Every finding on record at Columbia Crest Center

Based on interview and record review, the facility failed to ensure wound care practices were maintained in accordance with professional standards of nursing practice for 1 of 2 residents (Resident 1) reviewed for wound care. This deficient practice placed residents at risk of receiving inadequate wound care, delays in healing or potential worsening of wounds.Findings included.Revised Code of [NAME] (RCW) 18.79.040 (1)(e), Registered nursing practice means the performance of acts requiring substantial specialized knowledge, judgment, and skill based on the principles of the biological, physiological, behavioral, and sociological sciences in either:The executing of medical regimen as prescribed by a licensed physician and surgeon, dentist, osteopathic physician and surgeon, podiatric physician and surgeon, physician assistant, or advanced registered nurse practitioner.Review of the facility policy, Skin Integrity and Wound Management revised on 09/15/2025 showed Licensed Nurses (LNs) were to follow specific orders from the surgeon regarding care of surgical wounds and to notify physician to obtain orders.Review of the facility policy, Change in Condition: Notification of revised on 07/01/2024, showed the facility must consult with the physician when there was a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment or to commence a new form of treatment).Resident 1Review of the medical record showed Resident 1 admitted to the facility, on 06/05/2026, with diagnoses of left ankle surgical incision and drainage of an abscess (a localized, enclosed pocket of pus that forms in the body's tissues in response to an infection), cellulitis (a common, potentially serious bacterial infection of the skin and underlying tissues) to the left ankle and sepsis (the body's extreme, life-threatening response to an infection).Review of Resident 1's admission physician's orders, dated 06/05/2026, showed surgical incision wound care to the left ankle included washing with soap and water and covering with dry dressing twice daily.Review of the medical record showed a new wound care order was input by Staff C, Registered Nurse/Skin Lead, on 06/05/2026 at 2:58 PM, changing the type of treatment to the wound bed and decreased the frequency to once daily.Review of the medical record showed a new wound care order was input by Staff C, on 06/06/2026 at 1:22 PM, changing the frequency of the wound care to three times weekly on Monday, Wednesday, and Friday.Review of the nursing progress notes (PNs) showed no documentation of communication with a medical provider regarding the wound care order changes or notification of change in condition to prompt the change.During an interview, on 06/18/2026 at 12:10 PM, Staff D, Resident Care Manager, stated they received a phone call from Resident 1's surgeon's office clarifying the wound care orders were to return to the admission orders of cleansing the left ankle surgical incision with soap and water and applying a dry dressing twice daily.During an interview, on 06/18/2026 at 1:30 PM, Staff C stated they changed the wound care orders for Resident 1 based on their judgment to reduce the risk of exposing the incision to infection and to make it easier on the floor nurses. Staff C stated they did not speak directly with a medical provider when changing the orders because the medical director trusts my judgment, and they felt it was within their scope of practice to change wound care orders because of their training.Review of personnel records, on 06/18/2026, showed Staff C was hired on 04/01/2026 in the capacity of Skin Health Team Lead, and had no records of certifications or competencies related specifically to advanced wound care.During an interview, on 06/18/2026, Staff B, Director of Nursing, stated LNs were to obtain all orders from a medical provider, and it was not in their scope of practice to create or change existing orders. Staff B stated Staff C did not perform within their scope of practice when changing the wound care orders for Resident 1.Reference: WAC 388-97-1620 (2)(b)(i)(ii)

Based on interview and record review the facility failed to ensure 4 of 4 staff (Staff C, D, E, F) reviewed for abuse allegations, implemented the facility policy for identifying abuse and reporting to the state agency and administrator of an allegation of abuse involving Resident 1. This failure disallowed the facility administration with the ability to protect residents, report to state survey agency (SSA, State Survey Agency- responsible for oversight of Medicare certified Nursing Homes), investigate, and take corrective action. Further, the failure placed residents at risk for further abuse, injury, and diminished quality of life. Findings included .Record review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, showed the following:- the facility prohibited abuse of residents,- employees were designated as mandated reporters and were obliged to immediately report any reasonable suspicion of a crime against a resident,- abuse was defined as the willful infliction of injury, willful defined related to abuse means the individual must have acted deliberately, not that the individual must have intended to inflict harm or injury, physical abuse- physical abuse included hitting, slapping, pinching and kicking,- anyone who witnesses an incident of suspected abuse, were to tell the abuser to stop immediately and report the incident to their supervisor immediately, regardless of shift worked and the notified supervisor will report the suspected abuse immediately to the Administrator,- the Administrator was responsible for operationalizing policies and procedures that prohibit abuse,- the employee alleged to have committed the act of abuse would be immediately removed from duty, pending investigation,- immediately upon receiving a report of suspected abuse, the Administrator will report, to appropriate SSA and local authorities' allegations within two hours after the allegation was made. Record review showed the resident was admitted to the facility on [DATE] with diagnoses to include stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), hemiparesis (weakness on one side of the body), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), bipolar disorder (a disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows), and an anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Review of the 12/05/2025 comprehensive assessment showed Resident 1 had moderately impaired cognition, was dependent on two staff for bed mobility and toilet hygiene, had an indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) and was incontinent of bowel. Resident 1 had a Stage 4 pressure ulcer (localized damage to the skin and underlying soft tissue usually over a bony prominence, Stage 4 is full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) on their sacrum (area located at the bottom of the spine and ends at the tailbone) that required dressing changes. During a telephone interview on 01/21/2026 at 12:30 PM, Staff D, Nursing Assistant (NA), stated they observed Staff B, Director of Nursing Services, slap Resident 1 on their bare buttock after completing a dressing change to the tailbone. Staff D stated they were being trained by Staff E, NA and Staff F, NA, on day shift on or before 12/23/2025. Staff D stated Resident 1 had a bowel movement that soiled their wound dressing and they notified the cart nurse the dressing needed to be changed. Staff B was working on the medication cart that day and did the dressing change. Staff D stated that they were holding Resident 1 to the right in their bed during the treatment and the other two NAs were standing near the bed. When Staff B was finished, they slapped the resident on their left butt cheek, to which Resident 1 asked what was that for? and Staff B responded with just to let you know I was done. Staff D stated the resident said nothing more. Later that day, Staff D stated they told the other two NAs that they were real uncomfortable with what they witnessed and were going to report to the hotline. Staff D stated they did not report the incident until after they had changed employers because they were afraid of what would happen to them. (The report was around 30 days after Staff D witnessed the incident). During an interview on 01/21/2026 at 2:13 PM, Staff A, Administrator, stated there had been no reports that Staff B had been inappropriate with any of the residents. The Administrator was informed of the details of the incident, and they stated they were not aware. Staff A stated that Staff B had called off sick that day and was not at work. On 01/21/2026 at 2:30 PM Resident 1 stated that they did not recall the incident as described and responded with I would be alright with it but did agree that slapping him on the butt was not professional or appropriate interaction between staff and residents. During an interview on 01/21/2026 at 2:40 PM, Staff E, NA, stated they were trained to report suspected abuse to Staff A because they were the abuse coordinator and would decide whether to call the state hotline. They stated that they did witness Staff B slap Resident 1 on their bare butt cheek after the dressing was finished and I did not think it was abuse and [Staff B] was just playful and it did not need to be reported to [Staff A] or the hotline. During an interview on 01/21/2026 at 2:50 PM, Staff F, NA, stated they would report suspected abuse to the head nurse and the Administrator. When asked what the definition of a mandatory reporter was, Staff F stated that if you see something, you say something. Staff F was aware of the state hotline and stated they would call if they (head nurse and Administrator) do nothing. Staff F stated they saw Staff B slap Resident 1 on the butt cheek and did not think it was abuse and did not report it. Another day, Staff D stated they were really uncomfortable with what they witnessed, and they were going to call the state hotline. During an interview on 01/21/2026 at 3:14 PM, Staff A stated that they had informed staff that if they observe abuse to call them right away, anytime day or night. During a telephone interview on 01/21/2026 at 5:03 PM, Staff C, RN Resource Clinician, stated that they were in the facility the day the incident occurred and I feel bad I did not take it any further. They stated Staff B came to them, told them they tapped Resident 1 on the butt cheek after finishing a dressing and the staff in the room looked at them funny and asked why did you do that? Staff C stated they talked to Resident 1 several hours later and the resident did not seem to be aware of Staff B's actions. Staff C stated that the staff had been trained that they were mandated reporters and encouraged them to go to the abuse coordinator/Administrator first and if they still had concerns to call the hotline. Staff C stated this incident should have been reported sooner. Had the resident voiced a concern, suspension and investigation would have occurred. Reference: WAC 388-97-0640(1)(2)(a)(b), (5)(a)(b), (7)(a)(b)

Based on interview and record review the facility failed to protect a resident's right to be free from physical abuse for 1 of 2 residents (Resident 1) reviewed for allegations of abuse. This failure placed residents at risk for further abuse, injury, and diminished quality of life. Findings included.Record review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, showed the following:- the facility prohibited abuse of residents,- the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish and the definition of willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm,- Physical Abuse included hitting, slapping, pinching and kicking,- the Administrator was responsible for operationalizing policies and procedures that prohibit abuse,- the employee alleged to have committed the act of abuse would be immediately removed from duty, pending investigation.- anyone who witnesses an incident of suspected abuse must also report to outside agencies such as the state survey agency and local law enforcement, Resident 1 Record review showed the resident was admitted to the facility on [DATE] with diagnoses to include stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), hemiparesis (weakness on one side of the body), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), bipolar disorder (a disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows), and an anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Review of the 12/05/2025 comprehensive assessment showed Resident 1 had moderately impaired cognition, was dependent on two staff for bed mobility and toilet hygiene, had an indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) and was incontinent of bowel. Resident 1 had a Stage 4 pressure ulcer (localized damage to the skin and underlying soft tissue usually over a bony prominence, Stage 4 is full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) on their sacrum (area located at the bottom of the spine and ends at the tailbone) that required dressing changes. During a telephone interview on 01/21/2026 at 12:30 PM, Staff D, Nursing Assistant (NA), stated they observed Staff B, Director of Nursing Services, slap Resident 1 on their bare buttock after completing a dressing change to the tailbone. Staff D stated they were being trained by Staff E, NA and Staff F, NA, on day shift on or before 12/23/2025. Staff D stated Resident 1 had a bowel movement that soiled their wound dressing and they notified the cart nurse the dressing needed to be changed. Staff B was working on the medication cart that day and did the dressing change. Staff D stated that they were holding Resident 1 to the right in their bed during the treatment and the other two NAs were standing near the bed. When Staff B was finished, they slapped the resident on their left butt cheek, to which Resident 1 asked what was that for? and Staff B responded with just to let you know I was done. During an interview on 01/21/2026 at 2:40 PM, Staff E, NA, stated that they did witness Staff B slap Resident 1 on their bare butt cheek after the dressing change was finished. During an interview on 01/21/2026 at 2:50 PM, Staff F, NA, stated they were in the room and saw Staff B slap Resident 1 on the butt cheek after the dressing change was finished. During a telephone interview on 01/21/2026 at 5:03 PM, Staff C, RN Resource Clinician, stated Staff B came to them, told them they tapped Resident 1 on the butt cheek after finishing a dressing and the staff in the room looked at them funny and asked why did you do that? Staff C stated they talked to Resident 1 several hours later and the resident did not seem to be aware of Staff B's actions and they did not interview the staff witnesses. Staff C stated they feel bad for not taking it any further and this incident should have been reported sooner. Reference: WAC 388-97-0640(1), (3)(a)

Based on interview and record review, the facility failed to ensure 4 of 4 staff (staff C, D, E, F) immediately reported suspected abuse to the State Survey Agency (SSA, responsible for oversight of Medicare certified nursing homes) and the facility Administrator according to CFR S483.12(c)(1) for 1 of 2 residents (Resident 1) reviewed for abuse reporting. This failure placed residents at risk for further abuse, potential for harm, and diminished quality of life. Findings included.Record review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, showed the following:- employees were designated as mandated reporters and were obliged to immediately report any reasonable suspicion of a crime against a resident,- anyone who witnessed an incident of suspected abuse, were to tell the abuser to stop immediately and report the incident to their supervisor immediately, regardless of shift worked and the notified supervisor will report the suspected abuse immediately to the Administrator,- immediately upon receiving a report of suspected abuse, the Administrator will report to the SSA and local authorities' within two hours after the allegation was made. Resident 1Record review showed the resident was admitted to the facility on [DATE] with diagnoses to include stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), hemiparesis (weakness on one side of the body), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), bipolar disorder (a disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows), and an anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Review of the 12/05/2025 comprehensive assessment showed Resident 1 had moderately impaired cognition, was dependent on two staff for bed mobility, was incontinent of bowel and had one Stage 4 pressure ulcer (localized damage to the skin and underlying soft tissue usually over a bony prominence, Stage 4 is full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the ulcer) on their sacrum (area located at the bottom of the spine and ends at the tailbone) that required dressing changes. During a telephone interview on 01/21/2026 at 12:30 PM, Staff D, Nursing Assistant (NA), stated they observed Staff B, Director of Nursing Services, slap Resident 1 on their bare buttock after completing a dressing change to the tailbone. Staff D stated they were being trained by Staff E, NA and Staff F, NA, on day shift on or before 12/23/2025. Staff D stated Resident 1 had a bowel movement that soiled their wound dressing and they notified the cart nurse the dressing needed to be changed. Staff B was working on the medication cart that day and did the dressing change. Staff D stated that they were holding Resident 1 to the right in their bed during the treatment and the other two NAs were standing near the bed. When Staff B was finished, they slapped the resident on their left butt cheek, to which Resident 1 asked what was that for? and Staff B responded with just to let you know I was done. Staff D stated the resident said nothing more. Later that day, Staff D stated they told the other two NAs that they were real uncomfortable with what they witnessed and were going to report to the hotline. Staff D stated they did not report the incident until after they had changed employers because they were afraid of what would happen to them. (The report was around 30 days after Staff D witnessed the incident). During an interview on 01/21/2026 at 2:13 PM, Staff A, Administrator, stated there had been no reports that Staff B had been inappropriate with any of the residents. The Administrator was informed of the details of the incident, and they stated they were not aware. Staff A stated that Staff B had called off sick that day and was not at work. During an interview on 01/21/2026 at 2:40 PM, Staff E, NA, stated they were trained to report suspected abuse to Staff A because they were the Abuse Coordinator and would decide whether to call the state hotline. Staff E stated that they did witness Staff B slap Resident 1 on their bare butt cheek after the dressing was finished. Staff E stated I did not report it because I did not think it was abuse and was just playful behavior between the staff and resident. During an interview on 01/21/2026 at 2:50 PM, Staff F, NA, stated they would report suspected abuse to the head nurse and the Administrator. When asked what the definition of a mandatory reporter was, Staff F stated that if you see something, you say something. Staff F was aware of the state hotline and stated they would call if they do nothing about it. Staff F stated they saw Staff B slap Resident 1 on the butt cheek and did not call the hotline because they were training Staff D and they stated they were going to call. During a telephone interview on 01/21/2026 at 5:03 PM, Staff C, Registered Nurse/ Resource Clinician, stated that they were in the facility the day the incident occurred and I feel bad I did not take it any further. They stated Staff B came to them, told them they tapped Resident 1 on the butt cheek after finishing a dressing and the staff in the room looked at them funny and asked why did you do that? Staff C stated they talked to Resident 1 several hours later and the resident did not seem to be aware of Staff B's actions. Staff C stated that the staff had been trained that they were mandated reporters and encouraged them to go to the Abuse Coordinator/Administrator first and if they still had concerns to call the hotline. Staff C stated this incident should have been reported sooner, I should have reported that day. Reference: WAC 388-97-0640(1)(2)(b), (3)(a), (5)(a)(b), (7)(a)(b)

Based on interview and record review, the facility failed to ensure residents were given the opportunity to formulate advanced directives (AD) nor periodically notified of their right to formulate an AD for 3 of 4 residents (Resident 56, 8 and 61) reviewed for AD. This failure denied residents the right to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent/end-of-life care. Findings included .Review of the facility's policy titled, Health Care Decision Making, dated 06/05/2025, showed that AD were written instructions, such as a living will (a legal document that specifies an individual preferences regarding medical treatment) or durable power of attorney for health care (a document delegating an person that is authorized to make health care decision for you, if your unable to communicate the decisions yourself). The policy showed that facility residents would be provided with written information regarding AD and offered the right to formulate or not formulate AD. The policy stated residents would be approached by the facility's social services staff member on admission and quarterly to discuss the residents' wishes to develop an AD. The policy stated that if the resident had completed AD or were previously brought into the facility by the resident or their representative a copy would be placed in the resident's medical record. Resident 56Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a lung condition, anxiety and depression. The 10/28/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Additionally, the resident's medical record did not include AD documents. Review of the social service quarterly assessment dated [DATE], showed Staff F, Social Service Director (SSD), documented that Resident 56 had an AD already completed and a copy was placed in their medical record. The record showed that no additional conversations regarding advance care planning was provided to Resident 56. During an interview on 01/08/2026 at 2:01 PM, Resident 56 stated that facility staff had reviewed and educated them on the physician orders for life-sustaining treatment (POLST, a document designed to improve resident care by creating a form that records treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency and is not an AD), but they had never been given the opportunity to formulate an AD or education on what an AD was. The resident stated they had recently added selective treatment on their POLST form due to wanting specific care completed in the event of an emergency and was not aware that an AD could specify that for them. Resident 56 stated they would have wanted to formulate an AD. Resident 8Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stroke (when blood supply to the brain is blocked or reduced), dysphagia (difficulty swallowing) following the stroke, and dysarthria (a speech disorder, sometimes following a stroke, that occurs when muscles used for speech are weak or difficult to control, leading to slow or slurred speech). The 09/05/2025 comprehensive assessment showed the resident had a severely impaired cognition but was able to make their needs known. Additionally, the resident's medical record did not include AD documents. Review of the social service quarterly assessment dated [DATE], showed Staff F, documented that Resident 8 had an AD already completed and a copy was placed in their medical record. The record showed that no additional conversations regarding advance care planning was provided to Resident 8 or their representative. During an interview on 01/08/2025 at 2:36 PM, Resident 8 stated they had informed facility staff before on an AD that was previously completed and was informed that it was in their medical records. Resident 8 stated they would want to have one formulated so their representative could make health care decisions for them in an emergency. Resident 61Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, anxiety and depression. The 10/17/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of the social service initial assessment dated [DATE], showed Staff F, documented that Resident 61 had an AD already completed and a copy was placed in their medical record. The record showed that no additional conversations regarding advance care planning had been provided to Resident 61. During an interview on 01/08/2026 at 1:07 PM, Staff F stated that all facility residents were offered information on AD when they were admitted into the facility. Staff F stated residents were given the opportunity to formulate an AD, but they never want to, and referred the Surveyor to a POLST form. Staff F stated the POLST form was reviewed on admission/quarterly during the social service assessment and that when the resident wanted to make changes, the POLST form would be reviewed with the resident and updated. Staff F was not aware the POLST form was not an AD and had not been providing residents with the opportunity to formulate an AD. During an interview on 01/08/2026 at 1:44 PM, Staff U, Regional Social Services, stated they oversaw/worked with social services in the facility. Staff U reviewed Resident 56 and 8's medical records and did not see AD documents in either of the resident's medical records. Staff U stated the SSD was mixing up the POLST versus the AD. Staff U stated the SSD had not been following the facility's process with discussing or providing facility residents with the opportunity to formulate an AD. During an interview on 01/09/2026 at 12:50 PM, Staff A, Administrator, stated AD should be discussed with all facility residents or their representative and facility staff should be providing all facility residents with the opportunity to formulate an AD. Staff A stated the correct process was not being followed. Reference: WAC 388-97-0280 (1)(3)(a)(c)(d)

Based on observation, interview, and record review the facility failed to review, and validate the Preadmission Screening and Resident Reviews (PASARR, an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were correct on admission or corrected and updated for 3 of 5 residents (Residents 50, 7 and 35) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Finding included.Resident 50Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (a feeling of unease, worry, or fear about something that might happen in the future). The 12/22/2025 comprehensive assessment showed Resident 50's cognition was intact and received anti-anxiety and anti-depression medications. Review of Resident 50's 12/11/2025 Level 1 PASARR assessment showed the resident had SMIs documented for their diagnoses of depression and anxiety but then documented no to the SMI question. The assessment also showed the resident did not require a Level II referral, which was required when a resident had SMIs. Resident 7Review of the medical record showed the resident was admitted on [DATE] with diagnosis including a stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage) dementia (a progressive disease that destroys memory and other important mental functions), bipolar (a mental illness that causes extreme shifts in an individual's mood, energy, and activity levels) disorder, anxiety and narcolepsy (a disorder that affects the brains ability to regulate sleep-wake cycles leading to daytime sleepiness and sudden sleep attacks). The 12/30/2025 comprehensive assessment showed the resident had a moderately impaired cognition and was on psychotropic medications (medications capable of affecting the mind, emotions, and behavior). Review of Resident 7's Level I PASARR screening, dated 01/03/2025, showed the resident had serious mental illness indicators for bipolar and anxiety. A Level II referral was documented as required, but no records of a Level II referral being sent/completed were noted in Resident 7's medical records. Resident 35Review of the medical record showed Resident 35 was admitted to the facility on [DATE] with diagnoses including insomnia, depression, anxiety and chronic pain. Resident 35's most recent comprehensive assessment dated [DATE] showed they were cognitively intact and were ordered medications for anxiety, depression and insomnia. Review of Resident 35's PASARR Level I dated 11/07/2025 showed it was completed at a different facility with the diagnoses of depression and anxiety listed, as well as checked as exempt from requiring a Level II assessment because a less than 30-day stay was expected in the other facility. Resident 35 moved to the facility on [DATE] and a new PASARR Level I had not been completed as of 01/08/2026. During an interview on 01/08/2026 at 3:28 PM, Staff E, Admissions Coordinator, stated they received Level I PASARR assessments prior to a resident being admitted . Staff E stated they reviewed the assessments for accuracy and whether the resident required a Level II referral and ensured they were referred prior to admission. Staff E stated the PASARRs then would be the responsibility of the Social Services Director (SSD) for any follow-ups, updates, or changes. Staff E stated they were not normally responsible for reviewing the PASARRs and had recently taken them over while the new SSD had been trained. Staff E stated they did not realize Resident 50's SMIs were incorrectly completed, therefore they did not realize they required a Level II referral. Additionally, Staff E stated they were not aware of Resident 7's Level I PASARR completed on 01/03/2025 and was not able to present documentation of the Level II referral being completed. During an interview on 01/09/2026 at 2:40 PM, Staff A, Administrator, along with Staff R, Resource Nurse Manager, stated they were not aware the process for PASARRs needed worked on but realized there were gaps that need to be worked on. Reference: WAC 388-97-1915 (1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to ensure residents were provided with food preference/substitute meal choices for 3 of 5 residents (Residents 61, 16 and 47) reviewed for dining. This failed practice put residents at risk for decreased intake and nutritional complications.Findings included .Resident 61Review of the medical record showed the resident admitted to the facility on [DATE] and was alert and oriented. Resident 61's meal order was a regular low salt diet. The 11/10/2025 food preferences interview sheet showed the resident preferred whole milk with meals. Resident 61 meal dislikes included fruit juices, oatmeal, hot cereals and cold cereal.to include any type of melon.During an observation and concurrent interview during the lunch meal on 01/07/2026 at 12:30 PM, Resident 61 stated the food has not met their needs and was not satisfying. They were a meat and potato person and did like cottage cheese which they had ordered with each meal. The resident was served a small cheeseburger with potato chips and cottage cheese. During the conversation the resident stated they would even like a baked potato once and in while to enjoy. Resident 61 stated they usually ordered a sandwich or a cheeseburger, cottage cheese and chips off the secondary menu.During an observation and concurrent interview during the lunch meal on 01/08/2026 at 11:40 AM, Resident 61 was not satisfied with their noon meal. The meal ticket showed cheeseburger with chips. Resident 61 stated they were told the kitchen ran out of cottage cheese and no alternative was offered. The meal ticket showed the resident did not want orange juice, no melon of any kind. The resident was served cantaloupe (a dislike item), hamburger and chips. Resident 61 was not happy with their meal.Resident 16Review of the medical record showed the resident admitted to the facility on [DATE] and was alert and oriented. Resident 16's diet was a regular diet. The 11/20/2025 food preference interview showed the preferred water, fruit juices and disliked milk, hot cereal, coleslaw and buttermilk but liked sausage and bacon.During an observation and concurrent interview on 01/08/2026 at 11:50 AM, the resident was seated in their wheelchair in front of their bedside table with their lunch tray which consisted of a cheeseburger, French fries, cantaloupe and drinks. Resident 16 stated they disliked cheese on their hamburger and it was a consistent mistake. Resident 16 stated they requested different foods but were told they could not have anything unless it was on the menu.Resident 47During an interview on 01/08/2026 at 12:15 PM, Resident 47 stated they continue to receive oatmeal in the morning even though they had marked their menu not to have oatmeal. During the interview Resident 47 showed a copy of the menu items they submitted to the kitchen for the week of January 4, 2026, through January 10, 2026, which showed their request for hot cream of wheat for their breakfast cereal. The resident stated they had talked to the charge nurse and other staff about the situation.During an interview on 01/08/2026 at 12:20 PM, Staff N, Registered Nurse, stated there was a lack of communication with kitchen staff and did report resident's concerns, but it did not always get addressed for the residents.During an interview with Staff K, Dietary Manager, they stated Resident 61 did not get cottage cheese because they ran out of it and no alternative was offered. Staff K stated Resident 16 had complained about food choice and had not been satisfied with meals. Additionally, Staff K had received Resident 47's request and placed it on their meal ticket, but the dietary staff had not recognized the change and did not follow through.During an interview on 01/08/2026 at 12:15 PM, Staff W, Kitchen Manager stated that Staff K was to utilize a shopping list, review menus, recipes and inventory to ensure there would be enough food to support any changes made to the menu. There should have been a substitute offered. Staff W stated that all staff should read the residents' meal tickets carefully and anything listed should be provided (special request, dislikes and condiments). The cook needed to read the ticket first and then the dietary aide to make sure the meal served was correct. Dietary staff did not follow the procedures.Reference WAC 388-97-1140(6)

