Every finding on record at Crescent Health Care

Based on observation, interview and record review the facility failed to identify and prevent an avoidable accident hazard in the resident's environment for 1 of 3 residents (Resident 1) that used both bed bolsters (a soft barrier along the edge of the bed that minimizes the risk of rolling off the bed) and required mechanical lift transfers. Resident 1 experienced harm when they slid out of the lift sling during two-staff assist transfer when the resident in the sling did not clear the top edge of the bolster there by lifting the lower left sling loop up off the lift hook due to no longer being taut and the loop disconnected from the lift. The fall resulted in pain, a forehead wound, and transfer to the hospital where they were diagnosed with an ankle fracture. This failure placed resident with mechanical lift transfers at risk for injury and a diminished quality of life. Findings included.Review of the medical record showed that Resident 1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's dementia (a degenerative brain disorder and the most common cause of dementia, characterized by progressive memory loss, cognitive decline, and behavioral changes that interfere with daily life), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), and osteoarthritis (a long-term degenerative joint condition in which the joints gradually deteriorate, causing pain and stiff joints). Review of a [DATE] comprehensive assessment showed that Resident 1 had moderate impaired cognition, was dependent on staff for grooming, bed mobility, transfers and was at risk for falls. Record review of Resident 1's fall care plan dated [DATE] showed as a fall risk intervention the left side of their bed was positioned against the wall to help prevent falls/rolls out of bed. The care plan, reviewed on [DATE], showed no interventions that included a bolster. Review of a [DATE] at 6:35 AM progress note by Staff B, Director of Nursing, showed Resident 1 fell out of a mechanical lift sling during a transfer from their bed to the wheelchair. The resident was observed lying on the floor with left shoulder, arm, hip and foot on the mechanical lift leg. There was bleeding from a one centimeter (cm) by 0.5 cm laceration (a torn or jagged wound to the skin and soft tissue underneath) to the left side of forehead. The left arm had bruising developing to their left arm and elbow. There was also a two cm by one cm skin shearing (occurs when the skin remains relatively stationary while underlying tissues or bones move in opposite directions. This parallel force stretches and distorts deeper tissue layers, damaging blood vessels and separating skin layers beneath the surface) on the left ankle with bruising and swelling. Resident 1 was sent to the hospital for further evaluation. Review of a [DATE] at 1:00 PM progress note showed that Resident 1 returned from the hospital with a left ankle bone fracture that was supported by a leg splint and a shallow scalp laceration (a torn or jagged wound to the skin and soft tissue underneath). Resident 1 was yelling out in pain upon their return. On [DATE] at 2:50 PM Resident 1 was observed lying in a low bed, head of bed elevated, with the left side against the wall and a blue wedge-shaped bolster was along the right side of the bed. The top of the bolster was eight inches above the bed surface. Resident 1's eyes were closed and did not open with the door knock and announce visit from the investigator. There was a two cm by two cm bruised area to the left side of their forehead. On [DATE] at 3:10 PM, Staff C, Registered Nurse (RN)/ Restorative Nurse, stated the nursing assistants (NA) staff present for Resident 1's transfer were Staff D, NA, and Staff E, NA. Staff B stated they had the NA's witness statements, and they told Staff C that while moving the resident in the sling, over the left side of the bed, the lower left sling loop somehow came off the lift hook and Resident 1 slid to the floor. On [DATE] at 3:15 PM, Staff B stated that they were at the medication cart near Resident 1's room when the NA came out to find a nurse. Staff B stated that when they entered the room, they saw the mechanical lift legs were parallel to the bed, [Resident 1] was on their left side on the floor, bleeding from the left side of their forehead and [Resident 1] was crying it hurts, it hurts. Upon assessment there was skin shearing, bruising and swelling to the resident's left ankle. On [DATE] at 3:44 PM, Staff G, NA, stated when they did mechanical lift transfers for residents with bed bolsters, they would release the bolster wedge and move it to the foot of the bed. Staff G stated, If you don't do that the sling can get caught on the bolster. On [DATE] at 4:30 PM, Staff C could not produce any mechanical lift policies or training that were documented. Staff C stated staff receive lift training all the time but not related to beds with bolsters stated and probably not documented. Staff C stated there were no written guidelines for staff to follow for mechanical lift transfers and or use of bolster wedges on resident's beds. On [DATE] at 4:50 PM, Resident 1 was observed lying in their bed, groaning and moving head from side to side. Resident Representative 1 (RR1) was seated at the resident's bedside. RR1 stated that it was the first time they had seen [Resident 1] since going to the hospital that day. RR1 stated in an upset tone this was clearly negligent and the facility was at fault. During a telephone interview on [DATE] at 5:22 PM, Staff E, NA, stated that they had assisted with mechanical lift transfers for [Resident 1] many times. They stated, Today, [Staff D] had [Resident 1] ready with the sling already hooked up to the lift when they came to assist. Staff D operated the lift remote while they were watching the resident's position in the sling. Staff E stated, It happened so fast when the loop came out of the lift hook. Looking back, the bed was too high, the bed only needed to be high enough to get the lift legs under the bed. Staff E stated that the bolster-wedge should have been removed before the transfer. On [DATE] at 11:45 AM, Resident 1 was observed in bed, with Resident Representative 2 (RR2) at the bedside. RR2 stated they were at the hospital that morning with Resident 1 and they were hollering out in pain. RR2 stated the wound on Resident 1's head did not need stiches, and they could not surgically repair the fractured ankle, so they were treated with a splint on lower left leg. RR2 stated, This was an accident that should not have happened. RR2 stated the bolster wedge had been on the bed for a couple of years and did not recall being informed of risks and benefits of its use. On [DATE] at 12:15 PM, Staff B, stated they did staff training last Fall on resident transfers using a picture board. Staff B provided the visual aid used for the training. Looking at the board, the instructions for mechanical lift showed residents should initially be lifted two inches off the surface to complete checks for safety and comfort and then slowly lift the residents as high as necessary to complete the transfer. Staff B stated, The staff should have been taking down the bolster wedge, and I had no idea the staff were not. On [DATE] at 12:30 PM, Staff D stated that they had provided care for [Resident1] many times. Yesterday morning they readied Resident 1 to transfer to their wheelchair. The bed was at working height to dress and place the full body sling under Resident 1. They stated that while operating the lift to transfer, they did not realize the sling got caught on the bolster. Then suddenly, Resident 1 slid out of the sling and was on the floor. Staff D stated they had not removed the bolsters for mechanical lifts, No one told me to. On [DATE] at 12:50 PM, Staff C stated that they could not find a physician order, assessment, care plan, or representative consent for Resident 1's bolster. On [DATE] at 3:10 PM, Staff A, Administrator, stated that they were not aware the bolsters could be a hazard, acknowledged there were no policies for lifts and Staff A stated, The bolster should have been taken down. Reference: WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to provide adequate supervision, immediately assess a resident after a fall, implement and evaluate care-plan interventions for efficacy, and ensure care-planned interventions were consistently followed to prevent an avoidable fall for 1 of 5 residents (Resident 54) reviewed for hospitalizations. Resident 54 who had moderately impaired cognition with a known history of falls prior to admission and was assessed at high risk for falls, experienced harm when they had an unwitnessed fall, were found face down on the floor with multiple lacerations, required transfer to the hospital for pain, and were diagnosed with multiple complex fractures (left humerus, hip, and left tibia) which required surgical intervention.Findings included .Review of the facility's policy titled Falls Clinical Protocol, dated 01/2022, showed the facility would identify and document residents' fall-risk factors and develop individualized, resident-centered fall-prevention plans that address underlying medical conditions that may increase risk of fall-related injury. Record review showed Resident 54 admitted to the facility on [DATE] with diagnoses to include traumatic subdural hemorrhage (a serious head injury involving bleeding between the brain and its outer covering following a blow to the head), dementia (a decline in mental ability severe enough to interfere with daily life), and a history of falls prior to admission. Review of the comprehensive assessment dated [DATE] showed Resident 54 had moderately impaired cognition and required assistance of one staff members for activities of daily living. Review of the 08/08/2025 admission fall-risk assessment showed Resident 54 was assessed at high risk for falls. Review of the comprehensive care plan dated 08/08/2025 showed no specific care plan had been initiated for falls and no interventions were in place to address the resident's high fall risk. Review of the facility's investigation dated 09/11/2025, showed at 4:20 AM Resident 54 was found face down on the floor in their room by Staff Q, Nursing Assistant, (NA). Staff R, Licensed Practical Nurse, (LPN), entered the room and assisted Staff Q in lifting the resident from the floor into a wheelchair using a gait belt (a sturdy strap put around someone's waist to help safely assist them with walking, standing up, or moving from surface to surface). The investigation documented that Resident 54 had lacerations on the left hand, left forearm, left elbow, left shoulder, and left temporal (side of head near temple). The resident verbalized significant pain, stating, It hurts so much. During an interview on 12/05/2025 at 9:11 AM, Staff R, LPN, stated that during their final rounds on the morning of 09/11/2025 at approximately 4:20 AM they passed by Resident 54's room and saw the resident lying face down on the floor with Staff Q, NA, present. Staff R stated they entered the room and helped lift the resident into a wheelchair. Staff R stated they asked the resident what happened, and the resident reported they were trying to go to the bathroom. Staff R stated the resident had multiple lacerations, which they cleaned and dressed before notifying the provider. Staff R reported they had passed by the resident's room approximately 30 minutes earlier and the resident had been sleeping in bed. Staff R stated they did not perform a complete physical assessment until after the resident was transferred into the wheelchair. Staff R stated the resident did not complain of pain while lying on the floor but verbally expressed they were having significant pain to their left arm when placed in the wheelchair. Staff R stated there were not any fall risk interventions in place for Resident 54. During an interview on 12/05/2025 at 9:37 AM, Staff Q, NA, stated they found Resident 54 lying face down on the floor and it appeared the resident had been walking toward the bathroom. Staff Q stated Staff R entered the room and helped lift the resident into the wheelchair. Staff Q stated that after Staff R left the room, another NA assisted them in helping Resident 54 to the bathroom. Staff Q stated the resident had cuts all over and was moaning in pain continuously from the time they found them on the floor. Staff Q stated they did not have any fall interventions to follow on Resident 54. During an interview on 12/04/2025 at 2:08 PM, Staff H, Clinical Case Manager, stated their responsibility was to conduct the fall risk assessment upon admission and develop appropriate, individualized care plan interventions at that time. Staff H stated the care plan developed for Resident 54 should have been more specific, given the resident was identified as high-risk for falls with a documented history of falls prior to their admission. During an interview on 12/04/2025 at 3:45 PM, Staff B, Director of Nursing Services, stated they expected the Clinical Care Manager to initiate an individualized fall risk care plan with appropriate interventions for any resident identified as a high fall risk or who possesses a history of falls. Staff B stated Resident 54's current care plan was deficient, stating it was not correct and lacked the necessary required information and interventions. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, comfortable environment was maintained for 2 of 3 shower rooms (East Hall and North Hall), reviewed for environment. This failure placed the residents at risk of an unpleasant, uncomfortable living environment, and safety hazards. Findings included. Review of the maintenance logbook for November 2025, and December 2025, showed no entries for repair of the East Hall shower room. East Hall Shower Room An observation on 12/02/2025 at 7:31AM, showed the East Hall shower room with three feet (ft-unit of measure) by four ft divider wall with multiple loose, cracked, chipped, and black/brown stained tiles on the shower floor that connected to the base of the divider wall. On the corner of the divider wall was a 12 inch (in-unit of measure) by 10 in corner section of the divider wall without tile that exposed a black/brown substance and yellow and white flaky wall debris that crumbled when touched. On the top of the edge of divider wall was a two in tile that was cracked in half with sharp edges. During a concurrent observation and interview on 12/05/2025 at 8:33 AM, Staff D, Maintenance Director, stated staff were to report issues with the facility that needed repairs into the maintenance logbook. Further observation of the shower room showed a resident shower chair with wheels coated in dark reddish/brown thick debris. Staff D stated they were unaware of the identified concerns with the East Hall shower room. Staff D stated the broken, missing shower tiles should be repaired and/or replaced and the shower chair wheels needed to be replaced. During a concurrent observation and interview on 12/05/2025 at 11:47 AM, Staff A, Administrator, stated they were unaware of the condition of the East Hall shower room. Staff A stated the shower tiles were uncleanable and needed to be repaired. Staff A further stated the resident shower chair should not be in use and needed to be disposed of. North Hall Shower Room Review of the maintenance logbook for November 2025 and December 2025, showed no entry for the North Hall shower room. An observation on 12/02/2025 at 11:10 AM, showed the North Hall shower room floor with pink and dark brown substance in the tile grout (a paste for filling crevices, especially the gaps between wall and floor tiles), pink and yellow soap scum on the tile floor. The shower drain had a broken drain guard, exposing an opened drain. During an observation and concurrent interview on 12/03/2025 at 8:36 AM, Staff T, Nursing Assistant, (NA), stated that the facility did not have a shower team, and the NAs were assigned a shower for their shift. Staff T stated they used a sanitizing spray to clean after a shower. Staff T stated they were unsure of who was responsible for the deep cleaning of the shower. Observation of the shower room showed a pink/yellow residue on the tile floor and dark brown substance on the tile grout. During an observation and concurrent interview on 12/05/2025 at 7:44 AM, Staff D, showed the North Hall shower room tile floor, had pink and dark brown substance in the tile gout, the broken drain guard exposing the open drain. Staff D stated they were not aware of the issues, and their goal was to get the facility into shape. Staff D stated staff used a maintenance log located at the South Hall nurses' station to communicate any facility issues that needed their attention and reviewed the log daily. Reference WAC: 388-97-3220(1)

Based on observation, interview, and record review the facility failed to provide residents and representatives, information on how to report concerns, incidents and grievances for 4 of 6 residents (35,19, 33and 18) reviewed for grievances. The facility failed to establish a grievance policy that included prominent postings throughout the facility, right to file a grievance by written means or anonymously, the right to review the complaint in writing, and a reasonable time frame for review resolution of the concern. This failure potentially affects residents' quality of care and unresolved concerns. Findings included . Review of the 08/2025 Resident Grievances policy showed residents have a right to file a grievance and encourage them to speak with the charge nurse, and if they did not feel comfortable with the charge nurse to speak with Social Services or the Administrator. If a grievance cannot be solved by Social Services, then a formal grievance investigation can be requested, and the Director of Nursing and Administrator will be notified. A grievance can be filed by the resident, family, and/or staff. Review of the 01/01/2023 Resident Personal Property & Missing item Policy showed the inventory and documentation of personal items was the responsibility of the Social Services department. The inventory process consisted of logging items was optional, but the facility strongly encouraged listing items of value (electronics, jewelry, cash, and sentimental items). The facility cannot be held responsible for lost or damaged items on the personal belongings list. During the Resident Council meeting on 12/02/2025, from 10:45 AM to 11:25 AM, the residents in attendance were, Resident 35 stated the facility did not respond to their missing money (twenty dollars) complaint of six months ago there was no follow up. Resident 35 stated when there was a concern, they reported it to social services, and social services filled out the grievance but no follow up was given to the resident. Resident 19 stated they had reported missing money (nine dollars) to social services, and they had not received information about the conclusion of the investigation, but social services gave them a lock on their drawer. Resident 33 stated they had missing blankets they had reported it to social services but no follow up. During the resident council discussion with Residents 35,19 and 33 they were unaware that there were grievance forms available, and they could file grievances anonymously or have other facility staff assist them in the grievance reporting process. The resident also stated only social services could assist them with a grievance and they had social services fill out the grievance forms. Additionally, residents were unaware of the grievance policy and the policy for lost money. The resident council members were unaware when they received any money from friends or family, they had to ensure it was noted on their inventory sheet or resident trust no matter what the amount. The residents did not know about the state hotline number or Ombudsman contact information. The meeting adjourned at 11:25 AM. During an interview on 12/03/2025 at 12:03 PM, Resident 18 stated if they had missing items and told staff and there was no follow up. Resident 18 stated they were unaware of how to file concern or grievance. During an interview on 12/02/2025 at 11:30 AM, Staff O, Activities Director stated they only took notes during resident council and shared them with social services and the administrator. Staff O stated they referred residents' complaints/grievances to social services. Additionally, the old business discussed in the resident council was not reviewed because social services or the administrator took care of those communications with departments. During an interview on 12/03/2025 at 12:03 PM, Resident 18 stated if they had missing items and told staff but had no follow up. Resident 18 stated they were unaware of how to file a concern or grievance. During an interview on 12/03/2025 12:13 PM, Staff N Social Services Assistant, stated if a grievance for lost clothing was reported they interviewed the resident and complete a report if it was in the laundry or looked where clothes could be kept and if found, we have solved the problem and there was no need for further investigation. Staff N stated if there was missing money, they looked for it but if it is not documented on the inventory sheet, the resident would not be reimbursed. Staff N stated most residents had dementia and could not remember what money they had or if a family member or a visitor gave them money. During an interview on 12/03/2025 at 12:30 PM, Staff M Social Services Director, (SSD) stated they attended the resident council meetings and instructed residents on the grievance process and there were forms located on the wall file in the [NAME] Wing of the facility. Additionally, Staff M stated if they looked for missing money and could not find it, they offered a lock box for the resident to secure their money. Staff M stated that if residents received any money and had not been logged on the inventory sheet the grievance would go to the administrator for the missing item or money to be reimbursed. During an interview on 12/04/2025 at 10:52 AM, Staff K Nursing Assistant, (NA) stated if a resident had a concern, they would place the concerns like lost money clothing etc. in the SSD grievance book at the nurse's station or tell the charge nurse. During an interview and concurrent observation on 12/04/2025 at 11:48 AM, Staff J, Registered Nurse, (RN), was unable to locate the grievance forms for the residents/staff they looked in a plastic wall file holder on the [NAME] Hall and East Hall, the state inspection binder was located along with other forms and other paperwork. Staff J found the grievance forms hidden and high up on the wall ion the [NAME] Hall in a folder, behind other paperwork and unlabeled. The residents and staff could not locate or reach the grievance form. Staff N stated that they were unaware that the grievance forms, grievance policy, state hotline poster and Ombudsman information were unattainable to residents. Staff N stated that the residents did not fill out the grievance forms that the SSD filled the forms out for the residents There really is no way that the residents can do the forms without SSD. During an interview on12/03/2025 at 9:35 AM, Staff A, Administrator, stated while reviewing the resident personal property and missing items policy it did not make sense. Staff A stated they would have to do some reworking on the policy. Staff A stated that if multiple residents who might not have had their cash documented on their inventory sheet were missing money and may have received it from their family would not be reimbursed for their loss if not documented on the inventory sheet. Staff A stated they might need to change the policy due to the way it read was not correct where the policy stated, the facility strongly encouraged listing items of value. Reference WAC 377-98-0460(1)(2)(3)(4)

