it sounds like it was a rumor mill and that the investigation showed no one actually saw anything other than him sitting in the chair next to her. During an interview on 05/25/2022 at 10:10 AM, Staff B, DNS stated that Resident 5 was very upset when all this happened . They were thick as thieves spent time together in activities and enjoyed each other's company. Staff B stated that based on the information, it was kind of like the phone thing . the story changed. Staff B stated that they do not believe anything occurred. During an interview on 05/25/2022 at 10:29 AM, Staff R, Activities Director stated that Resident 37 and Resident 5 were good friends and that she never had any concerns. Staff R stated each resident council meeting is started by reading Resident Rights and that during the most recent Resident Council Meeting which occurred on Tuesday May 24th, 2022 Resident 37, when the Resident Rights were finished being read, stated they told me I could be friends with anyone I wanted Staff R stated that they acknowledged that was correct to Resident 37 and told them, yes you can. Staff R stated I feel bad for (Resident 5) . I do not know where (Resident 5) is at . they were good friends. During an observation and interview on 05/25/2022 at 3:30 PM the resident was exiting the activity room where a monthly birthday party celebration for the residents was occurring. The resident stated that they had to leave as it's just so upsetting. The resident was missing their friend and (Resident 5) would attend these things with me. Stated that no one in the facility had spoken to them regarding the conclusion of the investigation. If I just knew where (Resident 5) was at, I'd be better. During an interview on 05/26/2022 at 8:52 AM, Resident 37 stated that someone came into their room 'last night and talked to them about the nurse and their medications. However, no one had yet to talk to her about the conclusion of the allegation and how to get in touch with Resident 5. They should have waited until the result before they accused (Resident 5) of anything. During an interview on 05/26/2022 at 9:10 AM, Staff B DNS stated, We talked to [Resident 37] last night (May 25th) and validated their feelings, told them nothing occurred. At that time, Resident 37 said they wanted to call Resident 5, but we did not have a phone number. Staff B acknowledged the timeline from start to finish of the investigation and confirmed the delay in notification to Resident 37. They had not able to reach the nurse (Staff T) and did not interview until their next shift, the evening of the 24th. Review of the investigative summary dated 05/24/2022 showed from 5/20/2022 through 5/24/2022, no documented attempts to reach Staff T; no written statements obtained nor follow-up to the interviews conducted on 5/20/2022 by Staff G; nor follow-up to the hospital summary dated 05/20/2022 - all of which collaborated with the residents account of the relationship. Review of the facility's grievance log, showed no grievance was completed when the resident sought resolution on 05/23/2022 through social services. During an interview on 05/26/2022 at 9:27 AM, Staff A, Administrator, when asked by this surveyor how the situation was resolved for the resident and the loss of companionship Staff A stated they would initiate a call to resident 5. it's a small town, I'm sure I can find [Resident 5]. No previous efforts had been attempted. Reference: WAC 388-97-0180 (1-4)

Based on interview and record review, the facility failed to ensure adequate supervision was provided for one of one resident (1) reviewed for accident prevention. Failure to implement interventions including adequate supervision with the use of a mechanical lifting device (hoyer lift) consistent with the resident's care plan, resulted in a significant head injury to the resident, requiring hospital intervention. Findings included . Resident 1. Per the medical record, the resident was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], kidney disease, diabetes and dementia. Review of Resident 1's most recent comprehensive assessment, dated 02/07/2022, showed they required extensive assistance of two caregivers for bed mobility, dressing, and toileting and was totally dependent on staff for transfers with a hoyer lift (a mechanical full body lifting device) with the assistance of two caregivers. Further review of Resident 1's care plan and a visual bedside kardex report, both dated 02/01/2022, showed the resident required two or more persons for transfers with a hoyer lift. Review of a facility incident report showed on 02/18/2022 at approximately 6:30 AM, Staff C, Nursing Assistant (NA), used a hoyer lift to transfer Resident 1 from their bed to their wheelchair without the assistance of a second caregiver. The report stated when Resident 1 was lowered into their wheelchair, the mechanical lift tipped over striking the resident on the head causing a laceration and bruising. The resident was immediately sent to the hospital where she was initially diagnosed in the emergency room with a concussion, a scalp laceration requiring two staples and an acute cervical (neck) sprain. Resident 1 was then sent back to the facility on the same day at approximately 10:30 AM. During an interview with Staff C on 03/10/2022 at 4:25 PM, they stated after they had gotten Resident 1 dressed and put a hoyer lift sling under the resident in preparation to get them up in their wheelchair for breakfast, Staff C left the room to go and get the lift. Staff C stated they did not ask anyone else to assist with the transfer because they were all busy and Resident 1 was anxious to get out of bed. Staff C also stated as soon as they got Resident #1 seated in the wheelchair but still strapped to the hoyer sling, the whole lift came flying toward them, hitting the resident on their forehead and top of head. Staff C stated the resident's head was bleeding and Staff C tried to remove the lift off of the resident but couldn't move it, so Staff C ran out into the hall and found another NA to assist them. During the same interview, Staff C stated they knew Resident 1 and all residents that used a hoyer lift required two people to be present for the resident's safety. Staff C could not explain why they chose to deviate from the care plan other than the resident was so anxious about wanting to get up. Review of nursing progress notes, dated 02/18/2022 by Staff B, Registered Nurse (RN), stated in part, that at 6:30 AM she was informed Resident 1 had been hit in the head by a hoyer lift and was bleeding. Upon assessment, the resident was found to be alert and had a small deep laceration to the top of their head with a moderate amount of blood draining from the wound. Two other raised bruises were noted, one on the forehead and one below the right eye. Following first aide to stop the bleeding by applying pressure to the laceration, Resident 1 was sent to the emergency room for evaluation of their head injury. Further review of nursing progress notes, dated 02/18/2022 by Staff B, showed Resident 1 returned to the facility at 10:30 AM from the emergency department with a diagnoses of a concussion and orders to hold the resident's blood thinning medication for that day. Staff B stated in the progress note they initiated neuro checks (a neurological assessment assessing mental status, cranial nerves, motor and sensory function, pupil response, reflexes and vital signs) upon Resident 1's return to the facility and found them difficult to wake up, their pupils were pin point (indicating brain injury) and their blood pressure continued to go down. Staff B stated they sent Resident 1 back to the hospital for further assessment and was called by the hospital at 12:00 PM stating the resident had been admitted for observation. Review of hospital records, dated 02/18/2022 through 02/23/2022, showed no acute changes to further brain scans from the initial diagnoses of a concussion, though scans of other body parts showed extensive metastatic cancer was found in Resident 1's lungs and liver. Resident 1 and their family decided on hospice services in the resident's home for end of life care. During an interview with Staff A, the Administrator on 03/08/2022 at 12:30 PM, they stated an immediate investigation was initiated after the incident and learning that Staff C had transferred Resident 1 without assistance of another caregiver. Staff A stated it was facility policy that all hoyer lift transfers required two people for resident safety and Staff C was immediately suspended from employement pending the outcome of the accident investigation. Reference WAC 388-97-1060(3)(g)