Based on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections for, 1) hand hygiene and glove change for 4 of 10 staff (Staff T, V, L, and Q) observed during resident cares and, 2) use of Personal Protective Equipment (PPE) in an enhanced barrier precaution (EBP, indicated with high contact resident care activities with an infection, a long term wound, central line device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism) rooms for 2 of 5 staff (Staff L and Q) reviewed for infection control. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included .Review of the facility's policy titled, Hand Hygiene, revised 05/01/2025, showed that hand hygiene was to be implemented by all facility staff to reduce the harmful spread of infections. The policy showed that staff were to perform hand hygiene before/after contact or performing cares on a resident and after touching a resident or their surroundings. Additionally, the policy showed the use of gloves did not replace hand hygiene and if a task required gloves, then hand hygiene would be performed by staff before putting on the gloves and immediately after removing the gloves. Review of Center for Disease Control and Prevention recommendations titled, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs, bacteria that has become resistant to certain antibiotic medications), dated 04/02/2024 showed EBP was the implementation of putting on PPE, a gown and gloves, for high-contact resident care activities, which included dressing, bathing/showering, transferring, providing hygiene, and when changing linens/briefs or assisting with toileting. Additionally, EBPs were to be used with residents that had indwelling devices like urinary catheters (device that can be placed with the bladder to drain urine) or any skin opening that required a dressing. Resident 7Review of the medical record showed the resident was admitted on [DATE] with diagnosis including a stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage) dementia (a progressive disease that destroys memory and other important mental functions) and kidney complications. The 12/30/2025 comprehensive assessment showed the resident had moderately impaired cognition but was able to make their needs known, a urinary catheter device was in place and they required wound care. Observations on 01/07/2026 from 9:46 AM to 10:32 AM showed Staff V, Nursing Assistant (NA), and Staff T, NA, in Resident 7's room, with a nurse, performing a brief change, bed bath and wound care on the resident after putting on a gown and gloves for EBPs. Care observations showed: Staff V's gloves were soiled (unclean or dirty) from cleaning up the resident's first bowel movement and without performing a glove change or hand hygiene, assisted the nurse in grabbing a cloth barrier for the resident's clean wound care supplies to be placed on. Staff V then proceeded to grab a trash bag from their pocket with the same soiled gloves and then touched multiple surfaces in the resident's environment before conducting a glove change without performing hand hygiene. Staff T was bathing the resident then proceeded to assist in cleaning the resident's second bowel movement and took off one pair of gloves with another pair underneath the first pair, without performing hand hygiene. Staff T then continued with bathing the resident while touching multiple drawers of the resident furniture and manipulating the resident's clean linen with the same soiled gloves. Staff T had just completed washing the resident's legs/feet then moved to perineal care (cleaning of the private areas on a resident) and with the same soiled gloves and cloth, used for perineal care, proceeded to perform urinary catheter care without conducting a glove change and hand hygiene. During an interview on 01/07/2026 at 10:55 PM, Staff T stated the correct process was not followed during Resident 7's brief change/catheter care. Staff T stated they should have performed glove change/hand hygiene when they moved from the resident's perineal care to the resident's urinary catheter care and should not have utilized the same soiled cloth. Resident 50Review of the resident's medical records showed they were admitted with diagnoses of urinary blockage and used an indwelling catheter (a tube inserted into the bladder that drains urine). The record showed Resident 50 required EBPs due to the use of the indwelling catheter. During an observation and concurrent interview on 01/07/2026 at 11:34 AM, showed Staff L, Licensed Practical Nurse, and Staff Q, Nursing Assistant, provided wound care for Resident 50. Staff L and Staff Q both washed their hands and put on gloves. Staff L removed the soiled dressing to the right heel and cleansed the heel with wound cleanser. Staff L then changed their gloves but did not perform hand hygiene before putting a new pair of gloves on. Neither Staff L nor Staff Q wore PPE consistent with the EBP. Staff L stated they should have put on gowns as well as gloves and needed to pay better attention to the signage outside of the door before entering. Upon leaving the room, there was a sign outside of the door that showed the resident required a gown and gloves to be worn during high contact resident care. During an interview on 01/09/2026 at 10:09 AM, Staff C, Director of Nursing Services, and Staff R, Resource Nurse Manager (stand in for Infection Preventionist), stated that facility staff should be performing hand hygiene with any glove change. Staff C stated that staff T should have completed a glove change and hand hygiene after providing perineal care for Resident 7 and before moving to the resident's urinary catheter care and the same cloth should not have been used. Staff C and Staff R stated staff were not implementing correct infection control measures and that all staff should be wearing a gown and gloves when entering a EBP rooms to provide wound care. Reference: WAC 388-97-1320 (1)(2)(a)

Based on interview and record review, the facility failed to ensure residents were educated on the potential risk versus benefits when offering the pneumococcal and influenza immunization (specific vaccines that protects against pneumococcal bacteria and viruses that can lead to lung, nose and throat infections) nor documentation that indicated vaccinations were accepted or refused for 4 of 5 residents (Resident 61, 2, 72 and 35) residents reviewed for immunizations and infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risk/benefits in order to make an informed decision.Findings included .Review of the facility's policy titled, Pneumococcal Vaccination, revised 09/13/2024, and Influenza Immunization, revised 12/16/2024 showed the facility would provide its residents with the opportunity to accept or refuse the influenza and pneumococcal vaccines, obtain the immunization history of the residents and then offer the appropriate vaccination. The policy stated that a resident or representative would complete a consent form and staff would provide education/counseling on the benefits/potential side effects of the vaccine. Additionally, an immunization informed consent would be completed and documented in the resident's medical record. Resident 61Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, anxiety and depression. The 10/17/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and was not offered nor had they received the influenza or pneumococcal vaccine.Review of Resident 61's immunization informed consent record showed the resident had not been offered the opportunity to accept or refuse the influenza or pneumococcal vaccinations nor had they been educated on the risk versus benefits and potential side effects regarding both vaccines.During an interview on 01/09/2026 at 9:09 AM, Resident 61 stated they had not received any information or education regarding the risk versus benefits/potential side effect regarding the influenza or pneumococcal vaccines. Additionally, the resident had not been approached nor offered the opportunity to accept or refuse the influenza or pneumococcal vaccinations and would want information about them to make a decision.Resident 2Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including wound infection and depression. The medical records did not indicate a history of the resident being administered with any of the pneumococcal vaccines. The 12/17/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and the pneumococcal vaccine had been offered and refused by the resident.Review of Resident 2's immunization informed consent record showed the resident received the influenza vaccine September 2025, from an outside source, which was reported to facility staff by the resident on 10/07/2025. The records did not include documentation of the pneumococcal vaccine being offered after the resident's admission on [DATE] nor that education on the risk versus benefits and potential side effects was conducted with the resident.During an interview on 01/09/2026 at 9:58 AM, Resident 2 stated they had previously received the pneumococcal vaccine before admitting to the facility and decided to get the influenza vaccine outside of the facility but let the facility staff know after it was completed.Resident 72Review of the resident's medical record showed they were admitted to the facility on [DATE], with diagnoses including heart/lung complications and a bladder infection. The 12/31/2025 comprehensive assessment showed the resident had moderate cognitive impairments but was able to make their needs known, was offered the influenza/pneumococcal vaccines and refused them.Review of Resident 72's immunization informed consent record showed the resident refused the influenza and pneumococcal vaccines on 12/17/2025, but no documentation of the resident being provided education on the risk versus benefits nor the potential side effects when they refused both the vaccines.Resident 35Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including heart complications, anxiety and depression. The 11/13/2025 comprehensive assessment showed the resident had moderate cognitive impairments but was able to make their needs known and was administered the influenza vaccine on 11/12/2025.Review of Resident 35's immunization informed consent record showed the resident received the influenza vaccine but did not show documentation of the resident being provided education on the risk versus benefits and potential side effects regarding the influenza vaccine.During an interview on 01/08/2026 at 3:46 PM, Staff C, Director of Nursing Services, and Staff R, Resource Nurse Manager (stand in for Infection Preventionist), stated the facility's process was to offer all facility residents the influenza/pneumococcal immunizations and complete consent forms which included a resident's choice on accepting or refusing the vaccines and the education that was provided regarding the risk versus benefits with potential side effects of the influenza/pneumococcal vaccines. Staff C and Staff R stated they were currently hiring for an Infection Preventionist staff, they were aware that not all residents had been offered/educated, work in progress, and were currently working on getting all the residents vaccine records updated. When reviewing sampled resident record for immunizations, both staff stated the correct process was not being followed for offering/education or documentation of resident vaccinations and were unable to present additional records. Reference: WAC 388-97-1340(2)

Based on interview and record review, the facility failed to ensure residents and/or their representative were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (a specific vaccine for the COVID-19 virus) benefits/risks and potential side effects associated with the COVID-19 vaccine for 5 of 5 sampled residents (Resident 61, 2, 72, 35 and 56) reviewed for immunization status. This failure placed the resident and/or their representative at risk of making an uninformed decision and resident contracting the COVID-19 virus.Findings included .Resident 61Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, anxiety and depression. The 10/17/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and was not up to date on the COVID-19 vaccine.Review of Resident 61's immunization informed consent record showed the resident had not been offered the opportunity to accept or refuse the COVID-19 vaccinations nor had they been educated on the risk versus benefits and potential side effects regarding the vaccine.During an interview on 01/09/2026 at 9:09 AM, Resident 61 stated they had not received any information or education regarding the risk versus benefits/potential side effect regarding the COVID-19 vaccine. Additionally, the resident had not been approached nor offered the opportunity to accept or refuse the COVID-19 vaccinations and would want information about them to make a decision.Resident 2Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including wound infection and depression. The 12/17/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and was not up to date on the COVID-19 vaccine.Review of Resident 2's immunization informed consent record showed the resident had not been offered the opportunity to accept or refuse the COVID-19 vaccinations nor had they been educated on the risk versus benefits and potential side effects regarding the vaccine.During an interview on 01/09/2026 at 9:58 AM, Resident 2 stated they had previously received the pneumococcal vaccine before admitting to the facility, decided to get the influenza vaccine outside of the facility but let the facility staff know after it was completed.Resident 72Review of the resident's medical record showed they were admitted to the facility on [DATE], with diagnoses including heart/lung complications and a bladder infection. The 12/31/2025 comprehensive assessment showed the resident had moderate cognitive impairments but was able to make their needs known, was not up to date on the COVID-19 vaccine.Review of Resident 72's immunization informed consent record showed the resident refused the COVID-19 vaccine on 12/17/2025, but no documentation of the resident being provided education on the risk versus benefits nor the potential side effects when they refused the vaccine.Resident 35Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including heart complications, anxiety and depression. The 11/13/2025 comprehensive assessment showed the resident had moderate cognitive impairments but was able to make their needs known and was not up to date on the COVID-19 vaccine.Review of Resident 35's immunization informed consent record showed the resident had not been offered the opportunity to accept or refuse the COVID-19 vaccinations nor had they been educated on the risk versus benefits and potential side effects regarding the vaccine.Resident 56Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a lung condition, anxiety and depression. The 10/28/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and not up to date on the COVID-19 vaccine. Review of Resident 56's immunization informed consent record showed the resident had not been offered the opportunity to accept or refuse the COVID-19 vaccinations nor had they been educated on the risk versus benefits and potential side effects regarding the vaccine.During an interview on 01/08/2026 at 3:46 PM, Staff C, Director of Nursing Services, and Staff R, Resource Nurse Manager (stand in for Infection Preventionist), stated the facility's process was to offer all facility resident the COVID-19 vaccine and to complete consent forms which included education that was provided regarding the risk versus benefits with potential side effects of the vaccine. Staff C and Staff R stated they were currently hiring for an Infection Preventionist staff, they were aware that not all residents had been offered/educated, work in progress, and were currently working on getting all the residents vaccination records updated. When reviewing sampled resident for the COVID-19 vaccine, both staff stated the correct process was not being followed regarding offering/education or documentation resident COVID-19 vaccinations and they were unable to present additional information. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure residents on psychotropic medications (a collective term used for medication classes that affect brain activities associated with mental processes, emotions and behavior, like antipsychotics or anxiolytics) were being monitored for individualized behaviors prior to administration to reflect the adequate need of the medication for 1 of 2 residents (Resident 4) reviewed for psychotropic medication side effects. This failure placed residents at an increased risk for experiencing medication-related adverse side effects, and unmet care needs. Finding included . Review of the facility's policy titled, Behaviors: Management of Symptoms, revised 09/15/2025, showed that residents behavioral symptoms would be individually evaluated to identify the underlying causes that may contribute to the resident's behavior. The policy showed the facility would implement and monitor individualized, person-centered behaviors of residents on psychotropic medications.Review of the resident's medical record showed they were admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including progressive multiple sclerosis (a disease where the body attacks its own nervous system and can cause numbness, weakness, vision problems, balance issues and cognitive difficulties), heart complications, anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), end stage renal disease (the final stage where an individual's kidneys fail, requiring dialysis [the filtering of waste and/or extra fluid from blood] or a kidney transplant) and on palliative care (medical care focused on providing relief from symptoms, pain and stress for individuals with serious illnesses, aiming to improve the quality of life). The 10/14/2025 comprehensive assessments showed the resident was cognitively intact, able to make their needs known, and was receiving hospice care (a specialized, team-based approach on care focused on comfort, dignity, and quality of life for people with serious, terminal illnesses). Review of Resident 4's Physician orders, showed: On 12/19/2025 Haloperidol (an antipsychotics medication used to manage symptoms like hallucinations [a false perception of objects or events involving your senses that seem real, but are not] and disordered thinking) that could be administered every six hours as needed (PRN) for anxiety. On 12/22/2025 Lorazepam (an anxiolytics medication that slows down the brains activity, leading to relaxation and reduces nervousness) that could be administered every six hours PRN for anxiety, agitation (an unpleasant state of extreme restlessness, tension, and/or irritability) or shortness of breath. During a concurrent observation and interview on 01/05/2026 at 12:26 PM showed Resident 4 in their bed asleep, not able to wake with verbal communication. Staff T, Nursing Assistant (NA), came into the room and started cleaning out the resident's mouth with a wet sponge on a stick. Resident not waking and very slightly moved head to side as Staff T inserted the sponge into the resident's mouth. Staff T stated that Resident 4 had been asleep/non communicative .maybe a couple of weeks . Resident 4 observed to have a small/slight jerking of the head but did not wake and heard mumbling, very softly incoherent words then back to sleep. Observation on 01/06/2025 at 8:24 AM showed Resident 4 in bed, eyes closed, unable to wake or respond to verbal communication by the surveyor.Review of Resident 4's medication administration records (MAR) for January 2026 showed the resident was administered a dose of Haloperidol on 01/01/2026 at 5:10 AM and on 01/06/2026 at 9:53 PM. Additionally, the record showed the resident was administered doses of Lorazepam by Staff O, Licensed Practical Nurse (LPN), on 01/02/2026 at 4:54 PM and on 01/07/2026 at 2:44 PM. Review of Resident 4s Treatment administration records (TAR) behavior monitoring for January 2026 showed no documentation of Resident 4 having any behaviors requiring the used of the antipsychotic or anxiolytics medications were noted.During a concurrent observation and interview on 01/08/2026 at 9:44 PM, showed Resident 4 asleep in bed, not responding to verbal communication, unable to wake and open their eyes. Staff Y, LPN, stated Resident 4 had not been waking up or responding withing the past couple of weeks, and they had been monitoring for behaviors like agitation/anxiety with the resident crying out or waking from a bad dream scared. Staff Y stated the resident would communicate their symptoms of nausea (feeling like you are going to throw-up), agitation or anxiety verbally with the nursing staff, and Resident 4's behaviors would be documented on the TAR with the behavior monitoring. Staff Y stated they had not observed any behaviors with Resident 4 in January 2026 yet. During an interview on 01/08/2026 at 12:35 PM, a Collateral Contact associated with hospice provider, stated that Resident 4 had been obtunded (a reduction in an individual's responsiveness and no longer alert to the environment) the past two days they had visited and was no longer able respond to verbal or touch stimulation. The Collateral Contact stated that nursing staff should be monitoring Resident 4's behaviors before administering psychotropic medications like haloperidol or lorazepam and document the behaviors.During an interview on 01/08/2026 at 2:52 PM, Staff O, LPN, stated that all resident psychotropic medication behaviors were continuously monitored and documented in the TAR. Staff O stated with Resident 4 they monitored yelling out or the resident waking up scared from a dream about their significant other. Staff O stated they administered Resident 4 lorazepam on 01/02/2026 at 4:54 PM and on 01/07/2026 at 2:44 PM and documented anxious. Staff O stated they did not chart the actual behaviors and heard from another staff member that the resident was anxious. Staff O stated they did not document the behaviors on the TAR like they should have and were unable to give more information on the resident's behaviors. During an interview on 01/09/2026 at 11:14 AM, Staff J, Resident care Manager, stated that since Resident 4 was on psychotropic medication, nursing staff should be monitoring specific behaviors towards the resident anxiety/agitation, like yelling out, screaming, hallucinations and shortness of breath. Staff J reviewed Resident 4 records and stated that behaviors were not monitored with the psychotropic medications that had been administered in January 2026. Staff J stated the correct process was not being followed and nursing staff .should not be giving the Haldol or the lorazepam if you are not able to show why.During an interview on 01/09/2026 at 12:18 PM, Staff A, Administrator, stated they would expect nursing staff to document targeted behaviors to show the justification for administering psychotropic medications. Reference: WAC 388-97-1060(3)(k)(i)

Based on interview and record review the facility failed to provide the resident and their representative with a summary of a baseline care plan that included the initial goals of the residents, a summary of the residents medications and dietary instructions and services and treatments to be administered by the facility staff for 2 of 4 newly admitted residents (Residents 35 and 37) reviewed for baseline care plans. This failure placed the residents and their representatives at risk for a lack of knowledge regarding the initial care plan for delivery of care and services and unmet care needs.Findings included .Resident 35Review of the resident's medical record showed Resident 35 was admitted to the facility on [DATE] with diagnoses including a fracture of the left foot, a history of falls, chronic pain and diabetes. Review of Resident 35's comprehensive assessment dated [DATE] showed they were cognitively intact and required maximum assistance with bed mobility and transfers.During an interview with Resident 35 on 01/05/2026 at 11:10 AM, they stated they had not received a copy of their baseline care plan, nor had anyone discussed their care plan goals with them for things such as physical and occupational therapies, what medications they were taking, pain management, or discharge plans since they were admitted to the facility.Further review of Resident 35's medical record did not show that a summary of the completion of the baseline care plan was given and discussed with the resident or their representative. Resident 37Review of the resident's medical record showed Resident 37 was readmitted to the facility on [DATE] with diagnoses including a stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage), aphasia (a language disorder from brain damage that impairs speaking, understanding, reading and writing), and cardiac disease. Review of Resident 37's comprehensive assessment dated [DATE] showed they had severely impaired cognition and could rarely understand others. Review of Resident 37's medical record did not show that a summary of the completion of the baseline care plan was given and discussed with the resident's representative. During an interview with Staff D, Registered Nurse, Minimum Data Set (MDS) (a standardized comprehensive assessment tool used to collect essential clinical and functional data to develop care plans in nursing homes) Coordinator on 01/09/2026 at 11:35 AM, they stated they started a care plan on the day of admission and they and the nursing staff added information to it as they gained more knowledge of the resident during their stay. Staff D stated they had not specifically completed 48-hour baseline care plans or given a copy of the baseline care plans upon completion to the resident or their representative because they did not know there was a requirement to do so. In addition, Staff D stated they thought social services were responsible for setting up the initial care conference meeting but was uncertain if they or any member of the interdisciplinary team discussed the components of the baseline care plan or gave a copy to the residents or their representatives. During an interview with Staff C on 01/09/2026 at 11:55 AM, they stated facility staff used to complete baseline care plans per the requirement but with the multiple changes in the administrative staff and interdisciplinary team members over the past few years, components of the regulation could have easily been forgotten to be completed with new admissions. Reference: WAC 388-07-1060(a)(3)