Based on interview and record review, the facility failed to ensure investigations were completed and/or thorough for 3 of 5 residents (Resident 40, 35 and 14) reviewed for investigations. This failure to initiate and complete thorough investigations placed residents at risk for unidentified accidents, abuse/neglect and serious injuries. Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. A thorough investigation was a systematic collection of a review of evidence/information that describes and explains an event or a series of events to determine what occurred and make necessary changes to a resident's plan of care and services to prevent recurrence. The investigation should include the who, what, when, why and how, of the incident and establish a reasonable cause within 24 hours of the incident. Additionally, evidence of the investigation must be readily available to state licensing and certification staff and others according to their authority. Resident 40 Review of the medical record showed Resident 40 was admitted to the facility with diagnoses including osteomyelitis (infection in a bone), respiratory failure, gastrointestinal reflux disease (GERD-a condition when stomach acid flows back up into the esophagus causing a burning sensation in the chest), and a right side below the knee amputation. The 09/01/2025 comprehensive assessment showed Resident 40 was dependent on one to two staff members for activities of daily living (ADLs) and required supervision/touching assistance of one staff member for eating. The assessment also showed Resident 40 had mild cognitive impairment. Review of Resident 40's nursing progress notes, (PN), dated 11/15/2025, showed Resident 40 choked when they ate corn chips at dinner. Resident 40 was able to produce a hard cough and clear their throat. During an interview on 12/03/2025 at 12:07 PM, Staff C, Registered Nurse/Director of Rehab, (RN/DOR), stated Resident 40's choking episode was also not investigated because we did not perform a Heimlich maneuver (procedure for dislodging and obstruction from a person's throat by a sudden strong pressure applied on the upper abdomen). During an interview on 12/04/2025 at 2:24 PM, Staff A, Administrator, stated if the facility could identify how the incident happened, they did not need to investigate. In a follow-up interview on 12/05/2025 at 10:52 AM, Staff A stated they understood the process and these incidents should have been investigated. Resident 14 Review of the medical record showed Resident 14 was admitted to the facility with diagnoses including Alzheimer's (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out daily tasks) disease. The 07/14/2025 comprehensive assessment showed Resident 14 had severely impaired cognition and was dependent on one to two staff members for ADLs. The assessment further showed resident 14 required substantial to maximum assistance of one staff member for eating. Review of Resident 14's nursing PN, dated 09/02/2025, showed Resident 14 was provided with a cup of cocoa, removed the lid, and spilled the contents onto their left thigh. Assessment of the area noted a small, light red area of skin discoloration. Review of the September 2025 incident reporting log showed no documentation of an incident investigation or report completed for this specific event involving Resident 14. During an interview on 12/04/2025 at 2:08 PM. Staff C, RN, stated there was not an incident report completed for Resident 14. Resident 35 Review of Resident 35's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes (a disease in which the body does not control glucose (a type of sugar) in the blood.) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.). The comprehensive assessment dated [DATE] showed Resident 35's cognition was moderately impaired and required supervision/touching assistance of one staff member for ADLs. Review of Resident 35's PN dated 10/09/2025 showed Resident 35 and the Activities Director entered the Social Services office and reported that they were upset and bothered that a staff member had touched them without asking permission. During an interview on 12/04/2025 at 12:50 PM, Staff G, Clinical Care Manager (CCM), stated they recalled the incident on 10/09/2025 for Resident 35. Staff G stated they had not investigated the incident, that the Social Services department had worked on it. Staff G stated Resident 35 had not been placed on alert charting (a nursing tool to monitor a resident after an incident) for the incident. Staff G stated their process for things of this nature would be to investigate and place the resident on alert for any signs of psychosocial harm. During an interview on 12/04/2025 at 1:03 PM, Staff O, Activities Director, stated, they recalled Resident 35's incident on 10/09/2025. Staff O stated they had reported it to the Social Worker and to the floor nurse that day. Staff O stated Resident 35 came in upset, not crying or anything like that upset, but pissed off upset that someone had put their hand down their shirt to look for a bra without asking the resident while they were in the hallway. Staff O stated they were not asked to write a statement about the incident. During an interview on 12/04/2025 at 1:11 PM, Staff B, Director of Nursing, stated the incident on 10/09/2025 for Resident 35 should have been thoroughly investigated to rule out abuse and neglect. Reference: WAC 388-97-0640 (6)(C)

Based on interview and record review, the facility failed to ensure that resident's received appropriate care and services for dialysis (a medical therapy that removes waste products, excess fluids, and toxins from the bloodstream) that were consistent with professional standards of practice for 1 of 1 resident (Resident 7) reviewed for dialysis. The facility did not provide ongoing monitoring or assessment of Resident 7's condition, including obtaining vital signs upon return to the facility after dialysis. The facility also failed to establish an effective, coordinated process for communication with the offsite dialysis center to promote continuity of care. In addition, the facility did not develop or implement an individualized care plan addressing the resident's dialysis needs, associated risks, and required post-dialysis monitoring. This failure placed the resident's at risk for unrecognized complications and adverse outcomes following dialysis. Findings included. Review of the medical record showed the resident was admitted to the facility with diagnoses including end-stage renal disease (a condition in which the kidneys are no longer able to remove waste from the blood) requiring hemodialysis (a process in which a machine artificially filters waste from the blood when the kidneys no longer work) and diabetes (a condition that happens when your blood sugar is to high). The 11/13/2025 comprehensive assessment showed Resident 7's cognition was intact and required the assistance of one-two staff members for Activities of Daily Living (ADL)s. Further review showed Resident 7 was receiving dialysis care. Record review of Resident 7's December 2025 physician's orders showed there were no dialysis orders in place. Review of the resident's progress notes from 06/01/2025 to 12/05/2025 showed no follow-up assessments to monitor for complications after the resident returned from dialysis. Record review of the resident's vital sign documentation showed no recorded post-dialysis vital signs between 11/01/2025 and 12/01/2025. Review of Resident 7's care plan showed no dialysis information or interventions. During an interview on 12/04/2025 at 8:58 AM, Staff G, Clinical Case Manager (CCC), stated Resident 7's dialysis days were Monday/Wednesday/Friday and licensed staff were to check the resident's blood sugar, administer insulin as ordered, and provide a meal upon their return. Staff G stated that post-dialysis vital signs should be obtained when the resident returns; however, the facility's current practice only required checking blood sugars. Staff G reported that they assumed vital signs were taken at the dialysis center and therefore did not routinely complete post-dialysis assessments upon the resident's return. Staff G reported they did not have a standardized communication form or routine communication method with the dialysis center, communication generally only occurred when there was a specific concern. Staff G further stated Resident 7 did not have a dialysis-specific care plan and should have had one in place that included monitoring for the presence of thrill and bruit, site care instructions, pre- and post-dialysis observations, and scheduling details. Staff G stated they did not have a defined process for dialysis residents and that improvements were needed. During an interview on 12/04/2025 at 10:30 AM, Collateral Contact 1 (CC1) associated with the Dialysis center, stated the communication expectations and clinical processes for nursing home residents receiving dialysis treatments were the nursing facility was responsible for initiating and sending all necessary communication forms to the dialysis center for completion. CC1 stated they did not recall Resident 7 ever arriving with a communication form from the facility and that the center typically received limited or inadequate information from the nursing home, aside from the weekly update sheet that the dialysis center itself provides. CC1 stated the nursing facility was expected to conduct post-treatment monitoring, explaining that residents returning from dialysis must be assessed for blood pressure drops, cramping, nausea, vomiting, or other signs of hypotension (low blood pressure). CC1 added that post-treatment vital signs should be obtained upon the resident's return to ensure stability. CC1 further stated dialysis access-site monitoring was required after treatment, including checking for breakthrough bleeding, ensuring pressure dressings were replaced with gauze and tape if needed, evaluating for signs of infection such as redness or swelling, and assessing for the presence of a bruit (the whooshing, blowing, or humming sound heard with a stethoscope over the dialysis access site). A concurrent observation and interview on 12/04/2025 at 11:16 AM, Resident 7 was in their room sitting up in their wheelchair. Resident 7 stated they went to the dialysis center on Monday/Wednesday/ Friday. Resident 7 stated they returned most evenings by 5:30 PM and did not recall staff obtaining their vital signs upon return from dialysis treatment. During an interview on 12/04/2025 at 11:20 AM, Staff B, Director of Nursing, stated they did not have a communication method that the facility was using to communicate with the dialysis center. Staff B stated they would expect physician's orders be in place and a dialysis specific care plan to reflect dialysis care and all relevant information. Staff B stated they were aware this was not being followed for Resident 7. During an interview on 12/04/2025 at 3:45 PM, Staff A, Administrator, stated they would expect any resident receiving dialysis services to be monitored pre- and post-treatment and to have a dialysis specific care plan in place. Staff A stated the correct process was not followed for Resident 7. Reference: WAC 388-97-1900 (1), (6)(a-c)

Based on observation, interview, and record review, the facility failed to promote and protect the rights of each resident, including being treated with dignity and respect, for 2 of 2 dining experiences (breakfast meal on 12/02/2025 and lunch meal on 12/05/2025), and 2 of 5 residents (Residents 35 and 51) reviewed for dignity. This failure had the potential to result in emotional distress for failed to treat residents in a dignified manner and honor their rights. Findings included . Review of the facility policy dated 12/01/2024, titled, Person Centered Care Philosophy/Resident Rights, showed the facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Federal and state laws guarantee certain basic rights to all residents of the facility and include the right to a dignified existence, be free from abuse, participate in care planning and treatment, and be supported by the facility to exercise their rights. Resident 35 Review of Resident 35's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes (a disease in which the body does not control glucose [a type of sugar] in the blood.) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The comprehensive assessment dated [DATE] showed Resident 35's cognition was moderately impaired and required assistance of one staff member with activities of daily living (ADLs). During an interview on 12/02/2025 at 11:20 AM, Resident 35 stated while they were sitting in the hallway, a staff member had placed their hand down into their shirt to feel if the resident was wearing a bra. Resident 35 stated the staff member did not ask if they could put their hand down their shirt. Resident 35 stated they do not have the right to put their hand down my shirt or pants to check to see if I'm wearing a bra or undies. Resident 35 stated it's embarrassing and that they were so upset they had gone to administration staff about it. During an interview on 12/04/2025 at 10:43 AM, Staff M, Social Services Director, (SSD), stated they recalled the 10/09/2025 incident for Resident 35. Staff M stated the resident came into their office with Staff O, Activities Director, upset and stated that a staff member had touched them to check to see if they were wearing a bra without, while sitting in the hallway, and without asking them. Staff M stated Resident 35 could not remember which staff member it was, just that it had happened in the morning. Staff M stated they had placed the incident on the grievance log and reported it to the Director of Nursing (DON) and the Administrator. During an interview on 12/04/2025 at 1:11 PM, Staff B, DON, stated, they recalled Resident 35's 10/09/2025 incident. Staff B stated they believed the Staff M went around and asked questions about the incident and spoke to Resident 35. Staff B stated that was all they knew about the incident. Staff B acknowledged that Resident 35's rights were not honored when they experienced unwanted touch in the hallway by a staff member. Dining Room During an observation on 12/02/2025 at 7:41 AM, breakfast in the south dining room showed 14 residents sitting with their breakfast meals on a pale-yellow tray while they were eating. During an interview on 12/02/2025 at 7:52 AM Staff E, Nursing Assistant (NA), stated they passed out the trays and assisted residents during meals. Staff E began to assist a resident with their meal still sitting on a pale-yellow tray. During an observation and concurrent interview on 12/03/2025 at 1:33 PM, Resident 35 in the south dining room with their empty plate on a pale-yellow tray. Resident 35 stated their meal on the tray while eating was uncomfortable, making it very easy to spill/drop their food and drinks. Resident 35 stated they would prefer their plate on a table. During an observation on 12/05/2025 at 11:35 AM, lunch in the south dining room showed all residents had their lunch meals on a pale-yellow tray while eating. During an interview on 12/05/2025 at 11:40 AM, Staff F, Dietary Manager, stated resident meals should not be left on the serving trays during their mealtime. Staff F stated, when we serve in the dining area, we take the meal off the trays to keep it like their home. During an interview on 12/05/2025 at 11:52 AM, Staff E, NA, stated they should not leave a resident's meal on the serving tray. Staff E stated they had started removing serving trays from the resident meals. During an interview on 12/05/2025 at 12:02 PM Staff C, Registered Nurse, stated they had completed dining room training years ago, and that serving trays should be removed from the meal when a resident is served. Staff C stated they were not sure when that practice had stopped. Staff C stated, this is the residents' home, and we should not be serving their meals on a serving tray. Resident 51 Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of heart disease, kidney disease and arthritis. Review of the resident comprehensive assessment dated [DATE], showed the resident was hard of hearing but understood what was said and could make their needs known. Resident 51 was alert and oriented and required staff assistance for transfers, dressing and ambulating with their walker. During an interview on 12/02/2025 at 11:36 AM, the resident was eating their lunch meal in their room. Resident 51 stated that staff did not treat them with dignity by not asking them if they wanted to get up and dressed for the day. The resident stated the staff just started moving them without explanation or permission into bed. During an interview on 12/03/2025 at 11: 40 AM, Resident 51's Power of Attorney (POA), stated that the resident was sad about the treatment and dignity of some of the ways staff treat them. The POA stated they did not want to cause problems for Resident 51. The POA stated they had spoken to the nursing staff but had no follow up. Reference WAC 388-97-0180 (1-4)

Based on interview, and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affects how the brain works, and causes changes in mood, awareness, thoughts, feelings or behavior) when they did not monitor resident specific behaviors or consistently attempt non-pharmacological interventions (alternative treatment of a resident's symptoms that do not involve medications and directed toward understanding, preventing and relieving a resident's distress or loss of abilities) prior to psychotropic medication use for 1 of 5 residents (Resident 54) reviewed for unnecessary psychotropic medications. This failure placed residents at an increased risk for falls, experiencing medication-related adverse side effects, and unmet care needsFindings included .Review of the policy titled, Antipsychotic (a type of drug that balances chemicals in the brain to manage symptoms of psychosis [when someone loses touch with reality]) Medication use, dated 01/2021, showed antipsychotic medications were to be used only when necessary to treat a specific, documented condition and not for behavioral symptoms resulting from mild symptoms like wandering or restlessness or impaired memory. The nursing staff and physician will monitor and document in detail the individualized targeted symptoms. The nursing staff will observe, document, and report what interventions were attempted and the outcome. Record review showed Resident 54 admitted to the facility on [DATE] with diagnoses to include dementia (a decline in mental ability severe enough to interfere with daily life) without behavioral disturbance and a traumatic subdural hemorrhage (a serious head injury involving bleeding between the brain and its outer covering following a blow to the head). Review of the comprehensive assessment dated [DATE] showed Resident 54 had moderately impaired cognition and required assistance of one staff member for activities of daily living (ADLs). Further review of the assessment showed Resident 54 had no wandering or refusal of care behaviors exhibited during the assessment period. Review of Resident 54's nursing progress note dated 08/10/2025, showed Resident 54 was self-transferring and walked without the use of their front wheeled walker. Resident 54 preferred to walk the halls independently. Review of Resident 54's nursing progress notes dated 08/13/2025, 08/14/2025, and 08/15/2025, showed Resident 54 had been exit seeking but staff were able to easily redirect them. Review of Resident 54's nursing progress notes dated 08/17/2025, 08/18/2025, 08/19/2025, 08/20/2025, 08/21/2025, and 08/22/2025 showed no behaviors were documented for Resident 54 during this period. Review of Resident 54's physician orders dated 08/08/2025 showed no orders were initiated to monitor for behaviors until 08/19/2025 (three days prior to an anti-psychotic medication being started) the medical record showed no non-pharmacological interventions had been implemented or documented for Resident 54 prior to the anti-psychotic medication being ordered. Review of the physician's progress note dated 08/20/2025, showed an order was written for Seroquel (a type of anti-psychotic medication) 12.5 milligrams (mg- a unit of measure) at bedtime for a chief compliant of worsening behaviors. Review of the August 2025 Medication Administration Record (MAR) showed Seroquel 12.5 mg was started on 08/22/2025 and to be given at bedtime for diagnosis of cognitive decline and sundown (a pattern of increased confusion, anxiety, and agitation that occurs in people with dementia during the late afternoon and evening) with dementia. Review of Resident 54's progress notes from 08/22/2025 to 08/28/2025 showed no documented behaviors. Further review showed a progress note dated 08/29/2025 that Resident 54 exited the front door and was immediately redirected by a visitor and was brought inside. Review of Resident 54's progress notes from 8/30/2025 to 09/03/2025 showed one episode of exit seeking and wandering in the hallway and no other behaviors were noted. Review of the physician's visit progress note dated 09/03/2025, showed an order was written to increase Seroquel from 12.5mg to 25mg at bedtime and start Zoloft (a type of anti-depressant medication) 25 mg daily for seven days and 50 mg daily thereafter. The diagnoses used were unspecified dementia sundown with hallucinations (seeing, hearing, smelling, tasting, or feeling something that is not actually there), delusions ( a false belief that someone holds true, even when presented with clear proof that it isn't), and exit seeking, even though there were no documented behaviors or progress notes to show the resident had these behaviors. Review of an incident report dated 09/11/2025 showed Resident 54 had a fall that resulted in multiple fractures (eight days after the increase of the anti-psychotic and the start of the anti-depressant medication). Review of [NAME] (2025), clinical guidelines, classify both antipsychotics and antidepressants as Fall-Risk- Increasing drugs, injuries being highest in the initial weeks after starting the medications. During an interview on 12/03/2025 at 11:30 AM, Collateral Contact 2 (CC2), stated the expectation was for clear, specific charting of resident behaviors in the medical record and non-pharmacological interventions were attempted first especially before medication initiation or dosage increases. The CC2 stated the rationale for any medication change should have been thoroughly documented and they assumed the behavior monitoring was in place based on verbal reports from nursing staff. The CC2 stated they relied on the nurses for that documentation. During an interview on 12/04/2025 at 11:09 AM, Collateral Contact 3 (CC3), associated with the Pharmacy, stated behaviors should be monitored for a minimum of 30 days prior to initiating psychotropic medications. The CC3 stated if behaviors were infrequent or showed no clear pattern, the facility should have continued monitoring. The CC3 stated the interdisciplinary team should have first ruled out underlying, non-dementia related causes for behaviors before starting a psychotropic medication. During an interview on 12/05/2025 at 10:19 AM, Staff I, Licensed Practical Nurse, stated they were aware Resident 54 had exhibited increased behaviors and updated the CC2 during rounds. Staff I reviewed Resident 54's medical record and stated they clearly did not have enough documentation to support the addition of the psychotropic medications. During an interview on 12/05/2025 at 3:45 PM, Staff B, Director of Nursing Services, stated residents prescribed psychotropic medications were expected to have resident specific behavioral monitoring and resident specific non-pharmacological interventions in place. Staff B stated Resident 54's medical record lacked sufficient documentation of behaviors, monitoring, and necessary interventions to justify adding psychotropic medication. Reference: (WAC) 388-97-1060 (3)(k)(i)(4)

