Every finding on record at Heartwood Extended Healthcare

Based on interview and record review the facility failed to provide care for an indwelling urinary catheter (a flexible tube placed inside the bladder to drain urine continuously into an external bag), according to physician orders and plan of care, for 1 of 5 sample residents (Resident 1) reviewed for catheter care. Resident 1, who had a know history of catheter related infections, experienced harm from staff failing to flush their catheter leading to a hospitalization for bacteremia (when bacteria enters the blood stream). This failure placed facility residents at risk of infection, poor clinical outcomes and a decreased quality of life.Findings included. Review of the quarterly minimum data set (MDS, a required assessment tool), dated 05/21/2026, showed that Resident 1 admitted to the facility on [DATE] with diagnoses including, but not limited to, quadriplegia (paralysis of all four limbs) and obstructive uropathy (a blockage that slows or stops the normal flow of urine in the urinary tract). The MDS further showed that Resident 1 had an indwelling urinary catheter, and that Resident 1 was wheelchair-dependent and required staff assistance for all care, mobility and activities of daily living. Additionally, the MDS showed that Resident 1 was their own legal representative, was alert and oriented, and was able to understand others and communicate their own needs clearly to others. During an interview on 08/04/2026 at 2:50 PM, Collateral Contact (CC1) stated that Resident 1 had a history of recurrent urinary tract infections (UTI), and was currently in the hospital for a catheter infection. CC1 stated that the facility had not been properly caring for Resident 1's catheter and had not been following the doctor's orders. Review of the medical record showed that Resident 1 had been hospitalized for urinary tract infection, sepsis (a serious medical emergency that happens when the body has an extreme, harmful response to an infection), and/or bacteremia on the following dates: 03/15/2026 to 03/20/2026, 04/03/2026 to 04/10/2026, and 08/01/2026 to 08/05/2026. Review of the physician orders showed that Resident 1 had an order, dated 05/15/2026, which instructed staff to flush Resident 1's catheter with normal saline every day shift. Review of the treatment administration record (TAR), dated July 2026, showed that Resident 1's catheter flushing was not completed on 12 of 31 days. Review of the progress notes showed corresponding notes explaining why Resident 1's treatment was not completed: 07/07/2026 - absent from facility; 07/10/2026 - resident refused; 07/11/2026 - in chair; 07/17/20026 - on order; 07/20/2026 and 07/21/2026 - on order; 07/22/2026 - blank space on the TAR, no progress note; 07/24/2026 - in w/c [wheelchair]; 07/26/2026 - saline on order; 07/29/2026 - on order; 07/30/2026 - in w/c; and 07/31/2026 - on order. Further review of the July 2026 progress notes showed no staff communication with the physician about Resident 1 missing the catheter flushing treatments, and no documentation about reapproaching Resident 1 at different times to accommodate completion of the ordered catheter-flushing treatment. Review of a progress note, dated 08/01/2026, showed that Resident 1 was complaining of having chills around 3 pm. Vital signs were taken and were normal for Resident 1 at that time. Later, Resident 1 reported chills were still present and additionally, moderate to severe neck and back pain had started. Resident 1 requested to go to the emergency room because the last time they had felt this way, they had a UTI and sepsis. Resident 1 was subsequently transferred to the emergency room, on 08/01/2026 at 5:30 PM, and was admitted to the hospital. Review of a hospital document titled, After Visit Summary, dated 08/05/2026, showed that Resident 1 had been admitted to the hospital for bacteremia which was most likely related to their foley catheter. During interview on 08/26/2026 at 12:20 PM, Staff B, Director of Nursing Services (DNS), stated that it did not make sense for Resident 1's catheter flushing treatment to have not been completed due to the saline being on order, because saline should have always been in stock in the facility, and it was not something that the nurses would need to wait on for the pharmacy to deliver. Staff B, DNS, stated that they would investigate it. No additional information was provided. WAC Reference 388-97-1060(3)(c).