Based on interview and record review the facility failed to assess and implement interventions in accordance with professional standards of practice for one of four residents (#1) reviewed for diabetic management. Failure to monitor the resident's blood glucose (sugar) levels following notification of high blood glucose lab values, and discontinuance of a diabetic medication resulted in deterioration of the resident's medical condition, requiring hospitalization for emergency blood glucose management and related complications. Findings included . Resident #1. Per the medical record, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 02/18/2021, showed the resident required extensive assistance for all care and was unable to make decisions regarding daily activities due to severe cognitive impairment. Review of Resident #1's medical record showed on 06/23/2020 a physician order [REDACTED]. Review of Resident #1's lab reports showed the results of the HbA1c test on 06/26/2020 was 6.5 %. (The goal in DM management is for the HbA1c test to be below 7.0 %). Further lab report review did not show a follow up HbA1c was done six months later in December 2020 as ordered. Review of a physician progress notes [REDACTED].#1's DM was well controlled, her HbA1c test dated 06/26/2020 was 6.5 % and discontinued the oral DM medication. On 01/25/2021 the physician ordered new labs to be drawn, including a Comprehensive Metabolic Panel (CMP - a blood test that gives information about the body's fluid balance, levels of electrolytes and how well the kidneys and liver are functioning) and a HbA1c test. Review of the lab reports ordered on [DATE] showed blood glucose levels from the CMP were 339 milligrams (mg)/deciliter (dL) on 02/01/2021, (normal range for a blood draw glucose test is 70-99 mg/dL.) and the result of the HbA1c was 8.5 % on 02/05/2021, above the goal of 7.0 %. During an interview with the Director of Nursing (DON) on 03/01/2021 at 2:30 P.M. she stated she had noted that the HbA1c test was not done in December 2020 as ordered on [DATE], and the physician's decision to discontinue Resident #1's DM medication was based on the lab work done seven months previously on 06/26/2020. In addition, the DON stated that facility staff had difficulty getting a blood draw for the labs ordered on [DATE] due to poor vein access in Resident #1 and the blood draw was not completed until 02/04/2021, ten days after the order date. Review of Resident #1's Medication Administration Records (MAR) for January and February of 2021 showed the licensed nurses (LNs) were to be monitoring for signs and symptoms of [MEDICAL CONDITION] (high blood sugars) and [DIAGNOSES REDACTED] (low blood sugars), including taking a capillary blood glucose (CBG) level as needed. Review of nursing progress notes from 01/25/2021 through 02/08/2021 showed the LNs were aware of the discontinuation of Resident #1's DM medication and the results of the abnormally high glucose tests, though no CBGs were taken to assure Resident #1's blood sugars were within a normal range. A 02/08/2021 physician order [REDACTED]. Review of a nursing progress note, dated 02/13/2021 at 8:09 P.M., showed that a LN stated Resident #1 had been sleepy, did not eat her meals yesterday and had slept through breakfast, lunch and dinner today. The nurse stated she did a glucose check which resulted in a high glucose reading of 594 at 6:00 P.M. Further review showed the LN informed Resident #1's Representative of the high CBG reading and of her decline in condition. The Representative then requested the resident be sent to the hospital for an evaluation. Review of hospital records showed on 02/13/2021 Resident #1 was seen in the emergency room and was found to be in a severe [MEDICAL CONDITION]/hyperosmolar state, (a serious complication of DM which happens when blood sugar levels are very high for a long period of time, leading to dehydration, confusion, drowsiness, fever and other symptoms) had blood sugars over 700, and was in acute [MEDICAL CONDITION]. Resident #1 was admitted to the hospital for treatment and later discharged back to the facility on [DATE]. Readmission physician orders [REDACTED]. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to prevent an avoidable accident for one of three residents (#1) reviewed for falls. A Physical Therapy Assistant (PTA), Therapy Staff C, failed to utilize a gait belt (a belt placed around the resident's waist to aid in holding on to the resident for stability and/or safety purposes) during the therapy session. Additionally, the resident was unable to utilize her left ankle/foot brace during the session. While completing the fifth gait speed trial (timed walking exercise at an increased speed), the resident's left foot tripped over her toes and she fell forward. Although Staff A reached out to control/soften the descent, Resident #1 fell to the floor landing with her left ankle under her right leg resulting in a left upper leg/[MEDICAL CONDITION] requiring a surgical repair. Findings included: Review of the facility policy, entitled Gait Belts, stated, It is the policy of this facility that the staff will be required to use transfer/gait belts during transfers and ambulation of residents that require assistance, unless it is medically contraindicated for the resident as determined by RCM (Resident Care Manager) or therapy staff. The objective of this policy is to assure the safety of residents and staff. Resident #1: Review of the medical record revealed the resident was initially admitted to the facility on [DATE] for orthopedic aftercare following a displaced left [MEDICAL CONDITION] and pinning related to a fall. According to a 09/12/18 nursing entry, the resident had a critical lab value and was sent to the hospital. On 09/19/18 the resident returned to the facility for aftercare following a left total hip replacement at the hospital. Physician orders included an order for [REDACTED]. An AFO (an ankle/foot orthotic/brace) was to be worn on the left foot and checked every shift. Review of the 09/19/18 Physical Therapy (PT) Evaluation and Plan of Treatment by Therapy Staff A, Physical Therapist (PT), showed the resident had undergone a left total hip surgery due to migration of the screws and other complications. The resident was referred for PT services due to decreased strength, balance, and activity tolerance and an increased need for assistance with all ADLs (activities of daily living)/functional tasks. The PT evaluation noted the resident's gait showed a pattern that favored the left leg. Additionally, the resident was noted as at risk for falls. A 09/20/18 nursing entry showed the resident was able to walk short distances with weight bearing as tolerated and the use of a walker. A staff member was present with some hand contact on the resident to ensure her safety while walking. According to a 09/24/19 nursing entry, the resident complained of tightness in her left lower leg due to [MEDICAL CONDITION]. The resident was able to ambulate to the bathroom with staff assistance. Review of the 09/25/18 Physical Therapy Treatment Encounter Note, completed by Therapy Staff B, PTA, showed the Resident #1 participated in gait training with a front wheeled walker with stand by assistance and contact guard assistance. The session included walker management, having equal step length, and preventing rolling of the L (left) ankle .Patient has difficulty with left foot drop and internal rotation of the hip. The gait training required hands on assist; 1 or more cues for majority of task. A 09/26/18 nursing entry noted the resident had an orthopedic appointment that morning. Review of the ARNP's (Nurse Practitioner's) documentation revealed the resident was alert and oriented. The resident was being seen in the office following the left total hip surgery. The ARNP noted the resident was complaining of left foot/ankle swelling. The ARNP also included a new [DIAGNOSES REDACTED]. WBAT LLE (left lower extremity), Continue stretches & strengthening left foot . The resident had a 09/26/18 PT therapy session with Therapy Staff C, PTA. Therapy Staff C documented the resident required SBA (stand by assistance) and close supervision for the majority of her gait activity for safety with set-up but no physical contact. Additionally, Staff Therapy C noted the resident had a decreased stance on her left, foot drop on the left, and a decreased step height. On 09/27/18 Resident #1 had a therapy session with Therapy Staff C. The resident stated she was tired. Resident #1 further stated she had an AFO in the room but currently the AFO was too small d/t (due to) [MEDICAL CONDITION] in LLE. The resident walked in the gym with the PTA providing verbal commands for posture and incr (increased) step height and perform exaggerated step on L to compensate for drop foot. Additionally, Therapy Staff C had the resident perform gait speed trails with the use of the walker. At end of 5th trail of gait speed, pt (patient) was amb (ambulating/walking) with FWW (walker) SBA and L foot tripped over toes d/t foot drop on L, Pt(')s momentum carried her forward, PTA reached out to control descent and soften fall placing PTA's arms under pts shlds (shoulders) . Resident #1 landed on the floor with her left ankle under lower right leg. Pt screamed and reported she felt a break. Nursing staff were summoned and an ambulance was called. Further review of the 09/27/18 therapy notes revealed the resident's times on the gait speed trials was 6.2 seconds, 6.5 seconds, 5.52 seconds, 5.9 seconds, and 5.2 seconds. The 09/27/18 nursing entry documented