Based on observation, interview, and record review, the facility failed to ensure allegations of abuse/neglect involving unwitnessed events with substantial injuries were reported to the State Agency (SA), as required for 1 of 4 residents (Residents 35), reviewed for accidents. The failure to report to the SA resulted in the facility's inability to recognize patterns of potential abuse and/or neglect. Findings included . Review of the Nursing Home Guidelines The Purple Book dated October 2015, sixth edition showed, Immediate reporting is required when there is reasonable cause to believe abuse, neglect, abandonment, mistreatment, personal and/or financial exploitation, or misappropriation of resident property has occurred. Substantial injuries of unknown source must be reported within 24 hours if, through the process of a thorough investigation, the injury is not considered reasonably related to a disease process or known sequence of events. Resident 35 Review of Resident 35's medical record showed the resident was admitted to the facility with diagnoses to include heart disease, diabetes (a disease in which the body does not control glucose (a type of sugar) in the blood) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The comprehensive assessment dated [DATE] showed Resident 35's cognition was moderately impaired and required supervision/touching assistance of one staff member for activities of daily living (ADLs). During an interview on 12/02/2025 at 11:20 AM, Resident 35 stated a staff member had placed their hand down their shirt while in the hallway to check for a bra. Resident 35 stated the staff member did not ask for permission Resident 35 stated they do not have the right to put their hand down my shirt or pants to check to see if I'm wearing a bra or undies. Resident 35 stated it's embarrassing and they were so upset they reported it to administration staff. Review of Resident 35's progress notes dated 10/09/2025 showed Resident 35 and Staff O, Activities Director, entered the Social Services office and reported that the resident was upset that a staff member had touched them without asking permission. During an interview on 12/04/2025at1:03 PM,Staff O,stated they had reported the incident the Social Worker and to the floor nurse the same day. Staff O stated Resident 35 came into the activity office visibly upset that someone had put their hand down their shirt to look for a bra without asking. Staff O stated they were not asked to write a statement. During an interview on 12/04/2025 at 1:11 PM, Staff B, Director of Nursing, stated they recalled the incident on 10/09/2025 that involved Resident 35. Staff B stated the incident should have been investigated and reported to the SA. Reference: WAC 388-97-0640 (6)(c)

Based on observation, interview, and record review, the facility failed to ensure foods were stored in a clean, dry and sanitary manner and in accordance with professional standards of cleanliness and food safety for 1 of 1 kitchen, 1 of 1 ice machine, and 1 of 1 dry storage room reviewed for food safety. This failure placed residents at risk for ingestion of contaminated food or beverages, cross contamination, and a potential food borne illness. Findings included .Review of the Washington State Retail Food Code dated, March 01, 2022, showed Food must be protected from contamination by storing food: In a clean, dry location, where it is not exposed to splash, dust, or other contamination. At least six inches (a unit of measure) above the floor. Food in packages and working containers may be stored less than six inches above the floor on case lot handling equipment. Kitchen During an observation and concurrent interview on 12/02/2025 at 6:21 AM, initial kitchen tour showed the kitchen ceiling had black dirt buildup on the pipes and ventilation fan. Further observation of the top of the stove hood identified a vent pipe that had gray, fuzzy dust and dirt buildup. During an observation and concurrent interview on 12/03/2025 at 9:36 AM, Staff Dietary Manager, stated maintenance scheduled the cleaning of the kitchen ventilation fan and pipes. Ice machine During multiple observations on 12/02/2025 at 7:14 AM, 12/03/2025 at 8:08 AM, and 12/04/2025 at 7:45 AM, showed the ice machine located in the east hallway had a white residue on the inside of top lid and a pink slimy residue on the back and side of the walls. The ice machine contained ice, and a scoop was stored in a lidded plastic container mounted on the wall next to the ice machine. Additionally, on 12/03/2024 this surveyor placed a glove and wiped across the pink residue. The residue was slimy in texture and came off onto the glove. During an observation and concurrent interview on 12/04/2025 at 1:36 PM, Staff F, Dietary Manager stated there was only one ice machine in the facility located in the east hallway and that it was used for the residents. Staff F stated that maintenance was responsible for cleaning and maintaining the ice machine. During an observation and concurrent interview on 12/05/2025 at 7:44 AM, Staff D, Maintenance Director, showed the ice machine in the east hallway with the white and pink residue. Staff D stated they were new to the facility and were aware of the cleaning of the kitchen ceiling pipes but were unsure if they were responsible for the ice machine. Staff D stated they had a maintenance to do list in their office. Staff D reviewed the maintenance to do list that showed the ice machine was the responsibility of the maintenance department. Staff D stated they also had a note pad at the nurses' station that they checked daily. Staff D stated the staff would write down things that needed to be fixed, this way they could keep up with the daily maintenance needed for residents. Dry Storage During an observation on 12/02/2025 at 6:00 AM showed the office of Staff C, Director of Rehab, had four large boxes that contained boxes of muffin mix and seven large boxes that contained bags of decaffeinated coffee, the boxes were all sitting on the carpeted floor. During an observation on 12/03/2025 at 9:59 AM, dry goods and food items were stored in Staff C's office. Observation of boxes of hashbrowns, boxes of muffin mix, and boxes of coffee sitting on the carpeted floor. During an interview on 12/04/2025 at 3:40 PM, Staff F, Dietary Manager, stated they had been storing some of the kitchen dry goods in the staffing office because they did not have enough space in their office located in the kitchen. Staff F stated they were aware of keeping the dry goods off the floor, related to the possibility of the boxes getting wet when staff were mopping in the kitchen. Staff F stated they did not think about having the boxes on a carpeted floor and the possibility of cross-contamination. Reference: WAC 388-97-1100 (3)

Based on observation, interview, and record review, the facility failed to provide food that accommodated food preferences for 2 of 4 sample residents (Resident 9 and 51), reviewed for preferences. This failure placed the resident at risk for decreased dietary intake and decreased quality of life. Findings included . Resident 9 Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include Lewy bodies dementia (a brain disorder that causes problems with thinking, movement and behaviors due to a buildup of protein clumps [Lewy bodies] in the brain that leads to memory loss and confusion) and heart disease. Review of the 10/07/2025 comprehensive assessment showed the resident was able to make their needs known and required assistance with using utensils to bring food to their mouth and to monitor swallowing once a meal was served. During an observation and concurrent interview on 12/02/2025 at 12:00 PM, Resident 9 was served chicken nuggets and French fries. The resident's food card showed the resident was on a Mechanical Soft diet (a diet of foods that are easy to chew or swallow and often modified mashing or finely chopped), due to dysphagia (difficulty swallowing). The resident stated the chicken nuggets were too hard to chew and could not eat them. Resident 9 was not offered another meal selection. Review of the 10/03/2025 care plan showed the resident required setup assistance for their meals. The resident was able to feed themself. During an interview on12/03/2025 at 9:20 AM, Staff F, Dietary Manager, stated that Resident 9 was on a mechanical soft diet. Staff F was unaware the resident required a dysphagia diet. Staff F stated the resident should have been served softer mechanical soft food. Review of Resident 9's 12/02/2025 'Crescent Health Care Diet Type Report' showed the resident was on a regular mechanical soft diet with thin liquid, Easy to chew dysphasia regular diet. Add extra butter/sauce/gravy to meals. Give super cereal (fortified with increased calories and protein) the morning for breakfast. Give a high calorie supplement three times a day. Resident 51 Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of heart disease, kidney disease and arthritis. Review of the resident comprehensive assessment dated [DATE] showed the resident was hard of hearing but could understand others and made their needs known. Resident 51 was alert, oriented and required setup assistance for meals. During an observation and concurrent interview on 12/02/2025 at 11:50 AM, Resident 51 was served a lunch tray in their room which consisted of breaded chicken nuggets and French fries. The resident could not eat the chicken nuggets and stated they could not bite into them because they were tough. The residents' Power of Attorney (POA) stated they had talked to the Administrator and nursing assistants about the resident's diet stated the resident did not like chicken or pork. Review of the resident's diet card showed the resident was on a mechanical soft textured diet. There was no documented dislike of pork or chicken on Resident 51's diet card. Review of the 12/02/2025 'Crescent Health Care Diet Type Report' showed Resident 51 was on a no added salt, low fat diet with chopped meat and thin fluids. Additional directions showed no chicken or pork, no fortified juices. extra gravy/sauces soft no raw vegetables, nothing crunchy. During an interview on 12/03/2025 at 9:15 AM, Staff F stated Resident 51 who was on a mechanical soft diet did not like pork chops which was the second entre' choice on 12/02/2025 so they served them chicken nuggets instead. The resident's diet was mechanical soft with chopped meats. Reference WAC 388-97-1100(1)

Based on observation, interview and record review, the facility failed to ensure restorative therapy services including the consistent use of braces/splints were implemented timely to prevent avoidable reduction of range of motion (ROM) and mobility for 2 of 5 sampled residents (Residents 27 and 20) reviewed for restorative therapy. Resident 27 experienced harm when they developed right and left-hand 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). This failed practice placed other residents at risk for contractures, decreased mobility, and pain. Findings included . Record review of the facility policy titled, Rehabilitative Nursing Care, dated 01/2021, showed the facility had: .Nursing personnel who were trained in restorative nursing care. The facility will have an active program for restorative nursing which will be developed and coordinated through the resident's care plan. The facility's Restorative nursing care program is designed to assist each resident to achieve and maintain the highest practicable level of self-care and independence. The facility will carry out prescribed therapy exercises between visits of the therapist and will assist residents with their routine range of motion exercises . <Resident 27> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include bilateral (both) hip osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) and scoliosis (a condition where your spine, or back bone, curves sideways). The 10/16/2024 comprehensive assessment showed the resident required supervision or touching assistance with eating, extensive assistance of two persons with repositioning, transferring, and one-to-two-person extensive assistance with all other activities of daily living (ADL's). The resident was assessed to have moderately impaired cognition, with no ROM impairment to upper extremities. The assessment further showed that the resident did not have splint placement or skilled therapies during the assessment period. Record review from a 10/11/2020 hospital discharge history and physical, showed a physician ' s assessment that documented Resident 27 ' s musculoskeletal system (the bodies structural framework and system for moving, including bones and joints) as ROM full, muscles were not tender, there were no documented contractures. Record review of the facility's physician visit progress notes, dated 10/22/2020, 10/31/2023, 02/07/2024, 05/13/2024, and 08/15/2024 showed, Resident 27's musculoskeletal system was within normal limits (no contractures noted). Further review of the physician ' s visit progress note, dated 08/28/2024, showed Resident 27 complained of not being able to keep their right hand open and the musculoskeletal system showed a documented right-hand contracture. Record review of the Physical Therapy (PT) discharge evaluation, dated 11/04/2022, showed that Resident 27 was to have a ROM restorative program. Further review of the record showed no documentation of ROM restorative programs or continued therapy were in place for Resident 27 ' s upper extremities. Record review of the Rehab Nursing Assessment's completed by Staff E, Rehab Director, dated 10/15/2020 (admitted ), showed no documented contractures. Review of the next Rehab Nursing Assessment on 07/15/2023 (two years and nine months after admission) showed no documented contractures. Additionally, the Rehab Nursing Assessment, dated 10/22/2024 (55 days after the physician diagnosed Resident 27 with a right-hand contracture) showed Resident 27 had no contractures. Record review of a physician's visit progress note, dated 09/25/2024 (28 days after contractures were noted), showed a referral was ordered for PT, Occupational Therapy (OT), and Botox (injections that help treat contractures by relaxing the affected muscles) injections at an outside specialty hand clinic for a diagnosis of right-hand contracture. Additionally, a progress note, dated 11/05/2024 showed they were unable to take Resident 27 as a patient (42 days after the order for the Botox referral) a new appointment was made to another outside specialty hand clinic for 11/21/2024 (58 days after the order for the Botox referral). Record review of a nursing progress note, dated 10/22/2024 (56 days after contractures were diagnosed ), showed Staff E, Rehab Director, documented they placed Resident 27 on a ROM Restorative program for movement of all extremities with a focus that Resident 27 would not develop contractures. Further review of the record showed no documentation of a ROM program put in place for Resident 27's upper extremities. Record review of a progress note, dated 11/22/2024, showed 1) passive ROM to hands; 2) place a dowel (a device used to help position severely contracted hands to gradually reduce contractures) to hands 3) if able to gain more motion will make custom splints, diagnosis given for significant flexion (a chronic condition that occurs when a joint is bent and cannot be straightened) contractures to hands. Record review of an OT Evaluation and Plan of Treatment, dated 12/03/2024 (70 days after the referral was ordered), showed Resident 27 had significant flexion contractures to both hands. During an interview on 12/02/2024 at 1:57 PM, Resident 27's Representative (RR) stated they had noticed the contractures to Resident 27's hands in August 2024 and they did not have contractures prior to this. The RR stated the facility did not do exercises with Resident 27's hands as far as they knew, and they were at the facility often. The RR stated they tried to do exercises with Resident 27's hands when they visited, to stretch them a little bit. The RR stated Resident 27 was unable to eat independently any longer and was not able to independently ambulate in their wheelchair as they use to. Record review of Resident 27's care plan dated, 09/01/2023 showed Resident 27 required set up and cueing for meals. Further review showed Resident 27 was able to self propel their wheelchair. Record review of the nursing assistant tasks documentation from 11/17/2024 to 12/08/2024 showed Resident 27 was totally dependent on staff for eating and wheelchair mobility. During observations on 12/04/2024 at 8:49 AM, 12/04/2024 at 2:21 PM, 12/05/2024 at 8:48 PM, 12/06/2024 at 8:15 AM and 12/09/2024 at 9:15 AM, showed no dowel or equivalent to resident 27's hands. During an interview on 12/05/2024 at 8:48 AM, Resident 27 stated they were unable to hold utensils for eating any longer and it was almost impossible for them to do activities such as bingo and coloring. Resident 27 stated they would like to get their hands fixed so they could do their activities again. Staff Q, Occupational Therapist, entered Resident 27's room during this interview and stated this was the first time they had been asked to see Resident 27 and they felt if Resident 27 had therapy to their hands daily they could stretch their hands out. Staff Q stated they were aware Resident 27 was no longer able to eat independently and that was something they were going to look into. An observation on 12/05/2024 at 11:38 AM, showed Staff R, Activities Assistant, assisting Resident 27 with eating. Resident 27 attempted to grab the spoon off of the table with their right hand and was unable to do so. Staff R tried to place the spoon into Resident 27 ' s right hand and was unable to fit the spoon between the thumb and pointer finger related to the thumb and fingers being contracted inward. During an interview on 12/09/2024 at 1:31 PM Staff E, Rehab Director stated they had just found out about Resident 27 ' s contractures on Wednesday, 12/04/2024. Staff E stated they had not noticed anything ' different or wrong with Resident 27 during their last assessment on 10/16/2024 (contractures were diagnosed during a physician's visit on 08/28/2024). Staff E stated they were angry this got missed multiple different ways. Staff E stated Resident 27 should had been on a ROM Restorative program for their upper extremities to maintain their level of functioning and was not. <Resident 20> Review of the medical record showed the resident was admitted to the facility with diagnoses to include Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and contracture to left hand. The 10/01/2024 comprehensive assessment showed the resident required extensive assistance of two staff members for ADL ' s. The resident was assessed to have severely impaired cognition, with impairment to upper and lower extremities. The assessment further showed that they had a restorative program for ROM with splint or brace assistance during the assessment period. Record review of the care plan, dated 05/14/2024, showed Resident 20 was on a nursing restorative program for passive ROM to include placing and removing the [NAME] guard splint (a device that can protect and help with issues including finger contractures and prevents further decline of contractures) to the left hand. During observations on 12/02/2024 at 3:49 PM. 12/03/2024 at 9:35 AM, 12/04/2024 at 8:51 AM 12/04/2024 at 2:10 PM, and 12/05/2024 at 9:02 AM, showed Resident 20 had no [NAME] guard splint to their right hand. During an interview on 12/05/2024 at 9:08 AM, Staff Z, Nursing Assistant, (NA) stated they were not aware of any restorative programs and were unable to explain what a restorative program was. Staff Z stated Resident 20 did not have any splints or devices that were to be placed in their left hand that they were aware of. Additionally, Staff Z stated they did not do any exercises for Resident 20. During an interview on 12/09/2024 at 1:54 PM, Staff E stated Resident 20 was to have their splint placed every morning and removed in the evening. Staff E stated it was a restorative program, and they were not aware the program was not being followed, and the process was broken. During an interview on 12/03/2024 at 2:31 PM, Staff AA, NA, stated they were the restorative NA and had been pulled to the floor related to low staffing a while ago (one year ago). Staff AA stated they tried and do a little bit of the programs as they were working but were not able to get to any residents that were not on their assigned hallway. During an interview on 12/03/2024 at 2:44 PM, Staff O, NA stated they completed the restorative programs for residents if they were not busy. Staff O stated they were unable to do any programs that day during their shift they were just too busy. During an interview on 12/03/2024 at 2:49 PM, Staff N, NA, stated they only completed the walking programs on their residents. Staff N stated they have not been trained how to do ROM programs, so they did not complete them. During an interview on 12/09/2024 at 12:13 PM, Staff A, Administrator, stated they would expect braces and splints to be placed as ordered and any resident showing a decline to be evaluated and treated by both the Restorative Nurse and Therapy in a timely manner. Reference: WAC 338-97-1060 (3)(d)