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Residents 25) reviewed for activities of daily living (ADLs), received adequate dressing, grooming, nail, and oral care according to the resident's care plan. This failure placed the residents at risk for unmet hygiene needs.Findings included.Review of the resident's medical records showed they admitted to the facility with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of the brain and spinal cord nerve fibers that leads to communication issues between the brain and the rest of the body). The 11/12/2025 comprehensive assessment showed Resident 25's cognition was moderately impaired and required substantial to maximum assistance for their oral and personal hygiene needs and was dependent on staff for dressing. During an interview and a concurrent observation on 01/05/2026 at 12:17 PM, Resident 25 was lying in bed, dressed in a hospital gown, with a black, horseshoe-shaped neck pillow being used as a pillow under their head. Resident 25 had long fingernails with black and brown debris underneath the nail beds. Resident 25's Collateral Contact (CC) stated they visited Resident 25 often and the resident had not had their teeth brushed, fingernails trimmed and they had not been dressed in clothes, nor did they get up and in their wheelchair in a long while. The CC stated when they informed the Nursing Assistants (NAs) Resident 25 needed their nails cut, they handed the CC the tools for them to trim themselves. The CC stated they were the one to trim Resident 25's hair once a month. Staff S, NA, entered to assist the Resident with their lunch and stated they had worked at the facility for around two weeks, and they had not gotten the resident up out of bed nor did they offer. Staff S stated they were told the resident did not get out of bed. Review of the 01/02/2026 Care Plan (CP) showed on 01/02/2026 an intervention to provide oral care three times a day after meals. The CP showed when the resident refused cares, the staff were to encourage and reassure the resident. The CP showed another intervention on 04/26/2022 to provide oral care twice per day and as needed. The CP showed no interventions for nail care, daily clothes dressing, or how often their hair should have been trimmed. During a telephone interview on 01/06/2026 at 1:28 PM, the Resident Representative (RR) stated they had voiced their concerns to the facility management multiple times, regarding the inconsistency of nail care and the oral and mouth care. The RR stated care would improve for a few days but then would continue with the same behaviors. The RR stated there was no encouragement and if just asked and not encouraged, Resident 25 would lay in their bed all day. The RR stated Resident 25's mental capacity had changed due to their MS, so they needed encouragement. During an interview and concurrent observation on 01/07/2026 at 10:04 AM, showed Resident 25 lying in bed, unshaven, their teeth had yellow and white debris on the front of them, missing teeth, and dressed in a hospital gown. Resident 25 shook their head no when asked if their teeth had been brushed after breakfast. Resident 25's toothbrush and toothpaste were sitting on the sink in a basin, the toothbrush was dry, and the toothpaste was full. An observation on 01/07/2026 at 12:26 PM, showed Resident 25 lying in bed, same as they were that same day at 10:04 AM and the toothbrush was dry and in the same place. During interviews on 01/07/2026 at 2:56 PM and 4:07 PM, Resident 25 was lying in their bed, and when asked if they had their teeth brushed or had been cleaned up, the resident shook their head no. The toothbrush was dry and in the same place as seen at 10:04 AM and 12:26 PM. Resident 25's fingernails were long and had brown and black sediment underneath the nail and around the nail bed. During an interview on 01/08/2026 at 8:50 AM, Staff T, NA, stated Resident 25 did not get up as much since they returned from the hospital due to their pain. Staff T stated they would ask the resident if they wanted to get up and they would decline. Staff T stated they did not provide encouragement when the resident would decline. Staff T stated they provided oral care during first rounds and after meals, which would have been two to three times during their day shift (6:00 AM to 2:30 PM). Staff T stated they did not provide oral care that morning because they were short one NA for their shift. Review of the January 2026 physician orders showed on 01/02/2026 an order for Resident 25 to receive oral care three times a day after meals. During an interview on 01/08/2026 at 5:14 PM, Staff C, Director of Nursing Services, stated they had provided most of the nail care more recently and must have missed Resident 25. Staff C stated they would expect oral care to be provided after meals and at bedtime. Staff C stated they were aware they had issues with encouraging residents to participate in their care needs. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview, and record review, the facility failed to consistently offer or provide repositioning for a dependent resident for 1 of 2 residents (Resident 25) reviewed for quality of care. This failure placed all residents at risk for discomfort, skin breakdown, and negative health outcomes. Findings included.Review of the resident's medical records showed they were admitted to the facility with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of the brain and spinal cord nerve fibers that leads to communication issues between the brain and the rest of the body) and hemiplegia (severe or complete loss of use of one side of the body) to the right side. The 11/12/2025 comprehensive assessment showed Resident 25's cognition was moderately impaired and was dependent on staff for their positioning needs. During an observation and concurrent interview on 01/06/2026 at 9:51 AM, Resident 25 was lying in bed on their back and stated their bottom was hurting. Resident 25 stated they needed to move their bottom. Resident 25 turned on their call light for assistance with positioning. During an observation and concurrent interview on 01/06/2026 at 10:13 AM Staff C, Director of Nursing Services, entered Resident 25's room to answer their call light. Staff C exited the room less than a minute later with the call light back on. Resident 25 stated they were not repositioned and was observed still lying on their back, slumped (sit, lean, or fall heavily and limply) down in their bed. An observation on 01/07/2026 at 10:04 AM, showed Resident 25 lying in their bed, on their back, with a black horseshoe shaped pillow behind their neck. Resident 25 stated they had not been repositioned off their back that morning. An observation on 01/07/2026 at 12:26 PM showed Resident 25 lying on their back, same position as they were in at 10:04 AM observation with the same pillow behind their neck and head. Resident 25 was slumped down in the bed which caused the neck pillow to move up under the head and not the neck. During an observation and concurrent interview on 01/07/2026 at 2:56 PM and again at 4:07PM, Resident 25 lay on their back, the same position as they were in on the same day at 10:04 AM and 12:26 PM. Resident 25 shook their head from left to right when asked if they had been repositioned or moved side to side. During an observation and concurrent interview on 01/08/2026 at 8:50 AM, Resident 25 was lying in bed on their back. Staff T, Nursing Assistant (NA) exited the room with the breakfast tray. Staff T stated they repositioned the resident during their first rounds at the beginning of their shift and then again after meals and as needed. Day shift was from 6:00 AM to 2:30 PM. Staff T stated they were missing one NA for their shift so were unable to get that done during first rounds. During an observation and concurrent interview on 01/08/2026 at 10:41 AM, Resident 25 still lying on their back in the same position as they were on the same day at 8:50 AM. Review of the 01//02/2026 Care Plan (CP) showed a focused CP area for Resident 25 being at risk for having discomfort. The CP showed an intervention on 10/27/2014 to float the heels while in bed, and interventions dated 04/30/2021 to turn resident every two to three hours as needed and assist the resident to a position of comfort using pillows for positioning devices. The CP showed an intervention initiated 09/12/2024 for a positioning wedge to be used for offloading while in bed (there was no positioning wedge used or heels floated during observations on 01/05/2026, 01/06/2026, 01/07/226, or 01/08/2026). During an interview on 01/09/2026 at 12:39 PM, Staff V, NA, stated they were to trim nails and shave residents during showers twice a week. During an interview on 01/09/2026 at 2:40 PM, Staff A, Administrator, along with Staff R, Resource Nurse Manager, stated they identified there were issues with repositioning and mobility with their skin and pain issues and were working towards a process to improve in those areas. Reference: WAC 388-97-1060 (1)

Based on observation, interview, and record review the facility failed to provide specialized services for footcare for 1 of 2 residents (Resident 25) reviewed for activities of daily living (ADLs). This failed practice placed residents at risk of skin breakdown, infections, and discomfort.Findings included.Review of the resident's medical records showed they admitted with diagnoses to include Multiple Sclerosis (MS, a chronic disease where the immune system mistakenly attacks the protective covering of the brain and spinal cord nerve fibers that leads to communication issues between the brain and the rest of the body). The 11/12/2025 comprehensive assessment showed Resident 25's cognition was moderately impaired and required staff assistance for personal hygiene. During an interview on 01/05/2026 at 12:17 PM, showed Resident 25 lying in bed on their back with a visitor at their bedside. The Collateral Contact (CC) stated they visited Resident 25 often and the Nursing Assistant (NA) staff did not provide Resident 25 with good nail care. The CC stated if they wanted the nails to be trimmed, the NAs would bring them the tools to do it themselves. During a telephone interview on 01/06/2026 at 11:28 AM, Resident 25's Resident Representative (RR) stated they had asked the Nursing and Administration staff multiple times about the resident's nail care with no follow through. Review of the 01/02/2026 Care Plan showed no focus for nail care or Podiatrist (a medical professional who specializes in treating issues with the foot, ankle, and lower leg) services. During an observation of care on 01/08/2026 at 11:57 AM, Resident 25 was being provided care by two NAs. Resident 25's toenails to both feet were long, thick, and yellow in color with the nails curved downwards towards the skin, almost touching the top of the toes.Review of a 03/25/2024 Podiatrist note showed the resident had diagnoses of Onychomycosis (a fungal infection of the nails that causes the nails to thicken, discolor, and split) and Dystrophic (thickened, discolored or misshapen) nails. The note showed the Podiatrist recommended Resident 25 to be seen again in two to three months. The record showed no other Podiatry visits after 03/25/2024 (21 months and 13 days). Review of a 12/25/2025 hospital visit note showed severe toenail dystrophy, foot hygiene appears to be very poor. The note showed the RR was at the bedside and stated they had tried to coordinate footcare from the facility for quite some time but had been unable to. The note showed the toenails would begin to cause skin breakdown if not addressed in the near future. The note further showed there was an order for an outside Podiatry referral. Review of Resident 25's physician orders for December 2025 and January 2026 showed no referral had been ordered for Podiatry. During an interview on 01/08/2026 at 5:14 PM, Staff C, Director of Nursing Services, stated they used to have a Podiatrist that would come to the facility every three months, but they had retired. Staff C stated obtaining a new Podiatrist was a work in progress. Staff C stated they provided most of the nail care to the residents and must have missed Resident 25. Staff C stated they were not aware of the Podiatry referral ordered for Resident 25 on their return from the hospital and would check in to it. Staff C could not provide any further information on Resident 25's nail care. Reference: WAC 388-97-1060 (3)(j)(viii)

Based on observation, interview, and record review, the facility failed to ensure a resident was consistently supervised during smoking for 1 of 2 sampled residents (Resident 52) reviewed for smoking. This failure placed the resident at risk for avoidable accidents, injuries, and the potential risk of fire.Findings included.Review of a 02/24/2025 policy titled Smoking showed the staff responsible for supervising smoking would be in the direct area of the smoker, within eye contact and able to respond to emergency situations. The policy showed the resident's smoking materials would be maintained by the nursing staff and kept in the Nurse's station. Review of the resident's medical records showed they admitted with diagnoses to include a stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage) and seizure disorder. The 10/23/2025 comprehensive assessment showed Resident 52's cognition was moderately impaired and used a wheelchair independently for their mobility. An observation on 01/07/2026 at 10:07 AM, Resident 52 was observed outside, under the patio that was designated as the smoking area. Resident 52 was smoking a cigarette and there were no other residents or staff in the area. Resident 52 discarded their cigarette in the smoking receptacle provided and self-propelled themselves into the facility, backwards. Resident 52 went straight to their room and was not observed giving their smoking materials to the nurse. Review of Resident 52's smoking assessment, dated 10/21/2025, showed the resident was assessed to have a history of unsafe smoking habits and would share or sell their cigarettes or smoking materials to other residents. The assessment showed Resident 52 required supervision while they smoked. An observation on 01/07/2026 at 10:52 AM, showed Resident 52 in a stocking cap, outside smoking in the designated smoking area, unsupervised. During an interview on 01/08/2026 at 10:05 AM, Resident 52 stated they were supposed to have someone with them when they went outside to smoke but the facility did not always have someone to take them and would go outside on their own to smoke. Resident 52 stated the nurses were supposed to hold their cigarettes and lighter in between smoke breaks and declined to answer whether that was happening or not. During an interview on 01/08/2026 at 2:03 PM, Staff C, Director of Nursing Services, stated they did not have any residents that could go out and smoke unsupervised. Staff C stated they allowed smoking at the facility, but everyone could only smoke supervised and at the specified times. Staff C stated the staff shared responsibility of designated smoke times and there was not a specific designated staff member. Staff C stated if a resident wanted to go out to smoke, they could ask, and they would do their best to accommodate them. Staff C stated they were not aware Resident 52 was smoking unsupervised and did not think that was possible because the nursing staff held their smoking materials in between smoke breaks. An observation and concurrent interview on 01/08/2026 at 4:24 PM, Resident 52 was observed outside smoking in the designated smoking area, unsupervised. Resident 52 propelled themselves, backwards, to their room and did not give their smoking materials to the nurse prior to going to their room. During an interview on 01/08/2026 at 4:30 PM, Staff P, Registered Nurse, stated they had given Resident 52 their smoking materials prior to the resident going outside to smoke. Staff P stated they assumed one of the Nursing Assistants (NA) went outside to supervise the resident while smoking. Staff P attempted to provide a list that was kept by the time clock that showed who was responsible for the smoking breaks that day but could not locate one. Staff P stated it would have to have been one of the NAs on the [NAME] end of the hall, closest to the smoking area. Staff P stated they were not aware Resident 52 had returned to their room after their smoke break, and confirmed they had not returned their smoking materials to Staff P. During an interview on 01/08/2026 at 4:31 PM, Staff O, Licensed Practical Nurse, on the [NAME] side of the building, stated they did not have any residents that smoked on their side of the building so smoking supervision would not have been assigned to one of their NAs. Staff O stated it would be the responsibility of the North or East who have residents that smoke. During an interview on 01/09/2026 at 2:01 PM, Staff A, Administrator, stated they had completed a behavioral plan with Resident 52 previously for them not following the smoking policy and would need to figure out another plan. Staff A stated Resident 52 puts the facility and the other residents at risk when they continue to smoke unsupervised. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to implement and ensure their system of records for controlled substances (CS, categories of drugs, regulated and classified based on their potential for abuse and potential to cause physical or mental dependence) disposition (the process of returning and/or destroying unused medications) and accurate reconciliation (a system of recordkeeping that ensures an accurate inventory of CS received, administered or destroyed) was completed in sufficient detail to enable the accurate accounting with these types of medications for 1 of 2 medication carts/CS logbooks (West hallway medication cart) reviewed for storage/disposition of controlled medications. This failure placed residents at risk for potential financial loss, uncontrolled pain, and possible drug diversion (the abuse of prescription drugs used for purposes other than intended by the prescriber). Findings included .Review of the facility's policy titled, Controlled Medication Storage, dated January of 2025, showed that at each shift change two Licensed nurses would verify/document the accurate reconciliation of the CS was correct from the previous shift. The policy stated that if the counts were incorrect, they would be reported to the Director of Nursing Services (DNS) immediately. The policy showed CS that remained after an order had been discontinued would have restricted access until destroyed. During a concurrent observation and interview on 01/08/2026 at 5:38 PM Staff O, Licensed Practical Nurse, was overseeing the [NAME] hallway medication cart. Staff O stated they had already performed the shift change CS reconciliation and documented completed with two nursing signatures in the CS logbook. Staff O stated the CS logbook was for recording [NAME] hallway resident specific CS medications administration during nursing shifts so that an accurate count was maintained. Staff O showed a resident's CS medication card (multiple doses of CS medications individually packaged) along with the corresponding logbook reconciliation, but the count from the logbook and the medication card did not match. Staff O stated they had given the medication previously to the resident and was trying to catch up with the documentation in the CS logbook. The CS logbook showed that Staff O had administered the CS medication on 01/07/2025 and 01/08/2025 but the number of CS medication logged after the administrations differed from the CS medications left on the resident's medication card. Staff O stated the CS logbook was incorrect and they were unsure of what date they had administered the CS medication but that it was not given on one of the days. Observations on 01/08/2026 at 5:45 PM, showed Staff D, Registered Nurse and Staff C, DNS, conducting a CS reconciliation on the [NAME] hallway medication cart and CS logbook. During the reconciliation observations: Two CS medication cards were noted with a hole torn in the back of the package where the CS medications tablets were accessible and had the potential to fall out of its original packaging without anything to keep the tablet in place. Two CS liquid medication bottles of Hydromorphone (a CS medication for pain) were noted for the same resident but were logged in two separate logbooks. One of the CS medication bottles was brand new and the other showed on the logbook that 14 milliliters (ml, a unit of measure) were left in the CS medication bottle, but the bottle was noted to have 6 ml left (an 8 ml difference) and a broken cap. Two CS medication cards from a resident that had discharged from the facility on 01/01/2026 were still noted in the reconciliation. Two CS liquid medication bottles of Morphine (a CS medication for pain), recorded on the same page in the CS logbook, one bottle had 7 ml and the other had 3 ml. The logbook did not differentiate the amounts between bottle one and bottle two but showed 12 ml total (a difference of 2 ml)During an interview on 01/08/2026 at 5:55 PM, Staff C, DNS, stated the facility's process was to have licensed nursing staff flag CS medications that needed disposition during the CS reconciliation so they could be destroyed or returned and an accurate reconciliation could be completed/documented. Staff C stated the flagged items would have included the two CS medications cards from the resident that had already been discharged , the two CS medication cards that had the packaging torn open on the back, the liquid CS hydromorphone bottle with the broken cap and one of the two liquid CS morphine bottles that should have been documented on their own page. Staff C stated the CS reconciliation counts were not correct and needed further investigation. Staff C stated that accurate accounting and documentation of the CS medications was not maintained, and the facility process was not followed. During an interview on 01/06/2025 at 4:09 PM, Staff A, Administrator, stated that the CS medication count verification, logbook documentation and disposition should have been completed accurately. Staff A stated the correct process was not followed. Reference: WAC 388-97-1300(1)(b)(ii)

Based on observation and interview the facility failed to provide a sanitary environment by not providing scheduled maintenance services for cleaning for ceiling vents for 1 of 1 kitchen. This failed practice placed the residents at risk for cross contamination, food borne illness, and negative health outcomes.Findings included .During an observation on 01/05/2026 at 10:06 AM, the two 24 by 24 inches air vent in the kitchen located on the overhead in the middle ceiling over the food preparation areas had fuzzy brown substances that were unclean around the 24 by 24 inches square air vent grill. The air vent grill, located on the ceiling over the cook area, had multiple areas of a dark brown and grayish fuzzy substances. The 24 by 24 inches air vent grill, over the staff handwashing sink in the kitchen had accumulated brown fuzzy dust. The ceiling by the wall across the kitchen room had two 24 by 24 inches dirty air vents which had fuzzy gray dust hanging and brown dust located on the air vents.During an interview on 01/05/2026 at 10:20 AM, Staff K, Dietary Manager visualized the vents in the kitchen and stated they were dirty and were not cleaned for a while. Staff K stated they had not had a maintenance person for cleaning the vents in the kitchen for some time and was unsure about when the air vents were to be cleaned.During an interview on 01/07/2026 at 12:46 PM, Staff H, Maintenance Supervisor, stated they were new to the position and the cleaning of the kitchen vents and ceiling had not been on a scheduled cleaning and needed to be on a cleaning schedule.Reference: WAC 388-97-3220(1)

Based on interview and record review, the facility failed to establish a valid basis for discharge for 2 or 3 residents (Resident 1 and 2) who were not permitted to return to the facility after hospitalization and/or therapeutic leave. This deficient practice displaced residents from a safe home and placed them at risk for unmet care needs.Findings included.Review of the facility policy, Discharge and Transfer, revised on 06/11/2025, showed residents transferred to a hospital for unplanned, acute reasons must be permitted to return to the Center.Review of the facility policy Leave of Absence/Therapeutic Leave: Patient, revised on 07/15/2025, showed therapeutic leave was described as absences from the facility other than hospitalizations and cannot be a means of involuntarily discharging the patient.Resident 1Review of the medical record showed Resident 1 admitted to the facility, on 12/22/2023, with diagnoses of Chronic Obstructive Pulmonary Disease [(COPD) a progressive lung disease that blocks airflow, making it hard to breathe due to damaged airways], stroke, and polyneuropathy (damage to multiple nerves causing pain and numbness to hands and feet). Review of the comprehensive assessment, dated 08/26/2025, showed Resident 1 had moderate cognitive impairment, required the assistance of two people for dressing, bathing, incontinent care, bed mobility and transfers, and was administered supplemental oxygen continuously due to chronic shortness of breath.Review of the medical record showed Resident 1 was issued a 30-Day Notice to discharge on [DATE] for non-payment of room, board, and care costs. The medical record showed a request for an Appeal Hearing was submitted to the State Department on behalf of Resident 1 on 07/10/2025, the hearing took place on 07/28/2025, and the decision was for the facility to not proceed with the discharge.Review of the nursing Progress Note (PN), dated 11/11/2025 at 9:30 PM, showed Resident 1 experienced nausea/vomiting, respiratory distress (difficulty breathing) with abnormal vital signs and was sent to the local hospital for evaluation and treatment.Review of the medical record showed the Minimum Data Set [(MDS) a standardized assessment for nursing home residents, capturing health data (functional, cognitive, psychosocial) for care planning, quality reporting, and payment] discharge assessment, dated 11/11/2025, indicated Resident 1 was anticipated to return.Review of the medical record showed scanned e-mails, dated 11/17/2025 at 8:32 AM, of Staff C, Admissions Coordinator, confirming the facility's decision to red flag (Resident 1) as no readmission for non payment, and stated they would communicate that to the hospital.Review of the medical record showed scanned e-mails, dated 12/09/2025 at 3:24 PM, where Staff D, Paralegal-Regulatory Matters, communicated with Staff A, Administrator, and Staff C that (Resident 1) is still our patient at this time until we find an appropriate and safe discharge location. (The facility) can only refuse (Resident 1's) return from the hospital if (their) needs have changed and (the facility) can no longer meet them.Resident 2Review of the medical record showed Resident 2 admitted to the facility, on 07/09/2025, with diagnoses of diabetes (a disease that impairs the body's ability to process sugar), right below the knee amputation, and COPD. Review of the comprehensive assessment, dated 10/14/2025, showed Resident 2 was cognitively intact, required the assistance of one person for toileting, incontinent care, dressing, personal hygiene, and bathing, and was independent with their mobility by using an electric wheelchair.Review of the Weekly Interdisciplinary Discharge Planning Assessment, dated 08/14/2025, showed Resident 2 planned to stay at the facility as a long-term care resident once skilled therapy was completed.Review of the care plan, dated 10/13/2025, showed Resident 2 was able to go out in the community unsupervised and staff were to assist Resident 2 with appropriate preparations such as verifying the battery of their electric wheelchair was charged.Review of the nursing PN, dated 11/11/2025 at 10:51 AM, showed Resident 2 informed facility staff that they were incontinent of bowel and bladder during their outings from the facility, and they were aware this caused skin breakdown to their coccyx (tailbone). Resident 2 stated they preferred to be assisted with incontinent care and application of sav (skin healing ointment) upon their return.Review of the nursing PN, dated 12/10/2025 at 12:54 PM, showed Resident 2 signed themselves out of the facility for a Therapeutic Leave of Absence (LOA) on 12/07/2025 with the plan to return to the facility on [DATE].Review of the nursing PN, dated 12/12/2025 at 4:19 PM, showed Resident 2 contacted the facility stating they wanted to return to the facility and had experienced a fall while they were out of the facility. The PN showed Staff B, Director of Nursing, advised Resident 2 they would need evaluated by ER (emergency room) physician before (the facility) can accept them back.Review of the nursing PN, dated 12/12/2025 at 7:55 PM, showed the facility was contacted by the local hospital ER, on behalf of Resident 2, inquiring about their return to the facility. The ER Licensed Nurse (LN) stated Resident 2 was evaluated for skin breakdown to their coccyx due to having diarrhea for the last three days. The PN showed the facility staff informed the ER LN that Resident 2 could not return to the facility until they were reviewed as a new resident referral for admission, and this could not be completed until the next day.During an interview, on 12/23/2025 at 1:10 PM, Staff A stated the reason Resident 1 was denied readmission to the facility was related to financials, and they considered Resident 1's discharge to the hospital to meet the requirement of a safe discharge. Staff A stated Resident 1's care needs had not significantly increased or changed.During an interview, on 12/23/2025 at 4:40 PM, Staff B stated they directed Resident 2 to be evaluated at the ER before returning to the facility to ensure they were medically stable. Staff B stated they did not know why Resident 2 was not permitted to return on 12/12/2025 after being evaluated at the ER.During an interview, on 12/24/2025 at 4:15 PM, Staff E, Market Resource Clinician, stated they believed the facility policy was to review residents as new admissions if their Therapeutic LOA lasted longer than three nights. Staff E stated they were concerned Resident 2 developed new health issues including a wound to their coccyx. Staff E stated that information should have been explained to Resident 2, and that was the basis of the decision not to allow Resident 2 to return to the facility on [DATE].During an interview, on 12/24/2025 at 4:20 PM, Staff A stated they were unsure of Resident 2's desire or need to readmit to the facility as they had not spoken with them. Staff A stated Resident 2's friend/caregiver had contacted the facility inquiring about Resident 2's mail, and they believe (Resident 2) is with them. Reference: WAC 388-97-0120(2-3), -0160(5)