the resident had a left foot drop from the previous fracture and became more fatigued throughout the therapy session, causing her left foot to catch the foot and resulted in a fall to the ground. The resident had stated to the nurse earlier in the morning that she did not sleep well and was tired. The resident had stated, I almost fell asleep in the shower this morning I was so tired. The nursing entry also noted that after the fall the resident's left leg was externally rotated, slightly shortened, and the resident was reporting 10 out of 10 (the highest level) on the pain scale. The ambulance was called and the resident was transported to the hospital emergency department. Review of the 09/27/18 hospital physician's history and physical showed the resident had a left femur (upper leg bone) fracture surrounding the prosthesis (hardware from the previous surgery). The 10/03/18 hospital discharge summary noted the resident had required a surgical repair of the left hip. On 10/05/18 at approximately 11:30 AM, an interview was conducted with Therapy Staff C. Therapy Staff C recalled on 09/27/18 Resident #1 was tired. The PTA was aware of the new orders from the previous day that included wearing the AFO when out of bed but the resident's left leg was [MEDICAL CONDITION] (had a lot of fluid in the tissues resulting in swelling) and the AFO did not fit. She needed a custom AFO. The resident did not wear the compression hose (to help control the swelling) due to not having the right size of stockings. The resident had worn two different styles of tennis shoes that were equal in height for the therapy sesson. Therapy Staff C stated she did not see a need to alter the treatment plan and proceeded with the therapy session without placing a gait belt on the resident. She anticipated the resident would only require stand by assistance (SBA, without hands on the resident). Reportedly, it was the day to assess the resident's gait speed (with the walker), an assessment of the resident's gait and balance. Five speed trails were planned. On the fifth trial the resident caught her foot and fell . Therapy Staff C was positioned behind the resident. Therapy Staff C grabbed the resident's shoulders and tried to protect the resident's head as she fell . The resident screamed out in pain as she fell and stated I felt a break or I broke it again. Therapy Staff A, PT, was interviewed on 10/05/18 at approximately 1:15 PM and he stated he recalled completing an evaluation(s) on Resident #1. The resident had an AFO that didn't fit. If the PTA was unable to follow the physician's/provider's order(s) they should confer with the PT or the physician (about any necessary changes to the program/treatment plan). When asked about the use of the gait belt for the resident, Therapy Staff A stated he would have used a gait belt if he was working with Resident #1. He tended to follow the facility policy for gait belt use. Therapy Staff A typically used a gait belt for anyone requiring SBA or more assistance. When working with a resident with foot drop, therapy staff would teach the resident a compensatory gait pattern. Therapy Staff A was also asked about the gait speed trials. He responded that while the resident was performing the gait speed trials, therapy staff should watch and cue the resident to maintain a safe speed. The expectation was that the resident walk at a speed they can manage. Therapy Staff A stated he was present in the gym but was not watching Therapy Staff C at the time of the fall. On 10/05/18 at approximately 3:20 PM, the cognitively alert resident was observed in her bed. The resident reported she had fallen at home originally. The left foot drop had developed after her fall and [MEDICAL CONDITION]. The resident stated she had received an AFO at the hospital. However, she had developed a lot of swelling in her left leg and was unable to wear the AFO. The resident was also unable to wear the compression stockings that were provided as they didn't fit. She needed a larger one. On 09/27/18 the resident was unable to wear the AFO or the compression stockings. The resident identified the two shoes she had worn, one each from two different pairs of shoes. Per recall, on 09/27/18 Resident #1 had performed three to four speed trails. Then while walking, her left foot turned and she fell . Therapy Staff C did not have a gait belt on her. Resident #1 recalled excruciating pain related to the fall. After another the surgical repair, the resident had returned to the facility but she had to start at the beginning with her therapy. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide timely assessments of an injury and evaulate for changes and increased pain of a suspected injury to the right great toe for of 1 of 1 resident (#55) who experienced a change of condition. This resulted in actual harm to the resident due to his significant pain level and delay in appropriate medical treatment. Findings included: Resident #55. Per medical record review the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The 04/18/18 quarterly assessment showed the resident was alert and made decisions about daily routine and cares. The resident required extensive assistance for transfers and bed mobility and used a wheelchair to self propel in the facility. Review of the progress notes showed a 01/13/18 note where the resident complained that his feet hurt all the time. On 01/16/18 the resident complained of severe heel pain and the heel was hanging over the side of the bed. According to the (MONTH) (YEAR) progress notes and the 04/18/18 resident assessment, the resident experienced severe pain and received a narcotic [MEDICATION NAME] as needed. A review of the facility 02/20/18 skin grid documentation revealed the resident's right hallux (big toe) had a partial thickness abrasion. On 03/01/18 the resident's big toe had a dried/drained blister with pain. On 03/08/18 the big toe appeared to have a drained blister with a dry patch of skin and was blue/black with a red line to the border with pain. On 03/15/18 the big toe had an old dried blister without drainage, and the resident complained of pain. A review of the 02/20/18 provider note by Staff K, Advanced Registered Nurse Practitioner (ARNP), showed the resident had a small nick to the right great toe with a darkened area to the tip of the toe by the nail edge. An order was given for Epsom salt soaks for 10-15 minutes 3 times a day for five days. A follow-up 02/27/18 note by Staff K showed a small blood blister developed at the corner of the nail edge .the wound remains unchanged and reveals a small darkened area. The resident requested a podiatry consult last week (02/20/18) if warm compresses were not effective. On 02/27/18 at 3:30 PM the resident complained of severe pain in his right distal great toe. The 02/27/18 progress note revealed the resident asked for his narcotic pain medication religiously. An additional order for another pain reliever was ordered every 8 hours as needed for pain. A 03/01/18 resident progress note revealed that monitoring for a blister to the right great toe for sign and symptoms of worsening pain. On 03/03/18 the resident progress notes documented that the resident had complained of foot pain and was given a narcotic pain medication. Resident was upset about not getting his pain medication on time. On 03/04/18 resident complained of right foot pain an received another narcotic pain medication. Between 03/05/18 and 03/15/18 there were frequent complaints of unmanaged foot pain by the resident according to the resident progress notes. On 03/15/18 the resident progress notes showed the resident complained of severe pain of his right foot and toe and the ARNP added an additional dosage of a narcotic medication for the increase of pain. A 03/17/18 resident progress note showed the resident had an increase in pain even with the additional added narcotic medication dose. The resident had a temperature of 101 degrees orally and received 1000 mg (milligrams) of Tylenol. On 03/19/18 the resident progress notes documented that the resident requested a foam pad for his footboard on his bed due to the bed being too short for his height and for his foot comfort. The 03/22/18 Wenatchee Podiatry assessment revealed Resident #55's [DIAGNOSES REDACTED]. The resident stated that the pain symptoms had prevented him for 'going about normal activities.' The 03/22/18 assessment documented the podiatrist took the eschar off the right great toe non-healing ulcer and diagnosed the resident with 'severe/ advanced vascular disease' and recommended an immediate follow up with a vascular surgeon. A 04/19/18 Vascular Surgery report revealed the resident had critical blood flow blockage of the right leg according to a 04/04/18 angiogram (test to visualize arteries in the leg) with multiple areas that were blocked. The surgeon stented the arteries to improve blood flow. On 05/08/18 at 8:53 AM, Staff K stated the resident told her his toe nails were clipped and his right great toe was nicked which turned into a blood blister a couple of months ago. The resident ended up with an embolized (blockage of blood supply by blood clot) foot and ankle had stents (placement of wire mesh tube to keep blood vessel open) placed but that failed and now has to have a bypass (a procedure to place a graft to an artery to improve circulation) surgery of the right leg. On 05/08/18 at 9:12 AM Staff C, Assistant Director of Nursing Services (ADNS)/Registered Nurse (RN), stated the resident had an ingrown toenail beginning (MONTH) (YEAR) and on 02/03/18 a Licensed Nurse trimmed the toenail and nicked the right great toe area. Staff C then stated that the nurse did not nick the skin but the resident bumped his toe. The facility did not investigate the incident. On 05/08/18 at 9:19 AM Staff E, Licensed Practical Nurse (LPN), was unaware that the resident had an open area blister on right great toe or that there was an accident which caused an abrasion. On 05/04/18 at approximately 9:00 AM the resident stated that he had experienced severe pain related to his right foot for about the past four months, which started in (MONTH) (YEAR). The pain had increased to where he had taken more pain medication and did not sleep well at night which did decrease his mobility and normal activities. The resident stated that in (MONTH) (YEAR) a nurse had nicked his right toe while cutting his right great toe nail and his right foot had hurt so bad at night he had to dangle his foot off the side of the bed. The resident stated he requested an appointment with a podiatrist, but the staff wanted him to soak his foot first which made it worse. On 05/04/18 at approximately 9:30 AM, a small round area of eschar (scabbed area) was observed on the tip of the resident's right great toe and greenish-blue bruising to the right top side of the foot. The resident stated he did not always wear shoes but wore socks, to wheel himself outside and may have bumped his foot due to the difficulty he had getting out and back through the door to the smoking area. During an interview on 05/09/18 at 11:31 AM Staff B, Registered Nurse, Director of Nursing Services (DNS), stated whatever happened to the resident's toe, it became inflamed and resulted in an embolism due to a vascular deficit. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review the facility failed to assess the increased risks of skin breakdown and implement interventions necessary to prevent the development of pressure injuries for 1 of 4 (#1) residents admitted with increased risks to develop pressure injuries. This failure caused the resident harm when she developed four avoidable pressure injuries on her right foot after the placement of a new splint. Findings included: Resident #1. Per the medical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent comprehensive assessment dated [DATE] revealed she had severely impaired cognition and required extensive assistance of 2 caregivers for bed mobility, transfers, toileting and dressing. Review of the medical record revealed Resident #1 obtained a spontaneous displaced [MEDICAL CONDITION] distal femur and was sent to the emergency room for evaluation and treatment on 03/05/18. Review of nursing progress notes revealed Staff A, RN, documented Resident #1 returned to the facility following the emergency room visit on 03/05/18, in a soft splint with a firm posterior immobilizer and ace wraps securing the leg from her toes to her mid thigh. The resident's immobilizer was assessed by Staff A as in place and her toes had good color, movement and sensitivity to touch. Review of Resident #1's nursing progress notes dated from 03/06/18 to 03/11/18 revealed on 03/06/18 Staff A, RN, documented a fax was sent to the orthopedic physician who placed the splint requesting orders for the use of the splint and when it could be removed for skin checks. On 03/06/18 a notation was made in the progress notes by Staff B, RN, that she received a call from the orthopedic physician stating the splint was for comfort only as the resident did not ambulate and did not require any follow up from him. There was no further documentation in Resident #1's record in regards to the splint until 03/11/18 when Staff A documented that she processed an order from the orthopedic physician dated 03/07/18. Staff A documented the order stated the splint was for comfort only and if the resident was not in pain she did not need to wear it as she was non-ambulatory. Staff A documented she removed the splint on 03/11/18 and described Resident #1 of having multiple areas of unstageable wounds to her right foot. She described 4 wounds as: 1. Right heel, a 3 cm. circular wound with leathery intact skin, edges reddened, poorly blanchable. (If the skin is poorly blanchable or unblanchable it means redness to the area does not fade when pressed indicating a disruption of blood flow to the area.) 2. Right outer bony ankle protrudence wound, a 2 x 1.25 cm irregular circle with tan crusted area in the center, poorly blanchable. 3. Right inner ankle protrudence wound, a 3 x 1 cm circle with a tan crusted area in the center, poorly blanchable. 4. Right top of foot, a 1 cm. irregular with tan crusted center, poorly blanchable. Review of Resident #1's skin assessment sheets and treatment sheets had no listing of skin assessments or treatments to the skin under the brace until 03/12/18. Observation of Resident #1 on 03/16/18 at 3:45 PM with Staff C, RN, showed her lying on her back in her bed with the splint in place on the right leg. She was awake and alert though had no knowledge of what had happened to her leg when questioned. Staff C asked if we could remove the splint and look at her foot and she agreed. Resident #1's right heel wound was unstageable, measuring approximately 4 x 4 cm with a black center and redness surrounding the area. The other 3 wounds measured as described by Staff A and were difficult to stage as they had a sure prep clear dressing in place. In an interview with Staff C on 3/16/18 at 4:10 PM, he stated he was unaware the resident had wounds until 3/12/18. He stated he did not know why the splint was not removed for 6 days for a skin check other than the nurses were waiting for orders from the physician to do so. In an interview on 03/16/18 at 4:25 PM with Staff D, RN, Assistant Director of Nursing (ADNS), she stated that the nurses missed taking the splint off and can only assume they were waiting for physician orders [REDACTED]. In an interview with Staff A on 03/19/18 at 9:00 AM, she stated she had written the physician requesting orders to remove the splint on 03/06/18 but had not heard back from him by the time she left for 6 days off. She stated she returned to work on 03/11/18 and discovered that no one had removed the brace or looked at the skin underneath it. She stated she removed the splint and found the wounds and called Resident #1's physician and the Director of Nursing to inform of her findings. She stated she was very angry that no one had followed up while she was off work. In an interview with the Director of Nursing (DNS) on 03/19/18 at 3:30 PM, he stated he first heard of the wounds when staff A called him on 03/11/18. The DNS stated he had no explaination of why her risk factors had not been careplanned after the splint was placed or how the nurses working missed checking the skin under the brace for 6 days. He stated he had interviewed and counseled all involved on facility policies regarding skin care following this finding. Reference WAC 388-97- (b)

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (#30), reviewed for the use of anti-psychotic medications, was administered the medication in a manner that promoted dignity and respect, and resulted in a violation of the resident's right to make choices that were significant to maintaining his individually. The resident's medication was hidden in the resident's food by staff after the resident clearly indicated by his actions that he did not want to take the medication with food. From a reasonable person's standard, this was an affront to the resident's dignified existance. Findings include: Resident #30. Per medical record review, he was admitted in 01/2015 with [DIAGNOSES REDACTED]. The resident was Spanish speaking only. The medication administration records from November 2016 through February 2017 contained directions for medications to be mixed with meals. [MEDICATION NAME] (anti-psychotic) 50 milligrams twice a day was listed on the medication records. On 02/13/17 at 7:45 p.m., Staff Member EE, a Licensed Nurse (LN), stated she worked the day shift. She stated she had problems trying to get the resident to take his medications. It's a real trick to get him to take something. She stated she had the Spanish speaking nursing assistants tell him what was being given and why but he usually refused. On 02/13/17 at 7:42 p.m., Staff Member P, a LN, stated she worked from 6:00 p.m. to 6:00 a.m. If the resident was in pain, the staff told her and she attempted to give him pain medications, but It's hit and miss if he will accept it. She stated he was on [MEDICATION NAME] (anti-psychotic) because he could hit and spit at the caregivers. Those were the only behaviors she was aware of for