Based on observation, interview, and record review the facility failed to consistently assess skin and/or wounds or implement interventions to ensure the prevention and the worsening of facility-acquired pressure injuries (PI) for 1 of 4 residents (Resident 30) reviewed for PIs. Resident 30 experienced harm when they developed three avoidable PIs (right heel, left heel, and left calf) that were not present upon admission, and a decreased quality of life due to the pain. Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 PI 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 PI is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. <Resident 30> Review of Resident 30's medical record showed they admitted on [DATE] with diagnoses to include kidney and heart failure. The 10/22/2024 comprehensive assessment showed the resident's cognition was severely impaired, and substantial to maximum staff assistance with bed mobility and transfers. The assessment also showed the resident was at risk for developing PIs and had no PIs on admission. Review of the October 2024 Treatment Administration Record (TAR) showed an order on 03/17/2024 to monitor heels daily, ensure they are floating (a process that allows the legs to be elevated on pillows that keep the heels from touching the bed), and document weekly (no specified day of the week) for mushy [soft] heels; an order on 10/11/2024 to monitor an abrasion (superficial cuts or scrapes to the skin that occur due to impact, pressure, or friction) to the left outer lateral calf daily; an order on 10/30/2024 for treatment to a pressure wound to the left outer lateral calf (unstaged) and to ensure offloading [positioning the body so that pressure does not rest on top of the wounded area], and the TAR showed no orders for the Stage 1 PI to the right heel. Review of the November 2024 TAR showed an order on 11/07/2024 for treatment to a left heel pressure wound (unstaged). An observation on 12/02/2024 at 9:45 AM, showed Resident 30 lying in bed, on their back, with the head of the bed elevated. There were two purple, foam, heel protectors (used to cradle and cushion sensitive heel/ankle areas, helping protect against nerve damage, bed sores and skin breakdown) sitting on the seat of a chair in the corner of the room, at the end of the bed. Additionally, there was an air mattress overlay (an additional support surface designed to be placed directly on top of an existing surface) on the bed. An observation and concurrent interview on 12/03/2024 at 9:01 AM, showed Resident 30 lying in bed on their back, both purple heel protectors sitting on the chair in the corner of the room. Resident 30 had facial grimacing and was moaning ow, ow. Resident 30 pointed to their left lower leg when asked where their pain was and lifted their left leg slightly off the bed. An observation and concurrent interview on 12/03/2024 at 2:01 PM, showed Resident 30 lying in bed and purple heel protectors were located in the same place as previously observed at 9:01 AM. Staff M, Nursing Assistant (NA), and Staff N, NA, provided incontinence care to Resident 30. Staff M stated Resident 30 had a wound to their left calf and left heel. The left calf was covered with a white gauze bandage, there was a dressing patch over the left heel, and the ball of the top of the left foot, underneath the toes, was bright red. Also, the right heel had an area the size of a quarter that was slightly green, brown, and purple in color. Staff M stated they observed Resident 30 had an area to their left lower calf area that wasn't right and they had reported it to the nurse. Staff M stated they did not have a place to document abnormal findings and could not recall when it was reported, what nurse they reported it to, or what the area looked like at that time, only that the left lower calf area had worsened from when they originally reported it. Lastly, Staff M stated due to Resident 30 ' s wound to their left calf, they could no longer transfer to their wheelchair to get up and out of their bed as often as they used to. Review of nursing progress notes from 09/08/2024 through 12/08/2024 (90 days) showed no weekly documentation had been charted for the weekly heel assessments other than notes that showed the heels were floated. A crossed-out progress note on 10/10/2024 at 2:09 PM showed Staff M reported a red mark to Resident 30's left outer lateral calf, what appears to be an abrasion; and a note on 10/18/2024 at 2:43 PM that showed a Stage 1 PI to the right heel with no measurements, description, or treatment orders to monitor; and a note on 11/06/2024 that showed a pressure area to the left heel with no description or measurements. Review of the weekly skin observation assessments showed as follows: on 11/17/2024 (41 days after the previous skin assessment), a Stage 2 PI to the left heel two centimeters (cm, a unit of measure) by 2.5 cm and an Unstageable PI to the left outer calf that measured 4.5 cm by one cm. The 12/05/2024 (18 days after the previous assessment) skin observation assessment showed a PI to the left outer calf that measured five cm by three cm with areas of necrotic (dead) tissue and opened areas. The assessment did not show the left heel PI, or the right heel area observed by the Surveyor on 12/03/2024. There were no other weekly skin assessments for the left outer calf, left heel, or right heel. Review of the 10/28/2024 contracted medical provider's note, showed Resident 30 was assessed to have a Stage 1 PI to their left calf. The contracted provider's note on 11/08/2024 showed a Stage 2 PI to the left heel, and an opened, beefy red area. The note further showed the right heel was redness/boggy [soft] and to float the heels or obtain Podus boots (a type of boot/splint that is used to help keep pressure off the heel to prevent heel ulcers or relieve pressure if ulcers start) for offloading. The note showed the Stage 1 PI to the left outer calf was opened. The contracted medical provider's note on 12/06/2024 showed an unstageable pressure ulcer [injury] to the left calf. Additional observations on 12/04/2024 at 8:40 AM, showed Resident 30 lying in bed, slightly positioned to their right side and sleeping. The two purple heel protectors were on the chair in the corner of the room. An observation at 11:31 AM, showed Resident 30 in the same position and Staff O, NA, picked a pillow up off the floor at the end of the bed, picked up the two heel protectors and placed the pillow on the chair with the heel protectors placed on the pillow. Staff O then repositioned the resident's pillows under their head but did not assess their legs/feet to see where the pillow on the floor belonged, nor did they reposition the resident. An observation at 2:42 PM, showed Resident 30 lying in the same position observed at 8:40 am and 11:31 AM, heel protectors were in the chair, and the resident's legs were floated on a pillow, but the pillow was not thick enough for the heels to be floated, so they rested on the bed. An observation and concurrent interview on 12/05/2024 at 8:51 AM showed the resident lying in bed on their back. Resident 30 stated they liked bingo and would like to attend if their pain was tolerable. Resident 30 had a flat pillow underneath both calves and their heels rested on the bed. The purple heel protectors were sitting on the chair in the corner of the room. During an interview on 12/05/2024 at 1:31 PM, Staff S, NA, stated Resident 30 required staff assistance for bed mobility and could not do that on their own. Staff S stated when a resident had an intervention or equipment change, they would find that information in the care plan (CP). Staff S stated the purple heel protectors were for the resident's heels but didn't believe they were to use them anymore and they had not been taken out of the room yet. An observation and concurrent interview on 12/06/2024 at 11:32 AM, showed the Contracted Medical Director (CMD), along with Staff C, Resident Care Manager, and Staff G, Registered Nurse, changed and assessed Resident 30's wound to the left calf. Staff C removed the dressing, and the wound was less than 10 inches in length, from upper calf to the lower portion of the calf, located on the outer, posterior part of the calf. There were brown, hardened areas that ran about three quarters of the way down the wound, less than two centimeters wide, with the upper portion having an area the size of a baseball of brown hardened areas that showed some lifting off of the hardened brown areas with stringy skin attaching the hardened area to the wound. The edges around the wound were bright red (assessed as an unstageable pressure injury per the CMD). The resident had been pre-medicated prior to the dressing change but was still moaning out in pain during the dressing change. Staff C stated when asked if they were going to measure the wound, no, that was done yesterday during the dressing change. There was a dressing to the left heel that the CMD asked to be removed so they could assess it. There was an opened, 1.5 cm PI to the left heel. The CMD assessed the right heel, which showed a quarter sized, dark purple area to the upper portion of the heel. Review of Resident 30's 10/03/2024 CP showed a 12/03/2023 focus for Activities of Daily Living (ADLs, basic skills you need to perform daily life activities, such as bathing, dressing, and eating ) deficit with an intervention to float the resident's heels while in bed; a 07/05/2024 fall prevention intervention to reposition Resident 30 in bed with care interactions; and an 11/06/2024 skin integrity focus for the left heel PI that showed a treatment intervention and for staff to use a draw sheet or lifting device to move the resident. The CP showed no focus for the left outer calf PI, the use of the air mattress overlay, or the purple heel protectors. During an interview on 12/06/2024 at 3:10 PM, Staff C stated skin and wound assessments were to be completed weekly using the skin observation assessment form. Staff C stated the last one they could find was from 11/17/2024. Staff C stated the purple heel protectors in Resident 30's room were to be used for Resident 30's heels and was not aware they were not being used. An observation on 12/09/2024 at 8:38 AM, showed Resident 30 lying in bed on their back, feet floated on a flat pillow so both heels were resting on the air mattress. One of the purple heel protectors was sitting in the chair and one on the floor underneath the chair, in the corner of the room. Additional review of the December 2024 TAR on 12/09/2024, showed no new orders for treatment or monitoring to the new PI to the right heel that was assessed on 12/06/2024. During a follow-up interview on 12/09/2024 at 11:11 AM, Staff C stated they missed updating the CP with the LLE PI and the heel protectors. Staff C stated they were not aware of a new PI to the right heel of Resident 30 and would assess and update the TAR. During an interview on 12/09/2024 at 2:34 PM, Staff B, Director of Nursing Services, stated Licensed Nurses (LNs) were required to complete weekly skin assessments on the skin observation assessment form and wound assessments should be done at the least weekly if not being done with every dressing change and was not aware those were not getting done. Staff B stated the Resident Care Managers were required to update the resident CPs at the time of changes in condition but since they worked the floor quite often, they were sure things were missed. Staff B stated NA staff were required to turn and reposition residents at the least, every two hours and if they had skin issues, it should be more often. Reference WAC: 388-97-1060 (3)(b)

Based on observation and interview, the facility failed to provide routine and repair maintenance services for a safe and sanitary environment in 1 of 1 kitchen. This failure placed residents at risk for infection by not having cleanable and maintained surfaces. Findings included . <Floor under the Oven/ Oven top dust> An observation on 12/02/2024 at 9:20 AM, showed the kitchen floor under the oven's right leg support, had an uncleanable, broken, and missing area of rubberized concrete which measured 6 inches by 4 inches. During an observation on 12/02/2024 at 9:23 AM, showed the top of the oven had several stainless steel appliances and inserts used for the steam table that were piled on top of the dusty oven. <Leaky Faucets> An observation on 12/02/2024 at 9:30 AM, showed the clean sink area had a leaking water faucet. Additional observations on 12/05/2024 at 11:10 AM and 12/15/2024 at 11:15 AM, showed the water leak had increased to the second faucet. During an interview with Staff FF, Dietary Manager, stated they had previously reported the issue a week before to Staff I, Maintenance Director, and they had stated they had ordered washers for the faucet. <Flour, powdered milk, and other dry good storage> An observation on 12/02/2024 at 9:45 AM, showed there were white plastic barrels with covers that were labeled powdered milk, flour, and other dried goods. The barrels were on rolling wheels and stored under the steam table. Due to the steam table's constant temperature of 180 degrees to 190 degrees Fahrenheit and the moisture created from the steam table, could affect the quality, texture, and shelf life of the stored products. During an interview on 12/02/2024 at 9:48 AM, Staff FF stated they had hardly any storage in the kitchen and they were unaware the moisture from the steam table, that was on constantly, could affect the dried goods stored under the steam table. < Black fuzzy dust on vents/ exposed insulation> An observation on 12/05/2024 at 11:10 AM, showed two dirty vents on the ceiling with black fuzzy dust, one on the dirty side of the kitchen and one on the clean side. The vent that was located on the dirty side of the kitchen showed a split in the ceiling on both sides. To the left side of the vent had a two-foot split with yellow insulation showing and to the right of the vent showed a foot and a half open seam with yellow insulation exposed. During an interview on 12/05/2024 at 12:00 PM, Staff FF stated they had not had a maintenance person for a while. Staff GG stated they now reported the kitchen issues to Staff I. During an interview on 12/06/2024 at 11:00 AM, Staff A, Administrator, stated they were unaware of the kitchen repair issues and needed to observe the kitchen. Staff A stated that the issues needed to be fixed. Reference WAC 388-97-3220(1)

Based on observation, interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice for 3 of 4 residents (Residents 12, 27, and 38) reviewed for trauma informed care. The facility failed to identify triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding history of Post-Traumatic Stress Disorder (PTSD, a mental health that is triggered by a terrifying event) and interventions. This failure placed the residents at risk for unidentified triggers and re-traumatization. Findings included . <Resident 12> Review of the medical record showed Resident 12 was readmitted to the facility with diagnoses to include end stage kidney disease with kidney dialysis (process of cleaning waste from the blood artificially), heart disease and failure, left above the knee amputation, and amputation of their penis due to gangrene (death of tissue due to lack of blood flow). Review of the [DATE] assessment showed the resident was alert and able to make their needs known. During an interview on [DATE] at 9:00 AM, Resident 12 was up in their wheelchair in the front room area of the facility, looking out of the large picture window facing the parking lot. When asked about how the resident was doing and how things were going with their care, Resident 12 stated they were very unhappy about their care at the facility. Resident 12 stated this past year had been hard on them with their spouse passing away, losing their left lower leg, and now possibly their right leg. The resident stated they had gangrene and an infection of their penis which was amputated, and now they had a suprapubic catheter. Resident 12 stated they felt they had lost their manhood. The [DATE] psychosocial history assessment completed by Staff H, Social Services Director (SSD), showed the Resident 12 was a widower. The assessment did not show Resident 12's most recent trauma. During an interview on [DATE] at 9:45 AM, Resident 12 was seated in their wheelchair in the front room of the facility with tears in their eyes and stated they were very sad about the loss of their spouse, the loss of their leg, and their manhood. The resident stated they had disturbing dreams of not improving, and they were worried about not being able to stand on their right leg/foot. Resident 12 stated they wanted their right leg to heal so they could walk again, but they were not sure if that would happen. Review of Resident 12's [DATE] care plan showed no care plan focus for Resident 12's trauma concerns, triggers from the resident's conditions from the loss of their wife and amputations, or associated interventions to manage their identified trauma. During an interview on [DATE] at 12:53 PM, Staff H stated they were aware Resident 12 was widowed but unaware the resident's loss of their wife was so recent. Staff H stated they were unaware that Resident 12's loss of their penis and illnesses, to include amputations, were a significant trauma to them. Staff H stated they did not assess Resident 12 further to determine how the resident's health conditions impacted their mental health well-being. <Resident 38> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include cataracts (opacity of the lens of the eyes), dementia (cognitive impairment), and multiple falls with fracture. During an interview on [DATE] at 10:38 AM, Resident 38 stated they were disgusted and stated they did not like being at the facility and began to cry. Resident 38 stated they felt isolated from their Resident Representative (RR) and they felt that the RR did not want them. Additionally, Resident 38 stated they still were unable to forgive themselves regarding their younger child who died of alcoholism. Resident 38 stated it continued to bother them because they also had an issue with alcohol in the past. During an interview on [DATE] at 10:31 AM, Staff DD, Social Services Assistant, stated they were aware the resident had regrets about their child dying at a young age from alcoholism. Review of the [DATE] psychosocial history (completed by Social Services) did not reflect any of the issues discussed by Resident 38 or Staff DD. During an interview on [DATE] at 11:00 AM, Staff H stated there were no triggers or trauma-based care plan identified or initiated for Resident 38. 48368 <Resident 27> Review of Resident 27's medical record showed the resident admitted to the facility with diagnoses to include PTSD, anxiety (a feeling of fear, dread, or uneasiness), and depression (a prolonged feeling of sadness, hopelessness, or loss of interest in activities). The [DATE] comprehensive assessment showed Resident 27 required the assistance of two staff member for activities of daily living (ADLs, performing basic care needs) and was cognitively intact. During an interview on [DATE] at 1:51 PM, Resident 27's RR stated the resident had PTSD stemming from their parents not understanding their behaviors, so they yelled a lot, it was an ongoing thing. The RR stated Resident 34's triggers were yelling, and when anyone would yell out, Resident 27 would start yelling out with them. Record review of Resident 34's care plan, dated [DATE], showed no trauma informed based plan of care that included Resident 27's diagnosis of PTSD, triggers, behaviors, or interventions. During an interview on [DATE] at 2:01 PM, Staff H stated the process for trauma informed care was to fill out the PTSD form (which was not a trauma assessment) which included the resident's specific triggers and interventions. Staff H stated Resident 27's triggers and interventions should had been assessed and placed in the plan of care. Staff H stated Resident 27 did not have a trauma or PTSD assessment completed. Staff H further stated the trauma informed care process was not followed for Resident 27. During an interview on [DATE] at 3:50 PM, Staff B, Director of Nursing Services (DNS), stated that there was no assessment tool in the electronic health record for a trauma assessment. Staff B stated there were no trauma assessments completed for residents . WAC Reference: [DATE] (3)(e)

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR, a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment accurately reflected residents' mental health conditions for 2 of 5 residents (Resident 16 and 8) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 16> Review of the resident's medical records showed they admitted on [DATE] with diagnoses to include a stroke (when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients) and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). The 10/23/2024 comprehensive assessment showed Resident 16's cognition was severely impaired. The assessment also showed the resident had poor appetite and felt down and depressed. Review of Resident 16's 09/23/2024 PASARR assessment, showed the assessment was not completed by the hospital, but by Staff C, Resident Care Manager (RCM), upon admission to the facility. Resident 16 was identified to have a mood disorder with a yes answer for section A, question 1. The PASARR showed a level two evaluation was not indicated (even though one was required). <Resident 8> Review of Resident 8's medical record showed the resident admitted to the facility with diagnoses to include anxiety (a feeling of fear, dread, or uneasiness). The 10/29/2024 comprehensive assessment showed Resident 8 required the assistance of one to two staff members for activities of daily living and had a moderately impaired cognition. Review of a 07/18/2024 Level 1 PASRR section I: Serious Mental Illness/Intellectual Disability or related condition showed Resident 8 had an anxiety disorder. Further review showed No level 2 evaluation was indicated (even though one was required). During an interview on 12/09/2024 at 11:36 AM, Staff C and Staff D, RCM, stated they completed PASARRs on admission and did not know they were to be reviewed prior to the resident admitting to the facility. Staff D and Staff C stated they did not know the PASARR regulations had changed as of 07/01/2024 and were not offered/provided training. During an interview on 12/09/2024 at 12:47 PM, Staff A, Administrator, stated they were not aware of the changes to the PASARR had already been put into place and had not heard about any training on the new regulations. Reference WAC: 388-97-1915 (1)(2)(a-c) 48368