Based on interview and record review, the facility failed to provide notice of the option to hold a specific bed, when going on a therapeutic leave of absence, for three of three residents (Residents 2, 3 and 4) reviewed for admission, transfer and discharge. In addition, the facility failed to create a clear policy and procedure, for residents who wished to take a therapeutic leave of absence, to promote clear communication among the interdisciplinary team and safety and supervision during leave of absence.Findings included. Review of a facility policy titled, Bed Hold, reviewed May 2025, showed that a bed hold applied to the holding of a specific bed, and it was the policy of the facility to offer the resident and/or the resident's representative, in writing, the option to hold a specific bed upon transfer or leave of absence.Centers for Medicare and Medicaid Services (CMS) defines a Therapeutic Leave of Absence as, Absences for purposes other than required hospitalization. CMS guidance further explains that therapeutic leave of absence must be consistent with the resident's goals for care, be assessed by the comprehensive assessment, and incorporated into the comprehensive care plan. Resident 2Review of the electronic health record (EHR) on 08/24/2026 showed that Resident 2 was admitted to the facility on [DATE]. The EHR showed that Resident 2 was alert and oriented, with no documented cognitive impairment, and was their own responsible party. Review of the EHR showed that Resident 2 was out of the facility, on Leave of Absence, on the following dates:06/23/2026 to 06/25/202607/06/2026 to 07/08/202607/13/2026 to 07/15/202607/15/2026 to 07/18/202607/18/2026 to 07/20/202607/20/2026 to 07/22/2026 Review of the EHR showed no documentation that information for a bed hold was provided to Resident 2 on six of six leaves of absence. Further review of the EHR showed that, for six of six leaves of absence, there were no physician orders stating that Resident 2 could go on a leave of absence, and no orders for medication and treatment administration to be arranged; there was no documented communication with the physician about Resident 2 being out of the facility on leave of absence; there was no plan of care for the therapeutic leave of absence to include where Resident 2 was going, how long they intended to be gone, and contact information to use if the facility need to reach Resident 2. RESIDENT 3Review of EHR on 08/24/26 showed that Resident 3 was admitted to the facility on [DATE]. The EHR showed that Resident 3 was alert and oriented, with no documented cognitive impairment, and was their own responsible party. Review of a progress note, dated 07/25/2026 at 4:12 PM, showed that Resident 3 had left the facility with a young male stating they were, Going to get some stuff, and would return afterward. Review of a progress note, dated 07/25/2026 at 5:22 PM, showed that Resident 3 called the facility stating that they would be back on [07/27/2026], and that staff notified the doctor on call. Review of progress notes, dated 07/27/2026 and 07/28/2026, showed that Resident 3 remained out of the facility. Review of the EHR showed no documentation that information on a bed hold was provided to Resident 3 for their leave of absence. Further review of the EHR showed that there was no physician orders stating that Resident 3 could go on a leave of absence, and no orders for medication and treatment administration to be arranged; and there was no plan of care for the therapeutic leave of absence. Resident 4Review of EHR on 08/24/26 showed that Resident 4 was admitted to the facility on [DATE]. The EHR showed that Resident 4 was alert and oriented, with no documented cognitive impairment, and was their own responsible party. Review of a progress note dated 08/15/2026 at 10:23 PM showed that Resident 4 had left the facility earlier that morning, and had called to notify staff that they would be spending the night at their girlfriend's house. Review of a progress note dated 08/15/2026 at 10:26 PM showed that staff notified Staff B, Director of Nursing Services (DNS) and the on-call provider (doctor or nurse practitioner) of Resident 4's leave of absence. Further review of the EHR showed that Resident 4 returned to the facility on [DATE]. Review of the EHR showed no documentation that information on a bed hold was provided to Resident 4 for their leave of absence. Further review of the EHR showed that there were no physician orders stating that Resident 4 could go on a leave of absence, and no orders for medication and treatment administration to be arranged; and there was no plan of care for the therapeutic leave of absence. During an interview on 08/26/2026 at 10:59 AM, Staff A, Administrator, stated that a therapeutic leave of absence was something that should have been planned and arranged. Staff A, Administrator, stated that staff should be aware; the doctor should be aware; if at all possible, medications should be sent with the residents; staff should know, in advance, when residents were planning to leave, where they were planning to be, and when they were planning to return. Staff A, Administrator, further stated that they were not aware of the requirement to offer a bed hold when residents took a leave of absence from the facility. WAC reference 388-97-0120(3)(a)(4)(a)(b).