the medication. On 02/14/17 at11:00 a.m., Staff Member N, a LN, stated she gave the resident his [MEDICATION NAME] (anti-psychotic) and Metropolol (anti-hypertensive) in his breakfast meal. She crushed his [MEDICATION NAME] and put it in his yogurt, pudding, or even eggs; it depended upon the food served as to what it was put into. Staff tried hard to get him the medication; the guardian just wanted it given in his meals and it was her directive that he not know medications were in his food. Otherwise, he would refuse to take them. On 02/14/17 at 11:30 a.m., Staff Member W, an Activities Assistant, stated the resident often comes to the post-lunch activity. Staff Member W speaks to the resident in Spanish, but the resident would not really talk to her. He did more communication with his hands and noises he made. She stated the resident usually was happy to come into the activity, but when he did not want to, he would push his hands at them; it was easy to understand his preference for attending. On 02/14/2017 1:00 p.m., Staff Member T, a Restorative Aide, stated she fed the resident breakfast in the dining room. She stated the nurse would put the resident's medications in his food and then Staff Member T would feed it to him, if he would eat. On 02/14/17 at 1:15 p.m., Staff Member S, a Nursing Assistant (NA), stated she also assisted the resident by feeding his meals. She said the resident took his medications in his food. The LN would put it in his food and then stay there while the NA fed him the food with the medication in it. On 02/14/17 at approximately 3:00 p.m., the resident's family member/guardian stated she was unaware of why [MEDICATION NAME] was being used and that the medication was an antipsychotic. She thought it was for pain. She stated she had noticed if he did not want something then he might twist your arm or push you away. He had gone to the dentist about a month ago for infected gums and needing his teeth pulled. He had followed all of their instuctions without any problem during the procedure. She stated one of the evening nurses, she thought it was Staff Member P, always told her how important it was for the resident to take his medications. The guardian felt like he had to have those medications so she agreed with their use because it seemed so important he had them. She thought the [MEDICATION NAME] was for pain and did not realize the risks and benefits of such a drug (anti-psychotic). She did not want him to have any un-needed medications. She thought he understood what was wanted from him depending on how things were explained to him. She understood the medications were being put in his food to deceive him because then he would take them as he did not know they were there. On 02/15/17 at 9:50 a.m., Staff Member D stated she fed the resident his food that she had mixed his [MEDICATION NAME] into and she told him the medication was in the food. She stated she told him in English as she did not speak Spanish. (However, the resident was spanish-speaking only and, therefore, would not comprehend.) The resident's choice to refuse medications without the deception of hiding medications in food and not explaining in his native language caused the resident to receive an un-necessary medication that chemically altered his brain. Further, the resident's advocate and guardian was unaware of the consequences of taking an anti-psychotic medication. Cross reference F329 regarding further details of the innapropriate use of medication for Resident #30.

Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents (#146) was free from emotional abuse related to a staff-to-resident verbal abuse allegation. This failed practice caused the resident embarrassment and caused further emotional abuse when the staff member confronted the resident a second time, even after she had been directed not to have any contact with the resident. Findings include: Note: Washington State Nursing Home Guideline AKA The Purple Book, Sixth edition, October 2015, defines abuse as Impermissible, Harmful, Offensive, or Unwanted Physical, Verbal, or Non-Verbal Contact or Intervention with the Resident That Cannot Be Properly Justified and Willful infliction of Injury, unreasonable confinement, intimidation, or punishment. Resident #146. review of the resident's medical record revealed [REDACTED]. The most recent comprehensive assessment dated [DATE] documented the resident as needing assistance with activities of daily living (ADLs) and as cognitively intact. On 02/08/17 at approximately 9:00 a.m., Resident #146 was observed sitting on his recliner with a blanket covering him. When the resident was asked if he had been abused in the facility,he answered yes. The resident explained he had a concern related to Staff Member U, the Social Services Assistant. The resident stated approximately 2-3 days prior, there was an incident where he soiled the pad on his recliner with stool. When the resident was out of his room, he stated the Social Services Assistant went into his room and observed the stool on the pad and later approached him about it. Resident #146 stated Staff Member U told him how disgusting and how horrible it was that he soiled the pad on the recliner with stool. He stated the Social Services Assistant said to him, I was so sick, I almost puked. The resident stated he felt the situation was degrading and made him feel bad and embarrassed. The allegation was reported to staff by the resident, the day of the incident. In a second interview with Resident #146 on 02/10/17 at 11:17 a.m., he stated he was being discharged the next day. When asked if there was any follow-up to his concern, he added, Staff Member U had returned to his room the other day (after she was instructed not to go in to the room by her supervisor). Resident #146 stated while Staff Member U was visiting with the roommate, Resident #146 requested her assistance, she responded with I thought you didn't want to talk to me . She persisted with Why I didn't want to speak to her anymore. The resident stated he felt emotionally abused from the first encounter with Staff Member U. I did not want to talk to (Staff Member U) anymore, and was not sure why she went into his room a second time. On 02/13/17 at 1:13 p.m., Staff Member E, the Social Services Director (SSD), stated she first learned of the allegation of abuse from Staff Member U on 02/08/17 when the resident kicked Staff Member U out of his room. The SSD stated Staff Member U reported she did make statements to the resident about the stool and odor. She explained to the SSD the odor gagged her and she felt like throwing up in her mouth. The SSD stated she instructed Staff Member U to not go in to the resident's room and educated her on how to appropriately interact and speak to the residents with respect and dignity. Staff Member E stated the next day, the Social Services Assistant reported she did approach the resident to ask why he did not want to talk to her. The SSD stated she reported the allegation to the Administrator and the Director of Nursing Services (DNS), but did not tell them about the second encounter the Social Services Assistant had with Resident #146. On 02/13/17 at 1:43 p.m., Staff Members A, the Administrator, B, the DNS, C, the Assistant DNS, and DD, the Regional Nurse Consultant, were present during an interview about the abuse allegation with Resident #146 and Staff Member U. The administrator stated Staff Member U admitted to approaching the resident in a wrong manner and was on an administrative suspension pending the investigation of the abuse allegation. The administrative staff were not aware of Staff Member U going into the resident's room (even after instructed not to by her supervisor) confronting the resident a second time. Review of the facility investigation for the abuse allegation included a statement written in email on 02/09/17 by the SSD, which was sent to the Administrator and the DNS, stated, .She (Staff Member U) doesn't know how to handle people, even when I coach her. Also included in the investigation was a Conversation Record between Staff Member U and the Administrator. In regard to the resident's hygiene and complaints of his odor, Staff Member U stated to the administrator, I had the unfortunate task of talking to him about it. Review of the medical record did not reveal documentation for the monitoring of Resident #146 after he reported the abuse allegation to facility staff. (The resident was in the facility for two days after the allegation and prior to his discharge) The facility policy titled Abuse and Neglect Prevention with an effective date of October 1, 2013 documented It is the policy of this facility to prevent abuse and neglect of residents by .responding appropriately and promptly to all incidents of abuse .Facility staff will .protect residents .respond to findings, formulate conclusions, and implement measures to minimize future similar occurrences. The week of 02/13/17, the facility administrative staff reported Staff Member U was terminated as a result of their investigation related to the abuse allegation for Resident #146.