Based on interview and record review the facility failed to have a system in place to promptly resolve grievances that were voiced in Resident Council (a formal meeting for facility residents to communicate preferences and concerns) for 1 of 4 residents (Resident 9) who expressed concerns about broken medical equipment that had been reported during the meeting and not resolved. Additionally, 4 of 4 residents (Residents 13, 4, 6 and 33) who regularly attended Resident Council were unaware of how to file a grievance (a formal complaint by a resident or resident representative [RR]) or who the facility Grievance Officer was. These failures placed residents at risk for overall dissatisfaction with their lives and unresolved concerns. Findings included . Record review of a facility policy titled Resident Grievance updated 09/2023 showed a grievance was defined as a complaint or concern that a resident had about care, services, or any other problem that may arise during their stay. The Grievance Officer is the Social Services Director. The Director of Nursing or the Administrator investigates (the grievance). The resident and/or responsible party will be notified of the results of the investigation which may be requested in writing. A copy of all grievances filed by a resident, as well as the solutions, will be filed in a confidential file in the Administrators office . <Resident 9> Review of the resident's medical record showed they admitted with diagnoses to include hospice services (specialized services for end of life care) and diabetes (how your body uses sugar for energy). The 09/11/2024 comprehensive assessment showed Resident 9's cognition was moderately impaired. An observation and a concurrent interview on 12/03/2024 at 9:53 AM, showed Resident 9's bathroom had a toilet riser (a portable toilet seat that adds height to an existing toilet) with handles to each side that was not secured/fastened to the toilet. The bathroom also had portable handrails to each side of the toilet, that were not secured to the floor or the wall and had a broken, right, handrail grip. Resident 9 stated they had communicated the broken bathroom equipment a month or two ago in a resident group meeting (Resident Council) but was told nothing could be done about the equipment. During an interview on 12/06/2024 at 10:00 AM, Staff V, Activities Director (AD), stated they recalled Resident 9 voicing a concern about their bathroom toilet being wobbly and stated they reported it to maintenance either by writing it in the maintenance book or verbally telling them. Staff V stated resident concerns voiced during Resident Council were reported on the notes that were taken during the meeting and then sent to each department head. Staff V stated then each department head would address the concerns. Staff V stated they did not initiate grievances for resident concerns brought up in Resident Council because they assumed the concerns were taken care of by the individual departments. Staff V stated they did not follow up with those concerns to ensure they had been followed through. Record review of the Resident Council meeting minutes from May 2024 to November 2024 showed no concerns had been documented for Resident 9 related to their broken bathroom equipment that was brought up in Resident Council. Review of the Maintenance book from 05/30/2024 through 12/05/2024 showed no written concerns for Resident 9's bathroom equipment. During an interview on 12/09/2024 at 9:26 AM, Staff I, Maintenance Director, stated they were not aware of Resident 9's bathroom equipment. Staff I stated they had not seen it in the maintenance book nor had they been told about them. During an interview on 12/09/2024 at 12:47 PM, Staff A, Administrator, stated resident concerns verbalized in Resident Council should be written in the minutes, then sent to each department head, and then addressed by the department head. Staff A stated the Maintenance director was responsible for completing environmental checks on the resident's equipment, but had just started 10/01/2024, and may not have been able to do those recently. On 12/04/2024 at 1:15 PM, Resident's 13, 4, 6 and 33 attended Resident Council meeting. Resident 13 stated they were the Resident Council President and the council met monthly. Resident 13 stated they did not know how to file a grievance or who the Grievance Officer was. Resident's 4, 6, and 33 stated they were also not sure how to file a grievance or who the facility Grievance Officer was. During an interview on 12/05/2024 at 1:40 PM, Staff V stated they assisted the residents to organize monthly Resident Council meetings and took minutes. Staff V further stated there was no formal process or documentation of concerns from Resident Council meetings. Staff V stated they gave a copy of the meeting minutes to the department heads to review and provide any follow up as indicated. Staff V stated they were unaware that the concerns may be considered grievances. During an interview on 12/05/2024 at 2:50 PM, Staff A, Administrator, stated the Grievance Officer was Staff H, Social Services Director. Staff A stated residents were given the Grievance policy and a blank grievance form in their admit packet. Staff A stated they did not fill out grievance forms from information brought up in Resident Council. Their process was to pass out the Resident Council minutes to department heads who were responsible to provide follow up on resident concerns the only documentation would be provided in the residents record. During an interview on 12/09/2024 at 1:40 PM, Staff H stated they were the Grievance Officer and were responsible to provide resolution for resident concerns. Staff H stated they attended Resident Council meeting, so they were aware of resident concerns brought up in the meetings. Staff H stated they did not initiate written grievances based on concerns brought up by the residents in the Resident Council meeting. The process was the AD sent the meeting minutes to the department heads and if they heard the concern was not resolved they would go and interview the resident which was not documented on a Grievance form to give to the resident or the RR, further stating sometimes I write something in the residents record. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to ensure quarterly (every three months) personal fund statements were provided to residents and/or resident representative (RR) for 3 of 5 sampled residents (Resident 20, 23, and 27) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility. Findings included . <Resident 20> Review of the medical record showed the resident was admitted to the facility with diagnoses to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The 10/01/2024 comprehensive assessment showed the resident required extensive assistance of two staff members for activities of daily living (ADL's basic care needs) and had severely impaired cognition. During an interview on 12/03/2024 at 9:33 AM, the RR stated they had not received any statements regarding Resident 20's personal funds. <Resident 23> Review of the medical record showed the resident was admitted to the facility with diagnoses to include cerebral palsy (damage to or abnormalities inside the brain that disrupt the brain's ability to control movement and maintain posture and balance). The 09/24/2024 comprehensive assessment showed the resident required extensive assistance of one staff member for ADL's and had an intact cognition. During an interview on 12/03/2024 at 9:00 AM, Resident 23 stated they did not receive any statements regarding their personal funds. <Resident 27> Review of the medical record showed the resident was admitted to the facility with diagnoses to include scoliosis (a condition where your spine, or back bone, curves sideways). The 10/16/2024 comprehensive assessment showed the resident required extensive assistance of two staff members with repositioning, transferring, and one to two staff members for all other ADLs, and had moderately impaired cognition. During an interview on 12/02/2024 at 2:03 PM, Resident 27's RR stated they had not received any personal fund statements, they assumed it all went for their care. During an interview on 12/06/2024 at 10:56 AM Staff A, Administrator, stated their process was to send personal fund statements out quarterly. Staff A stated they were behind and had not sent any statements out in almost a year. Reference WAC 388-97-0340(3)(a)(b)(c)

Based on observation, interview, and record review, the facility failed to comprehensively assess and monitor the need of physical restraints (posey (a brand of roll bolsters, an alternative to bed side rails to help protect alert patients from rolling out of the bed) for 2 of 4 residents (Residents 30 and 39) reviewed for physical restraints. In addition, the facility failed to obtain consents in the language the resident was able to read/understand, to document ongoing re-evaluation for the need of the restraint, and to ensure a least restrictive intervention were attempted prior to the use of the restraint. This failed practice placed residents at risk for a diminished quality of life, freedom of movement in their bed, and skin breakdown. Findings included . <Resident 30> Review of the resident's medical record showed they admitted with diagnoses to include a mood disorder (a group of mental conditions that affect a person's general emotional state) and heart failure. The 10/22/2024 comprehensive assessment showed Resident 30's cognition was severely impaired, had range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) to both legs, and required substantial to maximum assistance for bed mobility. During an observation on 12/03/2024 at 2:01 PM, showed Resident 30 being provided incontinence care. Resident 30 was lying in bed, on their back, with an air overlay mattress (an additional support surface designed to be placed directly on top of an existing surface) placed on top of the mattress. Between both mattresses there was a set of roll bolsters jammed up underneath the air overlay. The positioning of the roll bolsters caused the air overlay mattress to be curled up on the sides, towards the resident's body (waist and hip area), to immobilize them towards the middle of the bed. Review of the October 2024, November 2024, and December 2024 physician orders showed no orders for the roll bolsters. Review of Resident 30's 12/14/2023 and 10/07/2024 Rehab assessments, showed no assessment had been completed for the use of the roll bolsters. Additionally, the assessment did not show least restrictive devices were assessed or used prior to the roll bolsters being placed. There was no on-going reassessments to show the roll bolsters were appropriate for use. Review of 12/03/2024 care plan showed a focus for fall prevention with interventions on 04/10/2024 for roll bolsters to both sides of the bed for improved self positioning and use of soft pillows to both sides of the bed for improved self positioning. During an interview on 12/03/2024 at 2:01 PM, Staff M, Nursing Assistant (NA), stated Resident 30 insisted on getting up on the night shift and because there was not enough staff to get them up, it's safer to put those [roll bolsters] there so [Resident 30] don't get up and get hurt During an interview on 12/06/2024 at 1:48 PM, Staff E, Restorative Director, stated Resident 30 needed the roll bolsters to maintain their alignment in bed while they were sitting up eating. Staff E stated they attempted to use soft pillows and rolled up blankets underneath the sheets and mattress, to keep the resident midline, but Resident 30 was rolling over the top of them so Staff E changed to the roll bolsters. Staff E stated they did not reassess interventions to see if they were still appropriate nor was there a medical diagnoses for using the roll bolsters. Additionally, Staff E stated they did not obtain physician orders or consents from the Resident or the Resident's Representative for the use of the roll bolsters. <Resident 39> Review of the residents medical record showed they were admitted with diagnoses including a stroke (blood supply is cut off from the brain), dementia (an ongoing brain disease that affects memory and judgement), and depression. The comprehensive assessment dated [DATE], showed the resident was severely cognitively impaired and required substantial assistance for bed mobility, dressing, and grooming. During multiple observations on 12/03/2024 at 3:10 PM, 12/04/2024 at 9:24 PM, 12/04/2024 at 2:10 PM, 12/05/2024 at 12:14 PM and 12/06/2024 at 3:30 PM showed resident 39 with bilateral roll bolsters attached to the sides of their bed which limited their freedom of movement and kept them positioned midline on their back. Record review of Resident 39's physician orders dated October 2024, November 2024, and December 2024, showed no order for the roll bolsters to identify medical rationale for their use as the roll bolsters limited their freedom of movement. Additional review of the record showed no assessment had been completed on the roll bolsters to justify and assess the necessity of their use. During an interview on 12/05/2024 at 2:15 PM, Staff D, Resident Care Manager, stated Resident 39 was very active in their bed movement and the roll bolsters were placed to prevent them from getting turned around in bed. During an interview on 12/09/2024 at 2:21 PM, Staff B, Director of Nursing Services, stated they were not familiar with roll bolsters and was told they were used to keep the residents' midline in bed. Staff B stated regardless of their knowledge of the equipment, they would expect an assessment, order, and consents, if needed to be used, and a re-assessment for continued use. Reference WAC: 388-97-0620 (1) 39652

Based on observation, interview, and record review, the facility failed to provide care that maintained a resident's dignity for 1 of 2 sampled residents (Resident 12) reviewed for dignity. This failure placed the resident not able to maintain their bowel continence (using the commode) status and only received one shower a week. These failures caused embarrassment for bowel incontinent accidents and lack of shower/cleanliness before going to appointments and family visits. This placed the resident at risk for decreased quality of life. Findings included . <Resident 12> Review of the medical record showed Resident 12 was readmitted to the facility on [DATE] with a fracture of the right lower leg and no weight bearing to the right leg. Diagnoses include end stage kidney disease with kidney dialysis (process of cleaning waste from the blood artificially), heart disease and failure, left above the knee amputation, diabetes (disease that occurs when your blood sugar is too high), gangrene (death of tissue due to lack of blood flow) of right fingers and left finger. Review of the 10/21/2024 assessment showed the resident was alert and able to make needs known, required a mechanical lift with assistance of two staff to transfer the resident to and from their wheelchair, bathroom, shower, and bed. The resident was continent of bowel and had a suprapubic catheter (a device that is inserted into the bladder to drain urine). The resident was not on a scheduled bowel toileting program. An observation and concurrent interview on 12/03/2024 at 8:45 AM, the resident was up in their wheelchair in the front room area of the facility, looking out of the large picture window facing the parking lot. The resident's right leg was elevated on a wheelchair leg extension with a brace and dressing to the right lower leg and upper right foot. The resident was amputated to above the left knee. When asked about how the resident was doing and how things were going with their care, Resident 12 stated they were very unhappy about their care at the facility. Resident 12 stated staff used the Hoyer (mechanical lift) to get them up. Resident 12 stated they preferred to use my own underwear not a plastic brief. The resident stated staff do not come in when they use their call light to use the bathroom and they messed in their underwear. The resident stated they were to receive one shower a week which was not enough for them. Resident 12 stated they would prefer to shower before appointments and on Saturday mornings before their family visits. Resident 12 had asked staff to have an extra shower a week, but they stated to the resident they had no time. The resident stated even though their assigned shower day was Tuesdays there were no set times and sometimes was a different day. Review of the Nursing Assistant (NA) Bowel continence task charting for Resident 12 showed on 12/03/2024 three incontinent bowel episodes, 12/04/2024 one incontinent bowel episode, and on 12/05/2024 one incontinent bowel episode. The NA task for showers given for the end of November 2024 and beginning of December 2024 showed three showers given on 11/19/2024, 11/26/2024, and 12/05/2024. Review of the 10/10/2024 care plan for Resident 12 showed for toilet use a two person Hoyer to the commode, and to give a shower or sponge bath; do not rub skin, and there was no identified timed toileting schedule for Resident 12. During an interview on 12/05/2024 at 9:29 AM, Resident 12 stated they had to wait to have a bowel movement for the Hoyer so they could use the commode, and had an incontinent bowel episode. During an interview on 12/05/2024 at 8:50 AM, Staff M, NA, stated the residents usually get one bath a week. It's difficult to use the Hoyer quickly when it requires two staff to operate it. Resident 12 had some incontinent bowel incidents. Staff M stated there were no directions/interventions on the 10/10/2024 care plan for Resident 12's toileting schedule. Staff M stated the resident was able to use their call light for their needs to use the commode and to have a bowel movement. During an interview with Staff B, Director of Nursing Services, stated that there would need to be another assessment to determine the resident's needs for a toileting program and more showers during the week. Resident 12 needs to be able to remain continent of bowel and the staff will need to accommodate their needs. Reference WAC 388-97-0108 (1-4)

Based on observation, interview and record review, the facility failed to identify and correct environmental hazards for assistive devices (wheelchair) and complete assessments for fall risks to reduce and/or eliminate falls for 3 of 4 residents (Resident 50, 25, and 48) reviewed for accident hazards. These failures placed the residents at risk for avoidable accidents and resulted in actual harm to Resident 50, when they experienced a fall from their wheelchair when the right brake failed to stay locked during a transfer from their wheelchair to their recliner, resulting in a fractured (broken) right wrist. Findings included . Review of the facility policy titled, Falls - Clinical Protocol, dated 01/2020, showed the nursing staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. <Resident 50> Review of the medical record showed Resident 50 was admitted to the facility on [DATE] with diagnoses including surgical amputation (loss or removal of a body part) of the left leg, and a blood infection. The 09/20/2023 comprehensive assessment showed the resident required limited assistance of one staff member for activities of daily living (ADLs). The assessment also showed the resident was cognitively intact and able to make their own decisions. Review of Resident 50's medical record showed a Fall Risk Assessment was not performed at the time of their admission to the facility (06/15/2023). Resident 50 experienced falls on 06/21/2023, 06/29/2023, 07/19/2023, 08/13/2023 (fall with major injury), and 10/25/2023. There was no evaluation to determine the need for additional fall interventions. There were no additional fall interventions added to Resident 50's care plan from 07/01/2023, until a restorative nursing program was initiated on 08/30/2023, despite the resident experiencing two additional falls. Review of a facility investigation report, dated 08/12/2023 at 10:20 PM (same day as the fall), showed Resident 50 was observed in their room, sitting on the floor, facing their recliner with their back against their wheelchair. The resident was holding their right wrist, was tearful, and stated their right wrist hurt. Resident 50 stated they were trying to get out of their wheelchair. When they stood up, the wheelchair rolled back. Resident 50 stated the right brake on the wheelchair was broken. They stated they had told staff the day before (the fall) that it was broken, and it did not lock. The report showed Staff D, Licensed Practical Nurse (LPN), verified the right wheelchair brake was not working at the time of the fall. Review of hospital medical records dated 08/15/2023 at 12:55 AM, two days after the fall, showed the resident was admitted to the emergency department (ED) for evaluation of a right wrist fracture (verified by an x-ray taken at the facility on 08/14/2023). The resident arrived at the ED wearing a splint provided by the resident's representative. A repeat x-ray was taken in the ED, which confirmed a break of the right wrist. The resident's wrist was placed in a cast and was returned to the facility on [DATE] at 5:17 AM. During an interview on 10/24/2023 at 12:25 PM, Resident 50 stated they had a fall and broke their wrist because the brake was not working on their wheelchair. Resident 50 stated they had told staff it was not working several times, and maintenance had repaired it each time. Resident 50 stated, the day before they fell , they had told Staff C, Case Manager (CM), that the brake was not working again. Resident 50 stated Staff C did not look at the wheelchair to see if it was working. During an interview on 10/26/2023 at 10:37 AM, Staff E, Maintenance Supervisor, stated they recalled fixing the wheelchair. They stated they went to Resident 50's room a few times and there was nothing wrong with the wheelchair. During an interview on 10/26/2023 at 10:59 AM, Staff F, Physical Therapy Assistant (PTA), stated the resident was able to safely self-transfer as of June 2023. Staff F stated when they last worked with the resident, they were able to do a stand from the wheelchair, and pivot to their recliner safely, without staff assistance. During an interview on 10/26/2023 at 11:10 AM, Staff G, Nursing Assistant (NA), stated on the night of 08/12/2023, they had heard a loud noise and found the resident sitting on the floor in their room. Staff G stated they had checked the brake on the wheelchair after the fall and it was not working. Staff G stated that when the wheelchair brake was locked, the wheelchair was still able to be moved around. During an interview on 10/26/2023 at 1:36 PM, Staff H, NA, stated that when Resident 50 fell on [DATE], it looked like the brake on their wheelchair was on, but it was not functioning. Staff H stated Resident 50 told them, at the time of the fall, that they had told Staff C, the day before the fall, that the brakes were not working. Staff H stated when they found Resident 50 on the floor, they complained of wrist pain and were crying. Staff H stated the resident was clearly hurting. During an interview on 10/26/2023 at 1:16 PM, Staff C stated they were aware that Resident 50's brake was not working before the fall with injury. Staff C stated Resident 50 had stopped them in the hallway, the day before the fall, and had reported to them that the brake was not working, Staff C stated they should have checked the brakes to see if there was a safety issue. During an interview on 10/30/2023 at 10:56 AM, Staff B, Director of Nursing (DON), stated they were aware of Resident 50's fall with injury that occurred in August 2023. Staff B stated that Resident 50 was cognitively intact and was told not to use the wheelchair if it was broken. Staff B stated Resident 50 should have known not to use the wheelchair if they knew it was broken. Staff B stated they expected Staff C would have checked the wheelchair for safety after Resident 50 reported the brake failure and should have given the resident an alternative wheelchair to use. During an interview on 10/31/2023 at 9:31 AM, Staff A, Administrator, stated that when Resident 50 reported the wheelchair brakes not working, the facility should have provided them a house wheelchair that was fully functioning. Staff A agreed that the fall with major injury was an avoidable accident. <Resident 48> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD [a lung disease that causes difficult breathing]), neuropathy (nerve damage that causes weakness, numbness and pain in hands and feet), and palliative care (specialized care for serious illnesses). The 09/13/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for ADLs. The assessment also showed the resident had an intact cognition. Review of Resident 48's medical record showed a fall risk assessment was not completed on their admission to the facility. Further review of the medical record showed the resident's baseline care plan, dated 09/01/2023, and revised care plan, dated 09/20/2023, showed no interventions for falls. Review of nursing progress notes showed the resident experienced a fall on 10/29/2023, that resulted in a skin tear to their right knee. During a concurrent observation and interview on 10/30/2023 at 8:57 AM, Resident 48 was seated in their recliner wearing non-skid socks worn. Their feet were flat on the smooth, linoleum floor. Resident 48 stated they had a fall the previous night. They stated their socks did not grip the floor and their legs slipped out from underneath them. They stated the did get a skin tear on their right knee. During an interview on 10/31/2023 at 9:47 AM, Staff C stated there were no fall risk assessments or care plan focus areas for fall risk preventions for Resident 48. Staff C stated they would have expected there to have been a fall risk assessment done on admission to the facility as well as care plan interventions for falls. In an interview on 10/31/2023 at 10:11 AM, Staff B, DON, stated they were aware that Resident 48 had a fall. Staff B stated they did interview Resident 48 about their fall history when they were admitted . Staff B stated they did not complete the admission Morse Fall Assessment (a commonly used assessment tool for predicting the potential of experiencing a fall). Staff B further stated they normally have the at risk for falls on the admission care plan but did not add this to Resident 48's care plan. <Resident 25> Review of the medical record showed Resident 25 was admitted to the facility on [DATE] with diagnoses including heart failure and a brain bleed. The 09/20/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for ADL's. The assessment also showed the resident had a moderately impaired cognition. Review of Resident 25's medical record showed a completed fall risk assessment dated [DATE] that showed the resident was at risk for falls. There were no additional fall risk assessments, despite Resident 25 experiencing many falls, most recently on 08/10/2023, 08/21/2023, and 08/22/2023. During an interview on 10/27/2023 at 12:37 PM, Staff B stated they were responsible for completing fall risk assessments, and they should have been completed on admission, quarterly with the comprehensive assessment, and after a fall. Reference: WAC 388-97-1060(3)(g) 39652 46722