Based on observation, interview, and record review, the facility failed to maintain resident rooms and bedside urinals in a sanitary and homelike manner for 2 of 3 residents (Resident 1 and 2) reviewed for environment. This deficient practice placed residents at risk for compromised dignity, diminished quality of life and potential infection control issues.Findings included.Review of the facility policy, Nursing Department Infection Control Guidelines: Care of Patient Care Equipment, dated 02/28/2021 showed Personal Care Equipment such as urinals were for single patient use only, to be cleaned and disinfected after each use, discarded if heavily stained or worn, and to be covered when being stored.Resident 1Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease [(COPD) a group of lung diseases that cause long-term breathing problems], cachexia (condition that causes significant weight loss and muscle loss), and major depressive disorder (a mental health condition where someone feels persistently sad and hopeless). Review of the comprehensive assessment, dated 07/18/2025, showed Resident 1 was cognitively intact and required the assistance of one person for personal hygiene, dressing, toileting, and incontinent care. Further review of the assessment showed Resident 1 was frequently incontinent of bowel and bladder.Review of the medical record showed Resident 1 was transferred to a local hospital for evaluation and treatment on 09/29/2025 at 10:30 PM.During an observation, on 09/30/2025 at 3:45 PM, Resident 1's room (room [ROOM NUMBER]) had multiple pairs of used gloves in the garbage can, the floor had areas of soilage causing footwear to stick while walking, dried pieces of food stuck on the floor near the bed, and the presence of a fly. Resident 1's bathroom had a strong, offensive odor of urine; multiple pieces of personal medical equipment stacked on top of each other including two specialized bedside urinals (a urine bottle with a 47-inch hose attachment and funnel). Both urinal funnels (the part that touches the body) and hoses had a visible, thick layer of a dried sediment substance-brown and white in color.During a concurrent observation and interview, on 09/30/2025 at 4:10 PM, Staff D, Nursing Assistant (NA), stated Resident 1 purchased their specialized urinals online, and would use the urinals for a long time before replacing them. Staff D demonstrated their process for cleaning the specialized urinals by running water through the funnel, the hose, into the bottle, and emptying it into the toilet. Staff D stated they did not use any cleaning or disinfecting solutions because Resident 1 does not like the smell of chemicals.During an interview, on 09/30/2025 at 4:30 PM, Staff E, NA, stated Resident 1's room was difficult to keep clean because Resident 1 did not like the smell of cleaning solutions. Staff E stated Resident 1's room had been deep cleaned that morning by housekeeping. Staff E stated they used water only to clean Resident 1's specialized urinals and they did not think the process was sanitary.Review of Resident 1's care plan on 10/01/2025, last updated on 09/03/2025, showed no documented preferences regarding cleaning solutions, chemical odors, use of personal equipment such as a bedside urinal, or interventions for maintaining and/or storing personal equipment.During an interview, on 10/01/2025 at 10:02 AM, Staff C, Infection Preventionist (IP), stated the process for cleaning bedside urinals was to rinse with water after each use and to discard and replace urinals when they became stained or odorous. Staff C stated they were unaware of Resident 1's specialized urinal and a plan for cleaning, disinfecting, storing, and maintaining would need to be developed. Staff C confirmed the current process for cleaning and maintaining Resident 1's specialized urinals did not meet infection control expectations.During an interview, on 10/01/2025 at 10:10 AM, Staff F, Housekeeping/Laundry Supervisor, stated Resident 1's room was deep cleaned on the morning of 09/30/2025. Staff F stated housekeeping staff used hot water to clean Resident 1's room because Resident 1 did not like the smell of cleaners. Staff F stated the facility had not attempted to use odorless or fragrance-free cleaning solutions for Resident 1's room. Staff F stated housekeeping clean every resident room every day and did a deep clean of every room at least once a month.During an interview, on 10/01/2025 at 10:30, Staff G, Housekeeper, stated their process for daily resident room cleans was to wipe down all surfaces, sweep and mop the floors, clean the toilet, sink and shower, and empty the garbage. Staff G stated multiple residents kept a lot of personal belongings in their rooms making it difficult to move things around to clean surfaces. Resident 2Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (a chronic condition that affects how the body uses sugar for energy), circulatory complications (blood flow impairment) and a foot ulcer (a wound that does not heal properly) related to DM. Review of the comprehensive assessment, dated 07/12/2025, showed Resident 2 was cognitively intact, required the set up assistance for dressing, personal hygiene, toileting, bathing, and was independent with self-propelling in the wheelchair.During a concurrent observation and interview, on 10/01/2025 at 1:10 PM, Resident 2 was in their room finishing lunch when a fly was noted to land on Resident 2's bedside table, lunch tray, shoulder, and bed. Resident 2 stated they always had a fly in their room. Observation of Resident 2's bed showed it was covered with personal belongings, food wrappers, empty soda bottles, and random loose papers. Observation of the sink and counter in Resident 2's room showed it was cluttered with personal belongings, hygiene supplies, empty medicine cups with ointment residue, food wrappers, and food crumbs. Multiple soda bottles were observed on the counter, on the bed, and on the nightstand to have a dark, moist substance inside (not soda), and Resident 2 stated it was chewing tobacco and spit. Resident 2 stated their room was cleaned two-three times per week which included sweeping, mopping, and cleaning the bathroom. Resident 2 stated housekeeping did not throw away any garbage that was in the room unless they put it in the garbage can. Resident 2 stated it had been a long time since their counter and sink were cleared off and wiped down.During an interview, on 10/01/2025 at 2:25 PM, Staff B, Director of Nursing, stated Resident 1's specialized urinals had been disposed of and replacements ordered. Staff B stated the current process for cleaning and maintaining Resident 1's specialized urinals did not meet infection control expectations.During an interview, on 10/01/2025 at 2:30 PM, Staff A, Administrator, stated resident rooms should be cleaned daily and have a deep cleaning at least once a month. Staff A confirmed facility policy for cleaning resident rooms and personal equipment was not followed for Resident 1 and Resident 2.Reference: WAC 388-97-0880 (1-2)

Based on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify, prevent, protect, investigate, and report abuse/neglect allegations for 3 of 3 residents (Residents 2, 38, and 62) who had reported allegations of abuse and neglect by filing out grievance forms. Review of the facility's Grievance/Concern forms, dated 06/01/2024 to 11/14/2024, showed 10 additional allegations of abuse/neglect involving 7 of 7 residents (Residents 226, 228, 227, 2, 54, 11, and 40) reviewed for abuse/neglect. The facility did not have a process to identify allegations of abuse/neglect, that were written as grievances and required thorough and timely investigations. The facility also failed to report the allegations to the State Complaint Resolution Unit (the section of the Department of Social and Health Services that is responsible for processing and initiating an electronic recording of all resident received reports) as required. This failed practice placed other residents at risk for abuse and neglect. The lack of recognizing allegations of abuse and neglect and taking any needed action constituted an immediate jeopardy (IJ). On 11/14/2024 the facility was notified of an IJ at, F607 42 CFR 483.12(b)(1)-(4) Develop/Implement Abuse/Neglect Policies when resident allegations of abuse and neglect in the form of grievances were not appropriately followed up on by identifying the allegations of abuse and neglect, protecting the resident, and conducting a thorough and timely investigation to determine if abuse or neglect had occurred. It was determined the IJ began on 11/14/2024 and the immediacy was removed on 11/15/2024 with an onsite investigation from surveyors. The facility removed the immediacy by conducting facility wide interviews with residents and/or families specific to abuse or neglect to identify if any additional allegations were made to provide the necessary follow up. Education was provided to staff on the grievance process and how to immediately identify and report abuse or neglect allegations to include protection of the resident during the investigation. Education was to be completed with all staff prior to their next scheduled shift. The measures put into place by the facility ensured that all staff were trained on identifying and reporting abuse. Findings included . Record review of a facility policy titled Abuse Prohibition revised of 10/24/2022 showed; The center will implement an abuse prohibition program through the following: * Screening of potential hires * Training of employees * Prevention of occurrence * Identification of possible incidents or allegations which need investigation * Investigation of incidents and allegations * Protection of patients during investigation * Reporting of incidents. <Resident 2> Review of the resident's medical record showed they were admitted with diagnoses including multiple sclerosis (a disease in which the immune system destroys the protective covering of the nerves) and diabetes (a chronic disease that causes too much sugar in the blood). Review of the comprehensive assessment dated [DATE] showed the resident's had mild cognitive impairment and experienced pain during the assessment period. During an interview on 11/13/2024 at 2:56 PM, Resident 2 stated Staff D, Licensed Practical Nurse (LPN), had refused to give them pain medication alleging Staff D was rude and verbally abusive. The resident stated Staff D often told them their medication was unavailable as well, so they had filed a grievance as they felt Staff D was purposely withholding their pain medication to be mean to me. Review of a Grievance/Concern Form dated 10/09/2024 showed Resident 2 had alleged Staff D would not give them pain medication and was picking on me. The grievance was signed by Staff A, Administrator, but not dated. Record review of the facility incident reporting log showed there had been no investigation into Resident 2's allegation against Staff D's treatment of them. <Resident 38> Review of the resident's medical record showed the resident was admitted to the facility with diagnoses including multiple sclerosis and chronic pain. Review of the resident's comprehensive assessment dated [DATE] showed the resident was cognitively intact with no memory deficits and suffered from frequent pain. During an interview on 11/13/2024 at 11:13 AM, Resident 38 stated they had filed a grievance about three weeks ago related to a nurse being rude, belittling and had refused to give them pain medications when they had requested. The resident identified the nurse as Staff D. Resident 38 stated Staff D was not allowed to pass their medications anymore, but had remained on the unit and they felt Staff D was able to retaliate against them as they would not report to the other nurse taking care of them when they wanted a pain pill Resident 38 stated I feel like (Staff D) was purposely ignoring my requests it was very uncomfortable with (Staff D) still on my unit. Resident 38 stated they would have to wait until Staff D left to get their pain medications. Review of Resident 38's Grievance/Concern Form dated 10/22/2024 showed the resident alleged Staff D was frequently rude and refused to listen to them. Further review of the allegation showed Staff D often refused the residents request for pain medication and was disapproving when they asked for pain medication. Staff D would blatantly refuse or tell them it was unavailable. The grievance was signed by Staff F, Unit Manager but did not include the date it was reviewed. Review of the facility incident reporting log showed no investigation had been completed into Resident 38's allegations of abuse/neglect made against Staff D. <Resident 62> Review of the resident's medical record showed the resident was admitted to the facility with a diagnosis of Parkinson's disease (a disease of the nervous system that affects movement and causes tremors). Review of the comprehensive assessment dated [DATE] showed the resident was able to make their needs known. During an interview on 11/13/2024 at 10:08 AM, Resident 62 stated they had missed their medication for tremors Carbidopa-Levodopa (a medication used to treat the symptoms of Parkinson's disease such as tremors) several days earlier. Resident 62 stated Staff D had told them they were out of the medication, and it was not available. The resident informed Staff D they needed their medication on time otherwise they would suffer from tremors. Record review of a Grievance/Concern form dated 11/08/2024 showed Resident 62 had notified the facility of the missed medication and had reported they had experienced intense shaking and tremors after the missed dose. The grievance was undated and signed by Staff F, Unit Manager and showed the medication had been found located in the medication cart. Review of the incident reporting log showed the facility had not recognized Staff D's frequency of allegations of abuse/neglect and a pattern of alleged medication errors as indicated by grievances filed on 10/09/2024 by Resident 2, 10/22/2024 by Resident 38 and 11/09/2024 filed by Resident 62. Review of the nurse's schedule dated 10/01/2024 to 11/14/2024 showed Staff D had continued to work with unsupervised access to residents and without a thorough and timely investigation into the allegations. During a concurrent interview on 11/14/2024 at 04:56 PM, Staff A, Administrator and Staff B, Senior Director of Nursing, stated there were no incident investigations that had been completed related to the allegations against Staff D filed by Residents 2, 38 and 62. Record review of the facility Grievance/Concerns forms dated 06/01/2024 to 11/14/2024 showed 10 additional allegations involving seven dependent residents (Resident's 226, 228, 227, 2, 54, 11, and 40) alleging abuse/neglect as follows; * 06/04/2024 Resident 226 allegation - the resident was left in their wheelchair without any care from 9:00 AM to 3:00 PM. * 06/20/2024 Resident 228 allegation - the resident had not been changed or turned and re-positioned on several occasions. * 06/14/2024 Resident 227 allegation - the nurse refused to let them keep their door open when they suffer from claustrophobia. * 07/18/2024 filed Resident 228 allegation - the resident was neglected and not changed two nights in a row. * 08/26/2024 Resident 2 - allegation their post-surgical bandage was not being changed by the evening nurses. * 09/26/2024 Resident 54 - alleged evening shift was rough with them. * 10/12/2024 Resident 54 - alleged staff were super rough with them. * 10/22/2024 Resident 11 - stated they did not like the way a nurse treated their wife. * 11/10/2024 Resident 40 - alleged a nurse used excessive force to clean their wound and they almost cried from the pain. Record review of the facility incident reporting log from 06/01/2024 to 11/14/2024 showed the facility had not recognized the above listed allegations as abuse or neglect therefore no thorough or timely investigations had been completed into the above allegations filed as grievances. During an interview on 11/15/2024 at 8:08 AM, Staff A, Administrator stated it's a very broken system for reporting allegations related to abuse and neglect. Staff A stated they had not been aware of some of the grievances alleging abuse/neglect filed as they had not been presented to them. Staff A further stated even though they did not see all the grievances I am the administrator so it's on me. Reference WAC-388-97-0640(2)

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 11 residents (Resident 35) reviewed for neglect. Resident 35 experienced harm when staff failed to provide Resident 35 water when requested, failed to assess skin excoriation (loss of the top layer of the skin and a portion of the middle layer of the skin due to scratching or an injury) to Resident 35's coccyx (tailbone) and perineum (the area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum), and administer pain medications as needed at their end of life per Resident 35's advanced directive (a legal document that outlines preferences for medical care in the event you are unable to communicate your wishes). These failed practices placed the residents at risk for dehydration, additional skin breakdown, and continued pain. Findings included . Review of a policy titled, Abuse Prohibition, dated 10/24/2022, defined neglect as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods, and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This includes the failure to implement an effective communication system across all shifts for communicating necessary care and information between the Center, patient, practitioners, and patient representatives. <Resident 35> Review of the medical record showed Resident 35 was admitted to the facility on [DATE] with diagnoses of Clostridium Difficile (a bacteria that causes diarrhea and other intestinal issues), malnutrition, and severe sepsis with septic shock (a life-threatening condition that occurs when the body's response to an infection progresses to a dramatic drop in blood pressure). The 11/11/2024 comprehensive assessment showed Resident 35 was dependent on one to two staff members for activities of daily living; touch assistance/supervision for eating. The assessment also showed Resident 35 had a moderately impaired cognition. <Water> During an observation on 11/13/2024 at 11:38 AM, Resident 35 was lying on their back in bed with their right arm outstretched, reaching towards their water cup on the bedside table. They were calling out ahh and ow. At 11:48 AM, Resident 35 was observed with the back of their hand against the water cup and was calling out water, water. At 11:50 AM, the first observation of staff hearing the resident's request for water, Staff C, Nursing Assistant (NA), walked past the resident's room and did not acknowledge their request for water. At 11:51 AM, Staff E, Director of Rehab/Physical Therapy Assistant (PTA), Staff N, NA, and Resident 52 (a resident that resided in the same hall as Resident 35) were in the hall outside of Resident 35's room, having a conversation. Staff E stated to the resident in the hall, I have a protein cafe latte for (Resident 35) today, I have it in the refrigerator and will give it to them later as Resident 35 was continuously calling out for water. Resident 52 wheeled themselves into Resident 35's room. Staff E told Resident 52 that was not their room, and the resident responded, I am going to check on them, entered Resident 35's room, and was observed talking to Resident 35 and patting their arm. Staff E and Staff N both left the area without responding to Resident 35's requests for water. At 11:55 AM, as Resident 35 was still calling out for water and reaching for their water cup, Staff C and Staff N were observed outside Resident 35's room, donning gown and gloves to enter the room next to Resident 35. Neither Staff C nor Staff N acknowledged Resident 35's requests for water. At 12:03 PM, Resident 52 was observed putting Resident 35's call light on, exited the resident's room, and stated to Staff O, NA, who was walking past Resident 35's room, Resident 35 wants water, needs water, I can't do it for them. At 12:07 PM, Resident 35 was observed still crying out for water. Staff O, again walked past Resident 35's room. They did not acknowledge the activated call light or Resident 35's requests for water. At 12:11 PM, Staff P, Licensed Practical Nurse (LPN), entered Resident 35's room, as they were continuously calling out for water. Staff P turned off the call light and stated, you need a drink of water? and exited the room without giving the resident water. At 12:16 PM, Staff N entered Resident 35's room with their lunch tray. Resident 35 yelled out water. Staff N stated, you need to wait a minute I have to go gown up. At 12:21 PM, Staff N re-entered Resident 35's room and gave the resident a drink of water, 31 minutes after staff first heard Resident 35 calling out for water. During an interview on 11/13/2024 at 12:50 PM, Staff P stated they went into Resident 35's room earlier that day to answer the call light and were going to get Resident 35 a drink of water. They stated they were going to put ice in their cup, left the room, and got sidetracked. Staff P stated the process for answering call lights was to turn them off when entering the room, then take care of the resident's need. They stated they turned the call light off because they did not want other family members or administrative staff to see that call lights were not being answered. During an observation on 11/15/2024 at 9:47 AM, Resident 35 was lying on their back in bed, their eyes and cheeks and were sunken in. Their mouth was open, their tongue and lips were dry and cracking. Their bottom lip was adhered to their bottom teeth and had a white film over it. Resident 35 stated yes when asked if they were thirsty and if they were in pain. Resident 35 was not able to state where their pain was located. <Skin> Record review of a NA assignment sheet, dated 11/10/2024, showed the NA had documented on their sheet that Resident 35 had extreme skin breakdown. Record review of a nursing progress note, dated 11/10/2024 at 9:29 PM, showed Staff Z, LPN, documented Resident 35 had an excoriated perineum that had an open area on the vulva (external female genital organs) that was bleeding that evening when the NA was providing incontinent care. During an interview on 11/15/2024 at 11:46 AM, Staff C stated they had reported Resident 35's skin maceration (the process of skin softening and breaking down due to prolonged exposure to moisture) to Staff F, Unit Manager (UM), on 11/11/2024. Staff C stated that morning, they were performing personal cares for Resident 35 and their skin was just wiping off. They stated Staff M, Registered Nurse (RN)/Infection Preventionist (IP) had been passing by Resident 35's room during the cares, and they asked Staff M to look at the macerated skin. Staff M advised them to use warm water to remove the thick paste that was covering the wound, but did not assess the wound. During an interview on 11/15/2024 at 12:18 PM, Staff F stated Resident 35 had the maceration from incontinence and sweating. They stated they were informed of the maceration on Tuesday (11/12/204) or Wednesday (11/13/2024). They stated they were informed of redness by maybe an aide but did not assess the areas. During an interview on 11/16/2024 at 9:07 AM, Staff M stated they were asked to look at Resident 35's perineum on either 11/11/2024 or 11/12/2024. They stated they were called into the resident's room by two NAs to assess the areas of concern. Staff M stated there was a thick layer of what looked like powder that had gotten wet, caked on Resident 35's perineum. Staff M stated there was so much powder and wet stool, they were unable to see any of the wound area. Staff M stated they did not assess the wound area. Review of a nursing progress note, dated 11/14/2024 at 7:15 AM, showed Staff B, Senior Director of Nursing, and Staff F assessed Resident 35's perineum and buttocks area, four days after the initial report of skin breakdown. Resident 35 had front peri area that is inflamed and reddened in color with erosion (occurs when the skin's outer layers break down) of skin folds, bilateral (both sides) buttocks have superficial (occurring on the surface) open areas . During an interview on 11/16/2024 at 2:24 PM, Staff Z stated they had reported the perineum concerns to the Registered Nurse that was on duty that night so they could assess Resident 35's condition. <Pain> An observation on 11/15/2024 at 10:01 AM, showed Staff C, Staff Q, NA, Staff O, and Staff R, LPN, outside Resident 35's room, putting on gowns and gloves. The staff entered the room and began to perform incontinent care for Resident 35. Observation of the resident's perineum showed severely macerated (softening and breakdown of the skin due to prolonged exposure to moisture or fluid) tissue that was bright red. As Staff C cleaned the perineum with cleansing wipes, Resident 35 squeezed their eyes shut, cried out in pain, made a fist with their left hand, and repeatedly punched Staff Q in the right forearm. Staff O stated they were training Staff R and stated to Staff R that they kept up on Resident 35's pain medication and were able to administer pain medications every eight hours as needed (provider order showed pain medication was to be given every six hours as needed). Staff O stated they were going to get Resident 35 an oxycodone (a medication used to treat moderate to severe pain) since it was time for their next dose (their last dose had been given at 3:23 AM). Staff O did not administer Resident 35 a pain medication, despite stating they would. Review of a provider progress note, dated on 11/14/2024 at 9:30 AM, showed Resident 35's provider had assessed them for an acute visit due to decreased activity, worsening pain, and progressive skin changes to their perineum. The provider note showed the resident was unable to feed themselves and had significant pain with repositioning. Resident 35 was observed laying in bed on left side with mouth open, dry mucous membranes. Patient unable to reposition self, due to weakness. The assessment showed their skin was macerated and erythematous (abnormally red skin due to inflammation) rash on buttocks, inner thighs, and bilateral labia (the folds of skin at the outer part of a woman's sexual organs), superficial sloughing (shedding) of dermal (skin) layer on buttocks bilaterally, roughly two to three centimeters (a unit of measurement) in circumference. Resident 35 had a new diagnosis of dermatosis (disease of the skin) of perineum consistent with atopic dermatitis (a condition of the skin that causes inflammation, redness, swelling, and cracking of the skin) reaction from their current conditions of c-diff colitis(inflammation of the large intestine), recurrent diarrhea/watery stools and sweat. Record review of a Nurse Practitioner (NP) provider note, dated 11/15/2024 at 9:30 AM, showed Resident 35 was seen to follow up on concerns of moisture associated skin damage [(MASD) a general term for inflammation of skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, or sweat] of the genital area. The resident was unresponsive and quietly moaning (indicative of discomfort or pain). They were lying in bed, mouth open with dry mucous membranes. Resident 52 was unable to reposition themselves due to weakness and was moaning. Their genitourinary (organs of the urinary and genital system) area was excoriated, and red. New medications were ordered for pain, to be administered every two hours as needed, and anxiety, to be administered every four hours as needed. Review of the November 2024 Medication Administration Record, showed Resident 35 had received one dose of Tylenol (an over the counter medication to treat mild to moderate pain) on 11/15/2024 at 1:41 AM with ineffective results. They received one dose of oxycodone (a prescription pain medication used to treat severe pain) on 11/15/2024 at 3:23 AM, despite Staff O stating they would give a pain medication at 10:01 AM that morning. The facility did not provide Resident 35 any additional medications for pain control prior to them passing away at 9:00 PM, 17.5 hours after their last dose, despite the NP noting Resident 35 had been moaning that morning and had ordered additional medications for pain and anxiety. Record review of Resident 35's Advance Directive dated 12/12/2023, showed it is my desire that pain alleviation or control procedures or medication be administered and continued, and that as long as I live, I be kept as pain-free and comfortable as is reasonably possible. During an interview on 11/19/2024 at 10:27 AM, Staff B stated the process for change in condition did not happen for Resident 35. The new medications for pain and anxiety should have been pulled right away from the Pyxis (a medication dispensing system) and given. Advance Directives were reviewed upon admit by social services and that information should have been communicated to the unit manager. Staff B stated the provider should have been contacted sooner to address those concerns. During an interview on 11/19/2024 at 12:11 PM, Staff A, Administrator, stated they would have expected the staff to administer Resident 35 water, even if we had to have staff sit with (them). They stated the process for any skin change was to report it immediately to the licensed nurse, unit manager, and provider. They stated the process for Advance Directives included a review by Staff B to ensure that all the orders were being followed; that is (their) department and (their) duty. Staff A stated the facility did not follow their processes. Reference: WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to provide an environment that was free from avoidable accident hazards for 1 of 5 residents (Resident 4) reviewed for accidents with injury. This failed practice placed the residents at risk for avoidable accidents when Resident 4 experienced actual harm when their fifth toe on their right foot was broken while being pushed in their wheelchair. Additionally, the facility failed to ensure a safe smoking area and storage of smoking paraphernalia (items or equipment associated with a particular activity, hobby, or lifestyle) for 3 of 3 residents (Residents 13, 27, and 45) reviewed for safe smoking. The failure to ensure a safe smoking environment and storage of smoking paraphernalia placed the residents at risk for dissatisfaction with their smoking activity experience and injury. Findings included . Review of a policy titled, Accidents/Incidents, revised 03/01/2024, showed an accident was defined as any unexpected or unintentional incident that may result in injury or illness to a resident. After an accident occurred, the licensed nurse (LN) would report the accident and assist with a timely investigation to determine the cause. They would take immediate post-accident measures, implement appropriate interventions, update the care plan and communicate with the resident/representative, and complete nursing documentation and change of condition. Any incident that would be considered an allegation of abuse/neglect would be managed according to facility abuse prohibition policy. The LN would evaluate the resident, notify the physician, report the physical findings/extent of injuries, and obtain orders if necessary. The LN would create an event report in the medical record and document the accident in the resident's chart. All accidents would be reported to the supervisor. All accidents would be investigated to determine if the accident had been reported timely, investigated, and interventions were implemented. <Injury> <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including diverticulitis (inflammation of pouches in the colon that can cause abdominal pain, fever, nausea, vomiting, and sometimes bleeding), epilepsy (a brain disorder that causes people to have repeated seizures), and anxiety. The 10/24/2024 comprehensive assessment showed Resident 4 required substantial/maximal assistance of one staff member for activities of daily living (ADLs), including transfers and mobility. Resident 4 was able to make their needs known. During a concurrent observation and interview on 11/13/2024 at 3:21 PM, Resident 4 stated their right foot little toe was hurt from the accident that occurred two or three days ago, maybe Sunday. Resident 4 stated they were in their wheelchair that morning and someone had pushed them to the bathroom. Resident 4 stated they hit their foot on their roommate's bed. They stated their foot hurt and no one had looked at it. At 3:50 PM, Staff E, Director of Rehab/Physical Therapy Assistant (PTA) was attending to Resident 4's roommate. They came to Resident 4's bedside and removed Resident 4's right sock. The fifth toe showed blue/purple discoloration at the base of the toe that was one inch in length. The bruising was on both the top and side of the foot. Resident 4 stated to Staff E, I asked you to look at my foot earlier because it hurt and was bumped on their roommate's bed. Staff E responded, you asked me to remove your shoe. During an interview on 11/18/2024 at 8:49 AM, Staff E stated Resident 4 had told them that morning (11/13/2024) that their foot was sore. They stated they removed Resident 4's shoe, did not remove their sock, and asked the resident to wiggle their toes. Staff E stated Resident 4 was able to wiggle their toes and told the resident they were fine. During an interview on 11/18/2024 at 2:33 PM, Staff L, Registered Nurse (RN), stated the injury to Resident 4's foot was reported to them the same day the State Surveyor had reported it to the Administrator (11/13/2024). Staff L stated when they received the report, they assessed the foot and noted purple bruising on the outer side of the fifth toe. Resident 4 reported they had pain with palpation (the process of using one's hands to check the body). Staff L stated they administered pain medication, completed a risk management form, and reported it to the administrative staff. Staff L stated they notified the provider and an order for an X-ray had been placed. Staff L stated they were not notified of any accident or injury until after the State Surveyor had reported it. During an interview on 11/19/2024 at 8:43 AM, Staff F, Unit Manager, stated they were informed of the injury by Staff L. They stated the process was for staff to inform the nurse when an accident/injury had occurred. The licensed nurse would complete a change in condition form to notify the provider of the injury. Staff F stated Staff L completed the form and notified the provider electronically with a change in condition form the night they were told of the injury. Review of the medical record showed an x-ray had been obtained on 11/14/2024, one day after the Resident 4 reported the injury. The x-ray report showed a fracture of the fifth proximal phalanx (smallest toe). During an interview on 11/19/2024 at 10:19 AM, Staff B stated they were unable to determine who injured Resident 4's toe. They stated Staff F had assessed the resident's injury by removing both socks and comparing the feet but was unsure what day that occurred. Staff B stated Staff F reported no concerns at that time. Staff B stated it took a few days for the bruising to show. They stated they assessed the resident on 11/14/2024, saw the bruising, and ordered an x-ray. Staff B stated the process was for staff to report accidents, injuries, and pain to ensure those concerns were followed up on. Staff B stated the process was not followed. During an interview on 11/19/2024 at 12:34 PM, Staff A, Administrator, stated the process should have been for Staff E to report the injury as soon as Resident 4 informed them of the incident. Staff A stated Staff E should not have assessed the resident's injury, as that was not the process, nor their role. Staff A stated any injury should also be immediately reported to the provider, especially if there was pain and/or swelling. Staff A stated the process was not followed. <Smoking> Review of the policy titled Smoking, revised on 05/01/2024, showed smoking would be permitted in the designated area only, have a non-combustible container for cigarette disposal, and the outdoor smoking area would protect residents from weather conditions. The policy further showed smoking supplies to include tobacco, and lighters would be stored at the nursing station. <Resident 13> Review of the medical record showed Resident 13 with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), heart disease and absence of left lower leg. The 09/18/2024 comprehensive assessment showed Resident 13 was independent for ADLs, able to use a manual wheelchair for mobility, and had an intact cognition. Review of the Resident 13's smoking evaluation, dated 08/29/2024, showed they were allowed to smoke independently. The evaluation also showed they were aware of the designated smoking area, reviewed the smoking policy, and their smoking supplies would be maintained by staff and stored at the nursing station. During an interview on 11/13/2024 at 9:53 AM, Staff J, RN, stated Resident 13 would go outside to smoke multiple times per day. During an interview on 11/13/2024 at 9:55 AM, Resident 13 stated they were a current smoker and went outside to smoke five times a day. Resident 13 stated when the weather was good, they would smoke in the designated smoking area, however when the weather was raining, snowing, or hot sun, they would not smoke in the designated smoking area as there was no protection from the elements. Resident 13 stated they always kept their cigarettes and lighter in their room or with them at all times. Resident 13 stated they disposed of their used cigarettes in their empty cigarette pack and put them into their trash can in their room. An observation on 11/13/2024 at 11:31 AM, showed the designated smoking area was an uncovered cement area in the back of the facility. The current weather condition was heavy rain, and the area contained standing water on the pathway from the building to the cement area for smoking. An observation on 11/13/2024 at 1:12 PM, showed Resident 13's trash can in their room had an empty cigarette box with six smoked/used cigarettes in the box. An observation on 11/15/2024 at 10:50 AM, showed Resident 13 in front of the facility under the covered entrance smoking as it was raining. During an interview on 11/18/2024 at 3:04 PM, Resident 13 stated they would continue to go to the front of the facility under the covered entrance to smoke when the weather was bad, as the facility had not provided a covered area in the designated smoking area. Resident 13 stated they had continued to put their used cigarettes in their empty cigarette box and brought to their room to dispose of in their trash can. Resident 13 further stated the nurses were supposed to keep their cigarettes and lighter until they asked for them. Resident 13 stated the nurses had never stored their smoking supplies as they kept the supplies with them. During an observation on 11/19/2024 at 12:47 PM, Resident 13 was smoking in front of the facility under the covered entrance. <Resident 45> Review of the medical record showed Resident 45 with diagnoses including stoke with left sided weakness and depression. The 10/25/2024 comprehensive assessment showed Resident 45 required supervision of one staff member for ADLs, independent for use of manual wheelchair for mobility, had a moderately impaired cognition, and was able to make their needs known. Review of Resident 45's smoking evaluation, dated 11/11/2024, showed they were allowed to smoke independently. The evaluation also showed they were aware of the designated smoking area, reviewed the smoking policy, and their smoking supplies would be maintained by staff and stored at the nursing station. During an interview on 11/14/2024 at 10:04 AM, Resident 45 stated they were a current smoker, and they were able to smoke when they wanted. Resident 45 stated they smoked in the facility designated smoking area and disposed of their used cigarettes in the cigarette disposal container. Resident 45 stated they kept their cigarettes and lighter with them in their room. An observation on 11/17/2024 at 10:04 AM, showed Resident 45 outside the exit door on the west hall smoking a cigarette. Resident 45 was not smoking in the designated smoking area. An observation on 11/18/2024 at 2:51 PM, showed Resident 45 smoking outside the exit door on the west hall and not in the designated smoking area. During an observation on 11/19/2024 at 11:02 AM, showed Resident 45 and Resident 13 in the front of the facility under the covered entrance smoking. The current weather condition was cool, dry and windy. <Resident 27> Review of the resident's medical record showed they were admitted to the facility with diagnoses including End Stage Renal Disease (the kidneys no longer function properly) with dialysis (a treatment that removes waste and excess fluid from the blood) and a history of a cerebral vascular accident (damage to the brain from interruption in blood flow) with right arm hemiplegia (a condition that causes paralysis or weakness to one side of the body). Review of the most recent comprehensive assessment dated [DATE] showed the resident had mild cognitive impairment and limited use of their right arm. During an interview on 11/13/2024 at 10:59 AM, Resident 27 stated they had smoked since they were [AGE] years old and were not interested in quitting. The resident patted their upper right pocket and stated they had a pack of cigarettes and a lighter under their jacket so they could smoke out front when they wanted to. Resident 27 was asked if they were aware there was a designated smoking area in the back of the building, and they stated yes but only smoked out front and further stated they kept their cigarettes and lighter in their room. I don't turn them in because I like to keep them close. Review of a document in the resident's record titled Smoking Policy showed Resident 27 had signed it on 05/24/2024. The document outlined the conditions for remaining an independent smoker as follows: Smoking materials must be stored at the nurse's station. Residents cannot keep materials in their room or on their person. The resident smoking area is located off campus (out back), there are no other designated smoking areas on the campus. Residents who fail to comply with this policy will lose their independent smoking privileges and may be subject to discharge. During a concurrent observation and interview on 11/17/2024 at 1:40 PM, Resident 27 stated they had a new carton of cigarettes and showed the surveyor where they kept them along with their lighter in the top right drawer of their nightstand. I can keep them safe here; I do not need to give them to the nurse. During an interview on 11/17/2024 at 2:00 PM, Staff FF, Licensed Practical Nurse, stated they were aware that Resident 27 had cigarettes and a lighter in their room. Staff FF further stated they never turned in their cigarettes and lighter for safe storage at the nurse's station and preferred to keep them in their room. During an interview on 11/18/2024 at 11:12 AM, Staff A, Administrator, stated they were aware of the residents who kept their smoking equipment in their rooms and were not smoking in the designated area. Staff A stated their preference was for the residents to comply with the smoking policy however they just do not. Reference: WAC 388-97-1060(3)(g) 46722 39652