Based on observation, record review, and interview, the facility failed to provide necessary care and services to prevent a serious infection for 1 of 3 sampled residents (#5). Resident #5 failed to receive timely catheter care in accordance with his physician's orders [REDACTED]. Findings include but were not limited to: Resident #5: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. The resident's plan of care noted he required an indwelling urinary catheter. The catheter was to be changed in accordance with the physician's orders [REDACTED]. The resident's care plan goal was to "have catheter care managed appropriately as evidence by: not exhibiting signs of urinary tract infection..." physician's orders [REDACTED]. Additionally, the Foley catheter was to be irrigated with 60 cubic centimeters (2 fluid ounces) of normal saline (a salt solution compatible with the body fluids) every evening at bedtime to maintain its patency. Review of the August 2013 catheter flow sheet revealed the resident's Foley catheter was changed on 8/03/13. Nightly catheter irrigations were documented 21 of 31 nights with the last documented on 8/30/13. The September 2013 catheter flow sheet failed to document the order for the nightly catheter flush and contained only an order for [REDACTED]." No catheter change was noted at the monthly interval (approximately 30 days) after the previous 8/03/13 change. No nightly catheter flushes were documented and no PRN flushes were documented prior to 9/10/13 (following a new order to address a problem with the catheter). Additionally, the nurses were to assess the resident's catheter "Q (every) shift for patency, UTI (urinary tract infection), skin irritation." Of the shifts between 9/01/13 and 9/09/13, documentation reflected the resident's catheter was checked for functionality only 14 of the 27 shifts. Staff Member A, a licensed nurse, was interviewed on 9/25/13 at approximately 12:40 p.m. and stated the nightly catheter irrigation order did not show up on the September 2013 catheter flow sheet despite the physician's orders [REDACTED]. Urinary output was recorded in the computer. A computer generated report identified the resident had 175 cubic centimeters (approximately 3/4 cup) of urine out on the 9/09/13 shift 1 between 11:00 p.m. to 7:00 a.m. Thereafter, no output was documented for three shifts 9/09/13 between 7:00 a.m. and 9/10/13 at 7:00 a.m. Fluid intake was noted as 660 cubic centimeters (about 2 1/2 cups) for the day shift. There were no specific intake entries of lunch or dinner on 9/09/13. Despite a decline in the resident's intake documentation and no noted output after the night shift on 9/09/13, there was no nursing entry documenting an assessment for any changes in the resident's condition. The catheter flow sheet only documented the resident's catheter assessment for patency on the night shift on 9/09/13 (prior to day and evening shifts). No assessment was noted for the day or evening shifts on 9/09/13 on the catheter flow sheet and no irrigation was documented. On 9/26/13 at approximately 11: 50 a.m., Staff Member C, a licensed nurse, was interviewed about the resident's condition the night shift of 9/09/13 going into 9/10/13. Staff Member C stated she didn't remember a lot of specifics. She recalled attempting to flush the resident's catheter that night but had trouble flushing when pushing and pulling (with the syringe). Staff Member C didn't attempt to change the catheter at that time; she thought there was urine present in the bag. When asked about the lack of documentation pertaining to the flush problems and condition of the catheter, she stated she possibly didn't chart the flush and probably should have made a nursing entry related to the problem with the catheter. Staff Member C stated it might have been the night they found a clamp on the catheter tubing. She stated she did not think they took any vital signs on the resident that night. A 9/10/13 nursing entry (day shift), revealed the resident's family had expressed concern that the resident was "uncontrollably shaking." An assessment of the resident identified his Foley bag was empty. The urinary catheter would not flush. The catheter was changed and urinary output equaled 1200 milliliters (approximately 5 cups of urine). The resident was "still shaky and not quite responsive." The nurse practitioner (ARNP) was notified and evaluated the resident. The 9/10/13 ARNP documentation revealed the resident was "diaphoretic (cool, clammy skin), pale, and clenching onto the side of the bed. Head of penis is also pale. There is some sediment in the Foley (sic) line but no urine. Once the catheter is changed > (greater than) 800 cc (cubic centimeters) of urine...There is hematuria (blood in the urine), foul odor, and sediment. (The resident) has just returned from therapies in the gym and now he is not responding. Family in earlier and concerned about his situation." The resident's pulse was 135 (very elevated). An hour later the resident's blood pressure (Bp) had dropped from 130/65 to 101/40 and his temperature had risen from 98.8 degrees Fahrenheit (F) to 101.9 degrees F and his pulse remained between 135-142. The resident appeared to be sleeping. The ARNP assessment included: Obstructed Foley catheter, Hematuria, Urine Retention, Urinary tract Infection, site not specified, and [MEDICAL CONDITION](rapid heart rate). The ARNP plan included [MEDICATION NAME] once for the rapid heart rate, antibiotic injections, a urinalysis, treatment of [REDACTED]. The resident's family legal representative wanted treatment at the facility attempted prior to sending him to the hospital if needed. Although the ARNP documentation noted hourly monitoring, the actual orders identified monitoring for fever, pulses, and blood pressure for the next 24 hours. Review of the 9/10/13 evening shift documentation by Staff Member B, a licensed nurse, noted the resident was very lethargic, difficult to wake until approximately 6:30 p.m. The resident ate 20% of his dinner. Vital signs (without an identified timeframe) recorded the resident's blood pressure was "65/43 (very low).. when lethargic." The catheter was draining pink urine. At 10:00 p.m. vital signs included a blood pressure of 141/98 and other vital signs were within an acceptable range. On 9/25/13 at approximately 1:55 p.m., Staff Member B stated she thought the drop in the resident's blood pressure was related to the [MEDICATION NAME]. She was unaware of when the first blood pressure at 65/43 was taken. She checked it later and it had improved. Staff Member B later provided a written statement containing more information about the 9/10/13 evening shift. She recalled at dinner time the nursing assistants had informed her the resident was in a deep sleep. Vital signs were taken and she found his vital signs to be "normal but BP (blood pressure) low normal." Staff Member B recalled she lost the paper with the resident's vital signs at some point during her shift but didn't realize it until the end of the shift charting time so she went and got another set of vital signs that were normal except for a "very low Bp (blood pressure)". A follow-up Bp recheck revealed all vital signs were normal then and the very low value had not been deleted. She recalled she had checked the resident frequently during her shift. Review of intake and output records for the 9/10/13 evening shift noted 150 cubic centimeters (a little over 1/2 cup) of intake during the evening shift. No physician notification was found reporting the intermittent low blood pressure reading(s), lethargy, and poor oral intake. Nursing entries on the night shift 9/10/13 going into 9/11/13 noted the resident had vomiting and had low blood pressure readings of 84/58 and 64/44. The family preferred treatment at the facility and intravenous fluids were ordered. Later in the shift a suspicious emesis (vomit) was present and the resident was sent to the hospital. Resident #5 was sent to the intensive care unit. Review of the 9/14/13 hospital discharge summary revealed Resident #5 was admitted with a kidney infection complicated by an indwelling urinary catheter and septic shock (from the infection). Initially, he "required aggressive fluids and (a type of medication) to maintain adequate blood pressures." Observations on 9/25/13 at approximately 3:20 p.m. revealed Resident #5 was up in the wheelchair in the dining room by himself. He was wearing a leg bag and there was clear amber urine present. The resident reported he had been in the hospital recently but appeared unable to offer any details. The facility failed to provide care in accordance with physician orders, promptly detect a change in the resident's condition, consistently report ongoing symptoms of physical compromise, and facilitate necessary care in a timely manner.