Based on observation, interview, and record review, the facility failed to operationalize all components of an effective infection prevention and control program (ICP) when there were multiple breaches in the ICP related to the following failures: A) Implementation of correct transmission-based precautions (TBP, safeguards to prevent spread of diseases) in six out of six (18, 20, 21, 22, 23, and 24) resident rooms that were confirmed positive for the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) virus; B) Utilization of full Personal Protective Equipment (PPE) in protecting the safety/well-being of residents which included correct donning/doffing (to put on/to take off) of PPE and fit tested for a N95 respirator mask (masked used for protection against the COVID-19 virus) for five of five staff observed during entrance/exit of a COVID-19 positive resident isolation room; C) Implementation of a COVID-19 infection surveillance plan that included current Center for Disease Control and Prevention (CDC) guidance on criteria for three of three COVID-19 positive Health Care Providers (HCP/staff) screening and returning to work criteria after an exposure or after contracting COVID-19. These failures placed the residents, visitors, and staff at risk for potential exposure to COVID-19 and increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ). On 02/04/2022 at 4:30 PM, the facility was notified of an IJ at CFR 483.80 (a)(2)(iii) F880 related to the facility's failure to implement correct TBP for COVID-19 positive residents in isolation, proper use of PPE for COVID-19 positive residents and an effective COVID-19 infection surveillance plan for staff screening/returning to work criteria. The facility removed the immediacy on 02/15/2022, with a validation date of 02/16/2022 at 10:20 AM by implementing a removal plan with policy changes for identifying TBP and use of PPE for COVID-19 positive residents. The facility implemented a staff screening and infection surveillance process to include appropriate return to work criteria for staff with signs and symptoms of illness or a positive COVID-19 test result. Education/training was provided to staff on policy and process changes. Findings included . Review of the Washington State Department of Health (DOH) recommendations titled, Recommendations for Charting in Long-Term care Facilities During a COVID-19 Outbreak, dated 09/30/2021 showed: -Quarantine: The TBP used to keep someone who might have been exposed to COVID-19, away from all others to prevent potential transmission of COVID-19. -Isolation: The TBP used to keep someone who has confirmed COVID-19, away from others to prevent transmission to others. Further review of the same DOH recommendations section title, Isolation vs. Quarantine for Long-term Care facility Residents, showed residents with .confirmed COVID-19 . were to use droplet/contact precautions. The TBP required staff to have .respirator and eye protection always anywhere on the unit .gowns and gloves when entering residents' rooms . Furthermore, .if active outbreak in the facility, all HCP should wear fit-tested National Institute for Occupational Safety and Health N95 . and N95 respirators must be fit-tested . Record review of a policy titled [Facility] Covid Surveillance, revised 10/25/2021, showed .visitors/staff will be screened upon entry to the facility for the following . *travel history/exposure *fever of 100.4 or higher *cough *sore throat *chills/shaking *shortness of breath *muscle pain *headache *vomiting *diarrhea *loss of taste *loss of smell . The policy further stated, .Staff or visitors who screen positive tor any of the above symptoms will immediately be given a mask, sent home .advised to self isolated at home . CDC guidelines titled, Interim Guidance for Managing Healthcare Personnel with SAR-CoV-2 (COVID-19) Infection or Exposure to [CONDITION(S)]-CoV-2, updated 01/21/2022, showed COVID-19 positive staff (despite vaccination status) were able to return to work after ten days or after seven days with a negative COVID-19 test if they were .asymptomatic or mild to moderate illness (with improving symptoms) . TBP/PPE An observation of the facility South Hall on 02/02/2022 at 11:20 AM, showed resident rooms 18, 20, 21, 22, 23, and 24 with the doors closed. The signs posted outside of the rooms showed the residents residing in the rooms were on Quarantine Precautions, which included the following directions: * Clean hands when entering and leaving room * Wear mask- fit-tested N95 or higher required with aerosolizing procedures * Wear eye protection * Gown and gloves when providing direct resident care * Clean and disinfect shared equipment (which would include disinfecting of reuseable eye protection/N95) The Quarentine Precautions signage that the facility posted outside of the COVID-19 positive resident rooms did not give the required directions for a TBP virus such as COVID-19. The facilty had additional signs for TBP titled Special Droplet/Contact Precautions which directed staff to (which was required/correct implementation of TBP for COVID-19 postitive residents): * Clean hands when entering and leaving room * Wear a fit-tested N95 mask * Wear eye protection (face sheild or goggles) * Gown and glove at door * keep door closed * Clean and disinfect shared equipment During an interview on 02/02/2022 at 11:15 AM, Staff B, Director of Nursing Services (DNS), stated that COVID-19 positive residents were residing in the quarantine designated rooms (18, 20, 21, 22, 23 and 24) on the South hall as the facility's process was to place all COVID-19 positive residents in quarantine precautions. The DNS stated staff were directed by the TBP signs outside of the resident rooms on which PPE was to be utilized prior to entering the COVID-19 positive resident rooms. Staff B stated staff were required to wear N95 masks and eye protection even in COVID-19 negative resident rooms however, were not required to sanitize eye protection or change N95 mask in between COVID-19 positive/negative resident rooms. Additionally, Staff B stated gowns and gloves were only required for staff in COVID-19 positive resident rooms if direct care was being provided. Staff B was unaware of the TBP criteria for active COVID-19 residents. During an interview on 02/02/2022 at 11:25 AM, Staff A, Administrator, stated the facility had enough supply of PPE to manage a COVID-19 outbreak and that they were not in a staffing crisis nor had they needed to hire agency staff (a person hired on a temporary basis). Staff A stated that they had not been in contact with the Local Health Jurisdiction (LHJ) in a while. During an electronic correspondence on 02/14/2022 at 9:48 AM, the LHJ stated that prior to the most recent facility outbreak contact (which was after surveyors had brought it to their attention on 02/02/2022 at 11:25 AM) they had not had any request/contact from the facility for guidance or direction with COVID-19 updates since 10/20/2021. During an interview on 02/02/2022 at 11:35 AM, when asked about TBP/PPE that had been implemented for the South Hall COVID-19 positive residents, Staff I, NA (assigned to South Hall), stated that they went in/out of all of the rooms within the South Hall (COVID-19 positive/negative resident rooms) and follow the quarantine precautions signs. Staff I further stated they had gone into the rooms (COVID-19 positive rooms) without a gown/gloves and used the same N95 mask (does not change it out after entrance/exit into any resident room). During a concurrent observation and interview on 02/02/2022 at 11:40 AM, Staff E, Housekeeping Supervisor, was observed going into room [ROOM NUMBER] (a COVID-19 positive resident room) and came into close proximity (within six feet) of the residents. Staff E, did not don additional PPE such as a gown/gloves and had entered the room with only an N95 mask and eye protection. Approximately three minutes later Staff E exited the room and went into the hallway without hand hygeine, disinfecting their eye protection or changing their N95 mask. Staff E stated that they did not clean their mask upon leaving the room but probably should have. In an interview on 02/02/2022 at 12:05 PM. Staff F, Registered Nurse (RN), stated that they do not don a gown or gloves when entering a COVID-19 positive room as they are not providing direct resident care and are only passing medications therefore they were not required to don any additional PPE other than an N95 and eye protection. Staff F stated it was not their practice to clean/disinfect their eye protection or change their N95 mask between COVID-19 positive/negative resident rooms as it was not necessary. Staff F pointed to the quarantine precautions sign outside of room [ROOM NUMBER] and stated we follow the directions on the sign. During an observation on 02/02/2022 at 12:10 PM, Staff G, Activities, delivered a tray to room [ROOM NUMBER] which was designated as a COVID-19 positive room. Staff G did not don a gown or gloves when entering the room. Staff G was wearing an N95 mask and eye protection however did not disinfect their eye protection or change their N95 mask when they exited the room. Staff G continued down the South hall passing out resident lunch trays going in and out of COVID-19 positive/negative rooms without disinfecting their eye protection, changing their N95 mask or donning the appropriate PPE for respiratory precautions. Observation on 02/02/2022 at 12:17 PM showed, Staff D, Assistant to an NA, entered room [ROOM NUMBER] (a COVID-19 positive resident's room) without donning a gown and gloves. Further, upon exit Staff D did not disinfect their eye protection or change out their N95 mask and was observed with an inch long beard/facial hair sticking out of the bottom end of their N95 mask (which did not allow for an appropriate seal for their N95 mask). During an interview on 02/02/2022 at 12:22 PM, when asked what they did after entering room [ROOM NUMBER] (a COVID-19 positive room), Staff D, Assistant to an NA, stated that they delivered a meal tray, picked up trash, and helped organize the resident's room (within close proximity of COVID-19 postive resident). Staff D also stated that they did not don gown/gloves or disinfect their eye protection/don a new N95 mask after exiting the resident room. During the same interview on 02/02/2022 at 12:22 PM, Staff D, Assistant to an NA, stated that they had not received any education on TBP with COVID-19 or donning/doffing PPE to include their N95 mask. Staff D stated that they were never informed to not go into a COVID-19 positive room without a fit tested N95 mask or facial hair. Furthermore, Staff D stated that it was not their practice to disinfect their eye protection or change out their N95 mask after exiting a COVID-19 positive resident room even if they were going into another resident's room. Observation on 02/02/2022 at 1:20 PM, showed Staff J, Assistant to the NA, in the South hall passing out ice water (COVID-19 positive resident hallway) within resident's reach (which was in close proximity). Staff J was going from room to room including COVID-19 positive/negative resident rooms without donning a gown and gloves or sanitizing eye protection or changing out their N95 mask. Record review of the facility's respiratory mask fit testing records showed, Staff G, Activities, Staff D, Assistant to an NA or Staff J, Assistant to an NA, had not been fit tested for the N95 mask they were wearing even though they came into close proximity of COVID-19 positive residents when going in and out of their rooms. During an interview on 02/02/2022 at 1:35 PM, Staff B, DNS, stated that facility staff were fit tested for an N95 respirator only if they had direct contact with residents which did not include Assistants to an NA or Activities staff. During an interview on 02/03/2022 at 1:15 PM, when asked about placing COVID-19 positive residents on Special Droplet/Contact isolation precautions signs for COVID-19 positive residents instead of Quarantine Precautions (which were still in place) signs, Staff B stated they did not understand the difference. Infection Surveillance Record review of Washington State Complaint Resolution Unit intakes did not show that the facility had reported any COVID-19 positive staff in January 2022, as required during a outbreak. Record review of the facility's January 2022 COVID-19 testing log showed a total of 18 staff that tested positive: -Staff C, Nursing Assistant (NA), positive 01/14/2022. -Staff H, Licensed Practical Nurse (LPN), positive 01/21/2022 -Staff D, Assistant to an NA, positive 01/27/2022. Further review of the facility's January 2022 COVID-19 testing logs showed that if staff tested positive then they would not be retested for 90 days. Record review of staff COVID-19 vaccination logs showed, Staff C, NA, was unvaccinated. Record review of January 2022 Staff Time Attendance Report together with Employee Self-Screening Log for COVID-19 positive staff showed: -Staff C, NA, worked 01/14/2022, 01/15/2022, 01/17/2022, 01/18/2022, 01/19/2022, 01/20/2022 and 01/21/2022 (staff continued to work after COVID-19 positive test results on 01/14/2022). Screening logs showed Staff C first had symptoms of a headache on 01/15/2022 and then also noted a loss of taste/smell from 01/15/2022 to 01/21/2022. During a telephone interview on 02/07/2022 at 3:09 PM, Staff C, NA, stated they had experienced symptoms of a headache, stuffy nose and loss of taste and smell but had met with the Infection Preventionist and were told they could continue working as their symptoms were mild. -Staff H, LPN, worked 01/21/2022, 01/22/2022, 01/23/2022 and 01/24/2022 (continued to work after COVID-19 positive test results on 01/21/2022). During a telephone interview on 02/07/2022 at 11:04 AM, Staff H, LPN, stated they had not been informed by the facility that they had tested positive for COVID-19 on 01/21/2022. Staff H stated that they should have been told as they were concerned about passing the virus to their family. -Staff D, Assistant to an NA, worked 02/01/2022 and 02/02/2022 (staff returned to work on the fifth day after COVID-19 positive test results on 01/27/2022). Record review of the facility's visitor screening logs from 01/01/2022 to 01/31/2022 showed six out of 31 visitors had not appropriately completed the screening logs to rule out signs and symptoms of COVID-19. The screening symptom evaluation portion of the tool was in place to prevent visitors with symptoms of COVID-19 to be evaluated prior to entering the facility. During a telephone interview on 02/04/2022 at 12:00 PM, Staff A, Administrator, stated that they followed the CDC guidelines for staff returning to work after a positive COVID-19 test and that they had gone off the Staffing crisis column, when identifying if staff were able to work (facility did not meet appropriate criteria for a staffing crisis). Staff A further stated that they were aware that COVID-19 positive nursing staff were working in direct contact with COVID-19 negative residents. Reference WAC 388-97-1320(2)(b)

Based on observation, interview and record review the facility failed to ensure one of three residents (#1) reviewed for pressure injuries, received necessary care and services consistent with professional standards of practice to prevent a pressure injury from worsening. This failure resulted in actual harm to Resident #1 as the resident's wound deteriorated from a reddened excoriated area to a deep crater involving visible muscle, tendon, and bone. The facility did not provide adequate monitoring and coordination of wound care, to include timely follow up with a wound clinic recommendation (implemented three months later) by the Medical Director prior to Resident #1's wound's significant deterioration. This failure contributed to Resident #1's worsening of the pressure injury. Findings included . The National Pressure Injury Advisory Panal (NPIAP - an organization that sets professional standards for prevention and healing of pressure injuries) defines pressure injuries as injuries to the skin caused by unrelieved pressure to the area . with four stages of pressure injuries to include . *Stage I: The skin is red or discolored, but is still intact *Stage II: Partial thickness loss, the top layer of the skin is open creating a shallow sore *Stage III: Full thickness skin loss, skin is broken and extends into the tissues as a deep crater into the fatty tissue below the skin *Stage IV: Full thickness skin loss, the wound extends to the muscle, tendon and bone Additionally, the NPIAP recommendations for treatments of pressure injuries include . * Stage I and II pressure injuries requires relieving the pressure off of the sore so that it can heal, a protective dressing over the wound is recommended. *Stage III and IV pressure injuries require specialized wound care, and in some cases surgery to close the wound. Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current comprehensive assessment, dated 09/25/2020, showed the resident required extensive assistance for transfers, mobility and toileting. He was non-ambulatory and used a wheelchair for mobility needs. The assessment showed the resident was at high risk for pressure injuries. The assessment also noted that the resident had a Stage IV pressure injury which had developed in the facility. A progress note, dated 04/10/2020, showed the resident had developed an approximate 2.3 centimeter (cm) by 2.5 cm Stage I pressure injury on his left buttock. The skin was red and excoriated, but still intact. Additional weekly wound assessments in the progress notes showed the wound continued to worsen in size and depth, and on 05/22/2020, was first observed by a physician (Medical Director). Review of the physician's visit note, dated 05/22/2020, showed the resident's left buttock wound had increased in size and depth to 4 cm by 4 cm. The wound was diagnosed as a Stage II pressure injury, which included loss of the top layer of skin and an opening in the surface. The recommendation from the Medical Director was to consider follow up at the wound clinic if the wound continued to not heal and worsen. Further review of Resident #1's wound assessments in the progress notes showed the resident's pressure injury continued to deteriorate growing in size and depth, and had been treated for [REDACTED]. Review of a physician visit note dated 08/04/2020 showed Resident #1's left buttock pressure injury had worsened and was diagnosed as a Stage III pressure injury, which involved damage to the underlying skin and fatty tissue. The physician made a second referral to the wound clinic for specialized wound care. Review of the progress notes showed there there was no follow-up with the wound clinic until 09/08/2020, almost three months after the initial referral. Review of the wound clinic visit note, dated 09/08/2020, showed Resident #1's wound had worsened to a Stage IV pressure injury involving damage to his muscle, tendon and visualization of the resident's bone. Additionally, the wound had undermining (destruction of tissue under the skin so that the wound is larger at the base than at the skin opening) rolled wound edges and a sinus tract (a tunnel of tissue destruction under the surface of the wound). The clinic did not have a tool to measure the actual size of the sinus tract and documented it was greater than 15 cm. During an interview on 09/30/2020 at 12:45 PM, Staff A, Director of Nursing Services (DNS), stated Resident #1's wound care was monitored and assessed by the facility's wound and treatment nurses as they were responsible to ensure appropriate interventions and coordination of the resident's wound care. During an interview on 10/07/2020 at 10:30 AM, Staff C, Treatment Nurse, stated I'm not sure how often the doctors have actually seen the wound or why the wound clinic referral was not followed up on in May. Staff C stated she did not always notify the physician when Resident #1's pressure injury had significant changes, but only wrote out treatment orders for them to sign at a later time. Staff C further stated that she notified the Wound Care Nurse often on her concerns with the worsening of Resident #1's wound and would do what the wound nurse had advised her to do. I'm just the treatment nurse. I don't coordinate the care for any of the wounds. During an interview on 10/07/2020 at 2:30 PM, Staff B, Wound Care Nurse, stated It's up to me what kind of care and treatment a wound gets. She stated she did not know when the physicians had actually first observed Resident #1's pressure injury. I know it kept getting deeper and deeper, stating she would have liked to keep better track of the wound but had been distracted with other things. During an interview on 10/07/2020 at 11:15 AM, Staff A, DNS, stated the Resident Care Manager (RCM) was responsible to set up resident referrals and appointments. During an interview on 10/12/2020 at 9:30 AM, Staff D, RCM, stated she had not made a wound clinic appointment for Resident #1 until the second referral from the physician's visit on 08/04/2020. During an interview on 10/12/2020 at 11:40 AM, a wound clinic employee stated that the clinic had been accepting new patients since April of this year (2020). The employee verified Resident #1's initial appointment at the clinic was on 09/08/2020. Resident #1's wound was observed on 10/07/2020 at 10:00 AM during a dressing change performed by Staff A. The resident's wound was observed to be approximately 3 cm by 2 cm in size, with a 3 cm depth on the left buttock. The visualization of the inner wound showed tissue that appeared to be tendon and muscle. The base of the wound had approximately a 6 cm hard white area in which appeared to be bone. The wound edges were rolled under with a large area of undermining beneath the skins surface, During an interview on 10/08/2020 at 11:45 AM, the Medical Director stated the wound was sizeable by the time he had observed it and recommended the facility pursue outside wound care services after discussing it with the resident's representative. During an interview on 10/09/2020 at 11:00 AM, the resident's representative stated that she had not been informed of the initial wound clinic recommendation from 05/22/2020. She had no opportunity to provide input or make informed decisions around the resident's wound care related to its non-healing status. The resident's representative stated when she had attended the initial appointment with the resident at the wound clinic (09/08/2020), she was surprised how bad the wound was. It was a big hole in his (Resident #1) hip all the way to the bone. Reference: WAC 388-97-1060(3)(b)