Based on interview and record review, the facility failed to implement pressure offloading interventions timely to prevent the development and/or worsening of pressure injuries for 2 of 3 residents (Residents 1 and 3) reviewed for pressure injuries. Resident 1 experienced harm when they developed a facility acquired pressure injury with infection to their coccyx (tailbone) and placed other residents at risk of new or worsening skin impairments. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016 defines pressure injury stages as follows: Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin) . Stage 3 Pressure Injury 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 passage way under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 Pressure Injury is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. Unstageable Pressure Injury is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of the facility policy, Skin Integrity and Wound Management, revised on 02/01/2023, showed the facility would review pre-admission information to prepare of resident's skin and wound needs, complete a comprehensive evaluation of the resident on admission, implement pressure injury prevention for identified, modifiable risk factors, and determine the appropriate support surface for the bed and chair. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of lumbar spinal stenosis (the narrowing of the open spaces in the lower spine), lumbar spondylolisthesis (the misalignment of the bones in the lower spine often pinching the nerves), and lumbago with sciatica (back pain caused by pressure on the sciatic nerve located in the lower back, buttocks, and hip area). Review of the comprehensive assessment, dated 01/30/2024, showed Resident 1 had moderate cognitive impairment, required the assistance of one person with dressing, grooming, repositioning, and the assistance of two people for transfers with the use of a mechanical lift. Furthermore, the assessment showed Resident 1 had no skin impairments and was at risk for pressure injuries. Review of the nursing admission assessment, dated 01/24/2024, showed Resident 1 had chronic pain that was made worse by activity such as getting up or turning. The assessment showed Resident 1 had weakness in both legs, and impaired mobility to the right leg from sciatica. The assessment showed skin integrity issues to include a bruise to Resident 1's right antecubital (crook of the elbow) and several small, scattered scabs to the tops of their toes. Review of the baseline care plan, dated 01/25/2024, showed Resident 1 was at risk for skin breakdown due to decreased mobility and advanced age and preventative interventions were daily observations of skin by nursing assistants (NAs), weekly skin assessments by Licensed Nurses (LNs), reposition assistance every two to three hours, and application of moisture barrier cream to skin with every cleansing. Review of the medical record showed a skin assessment, dated 01/29/2024, documented no new skin issues. Review of the nursing progress note (PN), dated 02/03/2024 at 6:06 AM, showed a discolored area to right buttocks was noted with a plan to follow up with the treatment nurse. Review of the medical record showed no further description of the discolored area or update to the care plan. Review of the nursing PN, dated 02/03/2024 at 1:24 PM, showed a skin assessment was completed with documentation of an abrasion/blister to the right buttock and sacrum area (the upside-down triangle shaped area at the bottom of the spine). Review of the medical record showed no further description of the skin impairment was documented. Review of the nursing PN, dated 02/04/2024 at 8:01 AM, showed Resident 1 continues with discolored area on (their) bottom. Dressing placed. Review of the medical record showed no order for wound care or wound dressings were in place as of 02/04/2024. Review of the Wound Consultant PN, dated 02/05/2024 at 9:52 AM, showed Resident 1 had two wounds: Wound 1 was a Stage 3 pressure injury to the coccyx measuring 1.6 centimeters [(cm) a measurement of length] by 0.9 cm by 0.2 cm and Wound 2 was an abrasion to the right buttock measuring eight cm by 3.2 cm by 0.1 cm. The PN showed the wound care plan included recommendations for more aggressive offloading including air mattress. Maintenance request submitted today for mattress placement. Recommend wheelchair cushion evaluation for optimal offloading support. Review of Resident 1's Care Plan (CP), updated 02/15/2024, showed a Low Air Loss (LAL) mattress was implemented as an intervention for pressure reduction on 02/08/2024 (five days after pressure injury was identified). Review of the Wound Consultant PN, dated 02/12/2024 at 6:10 AM, showed Wound 1 had deteriorated severely, showed signs of infection with purulent (pus) drainage, a foul odor, and had increased in size measuring 4.2 cm by 4.6 cm (more than three times the previously documented size). The PN showed the actual depth of the wound was not measurable due to the presence of dead cells and necrotic (dead) tissue, and a culture (laboratory test that identifies the presence of germs such as bacteria, virus, or fungus) of the wound was obtained. Furthermore, the PN showed recommendations to obtain a Computed Tomography [(CT) computerized x-ray imaging that takes detailed pictures of areas inside the body] scan to rule out osteomyelitis (infection in the bone) of the coccyx. Review of the nursing PN, dated 02/15/2024 at 4:22 PM, showed Resident 1 discharged from the facility to a local hospital for a planned surgery to their lumbar spine. During an interview, on 03/18/2024 at 10:30 AM, Staff D, RN-Wound Nurse, stated it was the facility process to implement air mattresses for pressure reduction once a resident's skin impairment opened, and they did not use air mattresses as a preventative intervention. Staff D stated Resident 1 had a higher risk for skin breakdown due to their diagnoses of pain and immobility. When asked if different interventions were used for pressure injury prevention for Resident 1 due to their identified high risk for skin breakdown, Staff D stated the facility's standard interventions for pressure injury prevention were implemented and utilized an air mattress once Resident 1's pressure injury was identified. During an interview, on 03/18/2024 at 2:03 PM, Staff E, Licensed Practical Nurse (LPN), stated they completed the skin assessment on 02/03/2024 documenting a blister to the coccyx area. Staff E stated Resident 1 frequently refused to be repositioned while in bed due to pain in their lower back and right hip. When asked if Resident 1's refusals for repositioning made them an increased risk for skin breakdown, Staff E stated, Yea, I guess. Staff E stated they were not able to determine if Resident 1's skin impairments were pressure-related as it was the facility's process to have the wound management nurse and/or a Wound Consultant classify it. Staff E stated they applied a protective dressing, but was not able to put pressure relieving equipment, such as an air mattress, in place. Staff E stated this type of equipment could only be accessed during the week by management nurses. < Resident 3> Review of Resident 3's medical record showed they admitted to the facility on [DATE], with diagnoses of heart failure, immunodeficiency (a failure of the immune system to protect the body from infection), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the comprehensive assessment, dated 03/10/2024, showed Resident 3 required supervision or touching assistance for transfers, utilized a walker and wheelchair for mobility, and was cognitively intact. Review of the admission PN, dated 03/07/2024, showed Resident 3 had a pressure injury to their sacrum. No other description of the pressure injury was documented. Review of the nursing PN, dated 03/14/2024 at 10:40 AM, showed a skin assessment was completed and a Stage 4 pressure injury, measuring 2.5 cm by 1.8 cm by 0.3 cm, was observed to Resident 3's sacrum. During an interview, on 03/18/2024 at 11:45 AM, the Resident 3 stated they were aware they had a pressure injury to their sacral area and had acquired it while in the hospital prior to admitting to the facility. Additionally, Resident 3 stated they had just received a new air mattress today (11 days after admission) to help heal their backside. During an interview, on 03/18/2024 at 12:10 PM, Staff F, Maintenance Director, stated they placed air mattresses for residents when staff members placed work orders in the computer system. Staff F stated once they received the order for the mattress, they retrieved it from the facility supply, air it up to ensure there were no leaks to the mattress, and then placed it on the bed for the resident. Additionally, they stated the nurses were responsible for the settings of the mattress. During the same interview, Staff F stated they had an on-call phone number posted at the front office and the nurse's station for maintenance needs after hours and on weekends. Staff F stated they were on call for the weekends but had not received any calls. During an interview, on 03/18/2024 at 11:15 AM, Staff C, stated it was the facility process to use air mattresses for residents who have skin breakdown. Staff C stated the facility was aware of Resident 3's pressure injury prior to admission, and they should have had an air mattress on their first day. Staff C further stated that there was no way to determine if Resident 3's pressure injury had worsened or improved since there were no wound measurements available from admission for comparison. During an interview, on 03/18/2024 at 3:05 PM, Staff A, Administrator, stated the expectation regarding pressure injury prevention and treatment was to follow the facility's policy. During an interview, on 03/28/2024 at 11:10 AM, Staff C, RN-Resident Care Manager, stated Resident 1's wound culture results returned on 02/14/2024 showing a current infection, and an order was received to start antibiotic (medication that fights bacterial infections) treatment. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with standards of practice regarding thorough/accurate assessments, obtaining a medical evaluation, and implementing preventative measures to prevent the development or worsening of pressure injuries for 3 of 6 sampled residents (Residents 42, 45, and 15), reviewed for pressure injuries. This deficient practice resulted in actual harm to Resident 42 when avoidable, facility acquired pressure ulcers developed, and placed other residents at risk for worsening of pressure injuries, medical complications, and unmet care needs. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP), dated 2016, Pressure Ulcer (Injury) Stages included: Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. May indicate at risk persons. Stage II: Partial thickness loss of dermis (the middle layer of skin in your body) presenting as a shallow open ulcer with a red, pink wound bed. Stage III pressure injury full-thickness loss in which fatty tissue is exposed. Stage IV pressure injury full-thickness loss of skin and tissue with exposed bone and tendon. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown material in the wound bed) and/or eschar (tan, brown or black dead tissue that sheds or falls off from the skin) in the wound bed. Review of the facility's policy titled, Skin Integrity and Wound Management, dated 02/01/2023, showed nursing staff: Will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Complete risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Perform and document skin inspections an all newly admitted /readmitted patients weekly thereafter and with any significant change of condition. Perform daily monitoring of wounds or dressings for presence of complications or declines. Implement pressure injury prevention for identified modifiable risk factors. Notify Physician to obtain orders. Review care plan and revise as indicated. <Resident 42> Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including fractured right hip and, kidney disease (damage to the kidneys that impairs the filtering of blood). The admission comprehensive assessment, dated 03/13/2023, showed the resident required extensive assistance of two people with repositioning, transferring, and activities of daily living (ADLs). Further review of the assessment showed the resident had two facility acquired unstageable pressure injuries to the right and left buttocks and was at risk for potential pressure injuries. Record review of a wound progress note by the Contracted Wound Consultant (CWC), dated 03/13/2023, showed a right buttock deep tissue injury measuring 6.0 by 7.8 by 0.1 centimeters (cm, a unit of measure) and a left buttock deep tissue injury measuring 10.8 by 12.3 cm. Additionally, the CWC documented the buttock wounds were likely due to prolonged bed pan use, and recommended to discontinue the use of the bed pan. Further review of the resident's medical record showed no documentation between admission on 03/07/2023 and the CWC's visit on 03/13/2023 regarding the right and left buttocks wounds. During an interview on 10/13/2023 at 10:58 AM, a Resident Representative (RR) stated Resident 42 was admitted to facility for physical and occupational therapy, and the only skin issue was a surgical incision to their right hip. The RR further stated in the first few days, Resident 42 was bed bound and used a bed pan which resulted in two pressure injuries, to their right and left buttocks. The RR stated CWC had informed them the pressure injuries were acquired due to prolonged sitting on the bed pan. The RR further stated staff told them that they (RR) would have to turn Resident 42 every two hours because the staff did not have time to do so. On 10/13/2023, the State Surveyor attempted to observe wound and personal cares for Resident 42, however, the resident refused stating they did not feel comfortable. Record review of the care plan focus for incontinent care, dated 03/07/2023, showed staff was to provide a bed pan per the resident's choice. An intervention, dated 03/14/2023, staff were to line the bed pan with briefs to reduce pressure to buttocks. Record review of the care plan focus for actual skin impairment, dated 04/11/2023 (29 days after pressure injuries were found) showed the intervention of no bed pan use due to skin breakdown. Both care plans and their interventions were in place and active at time of review, showing different directives to staff for Resident 42's bed pan use. During an interview on 10/16/2023 at 7:24 PM, the CWC stated they had assessed the pressure areas on Resident 42 and noted that the wounds were the shape of the bed pan. The CWC further stated anything can cause a pressure injury if a person laid on it long enough. During an interview on 10/17/2023 at 12:29 PM, Staff O, Nursing Assistant (NA), stated they could not recall specific orders for the use of the bed pan for skin issues. During an interview on 10/18/2023 at 9:27 AM, Staff D, Treatment Nurse (TN), stated the prolonged use of the bed pan was the cause of the left and right buttock pressure injuries. Staff D further stated the minute the CWC observed and evaluated the wounds, they immediately knew it was caused from the bed pan because it was the exact shape of the bedpan. During an interview on 10/18/2023 at 8:34 AM, Staff B, Director of Nursing Services (DNS), stated that Resident 42's wounds to their right and left buttocks was from sitting on the bed pan for an extended period. Staff B further stated it was their expectation that residents should not sit on the bed pan longer than 15 minutes and that the correct process was not followed. <Resident 45> Review of the medical record showed the Resident 45 was admitted to the facility on [DATE] with diagnoses including right humerus (the largest bone of the arm) fracture, stroke, and dementia. The 08/28/2023 admission comprehensive assessment showed the resident required the extensive assistance of two people with repositioning, transferring, ADLs and had moderately impaired cognition. The assessment showed the resident had no skin issues and was at risk for pressure ulcers. Record review of the admission skin assessment progress note, dated 08/24/2023, showed Resident 45 was admitted with redness to their coccyx (tailbone). Record review of the physician's encounters dated 08/24/2023, 08/30/2023, and 09/01/2023, showed skin to be warm, dry, and intact. Record review of the August 2023 Treatment Administration Record (TAR) showed no orders to monitor the redness to the coccyx. Review of the September 2023 TAR showed an order, dated 09/01/2023, for barrier cream to coccyx every shift for skin breakdown prevention related to their incontinence and decreased mobility. Record review of the progress note, dated 09/07/2023, showed sheering (occurs when forces moving in opposite directions are applied to tissues in the body) to left buttock near the upper coccyx that was dime-sized and skin around the area was intact. The September 2023 TAR showed no orders related to sheering. Record review of the skin care plan, dated 09/07/2023, showed interventions initiated on 09/25/2023 for Resident 45 to be turned and repositioned every two hours and to apply barrier cream to the buttocks with each cleansing. Review of the CWC's progress note, dated 09/11/2023, showed a coccyx (tailbone) unstageable pressure injury measuring 5.0 by 8.0 by 0.1 cm at the wound base with eschar (dead tissue that forms over healthy skin) no slough (dead tissue that needs to be removed from the wound for healing to take place.) Further review of the progress note showed a recommendation for a Low Air Loss (LAL) mattress for more aggressive offloading due to wounds. Review of physician's orders, dated 10/03/2023, showed a LAL mattress was ordered (22 days after the CWC's recommendation). Record review of a skin assessment, dated 09/14/2023, showed nursing was still documenting only sheering to the left buttocks, near the upper coccyx that was dime-sized and the skin around the area was intact after the CWC assessed Resident 45 to have the coccyx unstageable pressure injury three days prior. Review of the change in condition evaluation form, dated 09/20/2023, showed notification to the physician of the skin issue, nine days after Resident 45 was assessed by the CWC . During an interview on 10/18/2023 at 8:41 AM, Contracted Physician Assistant-Certified (CPA-C) stated the change in condition evaluation form was how the providers get notified of any changes in condition, and that the CPA-C reviewed the forms daily. The CPA-C stated they were not sure when they were notified of Resident 45's change in condition and their expectation was to be notified within 24 hours, and for interventions to be placed immediately to prevent worsening of skin issues. During an interview on 10/18/2023 at 11:08 AM, Staff D stated their expectation was for the admitting nurse to place an order for any skin issues on the TAR. Staff D further stated that the correct process was not followed by the admitting nurse for Resident 45. During an interview on 10/18/2023 at 10:05 AM, Staff LL, Registered Nurse (RN), stated on admission, there was only redness to Resident 45's coccyx and they did not put an order to monitor the area on the TAR. Staff LL further stated that they did not follow the correct process. During an interview on 10/18/2023 at 2:25 PM, Staff B stated their expectations for the admitting nurse would be to have placed a specialty mattress right away and notified them that Resident 45 had compromised skin. Staff B further stated that an order to monitor the redness to coccyx should have been put in on the admitted . Additionally, Staff B stated that the correct process was not followed by the admitting nurse. <Resident 15> Review of Resident 15's medical record showed the resident admitted on [DATE] with diabetic neuropathy (nerve damage due to chronically high levels of glucose, or sugar, in the blood), and depression. The admission comprehensive assessment, dated 07/24/2023, showed the resident had moderately impaired cognition, required limited staff assistance with bed mobility, transfers, walking, dressing, and two person staff assistance with their toileting needs. The assessment showed Resident 15 had no wounds or skin issues on admission and was assessed to not have any risk for pressure ulcers or injuries. A concurrent observation and interview, on 10/11/2023 at 12:36 PM, showed Resident 15 was sitting in their wheelchair (w/c) with both feet wrapped with white gauze that extended from the heel to the ankle. Both feet were extended out in front with toes pointed to the ceiling and the heels resting on the floor. The resident stated they had ulcers on the back of both of their heels that they acquired while wearing crocs (a type of slip-on sandal shoe, with an open back and a strap, made of foam) shoes. The resident further stated they had worn their shoes while lying in bed, with their heels resting on the back strap of the shoe and caused the ulcers. Resident 15 further stated I have diabetic neuropathy, so I don't have any feeling in my feet. Review of nursing progress notes, dated 08/10/2023, showed the resident was noted to have DTI [Deep Tissue Injury: A pressure-related injury to subcutaneous tissues under intact skin] purplish/red to the back of Resident 15's right heel, and a DTI to the back of the left heel w/drainage and increased swelling. The note further showed the resident can't feel [Resident 15] feet too well and the straps from their current shoes were rubbing on the heels from resident self-propelling in their w/c. The note also showed the CWC would see the resident on 08/14/2023. A 08/14/2023 progress note showed the resident would wear prevalon boots (cushioned boots that keep the heel floated off the mattress, relieving pressure and reducing bedsores) while in bed to off load pressure. Review of a wound note, dated 08/14/2023, showed the CWC diagnosed the ulcers as diabetic foot ulcers, and ordered protective dressings three times a week and as needed (PRN), appropriate footwear while in bed and ambulating, offloading [minimizing or removing weight placed on the foot to help prevent and heal ulcers] of the heels, and to wear prevalon boots while in bed or the recliner. Additional notes showed: a note on 09/11/2023 showed the CWC ordered tubigrip compression wraps (a multi-purpose support bandage that adjusts to the contours of the body and distributes pressure evenly over the surface) to be worn 23 hours a day with one hour of off time. a note on 09/18/2023, showed the resident was to be non-weight bearing to their left heel until their ulcer resolved. Staff reported the resident had been resting their feet on the footboard and after the CWC inspected the bed, the CWC recommended footboard extenders be added to the bed. The left ulcer had increased necrotic (the death of cells or tissue through disease or injury) tissue, exudate, and wound breakdown. The CWC ordered an antibacterial honey gel to be applied to the wound bed and changed the dressing changes from three days a week to daily and as needed. a note on 09/25/2023, showed the resident experienced unrelenting pain to their left lower extremity (LLE) and sent to the hospital for a possible blood clot. a note on 10/09/2023, showed the resident readmitted from the hospital on 10/02/2023 and was treated for an LLE infection. The note further showed the resident's left heel ulcer had exposed and displaced hardware from past surgery history and was seen by an orthopedic (focuses on treating the musculoskeletal system) surgeon while in the hospital with a follow up scheduled. CWC ordered continue ortho follow up for guidance on management .protein supplements twice daily with meals until wound closure . Additionally, orders for a barrier cream to the edges of the wound bed of the left heel ulcer had been discontinued. A note on 10/16/2023, showed an urgent referral to the orthopedic surgeon was needed and no culture was obtained because an antibiotic had already been started. Review of Resident 15's care plan, dated 08/15/2023, showed additional interventions for encouraging proper footwear and to offload/float heels with the boots or pillows while in bed. The care plan showed no documentation of the compression wraps, extended footboards, nor did the care plan reflect the changes to the ulcer. There was no documentation of changes or additional interventions that had been added or implemented and no documentation of the resident's refusals or non-compliance with current interventions. The care plan further showed no focus/interventions for the diagnosis of diabetic neuropathy or that the resident had no feeling to their feet. An observation on 10/12/2023 at 10:16 AM, showed Resident 15 sitting in their recliner, both feet resting on the floor, no offloading boots, footwear, or compression wraps were observed on either foot, or the bed extender. Staff E and Staff O, both NAs, entered the room to answer the call light. Neither NA offered to offload the resident's feet while in the recliner or offer offloading boots. A concurrent observation and interview, on 10/13/2023 at 9:28 AM, showed Resident 15 sitting up in their w/c, both heels were rested on the floor, toes pointed to the ceiling. There were no offloading boots, footwear, compression wraps, or footboard extenders observed. As this surveyor was exiting the room, the resident exited at the same time and was observed to be propelling their w/c with their heels out to the smoking area. Nursing staff observed the resident but did not encourage or educate the resident on their restrictions. A concurrent observation and interview, on 10/13/2023 at 1:02 PM, showed the resident lying in bed, both feet and heels resting on the top of a stack of two pillows, the two pillows rested on the footboard of the bed. The resident's left foot and ankle had increased swelling the size of a softball. The resident stated they informed the traveling nurse of the increased swelling. Resident 15 further stated they could not sleep the night before due to the increased pain. There were no offloading boots, compression wraps, or footboard extenders observed on the resident or in the resident's room. An observation on 10/16/2023 at 7:44 AM, showed Resident 15 sitting up in their w/c, non-skid socks on both feet, and both feet were resting on the floor. There was no footwear or compression wraps observed on the resident. Resident 15 stated they continued with increased pain and swelling to the LLE. A concurrent observation and interview, on 10/16/2023 at 9:08 AM, showed during wound rounds, the CWC observed the resident's LLE to have increased redness, pain, and swelling from their previous assessment. The resident had swelling and redness from the heel to above the ankle. The resident complained of pain from their knee down to the heel. There was an open ulcer, the size of a 50-cent piece to the back of the heel, with a dark green area where the CWC showed the hardware was protruding outward. The CWC stated the staff informed them an antibiotic had been started due to the increased swelling and redness. During the dressing change, Resident 15 was observed to have two new ulcers on the outer lateral part of the left foot, one in the middle, measuring 1.8 centimeters (cm, a unit of measure) x 1.9 cm and on the bony prominence below the small toe, a 0.9 CM x 0.9 cm blackened, crusted looking ulcer. Review of Resident 15's October 2023 Medical Administration Record (MAR), showed as of 10/18/2023 no order for antibiotics had been ordered or initiated. A follow-up interview on 10/16/2023 at 7:15 PM, the CWC stated they read notes in the hospital discharge documentation that showed the hospital had determined the left ulcer had hardware burrowing through their skin and the resident had been seen by the orthopedic surgeon while in the hospital with a follow-up scheduled. The CWC further stated they communicated with Staff D the need for the follow up with the orthopedic surgeon on the 10/09/2023 visit and thought it had been scheduled prior to today's visit. Review of the hospital discharge documentations, dated 10/02/2023, showed the resident had broken their left ankle years ago and hardware remains in place. The note further showed the resident was treated for a LLE infection. The notes showed no mention of an orthopedic surgeon consult, no mention of exposed hardware protruding or burrowing through the skin, and no follow-up had been scheduled. During an interview on 10/17/2023 at 12:11 PM, Staff D stated they were solely responsible for ensuring new or changed orders and recommendations from the CWC were initiated and completed after each visit. Staff D stated on days the CWC comes in, they are scheduled for 6 hours and that was not enough time to complete all the orders and recommendations and at times could take up to two days. Staff D further stated the footboard extenders and compression wraps must have been overlooked. Staff D stated they had not notified the provider of the resident's non-compliance with the offloading boots, nor had the resident been assessed for additional interventions due to that non-compliance. During an interview on 10/17/2023 at 3:00 PM, Staff F, Certified Dietician (CD), stated they reviewed the CWC's recommendation for increasing the protein supplement but decided against it because the literature didn't support the use of protein for healing diabetic foot ulcers. Staff F stated they did not document that decision, nor did they communicate it to the CWC. Review of Resident 15's September 2023 TAR showed, no new orders for the left heel ulcer had been started on 09/18/2023 for daily dressing changes and the antibacterial honey gel. The CWC's new orders were not initiated until 09/20/2023, and the first dressing change didn't get done until 09/21/2023. The resident missed two daily dressing changes and two days without the new antibacterial gel. Further review of the October 2023 TAR showed, the CWC's orders to discontinue the barrier cream to the wound bed edges was not initiated until 10/12/2023. Resident 15 received the barrier cream on 10/10/2023 and twice on 10/11/2023, once on the day shift and again on the evening shift. Review of the physician orders for September 2023, showed no new orders for the footboard bed extenders or the compression wraps and showed no new order for the twice a day protein supplement with meals. Review of the skilled nursing progress notes showed Staff G, Licensed Practical Nurse, documented on 10/11/2023 and 10/14/2023, showed the resident had redness and swelling to the left lower extremity (LLE) with no documented intervention or notification to the provider. An observation on 10/18/2023 at 9:56 AM, showed Resident 15 lying in bed, both feet are lying in the offloading boots. Boots are not closed, but they are on. During an interview, on 10/18/2023 at 10:02 AM, Staff G stated their documentation of Resident 15's LLE redness and swelling was thought to be left over from their infection from the hospital so wasn't sure if it was new or old so I didn't report it to the provider. Staff G further stated the staff don't always know Resident 15's actions and they will put themself into bed without the staff knowing and education is attempted but the resident is non-compliant. Staff G further stated they had not discussed risks and benefits of being non-compliant with their treatment nor had they notified the provider of the non-compliance. Staff G further stated Resident 15 will comply to recommendations if reminded and encouraged to do so. Staff G stated the resident had them on today and that made them happy. During an interview on 10/18/2023 at 2:22 PM, Staff EE, NA, stated Resident 15 will normally follow directions if they are encouraged and educated and will allow you to float their heels correctly. During an interview on 10/18/2023 at 8:26 AM, the CPA-C stated they were not notified the resident had surgical hardware protruding out of their heel ulcer, nor were they informed the resident had complained of increased pain, redness, or swelling to the LLE since 10/11/2023. The CPA-C stated they would have expected the nursing staff to notify them of any changes to the resident, whether it was old or new, and allowed them the ability to assess and make that determination, not just ignore it. The CPA-C further stated they had not had any visits with Resident 15 since the week prior so no antibiotics could have been started. The CPA-C further stated they did not communicate that information to the CWC and does not know where the CWC would have gotten that information. The CPA-C continued to say they were not notified Resident 15 needed a referral to the orthopedic surgeon and had not ordered one since readmission. The CPA-C further stated they had not made any further assessments or recommendations other than therapy for the resident's non-compliance with interventions. The CPA-C further stated, based off the information given of how the heel ulcers were acquired, their assessment would lean more to the ulcers being caused by pressure. Lastly, the CPA-C stated they would expect dietary recommendations made by the CWC should have been followed and did not recollect discussions with Staff F regarding the decision to not increase the protein supplement. Additional information provided by the facility on 10/20/2023, showed a provider's visit on 10/19/2023, showed Staff MM, Medical Director, assessed the resident to have ongoing left heel pressure ulcer with cellulitis .visible orthopedic hardware .left lateral foot stage II PU. Further review showed the resident had been started on an antibiotic to be taken four times a day and had been scheduled to see the orthopedic surgeon on 10/27/2023. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure restorative therapy services were implemented to prevent avoidable reduction of range of motion (ROM) and mobility for 2 of 3 sampled residents (Residents 39 and 4) reviewed for restorative therapy. This failure resulted in actual harm to Resident 39 who developed, right and left leg contractures (a condition of shortening and hardening of muscles, tendons, or other tissue that leads to muscle stiffening and loss of range of motion of the effected body part)and placed other residents at risk for contractures, decreased mobility, and pain. Findings included . Record review of the facility policy titled, Restorative Nursing, dated 08/07/2023, showed the facility will provide restorative nursing programs for residents who: .have restorative needs arise during the course of a longer-term stay . .will benefit from restorative programs .to help the patient obtain and maintain optimal physical, mental, and psychosocial functioning . Further review of the policy showed they would develop specific measurable goals and document goals and interventions on the resident's restorative care plan and document daily on the Restorative Nursing record. <Resident 39> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including stroke, dysphagia (difficult swallowing), and rheumatoid arthritis. The 09/30/2023 comprehensive assessment showed the resident required extensive assistance of two persons with repositioning, transferring, and activities of daily living (ADL's). The resident was assessed to have moderately impaired cognition, with range of motion (ROM) impairment to only left side of upper extremity (UE) and lower extremities (LE). The assessment further showed that they did not have any restorative programs or skilled therapies during the assessment period. A comprehensive annual assessment, dated 07/01/2023, showed no restorative programs or skilled therapies during that assessment period. Record review from a hospital stay, showed a physical therapy note dated 08/04/2022, that documented the resident was able to perform squat/pivot transfers with two-person extensive assistance with the improvement of their neurologic status and left side mobility and strength. There were no documented contractures in the therapy evaluation. Record review of the Occupational Therapy (OT) admission evaluation, dated 08/10/2022, showed that Resident 39 was able to go from a lying to a sitting position with assistance and from a sitting to lying position with assistance. No transfers or ambulation was attempted on admit. Further review of the record showed no contractures. Record review of the Physical Therapy (PT) admission evaluation, dated 08/10/2022, showed that Resident 39's right and left lower leg, hip and knee were able to contract and provide resistance and no documented contractures. Record review of the PT recertification, dated 09/09/2022 to 10/08/2022, showed that Resident 39 was able to lower their legs off of the edge of the bed with cueing and no documented contractures. Record review of the PT recertification, dated 10/6/2022 to 11/04/2022, showed that Resident 39 was able to lower their legs off the edge of the bed independently and was able to stand in the standing frame (an assistive device that supports the resident in a standing position). Further review showed no documented contractures. Record review of the PT recertification, dated 11/05/2022 to 12/04/2022, showed that resident 39 was able to ambulate with a front wheeled walker (FWW) with assistance up to 45 feet and no documented contractures. Record review of the PT recertification, dated 11/17/2022 to 01/16/2023, showed that resident 39 had a decrease in physical function after prolonged sitting in their wheel chair for an out of town appointment but progressed and was able to ambulate with a FWW up to 10 feet and no documented contractures. Record review of the PT recertification, dated 01/16/2023 to 3/18/2023, showed that resident 39 had a decline in function during this time period going from stand and pivot transfers to a hoyer lift (a device that allow a person to be lifted and transferred with a minimum of physical effort) and no documented contractures. Record review of the PT recertification dated 02/24/2023 to 03/25/2023, showed that resident had bi lateral (both sides) hip and knee contractures with a change in plan of care to focus on contracture management. Record review of the Functional Maintenance Transition Plan (FMP, a program to help resident's maintain the functionality, strength and independence they gained during their skilled therapy) dated 03/10/2023, showed a program was written for active range of motion and positioning with a goal to reduce the risk of bilateral lower extremity contractures. Further record review showed no FMP for the nursing assistants to perform restorative therapy services was active in the resident's medical record. Record review of the PT discharge summary, dated 05/25/2023, showed a discharge diagnosis of bilateral knee/hip contractures. Record review of Resident 39's care directives to staff in their medical record on 10/13/2023 showed no active FMP in place. Observations on 10/10/2023 at 11:53 AM, and 12:49 PM and on 10/11/2023 at 10:32 AM and 11:43 AM showed Resident 39 in bed, lying on their back rolled over on their left shoulder, and their neck contracted to the left . Resident 39's right leg was bent at the knee upward and externally rotated outward with their ankle touching outer thigh. Resident 39's left leg was bent at the knee upward with their ankle touching their outer thigh. Resident 39 was in the same position during each observation. During an interview on 10/12/2023 at 12:24 PM, Staff E, Staffing Coordinator/Nursing Assistant (SC/NA), stated that they did not have active restorative services only the FMP program. Staff E further stated that Resident 39 did not have an FMP program and they were not sure why. During an interview on 10/17/2023 at 11:20 AM, Staff, PP, Occupational Therapist, stated that Resident 39 should have been on an upper extremity FMP and the resident's neck contracture caused limitations that limited movement of their head and neck from left to right prohibiting full ROM. Staff PP stated this was new since they had last seen them. Staff PP further stated that unless someone reported to them there was a decline in functioning, they would not do an evaluation, and no one had reported anything about the neck limitations. Additionally, Staff PP stated that if Resident 39 had been on an FMP, their neck would not of had a decline in function and their expectations would be for Resident 39 to be on a ROM program daily to maintain their functioning. During an interview on 10/17/2023 at 2:53 PM, Staff L, Physical Therapist Assistant (PTA), stated that they called the original PT who completed Resident 39's assessment and they clarified there were no contractures documented on admission. Staff L further stated they noticed a higher increase in tone (tension in a relaxed muscle) to Resident 39's right and left leg in December 2023. Staff L stated, When the resident stood up, [they were] not able to put [their] right foot all the way down. Staff L stated that they increased Resident 39's exercises specifically for the contractures that were forming in the right knee. Additionally, Staff L stated that the last FMP program was initiated on 05/19/2023 and that they did not cancel it and was unsure as to why it was cancelled. Staff L stated it was their expectation that staff would go through therapy to cancel any FMP. During an interview on 10/17/2023 at 4:38 PM, Staff B, Director of Nursing Services (DNS), stated that their expectation was that any resident who would benefit from restorative therapy services, or who was showing any sort of decline, be evaluated by the DNS or the minimum data set nurse (MDS, a standardized assessment tool that measures health status in nursing home residents ) and have an FMP implemented. Staff B further stated that they had to maintain the resident's highest level of functioning and that was not done for Resident 39. Additionally, Staff B stated that Resident 39 should have had an FMP in place for their contractures and that they did not have a proper process in place. During an interview on 10/17/2023 at 5:23 PM, Staff C, Resident Care Manger/MDS Coordinator stated that they usually kept a good eye out for functional decline but during this time (February 2023 and March 2023) they had to work the floor due to short staffing. Staff C further stated that the correct process would have been to monitor Resident 39 for a significant change and have an FMP in place and that they did not follow the correct process. <Resident 4> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including parkinsons (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) peripheral neuropathy (when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged causing weakness, numbness and pain.)The 06/27/2023 comprehensive assessment showed the resident required extensive assistance of two persons with repositioning, transferring, and activities of daily living (ADL's). The resident was assessed to have intact cognition. Observation on 10/10/2023 at 12:05 PM, showed Resident 4's fingers curled inward towards the palm of their hand at the second knuckles. Record review of Resident 4's medical record, dated 06/21/2023, showed Resident 4 was diagnosed with left and right hand contractures. Record review of OT consultation, dated 07/18/2023, showed Resident 4 had contractures to both hands and that they made consistent progress towards goals. Resident 4 received those therapy services three times a day between 07/18/2023 and 08/16/2023. During an interview on 10/13/2023 at 9:02 AM, Resident 4 said they used to get therapy for their hands and then therapy showed the NA's how to do it. Resident 4 said they can't remember the last time a NA did the hand exercises with them. Resident 4 stated that their fingers were getting worse since therapy stopped. Record review of Resident 4's FMP dated 08/02/2023, showed staff to perform ROM exercises. The bottom of this document showed three NAs signed and dated that they were trained to perform these duties. Record review of NA Charting for Resident 4's ROM exercises, dated 09/18/2023 through 10/17/2023, showed to perform ROM exercises one time a day and as needed. There was no charting for 22 days over this 30 day look back period. During an interview on 10/13/23 at 9:08 AM and at 12:06 PM Staff M, NA, stated that Resident 4 was unable to do things with their fingers. Staff M stated that Resident 4 had a splint and needed to have finger exercises done for their contractures. Staff M stated that the PTA trained them on how to do the exercises and put the brace on. Staff M stated that these things were not being done because they did not have enough time on their shift to do it. During an interview on 10/17/2023 11:11 AM, Staff N, Licensed Practical Nurse (LPN), stated that Resident 4 had some ROM decline. Staff N stated that Resident 4's FMP was not being done because the NAs did not have time on their shifts to implement the program. During an interview on 10/12/2023 at 2:28 PM, Staff L, PTA, stated that residents received skilled therapy services and when their program was completed, they received a FMP. Staff L stated that NAs were trained to implement resident FMP'S during their work shift and chart it in their system. Staff L stated that they started this program this year and that it was an alternative to the true restorative therapy program they used to have. During an interview on 10/17/2023 at 12:55 PM, Staff B, DNS, stated that their expectation was NA's completed and charted residents FMP. Staff B stated that staffing could be a barrier and that NA's had a lot of work to do and may not have time to do the FMP's. Staff B stated that the post therapy system might need to be looked at to ensure those programs were being implemented. During an interview on 10/18/2023 at 1:35 PM, Staff A, Administrator, stated that they did not have a Restorative Therapy Aide and moved to the FMP. Staff A stated that they have not conducted an audit to see if the system was working. Staff A stated that not having enough staff on the floor would impact residents with high acuity needs leading towards a decline in some residents. Reference: WAC 338-97-1060 (3)(d) 39314