Based on record review and interview, the facility failed to provide sufficient supervision and assistance devices to prevent an incident with injuries for 1 of 3 residents reviewed (#1) with incidents/ falls. Findings include: Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. The resident's plan of care noted she required one person assistance for transfers and was to wear non-skid footwear. A 10/09/12 nursing entry noted the resident was choosing to spend most of her time in bed as she felt it would help her wound healing. According to a 10/18/12 nursing entry by Staff Member A, a Licensed Nurse (LN), two staff members were assisting the resident out of bed when the resident started to slide to the floor. The resident was subsequently assisted to the floor to prevent injury. No injury was identified at that time. A mechanical lift was utilized to return the resident to her bed. On 11/07/12 at approximately 10:25 a.m., the Director of Nursing (DNS) stated that prior to the 10/18/12 fall, the resident had been refusing to get out of bed and was not receiving therapy. Historically, she required one person to assist her, was able to bear weight, and used a walker. On 10/18/12 two Nursing Assistants (NAs) were attempting to transfer the resident to a shower chair for a shower prior to her appointment at the wound clinic. No gait belt (a belt placed around the resident's waist so staff had a place to grasp onto while assisting the resident) was used during the transfer incident. No injury was identified directly after the incident and she was sent out to her appointment. Resident #1 was subsequently transferred to the hospital where her fracture was identified. No surgery was performed on her fracture(s) due to her venous insufficiency (poor circulation). The facility policy, entitled Gait/Transfer Belts, documented "It is (the facility's) policy that transfer/gait belts are used to transfer and ambulate residents. The belt is primarily used for safety purposes for the residents, as well as the staff. Other purposes include: control of the situation and allowing the resident to use his/her own strength." The policy did identify some situations or conditions which might preclude the use of the gait belt. When asked on 11/07/12 at approximately 11:30 a.m. about the gait belt policy and use on Resident #1, Staff Member D, the Restorative LN, stated there was no reason a gait belt should not be used on Resident #1. Review of the facility investigation pertaining to the 10/18/12 incident, revealed Resident #1 was initially standing with her walker but was unable to continue to stand, started to slide down, and was assisted to the floor by the two NAs. Staff Member A documented he educated the staff members to use a gait belt with every transfer and to put on her non-skid socks. Interviewed on 11/07/12 Staff Member B, the NA on-duty on 10/18/12, recalled she had been giving the resident bed baths but there was a plan to shower the resident prior to her appointment. She was planning to transfer the resident by herself but the resident requested Staff Member C, another NA, also assist with the transfer. Staff Member B stated they did not use a gait belt. She had not used a gait belt on the resident in the past and was unsure if a standard gait belt would fit her. The resident had transferred well in the past but she had been in bed for a while. Staff Member C recalled that when the resident was dropping to the floor her right leg "went toward the side" so Staff Member C pushed the resident's right leg forward. When she landed her left leg was bent underneath her. On 11/07/12 at approximately 12:55 p.m., Staff Member A, the LN, recalled when he arrived in the resident's room, one of the resident's legs was underneath her. The resident denied injury initially but complained of knee pain about a half hour later. The resident continued to have range of motion. She had just gotten her routine pain medication and it was a pretty high dose. Review of the resident's hospital physician's report, dated 10/20/12, revealed the resident had a fibular fracture (one of the bones in the right lower leg) and a question of a small fracture at the patella (knee cap). On 11/07/12 at approximately 1:10 p.m. the cognitively alert resident was interviewed. Resident #1 recalled that she had insisted on being in bed for an extended period of time and hadn't been out of bed for quite awhile, possibly six weeks. On 10/18/12 she could have had a bed bath but staff thought she would be more presentable for her appointment if she had a shower. Two caregivers assisted her up but when she was on her feet she knew she was "going down." The facility failed to formulate a safe transfer plan, and provide necessary supervision while transfering the resident. One caregiver planned to transfer the resident, without a gait belt or appropriate footwear, and the resident asked for an additional NA. Without the gait belt and/or a safe transfer plan, the NAs were unable to safely transfer the resident or guide her back to the bed. The resident was unable to maintain weight bearing status and dropped to the floor as NAs attempted to assist her. Subsequent to the fall, the resident was diagnosed with [REDACTED].

Based on observation, record review, and interview, the facility failed to provide appropriate, timely care and services for 1 of 2 sampled residents [MEDICAL CONDITION](#2). Resident #2 experienced harm as a result of the lack of: consistent monitoring, timely recognition and reporting of a change in the burn status, and implementation of a treatment. Findings include: Resident #2: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to her plan of care the resident was alert and oriented and was on a behavioral management plan for yelling behaviors. The cognitively impaired resident had a Power of Attorney (POA)/Family Member designated to assist her with decision making. The 6/22/12 evening shift nursing entry documented a report from a Nursing Assistant (Staff Member A) stating the resident had fallen off the bed sustaining a 1 by 3 centimeter cut (less than a 1/2 inch by more than an inch) on her forehead. The resident had fallen about 2 1/2 feet off the bed onto the "hard floor." The resident was sent to the hospital for an evaluation the evening of the fall. The ER report noted [DIAGNOSES REDACTED]. The resident was sent back to the nursing facility after the ER evaluation. A 6/27/12 evening shift nursing entry noted the resident had been "lethargic this evening. Refused dinner." The lethargy had continued according to the early 6/28/12 nursing entry. See F323 for further details. There was a 6/28/12 nursing entry documenting the resident had spilled coffee on her lap at lunchtime. There was a 10 by 7 (centimeters (cm) or inches not specified) reddened area on her (right) upper inner thigh. On 8/02/12 at approximately 11:55 a.m., Staff Member E recalled that on 6/28/12 Resident #2 was seated at the dining room table and appeared to be sleeping. Staff Member E placed a cup of coffee on the table with a lid and straw in place. The resident had historically voiced her displeasure about coffee with ice added to cool it down so she had not added ice to the cup. Some time later Staff Member E was notified by another resident that Resident #2 had spilled her coffee on herself. The 6/28/12 evening shift nursing entry noted the burn area was blistered. On 6/29/12 the blistered area was described as intact on the right upper thigh but no size was designated. Nurse Practitioner (ARNP) #1 examined the burned area on the right upper thigh on 6/29/12 and described it as approximately 5.5 centimeters in diameter (more than two inches), noting it was a first degree burn, "Red, tender to touch." Review of the facility June 2012 Treatment Record revealed no entries related to the burn or of a plan to monitor and specifically assess the condition of the burn. No treatments were evidenced. Nursing entries on 6/30/12 and 7/01/12 noted the burn area consisted of an intact blister but the size was not specified. Nursing entries thereafter focused on the resident's lethargy (See F323 related to the fall issue.) as well as intermittent diarrhea and dietary issues until 7/11/12, for 10 days. An ARNP visit on 7/05/12 from ARNP #1 documented the burn was a partial thickness burn about 6 cm on the right upper thigh and there was no evidence of infection. There was no mention of the burn site on the ARNP's 7/09/12 documentation. The 7/11/12 evening shift nursing entry noted a change in the status of the resident's burn. "Wound to (right) thigh previously blister from coffee burn has progressed area larger irregular