Based on interview and record review, the facility failed to accurately document skin condition, to include wounds and pressure ulcers (bed sores - skin damage caused by prolonged pressure, commonly in bony areas like heels, ankles, hips and tailbone), upon readmission from the hospital, for one of three residents (Resident 1), for three of four readmissions (03/20/2026, 04/10/2026, and 08/05/2026), reviewed for pressure ulcer treatment and prevention. This failure placed residents at risk for unidentified skin impairments, delayed treatment and healing, inaccurate medical records, and inaccurate communication of the residents' skin condition among the interdisciplinary team (doctors, nurse practitioners, nurses, wound specialists, skilled therapists).Findings included. Review of the quarterly minimum data set (MDS, a required assessment tool), dated 05/21/2026, showed that Resident 1 admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs) and pressure ulcers. The MDS showed that Resident 1 was wheelchair-dependent and required staff assistance for all care, mobility and activities of daily living. Review of a facility policy titled, Nursing admission Evaluation, updated July 2014, showed that an evaluation titled, Weekly Wound Evaluation, was to be completed during the initial nursing evaluation if wound/skin issues were identified during the nursing admission evaluation. Review of the electronic health record (EHR), on 08/14/2026, showed that Resident 1 had been hospitalized , and re-admitted to the facility, four times throughout their stay:03/15/2026 to 03/20/2026 - readmitted to the facility on [DATE]/03/2026 to 04/10/2026 - readmitted to the facility on [DATE]/26/2026 to 05/15/2026 - readmitted to the facility on [DATE]/01/2026 to 08/05/2026 - readmitted to the facility on [DATE]. Review of the discharge MDS's dated 03/15/2026, 04/03/2026, 04/26/2026, and 08/01/2026 showed that Resident 1 had pressure ulcers each time they were transferred to the hospital. Review of the re-admission Nursing Evaluation, dated 03/20/2026, showed that Resident 1 required skilled services to include wound care. There was no skin assessment or Wound Evaluation completed upon readmission on [DATE]. Review of the EHR showed no re-admission Nursing Evaluation, skin assessment or Wound Evaluation completed for Resident 1 upon readmission on [DATE]. Review of the re-admission Nursing Evaluation, dated 08/05/2026, showed no 'yes or no' response to the question, Does the resident [Resident 1] present with new skin impairments? and there was no Wound Evaluation or skin assessment completed. During an interview on 08/14/2026 at 1:58 PM Staff B, Director of Nursing Services (DNS), stated they would have expected the staff to follow the Nursing admission Evaluation policy on Resident 1's readmission. During an interview on 08/26/2026 at 1:35 PM, Staff E, Assistant Director of Nursing (ADON), stated that when Resident 1 re-admitted from the hospital each time, a skin assessment should have been completed by a nurse as part of the re-admission evaluation and assessment. Staff E, ADON, further stated that if evaluation form was not completed, then a skin assessment should have at least been documented in a progress note, to include description of skin impairments and wound measurements. WAC reference 388-97-1060 (3)(b).

Based on interview and record review, the facility failed to implement and follow a restorative nursing program (a structured care plan designed to help residents maintain their highest level of independence - common types of programs include bed mobility and transfers, walking, range of motion (ROM), and activities of daily living) for one of three residents (Resident 1) reviewed for restorative nursing programs. This failure place the resident at risk for declines in mobility and ROM, contractures (a permanent tightening of muscles, tendons, and nearby tissues that causes joints to shorten, stiffen and lose their full ROM), pain, and a diminished quality of life.Findings included. Review of the quarterly minimum data set (MDS, a required assessment tool), dated 05/21/2026, showed that Resident 1 admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs). The MDS further showed that Resident 1 was wheelchair-dependent and required staff assistance for all care, mobility and activities of daily living. Additionally, the MDS showed that Resident 1 was their own legal representative, was alert and oriented, and was able to understand others and communicate their own needs clearly to others. During an interview on 08/04/2026 at 2:50 PM, Collateral Contact (CC1) stated that Resident 1 was not getting any therapy, their arms and legs had become stiff from not moving, and that ROM in their joints had become worse. During an interview on 08/24/2026 at 1:30 PM, Staff C, Director of Rehabilitation Services (DOR), stated that Resident 1 had been discharged from skilled therapy services and referred to a restorative nursing program on 06/09/2026. Review of a facility document titled, Restorative Program Referral Form, dated 06/09/2026, showed that Resident 1 was to start a restorative nursing program to include passive ROM exercises (staff member moving a resident's joints through their normal motions while the resident remains relaxed without using their own muscles) for upper and lower extremities three to five times per week to maintain ROM for functional ability. Review of the electronic health record (EHR) on 08/26/2026 showed no documentation that Resident 1's restorative nursing program was completed per the care plan. There was no documentation from the restorative nurses aids, no progress notes, no documented evidence to show that the program was implemented. During an interview on 08/26/2026 at 11:04 AM, Staff D, Registered Nurse (RN)/Restorative Nurse, stated that they were unable to locate documentation to show that Resident 1's restorative nursing program had been implemented. Staff D, RN/Restorative Nurse, further stated that the restorative program had been entered into the EHR incorrectly so that the staff were not prompted to document the time they may have spent with Resident 1 completing the program. WAC Reference 388-97-1060 (3)(d).