Based on observation, interviews, and record review the facility failed to ensure the prevention and the development of facility-acquired pressure ulcers for two of five residents (1 and 2) reviewed for pressure ulcers. This failure placed residents at risk for a decreased quality of life and caused actual harm to resident 1 who developed an avoidable pressure ulcer that was not present upon admission. Findings included . Review of the National Pressure Ulcer Advisory Panel's (NPUAP) definitions showed: Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar .If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister . Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location . Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Review of the facility's 09/01/2022 policy, Skin Integrity and Wound Management, showed the practice standards were to complete a risk evaluation on admission/re-admission, weekly for the first month, quarterly, and with significant change in condition .the licensed nurse will perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter .implement pressure injury prevention for identified, modifiable risk factors .Notify Dietitian. Resident 1. Review of the resident's admission record showed the resident admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a progressive disorder that affects the parts of the body controlled by the nerves), failure to thrive (failure to grow or develop well or vigorously), severe protein malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), and diabetes (a disorder in which the body has high sugar levels for prolonged periods of time). Further review showed the resident had no redness, maceration, or skin breakdown, had dry and scaly skin, had the lack of ability to feel pain in one or both extremities, and was six feet tall. Review of the resident's comprehensive assessment, dated 08/05/2022, showed the resident's cognition was intact, required extensive one person assistance with bed mobility, toilet use, and personal hygiene. The resident was incontinent of bowel and bladder, and had no skin issues. The assessment further showed the resident was not at risk for pressure ulcers. Review of a 08/10/2022 Braden Scale (a tool used to predict pressure ulcer risk) assessment, showed the resident was at mild risk for pressure ulcers. Braden scale assessments on 08/17/2022 and 08/24/2022 also showed the resident was at mild risk for pressure ulcers. The record showed no assessment had been completed on 08/31/2022. Review of the Podiatrist notes on 08/30/2022, showed the resident had been seen for foot care due to increased risk status, and determined there were findings for decreased vascularization (the formation of blood cells). Review of Physician orders for November 2022, showed a 09/06/2022 order for Prevalon boots [a boot with a cushioned bottom that floats the heel off the surface of the mattress] on at all times in bed, and an 08/24/2022 order for a Low Loss Air mattress (LAL, a mattress designed to help treat and prevent pressure ulcers). An observation on 11/04/2022 at 11:45 AM, showed the resident lying in bed, head elevated, and both feet resting, flat footed, against the foot board of the bed. The resident's heels were not floated (heels are suspended in the air) and there were no Prevalon boots on the resident's feet. The resident stated, I am too tall for this bed, and my feet are always touching the bottom of the bed. The resident was observed to have a gauze dressing around their left foot. The resident stated they had a sore to their foot and had been in the same position since breakfast. Review of the facility's September 2022 Incident Reporting log showed the resident developed a facility-acquired pressure ulcer to their left heel on 09/06/2022. An observation of wound care on 11/04/2022 at 3:49 PM, showed Staff I, Licensed Practical Nurse (LPN), removed the resident's left boot, then the gauze dressing from their left foot, the gauze was not covering the wound itself, leaving the wound exposed while it was in the boot. There was an opened area the size of a fifty-cent piece, with a nickel sized area of black eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like), and maceration (soften or become softened by soaking in a liquid). The peri-wound had brown drainage to the top of the wound, and yellow slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) to the lateral part of the outer wound. There was another dime sized pressure ulcer to the lateral aspect of the foot that appeared macerated, and the resident's skin was extremely dry, and flaked off when the Nursing Assistant (NA) elevated the foot in the air. When applying the absorbent pad to the wound, the corner folded over in a triangle shape over the wound. Staff I did not straighten out the dressing before applying the gauze dressing. The resident's foot was then floated on a pillow and a new Prevalon boot obtained due to the drainage from the wound prior to the dressing change. An observation and concurrent interview on 11/09/2022 at 12:56 PM, showed Resident 1 lying in bed, feet resting flat against the footboard of the bed, head slightly elevated, and there were no Prevalon boots on or heels floated. Resident was observed grimacing and low sounding moans. The resident stated they had pain to their left foot and had just been given pain medication. The resident further stated the facility extended the foot of their bed to give them a little more room, but it didn't really help because they slid down all the time. An observation and concurrent interview on 11/09/2022 at 5:08 PM, showed the resident was in the same position as they previously were at 12:56 PM and stated they had not moved off of their back all day. An observation on 11/10/2022 at 9:29 AM, showed Resident 1 was lying in their bed, head at 30 degrees with the resident's body a quarter of the way down the bed from the head being elevated. The resident's heels were not floated, and their booted feet were touching the footboard of the bed. Follow-up at 10:26 AM showed the resident in the same position as they were at 9:29 AM. During an interview on 11/10/2022 at 11:38 AM, Staff F, Maintenance Supervisor (MS), stated they extended Resident 1's bed out as far as it could, go, but there were longer beds available, bariatric (treatment in the area of obesity) beds that can be used to give more length. Review of the resident's 08/03/2022 care plan showed an intervention added on 08/03/2022 to conduct a comprehensive skin inspection weekly due to diabetes diagnosis, on 09/06/2022 a low loss air mattress, and Prevalon boots while in bed. Review of the resident's weekly skin assessments showed no skin assessments had been completed during the first four weeks after admission. On the fifth week after admission, after the pressure ulcer had been discovered, showed a skin assessment, dated 09/07/2022. The assessment showed the resident had dermatitis (a skin condition characterized by a red, itchy, dry rash) to their buttocks, a DTPI to the left heel (acquired 09/05/2022), and a DTPI to the tailbone (acquired on 08/22/2022.) Review of the NA tasks showed the resident had tasks in the Electronic Health Record (EHR) for preventative skin care every shift as follows: 1. Heel protectors applied? 2. Lotion or cream applied? 3. pressure relieving device in place for bed and chair? 4. Did you turn the resident according to plan of care? Review of the August 2022 tasks showed staff failed to document care was provided for 50-51 out of 87-88 shifts. Review of the September 2022 tasks showed staff failed to document care was provided for 62-64 out of 90 shifts. Review of the October 2022 tasks showed staff failed to document care was provided for 73-74 out of 93 shifts. During an interview on 11/10/2022 at 9:35 AM, Staff D, Nursing Assistant Registered (NAR), stated they try to turn [resident 1] every two hours, but the ones [residents] that are 'heavier care' don't get moved as often because we get too busy and don't have enough time. Staff D further stated they were a newer NA and new to Resident 1's care and wasn't sure how often they should be turned, specifically, with a wound. During an interview on 11/10/2022 at 9:47 AM, Staff H, NA, stated they turned and repositioned Resident 1 every two hours, and floated their heels on pillows. Staff H stated they documented what they completed in the EHR and if there isn't documentation, it's because they [the resident] refused, or we [NA's] didn't do it. Staff H further stated there was an area in their charting for refusals and they would document a refusal there. Staff H further stated they were assigned to Resident 1 but had not repositioned them because they had been in a meeting. Review of the resident's 09/06/2022 nutrition assessment, showed no wounds had been identified and no interventions had been implemented. Review of the wound note on 09/12/2022, Staff E, Wound Consultant (WC), documented Resident 1 was treated for an unstageable pressure ulcer to left heel 4 cm by 3 cm by 0 cm. Review of the wound note on 10/17/2022, showed Staff E debrided (a procedure to remove debris or infected/dead tissue from a wound) the left heel, and the heel was now classified as a Stage 3 pressure ulcer. The note further showed the resident had decreased perfusion (the passage of blood, a blood substitute, or other fluid through the blood vessels or other natural channels in an organ or tissue) to the left lower extremity and ordered the resident to have an urgent vascular referral to rule out a blockage or peripheral artery disease (PAD, the narrowing or blockage of the vessels that carry blood from the heart to the legs). Review of the 10/25/2022 and 11/07/2022 wound notes showed the urgent vascular referral had still been pending. During an interview on 11/10/2022 at 4:09 PM, Staff E stated it was extremely important to follow the interventions put into place (eg. Prevalon boots) and to turn and reposition residents with wounds even if they were utilizing a LAL mattress, or any other kind of alternating air mattress. Staff E further stated they did not know what was holding up the referral for Resident 1, and just assumed it was difficult to get an appointment. During an interview on 11/14/2022 at 3:39 PM, Staff C, Resident Care Manager (RCM), stated they could not recall an urgent vascular referral had been ordered for Resident 1. Staff C stated their understanding was skin assessments were to be completed weekly and are also dependent on the wound, which could be more often and Braden scale assessments were to be completed on admission, quarterly, and with a change of condition. Staff C further stated they were aware there were gaps in the task documentation but they are slowly getting tighter. During a follow-up interview on 11/17/2022 at 2:26 PM, Staff C stated they had faxed the referral to the provider on 11/16/2022, the vascular provider then requested another study be completed prior to them seeing the resident. When the surveyor asked about the referral being sent prior to 11/16/2022, Staff C stated that the referral had been initially faxed on 10/25/2022 (8 days after the urgent request) through their computer system but did not have a confirmation or documentation that the fax had been sent or was received. Resident 2. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms that affects memory, thinking, and interferes with daily life) and heart failure. The comprehensive assessment, dated 08/28/2022 showed the resident's cognition was severely impaired, required extensive two person assistance with bed mobility and toilet use. The resident was incontinent of bowel and bladder, and had no skin issues. Review of the 06/13/2022 care plan showed the resident had a history of two DTPI's to their right heel, with prevention interventions of Prevalon boots while in bed, provide turning and repositioning assistance every two to three hours, off-load/float heels while in bed, and weekly skin checks by a licensed nurse. Review of Physician orders for November 2022, showed an order on 04/12/2022 for Prevalon boots on when up in WC [wheelchair] to protect footrests, and a 08/16/2022 order for a Promat mattress (alternating pressure therapy). Review of the facility's September 2022 Incident Reporting log showed the resident developed two facility-acquired pressure ulcers on 08/30/2022. One to the left heel and one to the right medial mid foot. Review of the facility's 09/01/2022 Incident Investigation Summary showed on 08/30/2022, during shift change, the resident did not have their Prevalon boots on and the resident had their feet crossed over one another. The LN assessed the resident's heel and observed two fluid filled blisters (Stage 2 pressure ulcers). One to the left inner heel that measured 3.5 centimeters (cm) by 5.5 cm, and one to the right medial mid foot that measured 3.5 cm by 3.5 cm. Review of the resident's Braden Scale assessments showed on 08/31/2022, the resident was at moderate risk for pressure ulcers, the only assessment since 02/01/2022 (seven months since previous assessment). Review of the resident's weekly skin assessment, dated 08/26/2022, showed the resident's skin was intact. The assessment further showed interventions to assist the resident turn and reposition every two to three hours, and to off-load/float their heels while in bed. Review of the NA tasks showed the resident had tasks to be completed every shift as follows: 1. Monitor the Prevalon boots were always on? 2. turn and reposition the resident every two hours? Review of the August 2022 tasks showed the staff failed to document care was provided for 62-63 out of 93 shifts. Review of the 09/01/2022 through 09/09/2022 tasks showed staff failed to document care was provided for 23 out of 26 shifts. During an interview on 11/09/2022 at 1:13 PM, Staff J, NA, stated they cannot recall when they last had education on pressure ulcer prevention. Staff J further stated when asked about missing documentation that they were taught if you don't write it down then it wasn't done. During an interview on 11/09/2022 at 5:17 PM, Staff K, NA, stated if they had missing documentation,it would be because we didn't do it, or that issue [task] wasn't addressed. During an interview on 11/10/2022 at 11:00 AM, Staff B, Director of Nursing (DON), stated they recognized there was an issue with facility-acquired pressure ulcers and they addressed those concerns during an all staff meeting the month prior but could not produce documentation to support that. Staff B stated their expectation was that LN's completed weekly skin assessments and recognized that was not being done. Staff B further stated the nursing staff had understood that when the resident was being followed by the wound consultant, the weekly skin assessments did not need to be completed, that was not the case. The wound consultant only focused on the wound assessment itself, and not the entire body. No education had been given to the nursing staff, maybe a little verbal reminder. WAC Reference: 388-97-1060 (3)(b)