shape wound bed dk (dark) color approx (approximately) 6 cm x (by) 6 cm area extending from it 8 cm x 4 cm white (with ) blister in L (left) side of white area. Total area 6 cm by 8 cm (approximately more than 2 by 3 inches)." Despite a deterioration in the site there was no documentation of notification of the physician or the Power of Attorney. Two days later, on 7/13/12 ARNP #2 documented that the facility staff had reported the burn looked worse. "It is red with dried scab in the center and has pus-filled pockets on the edges." An order was written for Epsom salt soaks four times daily to help remove the pus and daily monitoring. No dressing was specified. The ARNP documented, "I would like to start on antibiotics but she is not taking any oral medications due to general decline and lethargy." On 7/13/12 the burn site was added to the treatment record for the first time to monitor daily and treat, 15 days after the burn occurred. The 7/13/12 nursing entry documented the family was in and wanted to discuss the treatment of [REDACTED]. The 7/14/12 nursing entry noted a Family Member (POA) called and was upset about the right thigh "wound." The On-call Physician was contacted (at the insistence of the POA) and there was an order for [REDACTED]. A nutritional supplement was also added to enhance wound healing. During an investigative interview, the POA stated he was not notified of the burn event despite documentation recording his notification (on 6/28/12.) He was unaware of the burn or the deterioration until 7/13/12 at which time he requested Physician involvement and a treatment. Treatments continued during July 2012. On 8/01/12 at approximately 9:00 a.m. the burn site was observed. The site was irregular in shape and was approximately 3 by 3 inches at the widest part. There were three darker brownish areas in the center areas and reddened tissue around the edges. No drainage was noted. On 8/02/12 ARNP #1 examined the resident and noted the "Healing (second degree) burn on right upper thigh." The resident's appetite was noted to have improved somewhat. When interviewed on 8/02/12 at approximately 2:20 p.m., the Director of Nursing stated the resident should have been placed on alert charting after the burn and monitoring should have been initiated. There had been more than two weeks without consistent monitoring or treatment of [REDACTED]. Without a consistent monitoring plan in place it was unclear when the change in the burn site actually occurred but it was mentioned on 7/11/12. No further medical follow-up was documented for two days, until 7/13/12, when treatment and monitoring orders were obtained from the ARNP. A Family Member had to advocate for the resident to obtain Physician intervention and additional orders.

Based on observation, record review, and interview, the facility failed to provide sufficient supervision to prevent falls for 2 of 5 residents (#1 & #2) reviewed. Resident #2 experienced actual harm as a result of a fall from her bed. Findings include: Resident #2: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to her plan of care the resident was alert and oriented and was on a behavioral management plan for yelling behaviors. Historically, psychoactive medications were administered to help lessen the resident's anxiety/agitation. The resident required assistance from 1-2 persons for bed mobility. Review of a 6/19/12 nursing entry noted the resident was having increased anxiety "becomes overwhelming for her resulting in blood curdling screams." On 6/21/12 the resident was taken to the dining room for dinner but did not want her dinner. At 7:00 p.m. she started yelling in bed and later in the hallway. The 6/22/12 evening shift nursing entry documented a report from a Nursing Assistant (Staff Member A) stating the resident had fallen off the bed sustaining a 1 by 3 centimeter cut (less than a 1/2 inch by more than an inch) on her forehead. The resident had fallen about 2 1/2 feet off the bed onto the "hard floor." During an investigative interview (on 8/01/12 at approximately 4:30 p.m.) Staff Member A recalled that (on 6/22/12) he had been providing care for the resident by himself. He positioned the resident on her side "too close to the edge of the bed" facing away from him. Staff Member A turned around to get supplies and when he turned back he saw the resident falling off the bed onto the floor. She sustained a cut on her head. The resident was sent to the hospital for an evaluation the evening of the fall. The emergency room report noted [DIAGNOSES REDACTED]. The resident was sent back to the nursing facility after the ER evaluation. A 6/23/12 nursing entry, noted as a "late entry", documented the resident "has not been helping (with) turning by stiffening up and keeping her balance when turned on her side. She is more limp and will not try to balance on her side." This change was first noted approximately two weeks earlier. After the fall, nursing entries on 6/23/12-6/25/12 noted the resident was complaining of a headache and received Tylenol. A Nurse Practitioner (ARNP)#1 evaluated the resident on 6/25/12 and noted the resident's complaints of headaches and directed staff to monitor the resident for increased headaches, grogginess, or pain to the head. A 6/27/12 evening shift nursing entry noted the resident had been "lethargic this evening. Refused dinner." Additional entries on 6/28/12 noted the resident was "lethargic" and "somnolent" (sleepy). Nursing entries for 6/29/12 recorded the resident refused her meals and medication and was sleepy during the entire evening shift. On 6/30/12 the nursing entry continued to report lethargy. Entries on the Medication Administration Record, dated July 2012, revealed continued lethargy with medications held on 7/01/12-7/04/12 and on 7/08/12. Nursing entries also noted lethargy on 7/05/12-07/07/12. Review of ARNP #1's 7/05/12 note revealed she was seeing the resident "on the request of staff for decline in condition." The resident's diet was down-graded to a mechanical soft diet and thickened liquids. ARNP #1 evaluated the resident on 7/09/12 and recorded, "She has continued to be lethargic. She will answer with yes and no answers only. " Her diet was down-graded to a puree diet with thickened liquids. On 7/13/12 ARNP #2 documented the resident was not currently taking any medication "due to general decline and lethargy." The plan was to monitor and keep the resident comfortable. During an investigative interview, Resident #2's Power of Attorney (POA) , stated the resident's health had been failing after experiencing a fall and a burn (See F309). Observations on 8/01/12 at approximately 9:00 a.m. and 1:10 p.m. revealed the resident was resting in bed. When asked how she was doing she said only, "Okay" but would not respond further. Staff had to feed the resident her puree lunch. Resident #1: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. A 4/05/12 nursing entry documented the resident had frequent self-transfer attempts out of her wheelchair, usually in the bathroom. She was to be toileted before and after meals, at bedtime, and as needed. Due to her fall risk, the resident was placed on the "Falling Star Program." Review of the "Falling Star Program" documentation noted that residents on the program were not to be left unattended in their room at any time. According to 7/19/12 facility investigative documents, on 7/19/12 at 3:15 p.m., the resident was found on the bathroom floor laying on her back. She had sustained a skin tear to her right elbow and a bump on the back of her head. Staff Member B had assisted the resident to the bathroom and left her unattended in the bathroom. Staff Member D, the Restorative Nurse, was interviewed on 8/01/12 at approximately 2:45 p.m. and stated that residents in the "Falling Star Program" were not to be left unattended in their room or in the bathroom due to their fall risk. On 8/01/12 at approximately 3:40 p.m., Staff Member C, a Licensed Nurse, stated the resident's injuries had resolved (without further problems). When interviewed on 8/03/12 at approximately 3:32 p.m., Staff Member B recalled that on (7/19/12) he had assisted the cognitively impaired resident onto the toilet and left her, telling her to pull her call light when she had finished. Staff Member B recalled there were fewer caregivers on-duty that evening and he went back to performing his other duties after assisting Resident #1 into the bathroom. Staff Member B stated he had left her before unattended in the bathroom and she had used the call light but she didn't that evening. Facility staff failed to provide sufficient supervision to prevent falls with injuries.