Based on interview and record review that facility failed to capture leaves of absence from the facility for two of three residents (Residents 3 and 4) reviewed for admission, transfer and discharge. This failure placed residents at risk for potential billing errors and an incorrect medical record.Findings included. Resident 3Review of electronic health record (EHR) on 08/26/2026 showed that Resident 3 was admitted to the facility on [DATE]. The EHR showed that Resident 3 was alert and oriented, with no documented cognitive impairment, and was their own responsible party. Review of progress notes, dated 07/25/2026 through 07/28/2026, showed that Resident 3 had left the faciity on [DATE], and notified the facility on 07/28/2026 that they would not be returning. Review of the clinical census records of the EHR showed no leave of absence documented for Resident 3 for dates 07/25/2026 through 07/28/2026. Resident 4Review of EHR on 08/26/2026 showed that Resident 4 was admitted to the facility on [DATE]. The EHR showed that Resident 4 was alert and oriented, with no documented cognitive impairment, and was their own responsible party. Review of progress notes, dated 08/15/2026 through 08/17/2026, showed that Resident 4 had left the faciity on [DATE], and returned on 08/17/2026. Review of the clinical census records of the EHR showed no leave of absence documented for Resident 4 for dates 08/15/2026 through 08/17/2026. During an interview on 08/26/2026 at 1:00 PM, Staff F, Business Office Manager (BOM), stated that when a resident left the facility for a leave of absence, the nurse should have created a census line in the EHR to document that the resident was out of the facility on a leave of absence. WAC reference 388-97-1720(3)(c)(ii).

Based on observation, interview and record review, the facility failed to implement a process to maintain inventory of residents' personal belongings for 2 of 3 residents (Residents 1 and 2) reviewed for loss of personal property. This failure placed residents at risk for inability to safeguard personal property, inability to receive replacement/reimbursement for missing property, and increased the risk of theft, loss and misappropriation.Findings included. Review of a facility policy titled, Notice of Theft and Loss Control Policy, updated March 2025, showed that the facility made reasonable efforts to safeguard resident property and valuables, and that suspected theft or loss of resident property was timely and thoroughly investigated. The policy further showed that Personal Belonging Inventory was completed upon admission and updated as items were sent home and new items were brought in to the facility. Resident 1Resident 1 was admitted to the facility on [DATE] for skilled nursing and physical and occupational therapy services after surgery. Resident 1 was their own responsible party and was alert and oriented to person, place, time and situation. Resident 1 was able to make their needs known and they were able to understand others. During interview on 06/23/2026 at 12:01 PM, Resident 1 stated that they had several items that had gone missing since they admitted to the facility, to include three bottles of fragrance, eight baseball jersey-style tops that had Resident 1's name embroidered across the back, and two sweat suits that had Resident 1's name embroidered across the back. Resident 1 stated that they had the fragrance shipped to the facility since they admitted , but all the clothing they already had upon admission. Resident 1 further stated that no one completed inventory for their personal belongings, the facility ignored the grievances they filed about the missing items, saying they were not replacing anything because they could not prove it was there, and that facility staff had told Resident 1 to limits personal belongings and not have items shipped to the facility because things continued to come up missing. Review of a grievance form, dated 04/01/2026, showed that Resident 1 was missing many personal clothing items that were labeled with Resident 1's name. The written response from the facility was that a police report was filed. Review of a grievance form, dated 5/19/2026, showed that Resident 1 was still missing their clothing (jersey's and sweat suits with their name on them), and was requesting that laundry be searched and it they weren't found, that they be reimbursed for the missing clothing. The written response from the facility was that they were previously filed as a claim, the items were not on Resident 1's inventory list, and Resident 1 was informed to send their items to their fiance. Review of another grievance form, dated 05/19/2026, showed that Resident 1 reported a pair of earbuds missing. The written response from the facility was that Resident 1 was informed to not send items to the facility, and if they did, to add them to their inventory