Based on interview and record review the facility failed to ensure a resident's physician was immediately notified of a significant medication error and an acute change in condition for one of one resident (#1), reviewed for medication errors. This failure caused a delay in potential lifesaving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1. Per review of the medical record, the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent comprehensive assessment dated [DATE] showed she was alert and oriented and was independent in bed mobility, walking, toileting and grooming. Review of a facility incident report showed on 04/10/2021 at approximately 8:00 PM, Resident #1 was given another resident's medication in error. These medications included extended release [MEDICATION(S)] 60 milligrams (mg), a narcotic pain medication, [MEDICATION(S)] 10 mg, a muscle relaxant medication and [MEDICATION(S)] 25 mg an anti-[MEDICATION(S)] medication commonly used for itching. A common known side effect of all of these medications is drowsiness. Review of a statement written by Staff C, Registered Nurse (RN), the facility's corporate resource nurse dated 04/13/2021, stated in an interview she had with Staff A, Licensed Practical Nurse (LPN), he stated upon realization he had made the medication error, he contacted Staff B, the acting Director of Nursing (DON) for direction. He stated Staff B informed him to notify the resident's physician, her family and the resident of the error and to place her on alert charting. Further review of the statement written by Staff C showed Staff A told her he informed the resident and her family of the error but when he attempted to notify the physician, the person on the physician call line told him they would not be able to put him through to a provider until the next morning. Staff A reported that he did not follow up with reporting to anyone further that night though checked on the resident three times, took her vital signs and felt her mentation was normal. When Staff C asked if he had documented his assessments of Resident #1 that night, he stated he had not. Review of a nursing progress note dated 04/10/2021 at 8:36 PM, Staff A wrote, wrong evening medication was administered to the resident and medication error was reported to the DON, (Director of Nursing) PCP, (Primary Care Provider) and HCP. (Health Care Proxy, Resident Respresentative). During an interview with Staff B on 04/14/2021 at 4:10 PM, she stated Staff A contacted Staff B when the medication error first occurred, though Staff B was unaware that Staff A was unable to contact a provider to report the error as Staff B directed Staff A to do. Staff B stated that Staff A did not informt Staff B any further or ask any further questions the rest of the night. Staff B stated she had informed Staff A that she was concerned Resident #1 had received such a large dose of [MEDICATION(S)] and needed to be monitored closely. Staff B stated had she known Resident #1's physician had not been contacted she would have told Staff A to send the resident to the hospital for evaluation of a possible overdose of [MEDICATION(S)]. During an interview with Staff D, LPN, on 04/28/2021 at 5:20 PM, she stated she worked the day shift from 6:00 AM to 6:00 PM on 04/11/2021. She stated Staff A had reported the medication error to her when she came on duty and informed her Resident #1 had been stable through the night. Staff D stated he did not tell her a physician had not been notified of the error and she didn't question if it had been done because according to Staff A's charting in the nursing progress notes, it had stated a provider had been notified the evening before. During an interview with Staff A on 05/01/2021 at 12:30 PM, he stated he thought by calling the on call line he had attempted reporting even though he did not actually speak with a physician. He stated he monitored Resident #1 closely through the night, had spoken with her in the morning and felt she was stable and her vital signs were good when he went off shift at approximately 6:30 AM. Staff A stated he understood he should have notified Staff B when he could not get through to the physician for direction on how to proceed, and should have clarified in his nursing progress note that the physician had not been notified and should have reported this to the oncoming day shift nurse. Review of Resident #1's medical record showed she continued to steadily decline in condition and become less conscious as the day progressed on 04/11/2021. Her physician was not notified of the error and possible narcotic overdose until approximately 12:30 PM on 04/11/2021, approximately 16 hours after the error occurred. Reference (WAC) 388.97-0320(1)(a)(b)(c)

Based on interview and record review the facility failed to ensure services being provided met professional standards of care for one of three residents (#1) reviewed for quality of care. Failure to recognize the potential for harm by pre pouring medications, the severity of complications that could arise from a narcotic overdose of an elderly resident with multiple comorbidities, and provide early interventions when changes in condition were observed resulted in medical delay of potentially lifesaving treatment. Findings included . Resident #1. Per review of the medical record, the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her most recent comprehensive assessment dated [DATE] showed she was alert and oriented and independent in bed mobility, dressing, toileting and walking. During an interview with Staff A, Licensed Practical Nurse (LPN) on 05/01/2021 at 12:10 PM, he stated he worked a 12 hour shift from 6:00 PM on 04/10/2021 to 6:00 AM on 04/11/2021. Staff A stated that during his evening medication pass at approximately 8:00 PM, he prepared medications for Resident #1 and then prepared medications for a resident in the room next to Resident #1. Staff A stated he thought he put Resident #1's name on a prepared cup of medications and the other resident's name on the other cup of prepared medications. Staff A took the cup of medication with Resident #1's name on it to Resident #1 and watched the resident swallow the pills and then Staff A discarded the empty cup in a trash container in Resident #1's room. Staff A then returned to the medication cart to take the next cup of meds to the other resident and noted this cup also had Resident #1's name on it. Staff A stated he then went back into Resident #1's room and picked the medication cup he had just used out of the trash and saw it was also labeled with her name. He then verified the medications he left at the medication cart were Resident #1's and realized he had labeled both cups with Resident #1's name in error and had given the other resident's medications to Resident #1. These medications included extended release [MEDICATION(S)] 60 milligrams, (mg) a narcotic pain reliever, [MEDICATION(S)] 10 mg a muscle relaxant, [MEDICATION(S)] 25 mg an antihistamine medication used for itching and vitamin C 1000 mg. Resident #1 also received 300 mg of [MEDICATION(S)], an anticonvulsant medication, in which the resident routinely received this medication at 8:00 PM each evening with a 400 mg dose. Staff A stated he did not give Resident #1 her own medications in addition to the ones given in error that evening. Staff A stated he reported the error right away to the Director of Nursing (DON), who told him to notify Resident #1, her family and her physician right away of the large dose of [MEDICATION(S)] given for direction on how to proceed. He stated he informed Resident #1 and a resident representative and attempted to notify her physician but he was not available, so he called the on call line to speak with a physician on call and was told that no one was available to take his call until the following morning. Staff A stated he did not notify the DON that he could not reach a physician and thought he would just monitor Resident #1 closely and if he saw any changes in her condition before morning he would notify her. Staff A stated he did not know if the facility had a [MEDICATION(S)] (a medication that will rapidly reverse symptoms of a narcotic overdose) policy in place and didn't think of asking anyone if she should be sent to the hospital for monitoring and administration of [MEDICATION(S)] if needed. Staff A stated he checked in on Resident #1 three times between approximately 9:00 PM and 6:00 AM and took her vital signs twice and didn't feel she was showing any signs of distress. He stated he did not document any of these assessments in the resident's medical record. Review of a nursing progress note dated 4/10/2021 at 8:36 PM showed Staff A wrote, wrong evening medication was administered to the resident and medication error was reported to the DON (Director of Nursing), PCP (Primary Care Provider), and HCP (Health Care Proxy, a resident representative). During an interview with Staff A on 05/01/2021 at 12:10 PM, he stated he should have clarified in his progress note that he did not ever actually reach a practitioner only the on call line and should have documented his assessments that night. Staff A stated, I've been over that night a thousand times in my head and realize all the things I should have done differently. During an interview with a representative of Resident #1 on 04/14/2021 at 12:35 PM, she stated she called Resident #1 on her cell phone at approximately 8:00 AM on 04/11/2021 to see how she was feeling from the medication error and stated the resident told her she had 'just thrown up and was feeling very groggy and couldn't sit up straight. The representative said her words were slurred and she was difficult to understand. The representative stated she then called the facility and was told by Staff D, LPN that Resident #1 was stable through the night and was sleepy but arousable. The representative stated she continued to call Resident #1 multiple times throughout the day but she never picked up her cell phone which was unusual. The representative stated, she became very concerned, and called and spoke with Staff D again between 12:30 and 1:00 PM and was told Resident #1 was really out of it and difficult to wake up and the physician had been notified of the resident's condition and was not concerned at this time. The representative stated she went to the facility at approximately 2:00 PM and could not wake Resident #1 at all. The representative stated Staff D also attempted to wake Resident #1 with a sternal rub (a hard, painful rubbing to the chest wall) and Resident #1 only briefly fluttered her eyes open. The representative stated she asked that Resident #1 be sent to the hospital at that time and Staff D stated her vital signs were fine, her respirations (breaths per minute, normal being 16 to 18) were normal and the physician had said to let her sleep it off as long as her respirations were good. The representative stated Staff B then called her at approximately 7:00 PM on 04/11/2021, and told her Resident #1 could only be aroused with sternal rubs, she was having trouble breathing and her oxygen levels were dropping. In addition, she stated she was told Resident #1 was running a temperature and may have aspirated that morning when she vomited so she was being sent to the hospital and the paramedics had been called. Review of a nursing progress note, dated 04/11/2021 at 1:38 PM, Staff D wrote, reported to this LN by night nurse that resident had received another resident's narcotic in error, the resident is very sedated, responds to verbal and physical stimuli but goes right back to sleep. Vital signs are stable, no respiratory depression or shortness of breath. No eating, no getting up to go to the bathroom, had emesis (vomit) x 1 (one time) this am. Spoke with on call provider and he said if no respiratory depression and respirations are good then just monitor. No need for [MEDICATION(S)] at this time. During an interview with Staff D on 04/28/2021 at 5:20 PM, she stated she worked as day shift charge nurse on 4/11/2021 from 6:00 AM to 6:00 PM. Staff D stated Resident #1 did not wake up all day since shortly after breakfast when she vomited, and she did not eat or drink anything or get up to go to the toilet throughout her shift. Staff D stated she did not notify the resident's physician after her first call at 12:30 PM, that Resident #1 was becoming more difficult to arouse as the day progressed or that the resident's representative wanted her sent to the hospital when she was at the facility at 2:00 PM. Staff D stated she did assess Resident #1 many times throughout the day on 4/11/2021 and found her vital signs to be stable though she did not document her assessments in Resident #1's medical record until the next day in a late entry dated 04/12/2021 at 5:07 PM. During an interview with Staff B on 04/14/2021 at 4:10 PM, she stated she came on duty at 6:00 PM on 04/11/2021 and checked on Resident #1's status related to the medication error that happened the previous night. Staff B stated she found Resident #1 was only arousable with sternal rubs and only opened her eyes for a couple of seconds at a time. Staff B stated further examination showed Resident #1's breathing was wheezy sounding, her oxygen satuation levels were decreased and she had a temperature of 100.3 Fahrenheit (F). Staff B stated she notified Resident #1's physician and family of her condition and requested immediate transfer to the hospital. The paramedics were called for transport and arrived at the facility at approximately 7:30 PM. Review of the hospital emergency room (ER) records showed that Resident #1 was brought into the ER after she was given 60 mg. of extended release [MEDICATION(S)] the previous evening per a medication error. Per the paramedics report the resident was unresponsive on arrival at the nursing home and she was given 0.8 mg. of [MEDICATION(S)] at which time she did become responsive and was answering questions appropriately. During an interview with a representative of Resident #1 on 04/20/2021 at 8:10 AM, she stated Resident #1 remained hospitalized without ever fully regaining consciousness and she passed away on 04/18/2021 at 7:20 PM. Reference (WAC) 388-97-1620(2)(a)(b)(ii)