Based on observation, record review, and interview, the facility failed to implement planned interventions to address the resident's care needs for 1 of 3 sampled residents (#1). Failure to have a sufficient number of caregivers delivering Resident #1's care resulted in an avoidable fall out of bed. Resident #1 rolled off the bed onto the floor and sustained a laceration and bilateral brain injuries. Findings included: Resident #1: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident received aspirin 81 milligrams daily, a medication that could increase the bleeding risk. The resident's care plan, last revised on 10/06/16, documented the resident had an ADL (activities of daily living) deficit related to a history of left sided [MEDICAL CONDITION], limited mobility, generalized weakness related to [MEDICAL CONDITION](stroke), back pain, and advanced dementia with sequencing and initiating difficulties. Resident #1 required two persons with extensive assistance for toileting. She was incontinent of bowel and bladder and utilized briefs for dignity and skin protection. According to the care plan, the resident required one person for bed mobility. However, the 01/05/18 comprehensive annual assessment documented the resident required extensive assistance from two persons for bed mobility. Further review of the care plan noted the resident required two persons and the use of the hoyer (mechanical) lift for all transfers. The cognition care plan, last revised on 01/24/17, noted the resident had Impaired memories related to dementia. Both short and long term memories were impaired and she is pretty much non-verbal and is unable to make her needs known, she has impaired decision making skills. Review of a 02/17/18 nursing entry by Staff A, Registered Nurse (RN), documented he was notified by Staff B, a Nursing Assistant (NA), that the resident was on the floor in her room. Staff B explained that she was turning her to change her brief. The resident was fine and still and then for some reason started willfully rolling farther and ended up on the floor next to the bed. She struck her right forehead. There was a two cm (centimeter, less than an inch) laceration and bleeding. The RN applied pressure to the laceration, placed a pressure dressing, and then placed an ice pack. Vital signs were taken and an initial neurological assessment was completed. The resident was transported to the hospital via ambulance for further treatment. According to the 02/17/18 facility investigation, on 02/17/18 at 4:30 AM Staff B had entered Resident #1's room and determined that (the resident) needed a new brief, as well as a dry sheet under her. Staff B obtained the supplies and returned to the room. Staff B turned (the resident) from the center of the bed onto her left side, placing her on the left side of the bed. (Staff B) placed her left hand on (the resident's) right thigh to stabilize her as (Staff B) removed the right lower corner of the sheet from the bed. At that time, (the resident) reached toward the blanket in her w/c (wheelchair) on the left side of her bed. Due to no core strength and being on her left side, (Resident #1) rolled further over when she reached her right hand out, resulting in rolling off left side of bed and landing prone (face down) on floor, no obstacles struck. (Staff B) had tried to stop the fall, but was unable in the position where she was. She immediately went and got the nurse on duty. On 02/28/18 at approximately 11:50 AM, observations were conducted of Resident #1's bed and room with Staff C, RN/Restorative Nurse. Staff C described the placement of the resident's furniture on 02/17/18 and the sequence of events as reported by Staff B in conjunction with the facility investigation. There was an open floor area observed to the left side of the bed. On 02/28/18 at approximately 1:20 PM, Staff E, NA, was interviewed about Resident #1's care needs. Staff E was asked about Resident #1's care needs in relation to bed mobility and toileting. Staff E stated she always brought another staff member with her to assist. The resident didn't move herself but she had no upper body support and would lean forward. Staff F, a NA, was also interviewed on 02/28/18 at approximately 1:25 PM about Resident #1 and the care she required. Staff F stated the resident required total care for bed mobility, dressing, and toileting. She was incontinent of bowel and bladder. The NA stated the resident was unable to roll on her own and she had no trunk control. Staff F said she felt safer with two persons for care including bed mobility. An interview was conducted with Staff D, Director of Nursing, DON, on 02/28/18 at approximately 3:15 PM. Staff D affirmed that Resident #1's care plan directed that two persons were needed for toileting activities. On 02/17/18 Staff B had performed the resident's care without the second person. Staff B had rolled the resident onto her left side for changing her brief and the resident was no longer in the middle of the bed. The NA had her left hand on the resident's right thigh but the NA was closer to the foot of the resident's bed. Resident #1 began reaching with her right hand and then fell out of bed onto the floor. On 02/28/18 at approximately 10:32 PM, a telephone interview was conducted with Staff A, the RN on-duty on 02/17/18 at the time of Resident #1's fall. Staff B had approached him to report the fall. He responded to find the resident face down on the floor in a pool of blood. The resident was wide awake and was looking at him. Staff B assessed the resident and initiated measures to control the bleeding [MEDICAL CONDITION]. He further stated he knew the injury was worse than a superficial injury. Staff B had reported she was changing the resident and the bedding (by herself). Although the RN didn't recall the specifics of the resident's care plan at the time of the fall, he stated the resident appeared to require two persons for her care due to her condition. Staff A continued to care for the resident, including washing off blood from the bleeding laceration and feces from the resident's incontinent episode. An ambulance arrived to transport the resident to the hospital for further evaluation and care. Review of the hospital's emergency department records revealed on 02/17/18 the resident was evaluated after a fall from her bed at the nursing facility that morning. Resident #1 had a two centimeter laceration to the right forehead with a hematoma (a collection of blood in the tissue). CT scans of the head were performed on 02/17/18 at the hospital. The second CT scan documented an increasing right sided subdural hematoma (a collection of blood on the brain) measuring more than two centimeters and a smaller left lateral subdural hematoma on the left side of the brain. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, for one of two residents (#59) reviewed for accidents, the facility failed to develop and implement measures, and to provide supervision to prevent burns associated with the use of a hot pack. This resulted in harm to Resident #59, when she sustained blistering burns on her abdomen while using the hot pack. Findings included: Resident #59. According to the medical record, the resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's latest comprehensive assessment dated [DATE], revealed the resident had mild cognitive impairment and required extensive assistance with dressing and hygiene tasks. The resident did not walk. Review of the care plan revealed a focus on the resident's pain. The care plan noted the resident had chronic pain due to arthritis and also had chronic lower abdominal pain. The care plan directed staff to offer heat or ice first when (Resident #59) c/o (complained of) pain. This direction was started 06/23/15. Further review of the care plan showed the resident had impaired thought processes, including impaired insight, impaired decision making, impaired safety/danger recognition, and impaired comprehension. On 03/11/16, the plan directed staff to, Assure (Resident #59's) safety. In an interview on 09/15/17 at 11:19 AM, Staff H, Registered Nurse (RN) and Resident Care Manager (RCM), stated the resident had impaired safety awareness. She explained it was more pronounced in the earlier days of the resident's admission, when the resident would try to self transfer and did not use her call light. The RCM also noted the resident persisted in using particular lotions and rubbing alcohol on her face, even though it resulted in a rash. Review of an incident report dated 01/03/17, revealed Resident #59 was observed to have redness and a blister measuring 0.5 cm by 0.1 cm (less than one fourth inch) on her right lower abdominal area. The investigation revealed the resident had asked for, and was provided, a hot pack a few days before the injury was discovered. The hot pack was in a pillow case and the resident acknowledged she removed the pillow case and placed the pack directly on her skin when the pack cooled. The incident investigation documented the resident denied feeling the hot pack burn her skin and stated she often removed the hot packs from the pillow case because she wanted the heat to last longer. Further review of the incident investigation revealed the facility would try to prevent future burns by using the resident's re-usable hot pack in the microwave for her pain instead of the disposable hot pack. The facility also planned to educate the resident on the need to keep the pillow case wrapped around the disposable hot pack if it was used. The facility also educated nursing staff on the safe use of hot packs. Review of staff inservices dated 02/17/17 and 02/23/17 revealed nursing staff were educated to always place the disposable hot pack in a pillow case to protect from having heat directly on the skin. On 09/11/17 at 3:54 PM, Staff F, Licensed Practical Nurse (LPN), stated she often gave a hot pack to Resident #59. It was usually the disposable pack, but occasionally she heated the resident's pack for her. The nurse noted the resident had significant and ongoing abdominal pain. On 09/14/17 at 3:01 PM, Staff G, LPN, stated she helped Resident #59 many times with a hot pack for her abdomen. She stated she had been instructed not to use the resident's own pack, but instead to use the facility pack. She stated she put the pack in a pillow case and instructed the resident to notify her when it cooled. She stated she was never instructed on how long to leave it on or how often the resident should be monitored while she was using the pack. Review of the facility hot pack product (McKesson Instant Hot Compress) revealed instructions, Caution: Peak temperature may reach 160 F (degrees Fahrenheit) once activated. The pack instructions also directed use of a cloth or towel for protection and not to use the product more than 30 minutes. Note: A third degree burn (a burn that damages the full thickness of the skin) can occur with one second exposure to 155 F water. A third degree burn can occur with three-minute exposure to 124 F water. In an interview on 09/15/17 at 11:11 AM, Staff M, RN and Staff Development, stated she educated nursing staff after the January burn was sustained by Resident #59. She said she instructed them to make certain they placed the hot pack in a pillow case. She stated they did not implement a monitoring process for the resident's use of a hot pack because the resident used the packs very frequently. Staff M estimated the resident requested the packs one to two times a shift during the times she worked as a medication nurse. Staff M reviewed the instruction on the back of the disposable hot pack and stated she did not realize the hot pack could get as hot as 160 F. It is pretty hot. Review of an incident report dated 08/08/17 revealed Resident #59 was noted to have two intact blisters to her right abdomen with surrounding redness. One blister measured 1.3 by 1.2 cm (slightly less than 1/2 inch across) and the other measured 1 cm by 2 cm (less than 1/2 inch by ¾ inch). When asked how the blisters happened, the resident reported she removed a hot pack from the pillow case and placed it directly on her skin. On 09/15/17 at 11:19 AM, Staff H stated the hot packs were a non-pharmaceutical intervention for pain. She stated the resident used it on her abdomen most of the time, but on occasion used a hot pack for her shoulder. The nursing staff always prepared the hot pack, and the resident directed the placement of the pack. She noted the effectiveness of the intervention should be on the Medication Administration Record (MAR). She reviewed the MAR and said there was no documentation about the use of the hot pack on the MAR beyond the order to use it every shift. She stated she did not know the hot packs could get as hot as 160 F. At 11:32 AM, Staff H further stated she did not recall any instructions to nursing staff except to wrap the hot pack in a pillow case. She reviewed the resident's care plan and stated she did not see anything in the care plan prior to 08/08/17 on how to use or monitor the hot pack. She explained care plans were updated as a team and it did not appear the care plan was updated after the January incident to try to prevent further burns. She stated she did not see documentation the resident was educated about the use of the hot pack, or the risks and benefits of using a hot pack. She concluded it would be common sense for nursing to be more cautious with the use of the pack and to check on the resident more often when they were in use, but those approaches were not documented anywhere. She acknowledged the facility needed to try to keep the resident safe. Reference (WAC) 388-97-1060 (3)(g) This is a repeat deficiency from Statement of Deficiencies dated 01/27/17 and 04/06/17.

Based on observation, interview and record review, it was determined the facility failed to provide necessary monitoring or services to ensure that 1 of 1 sampled residents (#21) who entered the facility without a pressure ulcer did not develop a pressure ulcer and 1 of 3 residents (#64) who entered the facility with a pressure ulcer received accurate assessment of the wound. This failure resulted in the development of a painful unstageable pressure ulcer causing harm to Resident #21. The lack of accurrate assessment for Resident #64 placed him at risk for inappropriate treatment of [REDACTED]. Resident #21. admitted [DATE] from the hospital with [DIAGNOSES REDACTED]. Per the 11/26/13 admission comprehensive assessment, she was cognitively alert and required extensive assistance from staff with bed mobility and personal hygiene. The comprehensive assessment also reflected she had no unhealed pressure ulcers, but identified her as being at risk for pressure ulcers. On 02/27/14 at 10:15 a.m., Resident #21 was observed in her room in bed. She pulled back bed linens to uncover a black rigid brace on her right leg. The brace extended from mid-thigh to approximately 2 inches above her ankle bone and was fastened in several places with Velcro strapping. The resident related she broke her leg at home and she was in the facility to heal the fracture. She then stated she had a sore on her leg and pointed to an area on her right lower calf on the inside of her leg. "It was from the brace." Medical record review revealed the wound was first identified in the progress notes on 02/13/14, observing it to be unstageable (the depth of the wound cannot be determined because it is covered by dead tissue). The wound was further described as "Hardened eschar (thick, dry, dark dead tissue) visible, surrounded by small amount of [DIAGNOSES REDACTED] (redness). Wound measures approx 3x2 cm (centimeters, or approximately 1-1/4 by 3/4 inches)." Later the same day, a second progress note explained the resident had developed a pressure ulcer "3x3 cm (approximately 1-1/4 by 1-1/4 inches) at the inner aspect of right leg due to pressure applied by brace." The progress note entry further noted new physician orders [REDACTED].#21's leg. Review of the medical record Pain Management Flow Sheets for January 2014 revealed Resident #21 complained of pain 31 times throughout the 31 day month, with the location of the pain being her right knee area 15 times and her right lower extremity 16 times. On 01/24/14, the LN noted on the flow sheet the pain the resident complained of was precipitated by "brace pressing." Review of the medical record Pain Management Flow Sheets for February 2014 revealed Resident #21 complained of pain 38 times throughout the 28 day month, with the location of the pain being described 29 times as being in her right lower extremity and in her right leg 9 times. On 02/12/14 the LN described the precipitating factor as "brace against heel." Review of the care plan for Resident #21 identified she had the potential for impaired skin integrity related to impaired cognition and immobility. Interventions for this care issue were developed on 12/10/13 and included "Identify potential causative factors and eliminate/resolve when possible" and "Notify team leader of any redness or excoriation" as well as encouraging good nutrition, having a pressure mattress and cautious handling during transfers. However, the brace was not identified in the care plan as a potential cause of skin breakdown until 02/14/14, after the pressure wound was identified. At that time, the care plan was updated to include the treatment of [REDACTED]." On 02/17/14, the care plan was again updated to include "Monitor/document/report PRN (as needed) any signs/symptoms of .....skin breakdown...." On 03/05/14 at approximately 8:30 a.m., the lower part of the brace was removed to treat the wound. The wound was located approximately 4 inches above the resident's anklebone on the inside of her right leg. It appeared to be approximately 1 inch by 1 inch and circular, but was not measured by the licensed nurse. Eschar covered approximately 80% of the area of the wound, with [DIAGNOSES REDACTED] around the edges. Staff Member F, a licensed nurse (LN), stated the wound was improved and smaller than when it was discovered. After cleaning the wound, she placed padding around and over the wound to keep the brace away from the wound. Staff Member F did not loosen or remove the upper parts of the brace to assess the condition of the resident's skin in the area of her knee and thigh. On 03/05/14 at 2:20 p.m., Staff Member G, a LN, stated she monitors the brace placement by checking that the brace is not too tight but does not remove the brace to check for redness. She stated she just checks around the brace. Failure to identify the rigid brace as a potential cause of pressure related skin injury even after the resident complained to staff about the brace causing pain and failure to take measures to ensure the skin under this brace remained intact caused Resident #21 to develop a serious and painful pressure ulcer requiring ongoing treatment and care. Resident #64. hosptalized on [DATE] with chest congestion and shortness of breath. [DIAGNOSES REDACTED]. The hospital's assessment identified pressure ulcers present on the coccyx. The 01/15/14 admission summary documented a pressure ulcer on one side of buttocks with a 1 cm (approximately one half inch) scab and the coccyx inflamed "with open area." The 01/19/14 nursing documentation continued with three 1 cm (approximately one half inch) open areas to buttocks which were also red looking. Calmeseptine (moisture barrier ointment) was applied early morning and then a [MEDICATION NAME] dressing (absorbs exudate and creates a gel like dressing) was applied to the bottom. The 01/20/14 physician evaluation of the buttocks revealed the dressing was in place and was not disturbed for an observation. The 01/25/14 admission comprehensive assessment (MDS) identified unhealed pressure ulcers at Stage I or higher which were then documented as two Stage II pressure ulcers. The MDS documented there was no moisture associated skin damage. Further record review of "Skin Observation Tools" revealed two Stage II pressure ulcers (a partial thickness loss of skin presenting as a shallow open ulcer with a red wound bed) on 01/15/14, 01/31/14 and 02/08/14. The ulcers measured approximately 1/2 inch by 1/2 inch and approximately 1/2 inch by 1/4 inch on 02/08/14. However, on 02/14/14, the pressure ulcer was described as a single enlarged right buttock "excoriation" (superficial traumatic scratches or abrasions which remove some of the skin surface) measuring 4.8 cm by 2.0 cm (approximately 2 inches by 3/4 inches) cm. The assessments of the right buttock excoriation continued on 02/21/14 and 02/28/14. There was no further documentation or assessment of the pressure ulcers. On 02/26/14 at 11:30 a.m., the resident, seated in his geriatric chair complained of pain on his bottom and became distressed, raising his voice angrily at the nursing assistants stating he wanted to be in bed "now." He said he was in pain on his "behind." He was immediately transferred to bed. A short while later, Staff Member R, a nursing assistant (NAC), and Staff Member F, the treatment nurse, both said the resident started with several small areas on his buttocks that grew into one large area. On 02/26/14, when care was provided, an oblong area located between the coccyx and rectum was a dusky purple with delineated edges where there was skin loss visible approximately a layer deep. On 02/27/14 at 1:00 p.m. the resident was transferred to bed by two staff members when he said his "behind" hurt. During personal care, the area below the coccyx had a small dark brownish colored area at the lower left edge of the wound. One of the nursing assistants tried to clean it with a wet cloth, but it remained intact. Staff Member N, a NAC, said she saw the wound on 02/26/14 and she thought it was worse now. On 03/04/14 at 9:30 a.m., Staff Member F stated she had changed the resident's Stage II pressure ulcer to excoriation as she thought the dressing on it had made it appear macerated (an injury accompanied by soft, white deteriorating skin around the site of the original injury). Because she saw changes of the skin that seemed more like excoriation, she had changed it on her skin observation sheet to that instead of a pressure ulcer. She did agree that the resident was admitted with an assessment of a pressure ulcer. Although assessments of a pressure ulcer were completed in the hospital, upon admit and after admit, the ulcer was documented as a different type of skin injury when excoriation was determined to be the cause of the wound rather than pressure. A thorough assessment related to pressure ulcer versus excoriation was not completed by Staff Member F. Without the thorough assessment, consultation with the physician and proper treatment of [REDACTED].