sheet. Review of another grievance form, dated 05/19/2026, showed that Resident 1 reported a corset and three bottles of cologne were missing. The written response from the facility was that Resident 1 was informed that wedding supplies were to be sent to their spouse and not the facility. During interview on 06/24/2026 at 11:35 AM, Staff C, Registered Nurse (RN), stated that when a new resident admits to the facility, a certified nursing assistant (CNA) would complete their personal belongings inventory sheet, and if new belongings were brought in, staff would add the items to the resident's inventory sheet. Staff C, RN, stated that the inventory sheets were kept in a binder at the nurses' station. Review of the binder at the nurses' station showed that there was no inventory sheet for Resident 1. Review of Resident 1's electronic health record (EHR), showed no inventory sheet present and the facility was unable to provide an inventory sheet for Resident 1. Resident 2Resident 2 was admitted to the facility on [DATE]. Review of the binder at the nurses' station showed that there was no inventory sheet for Resident 2.Review of Resident 2's EHR showed no inventory sheet present and the facility was unable to provide an inventory sheet for Resident 2. During interview on 06/24/2026 at 12:30 PM, Staff A, Administrator, stated that when new residents admit, an inventory sheet should be completed, and as new items were brought in, those items should be added to the resident's inventory sheet with the assistance of facility staff. The inventory sheet should then be scanned into the resident's EHR, and every resident should have an inventory sheet on file. Staff A, Administrator, further stated that the facility had identified a weakness in this process. Reference WAC 388-97-0640 (2)(a)(3)(d).

Based on interview and record review the facility failed to conduct a thorough investigation into a resident's allegations of neglect to determine if abuse or neglect had taken place for 1 of 3 residents (Resident 3) reviewed for investigations. This failure placed residents at risk for ongoing abuse and/or neglect, feelings of insecurity in the facility, unmet care needs, psychological harm, and a diminished quality of life.Findings included. Review of the electronic health record (EHR) showed that Resident 3 admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis affecting arms, legs and torso). Further review of the EHR showed that Resident 3 was totally dependent on staff for mobility and all care needs. Resident 3 was alert and oriented and was able to communicate their needs to the staff. Review of a grievance form, dated 06/01/2026 at 07:45 AM, showed that Resident 3 reported that the previous midnight (06/01/2026 at 12:00 AM) two male nursing assistants agreed to reposition Resident 3 every two hours through the night, but they never came back. The grievance further showed that Resident 3 reported that the same thing had happened many times before, and that not being repositioned puts them in a lot of pain. The grievance showed that the facility converted this complaint into a reportable allegation of neglect, and the facility reported it to the State Agency. Review of the facility incident investigation, initiated 06/01/2026 and concluded 06/02/2026, showed that nursing documentation and staff assignments were going to be reviewed, staff interviews were to be conducted, Resident 3's care plan would be reviewed and revised, and that Resident 3 would be assessed for any skin impairments, pain, and any other adverse outcomes. Further review of the investigation showed no staff interviews, no resident interviews, no resident assessments, and no documentation of investigation findings to determine whether neglect had taken place. Review of the EHR, on 06/24/2026, showed that Resident 3's care plan had not been updated after the allegation was made, and there were no follow-up progress notes to show that Resident 3 had been monitored for continued care concerns. During an interview on 06/23/2026 at 12:52 PM, Resident 3 stated that the facility had not done anything in response to their report about not being turned through the night. Resident 3 stated that no one had come to talk to them or ask them any questions about their concerns. Resident 3 stated that it had been an on-going issue that had not yet been resolved. During an interview on 06/24/2026 at 2:00 PM, Staff B, Director of Nursing (DNS), stated that they could not provide staff interviews and that Resident 3's care plan had not been updated post-investigation. During the same interview, Staff A, Administrator, stated that it was expected that the facility conduct a thorough investigation into allegations of abuse and neglect, and that staff should have monitored Resident 3 for on-going concerns after the allegation was made. Reference WAC 388-97-0640(6)(a)(b).