Based on interview and record review the facility failed to ensure one of one resident, (#1) was free of significant medication errors. This failure resulted in the resident's a decline in condition, requiring emergency care and hospitalization and subsequent death. Findings included . Resident #1. Per review of the medical record, the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent comprehensive assessment, dated 03/17/2021, showed Resident #1 was cognitively intact and was independent in her activities of daily living. Review of a facility incident report showed on 04/10/2021 at approximately 8:00 PM, Resident #1 was given another resident's medication in error. These medications included extended release [MEDICATION(S)] 60 milligrams (mg), a narcotic pain medication, [MEDICATION(S)] 10 mg, a muscle relaxant medication and [MEDICATION(S)] 25 mg an antihistamine medication used for itching and relaxation. Review of a statement written by Staff A, Licensed Practical Nurse (LPN) dated 04/11/2021, he stated he had pre-poured medication to administer to Resident #1 and also for a resident in the room next to her and accidentally labeled both medication cups with Resident #1's name on them. Staff A stated he realized his error after returning to the medication cart and seeing Resident #1's name also on the other cup which contained her correct medications. Review of a statement written by Staff C, Registered Nurse (RN), the facility's corporate resource nurse dated 04/13/2021, stated education was provided to Staff A regarding pre-pouring medications, the importance of following proper medication pass protocols and on the severity of consequences that can occur with medication errors. During an interview with Staff A on 05/01/2021 at 12:10 PM, he stated he took full accountability for the error, had received training in nursing school on safe medication administration and understood he did not follow one of the core elements of a safe medication pass by preparing medications for more than one resident at a time. Review of Resident #1's medical record and interviews with facility staff who cared for her on 04/10/2021 and 04/11/2021, the day after receiving the [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] in error, showed she had an increasing decline in condition as the day progressed. During an interview with Staff E, Nursing Assistant Registered (NAR) on 04/27/2021 at 3:15 PM, he stated he worked the night shift from 10:00 PM on 04/10/2021 to 6:00 AM on 04/11/2021. Staff E stated on entering her room that morning at 4:00 AM, Resident #1 appeared sleepy though not unusually so and asked him to get her some ice water. During an interview with Staff F, NAR, on 04/27/2021 at 3:25 PM, Staff F stated she worked the day shift from 6:00 AM to 2:00 PM on 04/11/2021. Staff F stated Resident #1 was awake though drowsy when she came on shift. Staff F stated Resident #1 refused her breakfast and vomited shortly after it was offered. Staff F stated that whenever she checked in on Resident #1, the resident was sleeping and did not wake for the rest of the shift. During an interview with Staff G, Nursing Assistant Certified (NAC), on 04/27/2021 at 2:50 PM, he stated he worked the evening shift on 04/11/2021 from 2:00 PM to 10:00 PM. Staff G stated he checked on Resident #1 twice between 2:00 PM and 6:00 PM and she was really out of it and I could get her to wake up for maybe five seconds then she would go right back out. Review of a nursing progress note dated 04/11/2021, at 1:38 PM written by Staff D, LPN read in part, the resident is very sedated .responds to verbal and physical stimuli but goes right back to sleep. Review of a nursing progress noted dated 04/11/2021 at 10:13 PM by Staff B, RN read in part, when coming on shift I went in to check on resident related to the medication error that happened last night. Resident is difficult to awake, she would only arouse with a sternal rub (hard, painful rubbing with knuckles on the chest wall) and eyes open for seconds only. On call provider notified with new order to transfer to the hospital. Paramedics here at 7:30 PM. Review of hospital emergency department records dated 04/11/2021 showed in part, female who was erroneously [incorrectly] given 60 mg of extended release [MEDICATION(S)] at her care facility last night per EMS [Emergency Management Systems] [Paramedics] report. Somnolence [strong desire to sleep] suspected to be due to inadvertent narcotic administration resulting in acute respiratory failure. Review of Resident #1's hospital records showed she was admitted to the hospital on 04/11/2021 and remained hospitilized without fully regaining conciousness until she passed away on 04/18/2021. Review of Resident #1's final hospital diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the County Coroner on 04/30/2021 at 11:30 AM, he stated an autotopsy was performed on Resident #1 and the cause of death was labeled inconclusive until all of the pathology and toxicology reports were finalized. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to provide monitoring and care to prevent the development of a pressure ulcer for two of three sampled residents (1 & 2) reviewed for pressure ulcers. This failure placed residents at risk for unidentified pressure ulcers and a delay in initiating treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . A facility policy titled Skin Integrity Management last revised 01/31/2021, noted staff should complete a comprehensive skin evaluation of the patient upon admission/re-admission to the facility. This was achieved by completing a risk evaluation (Braden risk assessment), weekly for the first month, quarterly, and with significant change in condition. In addition, staff should perform a skin inspection on admission/re-admission and then weekly thereafter. If staff identified a new skin concern, staff should perform wound observations and measurements and complete a Skin Integrity Report for a pressure ulcer upon initial identification of altered skin integrity, weekly, and with anticipated decline of the wound. Resident 1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) assessment, a comprehensive assessment tool, dated 10/30/2020, determined the resident needed extensive assistance of one person to move and reposition in bed, transferring from one surface to another, and toileting. Her skin assessment identified areas with moisture associated skin damage to the groin and perineum (the area between the anus and the outer part of the external genitalia), but no pressure ulcer. Per facility policy, the resident should have had skin checks done weekly during the week of 11/02/2020, 11/09/2020, 11/16/2020, 11/23/2020, and 11/30/2020. Review of the resident's clinical record showed no weekly skin assessment was done from 10/26/2020 until 12/08/2020 (43 days after her admit). Resident 1's 12/08/2020 skin assessment showed the resident now had two pressure ulcers, one on her left buttock and one on her tailbone. Both of these pressure ulcers were assessed as unstageable due to dead skin tissue covering the pressure ulcer for staff to assess the extent of the injury. The resident was later discharged from the facility to the hospital on 12/10/2020, due to a change of condition. During an interview on 03/11/2021 at 10:54 A.M., Staff A, Resident Care Manager, stated upon admission of a new resident, a skin risk assessment (Braden) should be done, and then quarterly thereafter to determine each resident's risk for developing pressure ulcers. In addition to the risk assessment, each resident should have weekly skin checks done to identify any new pressure ulcers and/or monitor any existing skin concerns until healed. Resident 1's Braden assessment, dated 10/26/2020, determined the resident's risk to be mild and the plan of care was to provide the resident with a pressure reducing mattress, pressure reducing device for the wheelchair, and preventative skin care to prevent pressure ulcers. Review of Resident 1's clinical record showed she was diagnosed with COVID-19 infection on 11/16/2020. The following nursing progress notes showed Resident #1 decreased meal and nutrition intake: 11/25/2020 noted resident not eating well 11/27/2020 noted Resident is with [weight] change noted and provider is aware 12/01/2020 noted resident is fatigued and has poor appetite 12/02/2020 Resident continues with poor [oral] intake 12/05/2020 noted Resident continues to decline. She has been refusing to eat or drink at meals Resident 1 did not have another Braden assessment, to determine her risk of developing a pressure ulcer with her change of condition related to her decreased eating and drinking, as noted in the above nursing progress notes. During an interview on 03/11/2021 at 11:20 A.M., Staff B, Interim Director of Nursing, explained the weekly skin assessments were done by nurses working on the unit, and documented weekly in the electronic health record. When Staff B reviewed Resident 1's skin assessment, she confirmed that there was only one on record dated 12/08/2020. Staff B acknowledged that there should have been more weekly skin assessments for Resident 1. Review of the hospital record showed the resident's pressure ulcer was debrided (a surgical process used to remove dead or infected tissue from the pressure ulcer in order to facilitate healing) on 12/12/2020 by a general surgeon. Per the surgeon's assessment of the pressure ulcer after debridement, the pressure ulcer was staged between a Stage III-IV pressure ulcer (Stage 3: Full thickness tissue loss where subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle). The surgeon also noted the resident was quite uncomfortable with any attempts to turn her. In addition, the discharge summary from the hospital, dated 12/13/2020, noted Patient in obvious pain with any repositioning, provide pain medication for pain. During an interview with the Resident Representative on 03/15/2021 at 1:40 P.M., he/she stated the pressure ulcer was one of the big parts of Resident 1's pain towards the end of Resident 1's life. Resident 2 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MDS assessment (a comprehensive assessment tool), dated 12/16/2020, noted Resident 2 needed two person assistance with moving and turning in bed, transferring from one surface to another, toileting, and limited assistance with eating. This assessment did not identify the resident having a pressure ulcer at the time of assessment. Review of the resident's clinical record showed the resident had the Braden risk assessment completed on 06/10/2020 which determined the resident was at mild risk for developing a pressure ulcer. The resident did not have another Braden assessment on record until 02/03/2021 (about 8 months after admission) and then again on 03/09/2021, which both assessed Resident #2 as a moderate risk. Per facility policy, the resident should have had one assessment done at least quarterly. Resident 2's skin assessment, dated 01/14/2021, showed nursing staff assessed the resident having an unstageable pressure ulcer (covered by dead tissue therefore unable to stage) on her left outer ankle measuring 0.5 centimeters (cm) by 0.4 cm. Review of the resident's clinical record showed no treatment was initiated for the newly identified pressure ulcer, and no ongoing assessment of the pressure ulcer until 01/28/2021 (14 days later). Resident 2's skin assessment, dated 01/28/2021 showed nursing staff identified an unstageable pressure ulcer on the same left ankle that was noted previously on the 01/14/2021 skin assessment, and now measured at 0.8 cm by 0.4 cm. Nursing staff then notified the resident's physician and responsible party, and initiated treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/29/2021 at 12:15 p.m., Resident 2 was observed laying in bed and was eating her lunch. With Staff D, Licensed Nurse (LN) present, the resident's heels were observed. On the left outer ankle was the pressure ulcer identified in the skin assessments on 01/14/2021. Per Staff D, the pressure ulcer was now assessed as a Stage 2 pressure ulcer (upper layer of skin presenting as a shallow open ulcer with a red-pink wound bed) and the treatment continued for the resident's heels to be elevated while in bed (to reduce pressure) and apply skin protection to the affected area twice a day for healing. During an interview on 03/14/2021 at 11:20 A.M., Staff B, Interim Director of Nursing, reviewed Resident 2's skin assessment on 01/14/2021 identifying a pressure ulcer on the left ankle, and another skin assessment on 01/28/2021 identifying a pressure ulcer on the same left ankle. Staff B confirmed nursing staff should have followed up regarding the pressure ulcer on 01/14/2021, and that there should have been another skin assessment done the following week. Staff B was asked for additional documentation showing what nursing staff did after they assessed the resident with a pressure ulcer from 01/14/2021 and what treatment was done for Resident #2, none was provided. Reference WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to ensure one of four residents (#1), reviewed for accidents recieved the necessary assistance and supervision to prevent injury. This failure caused actual harm to Resident #1, who [MEDICAL CONDITION] his stomach and his right hand. Findings included . Resident #1. Review of the resident's medical record showed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] showed the resident was cognitively intact. He required extensive assistance of one person for eating. Record review showed a nursing progress note dated 03/17/19, that the resident had a change of condition, burned his chest and outer thumb side and a blister was formed on chest, 03/17/19 in the morning. A physician office visit note dated 03/25/19 showed the resident had second-[MEDICAL CONDITION] the right hand and anterior (front of his) abdomen. The facility incident report, dated 03/17/19, identified the resident had a history of [REDACTED]. Care plan was updated previously to have a cup holder in place on wheelchair to prevent spills . the cup holder broke and was not reported . During an interview on 04/23/19 at 2:55 PM, the resident was observed sitting in his electric wheelchair. His right elbow was bent, his right forearm was bent towards his chest, resting on the right arm rest of his wheelchair. He stated he is not able to use his hands. He stated if staff place a long straw inside a mug and they securely place the mug on the inside the bend of his right elbow, I can squeeze my elbow and it raises the mug so I can drink from it. He stated on the morning of the incident he had been sitting in his wheelchair in the dining room. He stated he had requested a cup of coffee. I had my cloth protector over my chest and right arm. The girl (Staff H) placed my silver mug filled with hot coffee on the bend of my right arm, when I tried to drink my coffee it spilled onto my stomach and I yelled for help. Resident #1 stated he had purchased the 12 ounce mug at a local store and the mug had a lid that was not secure. During an interview on 04/23/19 at 2:07 PM, Staff C, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated he had been working in the facility since 2014. He stated he was the RCM for Resident #1. Staff C stated the resident is only able to use his left hand to manipulate his wheelchair, he is not able to use his right hand nor raise his arms. Staff C stated the resident had been using a cup holder to hold his coffee mug, but it broke and we have been trying a new coffee cup holder which is not working well, so today I removed the cup holder from the armrest of his wheelchair one month after the Occupational Department documented the cup holder was not safe for the resident to use. Staff C acknowledged the resident's plan of care did not include how best to place the resident's coffee cup nor was it provided on the Kardex (a written plan provided to the nursing assistants instructing them as to the type of care the resident requires). The Occupational Therapy (OT) Evaluation, dated 03/22/19, showed the resident had been referred to their department to determine if the resident's cup holder was appropriate for the resident to use. The OT determined the cup holder was not safe and that the resident was at risk for future [MEDICAL CONDITION] hot liquids spills. The OT evaluation recommended to provide the resident with an insulated beverage bottle/mug with a screw on lid, a long straw for the mug, and caregivers to monitor every three hours while up in power chair for two weeks after the acquisition of the recommended mug. The resident's care plan, with a revision date of 01/14/16, showed universal flexible arm cup holder for independence with beverages when arrives. The resident Kardex included the use of the universal flexible arm cup holder for his independence with beverages. There were no documented instructions on how to properly place his coffee mug on the crook of his right elbow. During an interview on 04/23/19 at 2:44 PM, Staff D, Nursing Assistant (NA), stated she had worked in the facility for seven years and was familiar with the resident. She stated she had seen the resident carry his coffee mug under his right arm, he likes doing that. Staff D stated that no one had provided her with specific instructions on how best to secure his coffee cup on his right arm. During an interview on 04/23/19 at 3:00 PM, Staff E, NA, stated she was a new hire and had been working in the facility for two months. She stated she knew the resident carried a coffee mug on his right elbow. She stated she had seen the resident with a cup holder. She stated she had not been provided instructions as to what she needed to monitor or report to the nurse about the resident's cup holder or how to place the coffee mug on his arm. During an interview on 04/24/19 at 9:08 AM, Staff F,NA, stated she had been present when the resident had been burned on 03/17/19. We were serving breakfast to the residents in the dining room. Resident #1 requested a cup of hot coffee. I saw another nursing assistant fill his mug and place the mug on top of the clothing protector that covered his stomach and his right arm. She did place it on the crook of his right arm. Staff F stated they continued to serve other residents when within minutes of having provided the resident the cup of coffee he screamed for help. We turned towards him and he had spilled his coffee on himself and the mug was on his lap, we immediately took off his cloth protector and he was taken to the nurse. During a telephone interview on 04/24/19 at 9:46 AM, Staff H, NA, she stated she recalled serving the resident coffee and placing the cup of coffee on the bend of his right arm. He tells us how he wants the cup placed, he likes it on the crook of his arm. Staff H stated she did not see the resident spill the coffee on himself but heard him call out for help. Reference WAC 388-97-1060 (3) (g)

Based on observation, interviews, and record review, the facility failed to ensure residents were free from neglect when staff failed to provide timely care to avoid physical and emotional harm to 1 of 4 residents (#1) reviewed for neglect. This failed practice caused harm to Resident #1, who was left on a bedpan for approximately 3.5 hours, which resulted in skin problems and emotional distress. Findings included . Resident #1. The resident's medical record showed she was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was evaluated by Hospice on 12/21/18 and placed on services due to a decline in her condition. Review of the Brief Interview for Mental Status assessment, dated 12/2718, showed the resident was cognitively intact. The resident's plan of care, dated 06/11/18, showed she required two staff to assist with toileting, bed mobility, and dressing; and a mechanical lift for transfers. On 01/10/19 her plan of care identified her as being at risk for bruising and skin tears due to frail, fragile skin. Review of a facility investigaiton report, dated 01/23/19, showed at 10:40 PM the resident was screaming for help. When Nursing Assistant (NA) staff entered the resident's room she was found sitting on a bedpan, which was full of stool. Her linen was soiled with a urine stained ring on the bedding from the resident's knee to her shoulder. She was complaining of pain, with her skin indented and dark red. A later assessment at 5:45 AM on 01/24/19 showed a circular bruise measuring 2 centimeters (cms) to the left buttocks. The right buttock had a red area, curved to the shape of the bedpan, measuring approximately 25 by 0.5 cms. A written statement by Staff A, Nursing Assistant, showed she put the resident on a bedpan at approximately 7:15 PM on 01/23/19 per the resident's request. Staff A then left the resident's room and informed Staff B, NA and Staff C, NA, both standing at the nursing station, she had put the resident on the bedpan. They both acknowledged her statement by stating, okay. Staff A then continued with other tasks and never returned to the resident's room as she thought either Staff B or C had helped the resident off the bedpan. A telephone interview on 01/31/19 at 12:30 PM with Staff B showed at approximately 7:15 PM on 01/23/18 Staff A came out of the resident's room and told her she had just put the resident on a bedpan, however Staff A never requested her to check on the resident or remove her from the bedpan. Staff A informed Staff B between 8-8:05 PM she was leaving the facility to go home. Staff B stated, I was under the understanding she (Staff A) had taken care of it (referring to the bedpan). She was unaware if Staff C was in the vicinity when she was informed by Staff A of the resident being on the bedpan. Staff B stated, We help each other with call lights .team work. Staff C stated on 01/31/19 at 2:20 PM she was unaware of the resident being placed on a bedpan by Staff A on 01/23/19 as she was taking her lunch break at the time. She was informed of the incident the following day. She stated staff had to physically check the resident as she rarely used her call light. On 01/31/19 at 2:30 PM Staff D, NA, stated at 10:45 PM on 01/23/19 she was at the nursing station and heard the resident hollering, almost crying, my hips are broken .I'm going to die, my hips are hurting. It was not like the resident to holler and cry. When Staff D pulled the resident's sheet down in bed she observed a large, yellow ring of urine, saturated with urine. It was not until the resident was turned to her side did Staff D become aware the resident was on a bedpan. The bedpan was stuck on her bottom, and when it was removed there was a suction type noise. Staff D immediately called for the Licensed Nurse. I was livid for her (resident). The evening shift staff had already left the facility, and no one reported the resident was on a bedpan. There were scratches on the resident's skin from the bedpan and a dark, purple bruise where the bedpan handle would have been in contact with her skin. The resident stated she felt better after care was provided and immediately went to sleep, she was so exhausted. The resident was observed seated in a reclining wheelchair on 01/31/19 at 11:30 AM. She recalled she had been put on a bedpan by staff at approximately 8:00 PM and was left on it for three to four hours. She stated, hurting so bad I almost was crying. Her pain was in both hips, but primarily the right hip. They did not tend to me when I needed it. Reference (WAC) 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure one of three residents (#54), reviewed for falls, was provided the necessary assistance and supervision to prevent falls. Resident #54 suffered actual harm as a result of being left alone on the toilet despite a recent history of falls, a care plan directive that she was not to be left alone on the toilet, and multiple staff being aware that she was impulsive and would not ask staff for assistance. Findings included: Resident #54. Per the medical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent comprehensive assessment for a significant change of condition dated 10/27/18 showed resident #54 was alert and oriented and required extensive assistance of 2 caregivers for bed mobility and transfers. Review of Resident #54's plan of care showed the last date interventions were put into place to decrease the risk for falls was 12/11/17, which included the intervention Resident is not to be left alone in the bathroom. This intervention was also listed under the safety heading on Resident #54's Kardex which is where the nursing assistants review daily resident care needs. On 10/30/18 at 3:30 PM in an observation of Resident #54, she was lying in her bed, positioned with pillows on her left side and her right arm in a sling. She did not open her eyes or respond when spoken to. The room was dark and a family member was sitting in a chair at her bedside. The family member stated Resident #54 had a fall on 10/15/18 and had fractured her right arm in several places. The family member stated the resident had a big decline both in her abilities and her mentation and had been in a lot of pain since the fall. In addition, the family member stated Resident #54 was not a surgical candidate to repair the fractures due to heart problems and had to be hospitalized from [DATE] through 10/20/18 for a high fever and further decline in her condition which she believed was a result of the fall. Review of Resident #54's medical record and facility incident reports showed three recent falls. A fall dated 09/15/18 showed the resident was found on the floor in her bathroom stating she fell backwards trying to sit on the toilet. On 10/09/18 Resident #54 was found sitting on the floor in her room, stating she was attempting to move her chair when she fell hitting her shoulder on the refrigerator in her room and had a laceration on each hand from the fall. Review of the medical record showed the resident received pain medication for several days following the fall for right shoulder pain. On 10/15/18 the resident fell in the bathroom when she attempted to transfer herself from the toilet to her walker causing a large bump on her right forehead and fractures to the right arm. On 11/06/18 at 11:25 AM Resident #54 was sitting in a recliner in her room and stated she was just dozing a bit. She was alert and oriented stating it had been a difficult couple of weeks since her last fall but felt like she was slowly getting back to her old self and had been working hard with Physical Therapy. She stated on the night she fell and broke her arm, Staff K, Nursing Assistant, was her caregiver. She stated he assisted her to the toilet in her room, left the bathroom, and said to let him know when she was done. She stated she put her call light on when she was finished but he did not come back right away so she stood up to pull up her pants. She stated she suddenly felt weak so she went to sit on her walker seat beside her and it flipped on her causing her to fall face first to the floor. Resident #54 stated Staff K immediately came into the bathroom after hearing her fall. She stated she was sent to the hospital and was told she had fractured her arm. She stated it was placed in a sling and she came back to the facility. She stated she had hazy recollections of the next week or so because she was in such pain from her arm and barely recalled her hospitalization last month. Resident #54 stated she knew she was supposed to have someone stay with her in the bathroom so she wouldn't fall but Staff K, being male, liked to give her privacy in the bathroom and waited outside until she was done. She stated she did not mind anyone, male or female staying in the bathroom with her. She stated she knew it was for her safety because she always thought she was more capable to do things for herself than she really was and she wasn't very patient at waiting. She stated she knew the staff were busy and she didn't like bothering them to help her when she thought she could do it herself. On 11/06/18 at 11:40 AM in an interview with Staff T, Licensed Practical Nurse/Nurse Manager, he stated that Resident #54 was a known high fall risk as she attempted to transfer herself and believed she was capable of doing more than she actually was. He stated he didn't know what other interventions he could put in place for her, he stated he talked with her about placing a fall alarm on her but she did not want one. He stated with her transferring herself as she did and not asking for help he did not know what else could be done. Staff T stated he was aware that the resident's plan of care directed that Resident #54 was not to be left alone in the bathroom because of her history of transferring herself without assistance. In addition, he stated he was aware Staff K was not actually in the bathroom with her on the night she fractured her arm but waiting outside the bathroom door to give her privacy. Staff T stated he did not counsel Staff K for not following the plan of care and stated it was reasonable to say that had he been in the bathroom with Resident #54 as directed she would not have fallen and sustained a serious injury. On 11/07/18 at 10:30 AM in an interview with Staff K, he stated it was a pattern for him to wait outside the bathroom door for Resident #54 to finish using the toilet to give her privacy. He stated the night she fell he was waiting for her outside the closed door to say she was finished when he heard a loud crash and immediately went in finding her on the floor face first and right arm twisted behind her. He stated he did not hear her say she was finished and would not have noticed the call light being put on as he couldn't see it from inside her room. Staff K stated he did not know if he actually read the statement that Resident #54 was not to be left alone in the bathroom but he knew she wasn't and that was why he waited right outside the bathroom door. He stated he felt terrible that she fell and it was my bad that I wasn't in there with her. He stated she had never told him he couldn't be in the bathroom or that she wanted privacy in the bathroom. On 11/07/18 at 10:45 AM in an interview with Staff B, the Director of Nursing, he stated he did not know what other interventions could be done for Resident #54 to prevent falls since she consistently did not put on her call light or ask for assistance. Staff B stated after this last fall he had caregivers write out statements that Resident #54 frequently stated she did not ask for help because she knew the staff were busy assisting others and didn't want to bother them. In addition, he stated Staff K was not counseled about not following the plan of care to not leave the resident alone in the bathroom as he was technically with the resident, just outside the door giving her privacy. He stated he was unaware no new interventions to prevent falls were added to Resident #54's plan of care since (MONTH) of (YEAR) even though she had repeated falls with injury since that time. Staff B stated the facility did not currently have a fall prevention interdisciplinary team that assesses, problem solves and/or adds interventions to the care plan for residents who have had frequent falls. In addition, he stated the facility did not have a way for all staff to identify residents who are at a high risk for falls. Reference WAC 388-97-1060 (3)(g)

Based on observation, record review, and interviews the facility failed to ensure adequate supervision was provided to prevent falls for 1 of 3 residents (#1) reviewed for falls. Nursing Assistant (NA) staff did not follow the resident's plan of care for transfers. This deficient practice resulted in actual harm to the resident as he fell during the transfer and had increased complaints of pain to his left shoulder and neck area necessitating x-rays at the hospital to rule out a fracture. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital following surgery for [REDACTED]. Due to pressure ulcers on both heels the resident wore heel suspension boots (speciality boots). Review of a facility investigation report revealed on 7/9/14 the resident reported to dialysis staff that he had pain in his neck and shoulder as he was "dropped transferring to w/c (wheelchair) this morning" by staff doing a pivot transfer. The speciality boots were on at the time of the fall and were "slick" on the bottom. A telephone interview on 7/21/14 at 9:40 a.m. with a Licensed Nurse (LN) at the dialysis center revealed the resident came to the dialysis center on 7/9/14 in "a great deal of pain." Tylenol was administered to the resident due to his pain as they were not allowed to administer any other pain medications. The resident stated he had been dropped that morning during a transfer by two NAs. He slipped and fell to the floor causing pain to his left shoulder and neck. The resident stated he had been wearing his speciality boots that had "no grip at all." The LN stated there was "no way he could bear weight" due to his speciality boots. The resident was to be transferred with a mechanical lift at the facility. An interview on 7/21/14 at 4:10 p.m. with the resident revealed he informed the two NAs not to do a pivot transfer on him as he was unable to stand up as the speciality boots caused him to "skid out." Observation of the boots revealed metal, slippery bottoms with a small metal post protruding from the bottom of the boot. The resident was observed to be tall and of average weight. He stated the NA responded by stating, "there's two of us here, have confidence, we can do it." Following that one NA grabbed him under the right shoulder and the other NA under the left. He stated he had to help them. They began transferring him from the bed to the w/c and got approximately halfway when his right leg slipped out in front of him and he "dropped to the floor" on his bottom. The two NAs grabbed him under the shoulders and started trying to pick him up off the floor and eventually placed him in the w/c. He stated he "hit the floor pretty good." The resident stated he had pain initially in both shoulders following the fall. On 7/21/14 at 1:25 p.m. an interview with Staff A (NA) revealed she grabbed under the resident's right arm and the second NA was behind the resident during a pivot transfer from the resident's bed to his w/c the morning of 7/9/14. She stated the resident's feet were "slipping" and he was trying to get a grip with his feet. The transfer was "more harder" due to the resident moving. She stated he was "getting heavy" for them so he was lowered to the floor. The NAs then lifted him with a gait belt into his w/c. She stated the incident was not reported to LNs as the resident had not fallen to the floor. An interview on 7/21/14 at 1:40 p.m. with Staff B (NA) noted one NA was on one side of the resident and one on the other side during a pivot transfer the morning of 7/9/14. The resident was wearing his speciality boots on both feet at the time of the transfer. She stated the resident was able to partially stand up and then both his feet slipped and he was lowered to the floor. She was unable to recall if the resident complained of pain following the transfer. She also stated the incident was not reported to LN staff as the resident did not fall. Staff C (resident's Physical Therapist) was interviewed on 7/21/14 at 2:10 p.m. and stated therapy staff had provided training on 6/18/14 regarding the resident's transfer utilizing a sit to stand mechanical lift with two staff members (one holding the left leg and the other doing the transfer). He stated that transfer status had not changed. The resident required many verbal cues to not put weight on his left leg. Review of therapy notes dated 7/11/14 noted the resident had reported to therapy that he fell during a transfer and due to pain in his left shoulder he was sent to the hospital to get x-rays. Review of transfer instructions (found in the NA records and written by therapy staff) noted transfers were to be done using a sit to stand mechanical lift with at least two staff members. One staff member was to lift the left leg up so the resident was not putting any weight on it. Review of Progress Notes dated 7/10/14 noted documentation stating the resident complained of pain to the left shoulder and left upper arm prior to dialysis on 7/9/14. The physician was notified on 7/10 and x-rays were obtained at the hospital, which revealed no injuries. A telephone interview on 7/29/14 at 1:07 p.m. with Staff D (Director of Nursing) revealed the resident was six foot tall and weighed 203 pounds on 7/7/14 (two days prior to the fall). Despite the resident's specific transfer orders and training provided to staff, use of speciality boots that were not designed to be worn during pivot transfers, weight and height, [DIAGNOSES REDACTED].