Based on record review and interview, the facility failed to: A.) create and/or implement a comprehensive plan to ensure the resident maintained an adequate elimination pattern for 2 of 4 sampled residents (#3 & #4) and B.) implement a physician's orders [REDACTED].#3). Resident #3 experienced bowel issues including a small bowel obstruction, a urinary infection with [MEDICAL CONDITION], and an acute kidney injury. There were also other complications secondary to the acute kidney injury. Findings include but were not limited to: A.) Elimination Issues: Resident #3: Review of the medical record revealed the resident was admitted to the facility from the hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The Physician's Discharge Summary, dated 10/08/13, also noted the resident had experienced dehydration and constipation. The resident was discharged with a urinary catheter to facilitate his urinary output. admission orders [REDACTED]. [MEDICATION NAME], a laxative, was also added for administration every Monday, Wednesday, and Friday for constipation. The resident's plan of care documented he experienced bowel incontinence related to immobility and impaired memory and was to be checked every two hours and assisted with toileting as needed. Staff were to "Document prn (as needed) bowel elimination." The goal stated the resident will have "less than two episodes of incontinence per day through the review date." There were no other goals identifying the planned bowel elimination frequency. Fluids were to be encouraged with all cares and meals. Intake and output monitoring was to be completed in accordance with facility policy. The plan for the urinary catheter management had goals including no signs and symptoms of a urinary tract infection. Staff were directed to monitor and document symptoms of a urinary tract infection and for any alterations in bladder elimination related to the resident's obstructive urinary issues as needed. Intake and output monitoring was also directed per facility policy. Other care related issues were identified pertaining to care of the urinary catheter. Later, there was also a care plan for an actual urinary tract infection (dated 11/21/13). The Registered Dietitian's assessment on 10/21/13 documented the resident required 1725-2070 cubic centimeters (cm) of fluid per day (approximately 7 to 8 1/2 cups). Review of the nursing entries noted the resident had seen the urologist on 11/06/13 (and on) 11/11/13. The urinary catheter was removed on 11/07/13 and he was noted to urinate thereafter. Despite discontinuance of the urinary catheter, no changes were made to the plan of care specifically directing staff on how to monitor for any problems related to the resident's history of [MEDICAL CONDITION] and blockage. On 11/17/13 the resident had a temperature of 101.1 ax. (axillary, under the arm pit) and a urine sample was obtained. By 11/18/13 the resident was having a hard time swallowing and required assistance with eating. The urinalysis was positive and an antibiotic was ordered to treat the urinary tract infection. On 11/22/13 at 9:07 a.m. a nursing assistant reported the resident wasn't eating much and he was coughing and choking on thin liquids. The resident was being treated for [REDACTED]. Review of the November 2013 bowel records noted the resident had a large bowel movement (BM) on 11/18/13. It was four days before he had another BM, on 11/22/13. There was a 11/23/13 BM without a notation of size and then a medium BM on 11/26/13. The next sufficient BM (medium or larger) was on 12/01/13, five days later. No as needed bowel products were documented as administered per the November 2013 medication and treatment records despite the long intervals without a BM. On 12/02/13 the resident had a medium sized BM and a large BM on 12/03/13. Five days lapsed before the resident had another BM, a large. The resident had a rectal suppository on 12/08/13 (the only documented as needed bowel intervention during the months of November 2013 and December 2013). Three more days lapsed before the resident had a medium BM, on 12/11/13. On 12/04/13 the resident's Physician examined the resident in conjunction with "discharge plans." Staff were reportedly concerned about the the possibility of the resident being returned to the assisted living facility, at the request of the family member, and the resident's "total dependence for care." The physician's entry identified weight loss, constipation treated (despite the lack of as needed bowel interventions up to that time during 11/2013 and 12/2013), and (urinary) retention. The resident's weight had further declined to 138.2 pounds from 147.2 pounds the previous month. It was noted the staff had reported the resident chewed an excessive period prior to swallowing. On 12/04/13 the Physician assessed the resident's "Debility", weight loss, and total self care deficit. The follow-up plan included addition of a supplement, an antidepressant that typically increased appetite, and a diet change. a lab study was also ordered for 12/06/13. A 12/07/13 evening shift nursing entry noted the resident had increasing activity tolerance, took fluids well, and had no change in his bladder elimination pattern. By the following day, on 12/08/13, the day shift LN reported the resident ate a few bites of lunch and drank four glasses of water. There were no further assessments or data pertaining to the resident's intake except 300 cc (over a cup) total of nutritional supplements during the medication pass or of his output/elimination on 12/08/13. On 12/09/13 there were no nursing notes but computerized reports documented the resident ate three meals and took fluids with his meals and medication pass. There were no nursing assessments documented or reports of the resident's intake of meals or fluids for 12/10/13 except for the 300 cc of supplements. On 12/11/13 the day shift nursing entry documented the resident did not have signs of urgency or frequency but was having difficulty at meals, "constant chewing and drinking fluids." He almost gagged at meals. Staff started the resident on a puree diet and planned to add a high calorie supplement and juice to meals. Although the resident ate his puree diet and drank fluids at dinner, later that evening the resident had labored breathing and complained of his left side hurting. An assessment identified the resident's abdomen felt "hard slightly distended feeling." His heart rate was 134 and his respirations were 50 per minute (both very elevated). The resident was sent to the hospital. When interviewed about bowel management on 1/08/14 at approximately 1:45 p.m., Staff Member A, a Licensed Nurse (LN), stated typically she received a list of residents from the night shift LN reporting on residents who had not had a timely BM. If a resident had not had a BM by the third day the LN would administer senna or a fiber juice as a first step. The residents' bowel status/response to interventions would be reported to oncoming LN staff. On 1/08/14 at approximately 3:35 p.m., Staff Member B, the resident's LN care manager, was interviewed about the resident's care. Staff Member B stated the resident came in with a urinary catheter and it was discontinued during his stay. She was unable to locate an updated care plan and stated it probably wasn't updated following the removal of the catheter. It should have included interventions such as toileting every two hours and documentation of intake and output. Staff Member B was unable to locate any specific intake and output records. Review of the bowel management plan should have included a goal of a BM at least every three days and small BMs were not counted. If there had not been a BM in the past three days then the as needed bowel products should be started (senna and then the suppository, and enema later if needed). After reviewing the resident's bowel records, Staff Member B stated the resident had longer intervals without a BM and had not received timely as needed bowel products to relieve his constipation. Staff members were learning a new computer system during that time period. Review of the 12/11/13 emergency transport documents revealed an arrival time of 12/11/13 at 22:10 (10:10 p.m.). The resident's abdomen was "extremely distended" and he was hyperventilating with 45 breaths per minute. A 12/11/13 CT of the abdomen in the hospital revealed "Large amount of fecal material in the rectum compatible with fecal impaction" and "possible distal small bowel obstruction without definitive transitional point." Clinical correlation was recommended. emergency room records noted intravenous fluids were run "wide open" for the first liter. A catheter was inserted, documented at 1:32 a.m. on 12/12/13, with an output of 800 cubic centimeters of red cloudy urine with clots. The 12/15/13 admission and discharge summary documented the resident had a complicated urinary tract infection with a systemic infection, an acute kidney injury and fluids building up in the kidney(s), a small bowel obstruction, electrolyte abnormalities (blood chemistry alterations), and other evolving complications. Despite the history of infrequent BMs, recent infection and fever (requiring increased fluid intake), decreased food intake and weight loss, increased need for assistance, there was no re-assessment of the resident's abdominal status, his intake and output, or his urinary status (after 12/07/13) until 12/11/13, the day the resident evidenced distress and required transfer to the hospital. Resident #4: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's orders included twice daily stool softeners and two tablets of a laxative twice daily. Resident #4 also had an order for [REDACTED]. The resident required staff assistance for toileting. The resident had diarrhea related to an intestinal infection after returning from the hospital on [DATE]. The bowel protocol was incorporated on the resident's 11/2013 medication and treatment records. Review of the bowel records identified the resident had a large BM on 11/17/13 and did not have a sufficient BM until 11/27/13, 10 days later. A 11/22/13 nursing entry stated the resident received a "suppose" (rectal suppository) on the night shift but it was not documented on the medication or treatment records and no results were documented. As needed extra laxatives were given on 11/24/13 and 11/26/13, seven and nine days after the last sufficient BM. There were four small BMs during the ten day interval and two suppositories, given on 11/26/13 and 11/27/13 toward the end of the interval. No enemas were documented. There was another long interval without a sufficient BM between 11/30/13 and 12/09/13 when he had a medium BM, a nine day interval. A 12/06/13 nursing entry reported an extra laxative had been provided earlier that evening with very little result (sic) and a suppository was administered at the resident's request without result. Suppositories were also documented as administered on 12/05/13 and 12/08/13 with only small results. No enemas were documented despite a directive for the bowel protocol that allowed for an enema if the other interventions were not effective. Thereafter, the resident did not have a sufficient BM through 12/12/13, three more days. On 1/08/14 at approximately 4:25 p.m., Staff Member B, the resident's LN care manager, was interviewed about the resident's care. Staff Member B stated there were the same problems with long intervals without BMs and a lack of timely interventions as identified in Resident #3's record. B.) Implementation of physician's orders [REDACTED]. Resident #2: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's plan of care identified the resident had [MEDICAL CONDITION] and there was a potential for impaired skin integrity. The [MEDICAL CONDITION] status was to be documented as needed. The resident was weighed daily to monitor the [MEDICAL CONDITION]. Ace wraps were applied to both of the resident's lower legs during the day shift and removed before bedtime. On 10/16/13 the resident's Physician examined the resident. The Physician noted the resident had chronic [MEDICAL CONDITION]/[MEDICAL CONDITION] ([MEDICAL CONDITION] from a collection of lymphatic fluid). There were new orders written on 10/16/13 for an increase in the diuretic and potassium. In addition, the Physician wrote an order for [REDACTED]. Although the 10/16/13 order was written, there was no documentation that the order had been implemented. Review of a 12/20/13 nursing entry revealed the resident was complaining of leg pain and had requested Tylenol for pain. Her leg wraps were removed and they had made deep indentations on the right leg and a little on the left leg. The resident cried out despite the Tylenol when her right leg was moved. Family was present and requested she be evaluated in the hospital emergency room . Review of the 12/20/13 hospital records revealed the resident's wraps were too tight resulting in pain and swelling. At worse, her symptoms were moderate and her condition was stable. Follow-up orders included no wraps for 24 hours and a physician follow-up prior to re-starting the wraps. On 1/09/14 at approximately 10:50 a.m., Staff Member D, the LN on-duty on 12/20/13, recalled Resident #2 had an increase in her leg swelling that evening (and pain) and the LN had removed the wraps. There were indentations from the wraps. The family requested the resident go the hospital to be checked. When asked on 1/07/14 at approximately 3:45 p.m. about the status of the order for the lymphatic pump therapy to address the resident's [MEDICAL CONDITION], Staff Member C, a LN, provided an e-mail document, dated 11/05/13, approximately 3 weeks after the 10/16/13 order was written. Staff Member C had contacted the Therapy Director about the referral order for Resident #2's lymphatic pump therapy. The Therapy Director responded via e-mail that their therapists "can do lymphatic massage" and the resident was currently receiving physical therapy services. There was a plan to discuss the pump therapy with the physical therapist (PT). On 1/07/14 at approximately 4:15 p.m., PT A stated he had previously been working with Resident #2 on transfers, standing balance, and ambulation activities prior to her trips to the hospital, not her [MEDICAL CONDITION] treatment. Nursing staff had been handling the wraps at that time. On 1/13/14 at approximately 10:13 a.m., the Rehabilitation Director, stated she had not seen the actual order and was unaware it was written. The ordered therapy had not been implemented. She was unaware of any follow-up with the physician pertaining to the order/therapy referral. Although the resident had received PT it had not involved the lymphatic pump therapy.

Based on interview, and record review, the facility failed to ensure the resident remained free of accident hazards and received adequate supervision and assistance to prevent accidents for 1 of 3 residents (#85). The failed facility practice resulted in harm for Resident #85. Findings include: Resident #85, age 87 had fallen at her assisted living home on 12/4/12 and sustained a fractured right hip. At the hospital she underwent an open reduction, internal fixation surgery on 12/6/12 to repair the hip. On 12/10/12 she was admitted to the nursing facility for care, with tentative plans to return eventually to her assisted living home. She had multiple diagnoses, including dementia, osteoporosis and history of stroke. Initial orders allowed weight bearing as tolerated for transfers with no ambulation. A fall risk evaluation was completed on 12/11/13 by Staff Member H, a Rehabilitation Licensed Nurse (LN). Resident #85 was assessed to be at risk for falls (she was scored at 20 where a score of 10 or greater denotes risk). The initial care plan dated 12/10/12 indicated that resident #85 had impaired mobility related to her recent right hip fracture, osteoporosis, dementia and pain with movement. The care plan goal was to maintain strength and endurance, maintain ability to be up in chair three times per day and as desired. The approaches in the care plan (which was the same for all residents admitted with a fall risk, thus not individualized) for fall prevention included : Low profile bed Toilet Safety Frame Call light and personal items within reach Make sure floor clean, dry and free of debris. Between 12/10/12 and 12/16/12, Resident #85 appeared to be stable and improving, with comments from the progress notes: "ate 75% of dinner with verbal cues "(12/12/12), "appetite getting better" (12/13/12), "has a big smile" (12/14/12). However, on 12/16/12, nurse noted on progress notes at 1:05 p.m. that "resident made multiple attempts to stand up by herself. She needed frequent reminding to not get up by herself and to keep her right foot on foot pedal." Progress note of 12/18/12 at 10:20 p.m. noted that the "resident was found on floor leaning on right elbow and stated she was unsure what happened." The corresponding incident report stated that the time of the occurrence was 7:30 p.m. and that the resident was in the hallway at the time of the fall. It stated that the "resident was found on the floor, legs in front of her, leaning on right side on elbow." The incident report further stated that "during the time of fall, the staff on hall was at lunch break. I will have the team leader designate a staff member to keep resident engaged during all breaks from hall in future." The incident report was signed on 12/20/12 by Staff Member H. A progress note of 12/19/12 at 9:10 a.m. documented a change in condition for Resident #85. Her blood pressure was noted to be 94/68 and the nurse stated that "resident seems lethargic more today, with less verbal, increase confusion." The progress note on 12/19/12 at 11:30 a.m. documented "weakness to extremities ... facial droop." Note stated that the resident's son was called and he stated that she had a history of [REDACTED]. At 12:41 p.m. another progress note revealed that resident had rambling speech that could not be understood and that she "would not sit still in wheel chair. Resident had to be near someone all shift because she was not sitting still." There were no changes noted to the care plan related to mobility and fall prevention following the 12/18/12 fall. The progress note on 12/30/12 stated that "CNA (Certified Nursing Assistant) came and got LN Licensed Nurse) and asked me to go into the dining room. (Staff Member M) stated someone had fallen and she didn't know who it is." When the LN entered room resident was laying on right side with right arm folded under her. Resident's head was next to wheel chair. LN checked range of motion and found it intact. The resident was able to move her head. LN did state that she hit her head." The LN documented, "approximately a 50 cent size red spot in middle of forehead. " The corresponding incident report stated that the fall happened at 4:20 p.m. in the dining room. It stated that the resident was last seen by Staff Members M and S in the dining room at 4:15 p.m. The incident report also stated that, "When in the dining room, chair was placed in upright position in anticipation of resident meal. She leaned forward in chair with feet on the ground and did not have core strength to correct so fell out of chair and will have resident chair remain in 20 degree tilt until tray is in front of her and she has assist for meals in the future." The injury was described on the incident report was surface layers of skin on right elbow. The report was signed by Staff Member H and dated 1/2/13. It states that the fall was not witnessed but that she was the first to discover the resident following the incident. During a phone interview with Staff Member M, a CNA, on 01/11/13 at approximatley 1:00 p.m., she stated that resident #85's wheel chair was in the upright position prior to her fall and that she was the only staff person in the dining area at the time of the fall. Staff Member M was unaware of the supervision of resident #45 and did not know about the change. On 01/03/13 at approximately 1:30 p.m. Resident #85 was observed seated in the wheel chair in the upright position with no supervision. Review of a progress note dated 1/6/13 stated that "Resident was on the floor on her right side when I got down to the hall. Resident stated that she fell and hit her forehead again. Resident was alert and also stated that her right hip hurt." A corresponding incident report revealed that the incident happened at 1:30 p.m. in the hallway and states that "The housekeeper came to the charting area and said someone fell . I went running down the hall and seen the resident on the floor and was laying on her right side. Resident stated she hit her head again and her right hip was hurting." The incident report stated that the resident was last seen by Staff Member T in the East hallway at 1:25 p.m. The type of injury noted on the incident report was "bruise(s) of deep color" and that it was in an "area not generally vulnerable." The action taken was "first aid" and "care plan revision." It was signed by Staff Member H and Staff Member L on 1/8/13. Attached to the incident report was a witness statement submitted by Staff Member J (housekeeping). She documented that she did not witness the fall, but was the first to discover the resident after the incident. She also noted that she was taking a mop bucket down to the North hall, that she "heard a thump turned around and seen her on the floor." Also attached to the incident report was an investigation done by Staff Member H on 1/7/13. It stated that she (resident #85) was visualized at 1:15 p.m. by Staff Member J and there were no changes noted to the care plan related to mobility and fall prevention following the 12/18/12 fall. In an interview on 1/10/13 at approximately 9:05 a.m., Staff Member J stated that on 1/6/13 she saw resident #85 in her wheel chair in the hallway outside her room (Room 43). She stated that the resident was facing toward the exit door at the east end of the hallway and that her wheel chair was in the upright position. Staff Member J said she exited the housekeeping closet with a mop bucket and traveled down the east hall toward the north hall, going the opposite direction from resident #85. As Staff Member J went past the Director of Nursing Service (DNS) office, she stated that she heard a loud thump. She turned around and saw Resident #85 on the floor. Staff Member J stated that she immediately went to the nurse's station to get help for the resident. In progress note documentation on 1/6/13 at 10:05 p.m. the nurse noted that the "East hall CNA found part of a tooth in the residents room. No bleeding, no pain per east team leader." In progress note documentation on 1/6/13 at 10:15 p.m. the nurse stated that "CNA brought part of tooth that they found in resident's room to me. Charge nurse notified. Checked resident's mouth it was part of her 3rd tooth from the center on the upper right. No bleeding noted. No complaint of tooth ache. Resident was surprised to find out that she had lost part of a tooth. " On 01/08/13 at 3:45 p.m. in an interview with Resident #85's sister and two of Resident #85 ' s nieces, her sister stated that there was also a "near miss" fall since she arrived here, where a staff person was standing nearby and kept her sister from falling as she tried to stand up from her chair. She did not know what date that happened. The facility failed to assess and monitor resident interventions implemented to prevent falls and serious injury to Resident #85 with a clear history of falls with substantial injuries. The fall on 12/18/12 in a common area when it was stated on the incident report that the "staff had all gone to lunch." the intervention was to make sure that the," team leader will designate staff member to keep resident engaged." The fall on 12/30/12 was a fall in a common area of the dining room. The staff was going out of the dining area to get other residents for dinner. The resident was left at a table without frequent supervision and fell and sustained a skin tear on her right elbow and hit her head. On 01/06/13 the resident was again in a common area sitting alone in the hallway without supervision and sustained bruising on her face and broken teeth. There were changes in weight bearing. On 12/10/12 when the resident was admitted the weight bearing status was weight bearing as tolerated with transfers to chair and bed. No ambulation." then on 01/04/13 the weight bearing status was "Non-weight bearing" after an appointment with physician. On 01/09/13 the weight bearing status was changed to weight bearing with transfers and non-weight bearing to all other times. The facility failed to maintain a safe environment for the resident and did not supervise the resident and implement effective interventions to minimize fall risk and subsequent injuries.