Based on observation, interview and record review, the facility failed to coordinate podiatrist services for 3 of 3 residents (Residents 1, 2, and 3) reviewed for foot care. This failure placed residents at risk of infection, pain, discomfort, and a diminished quality of life.Findings included. Resident 1Resident 1 admitted to the facility on [DATE] with diagnoses to include left-side hemiplegia/hemiparesis (weakness or inability to move one side of the body) following a stoke, lung cancer, and diabetes. Resident 1 required moderate to maximum assistance from staff for activities of daily living (ADLs - dressing, bathing, eating, toileting, grooming, etc.). In an interview on [DATE] at 2:30 PM a collateral contact (CC1) stated that Resident 1 had needed podiatrist care for long, thick, ingrown toenails the entire time they were a resident in the facility, and they did not think nurses provided toenail care. CC1 further stated that Resident 1 was complaining of discomfort and had sores on their feet. CC1 stated that the last time they checked with the facility staff about Resident 1's podiatrist visit, they were told that they would be seen on [DATE]. CC1 stated that Resident 1 passed away on [DATE] without ever being seen by a podiatrist. Review of Resident 1's medical record showed a physician's order, dated [DATE], which read, May have medical consult and TX [treatment] as indicated. (Dental, Podiatry, Eye, Hearing, Psych and Wound Care, Cardio, Renal, Physiatry), and another order, dated [DATE], which read, Referral to podiatry for foot care. Review of Resident 1's care plan, initiated [DATE], showed, Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of Resident 1's electronic health record (EHR) on [DATE] showed no documentation that Resident 1 had been seen by a podiatrist during his stay. In an interview on [DATE] at 12:20 PM, Staff B, Assistant Director of Nursing (ADON), stated they could not find any documentation to show that Resident 1 had been seen by a podiatrist during their stay. Resident 2Resident 2 admitted to the facility on [DATE] with diagnoses to include quadriplegia (a form of paralysis that causes loss of movement and sensory function in all four limbs and the torso) and required total assistance from staff for all ADLs. In an interview on [DATE] at 12:27 PM Resident 2 stated, My toes are bad. I need to see a podiatrist. An observation at the same time showed Resident 2's left and right feet with long, yellowing, flaking, thick toenails. Review of the medical record on [DATE] showed that Resident 2 had nothing documented on the nursing admission assessment noting fungal issues with nails, no order for podiatry as needed, no care planning related to fungal toenails/fingernails, and no progress notes about fungal toenails/fingernails. In an interview on [DATE] at 12:30 PM, Staff D, Shower Aide, stated that during showers, they would clean and trim nails, but the nurses were responsible for nail care in diabetic residents. Staff D further stated that if a resident's toenails were very thick and not easily trimmed, they would tell the nurse, and the nurse could put them on the list for a podiatry referral. In an interview on [DATE] at 12:32 PM, Staff C, Appointment & Transportation Scheduler, stated that Resident 2 was not on the list for podiatry referral. In an interview on [DATE] at 1:40 PM Staff B, ADON, stated that if a resident admitted with long, thick, fungal toenails, it should be documented in a progress note because the nursing admission assessment did not have a place to document the condition of the nails. Staff B, ADON, further stated that if issues were identified with a resident's toenails, the nurse should communicate with the medical provider and request and order for referral to podiatry, and the problem should be care planned. Resident 3Resident 3 admitted to the facility on [DATE] with diagnoses to include diabetes, obesity, heart failure, and need for assistance with personal care. In an interview on [DATE] at 12:13 PM, Resident 3 stated that they had asked to see a podiatrist and thought that the doctor had wanted them to see a podiatrist, but the facility never set up an appointment for them to be seen by one. Resident 3 stated, I just gave up on it. Observation at the same time showed Resident 3's toenails were long, big toenails were thickened, and the skin of feet and toes were dry and flaky. Review of Resident 3's medical record showed a physician's order, dated [DATE], which read, May see podiatrist PRN [as needed] for foot related issues. Review of Resident 3's progress notes showed a Social Services note, dated [DATE], documenting that Resident 3 had accepted referrals for vision, hearing, dental, and podiatry. Further review of Resident 3's progress notes showed this physician note, Toenails fungal infection in both feet, repeatedly documented on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident 3's EHR showed no documentation that a podiatry visit had ever taken place. In an interview on [DATE] at 12:32 PM, Staff C, Appointment & Transportation Scheduler, stated that Resident 3 was not on the list for podiatry referral. In an interview on [DATE] at 12:20 PM Staff B, ADON, stated that there was a new podiatry practice that the facility had just contracted with and there was a brief time in with there was not a podiatrist seeing residents on-site. In addition, Staff B, ADON, stated that the person who had done the appointment scheduling had recently left the position, things were disorganized, and the new scheduler was trying to get a handle on everything. Staff B, ADON, further stated that the expectation was that podiatry referrals were to be written on an electronic communication board in the facility's EHR system, and the scheduler would then see the notes and would place the named residents on the list to be seen by a podiatrist. In an interview on [DATE] at 12:42 PM, Staff C, Appointment & Transportation Scheduler, stated that the process for staff to communicate residents' podiatry needs was verbal communication, use of the electronic communication board in the EHR, and/or written requests for follow-up from previous podiatrist appointments. Staff C further stated that the electronic communication board messages could be problematic because they expired after a set time, so there was a possibility of those messages being lost before they could be addressed. In an interview on [DATE] at 2:00 PM, Staff A, Administrator, stated that they were aware of deficiencies in the facility's process for podiatry referrals and care in the facility, and were working on them. Reference WAC 388-97-1060(3)(j)(viii).

Based on interview and record review, the facility failed to identify fall trends, evaluate the effectiveness of previous fall prevention interventions and to implement progressive resident centered interventions for 1 of 2 sampled residents (Resident 66) reviewed for falls. Resident 66, who had six falls in 10 weeks (two unwitnessed non-injury and four unwitnessed with injury), experienced harm when they fell, sustained a fracture of their right distal clavicle (collar bone) that required transfer to the emergency department for evaluation and treatment. This failure placed residents at risk of repeated falls and injuries. Findings included.Review of the electronic health record (EHR) showed Resident 66 admitted to the facility on [DATE] with diagnoses that included repeated falls, diabetes (too much sugar in blood), and dementia (decline in mental ability severe enough to interfere with daily life). Resident 66 was able to make needs known. Review of the minimum data set (MDS, an assessment tool), dated 01/19/2026, showed Resident 66 had a BIMS (a brief cognitive screening tool. 0-7 indicates severe cognitive impairment) score of 00 and required partial/moderate assistance with chair and toilet transfers. Review of the incident log from January 2026-March 2026 showed Resident 66 had unwitnessed non-injury falls 01/26/2026 and 02/11/2026. Resident 66 had unwitnessed falls with injury on 01/02/2026, 01/18/2026, 03/03/2026 and 03/14/2026. Review of Resident 66's Care Plan (CP) initiated 10/20/2025 showed the following interventions: Encourage call light use, initiated 10/20/2025. Do not put bed in lowest position, initiated 10/28/2025. Toilet Use: Max one person assist with toilet hygiene, initiated 11/06/2025. Encourage resident to call for assistance, initiated 11/06/2025. Frequent checks related to falls, initiated 11/11/2025. Encourage to attend social and recreational activities, initiated 12/31/2025. Offer assistance with toileting every two hours, initiated 12/03/2025. Review of the facility incident report, dated 01/02/2026, showed the incident report concluded the fall was Resident 66 was trying to pick up the remote. Resident 66 was transfered to the hospital and treated for a bruise on their face. No new interventions or corrective measures were documented. Review of the facility incident report, dated 01/18/2026, showed the facility concluded the fall was related to Resident 66's impulsiveness and continued to ambulate and self-transfer without using call light for assistance. Resident 66 sustained a skin tear of their left eyebrow where a previous fall bump was located. No new interventions or corrective measures were documented. Review of the facility incident report, dated 01/26/2026, showed the facility concluded the fall was the related to Resident 66 attempted to self-transfer to their wheelchair and fell due to the wheelchair brakes not being locked. Planned intervention to prevent recurrence was for therapy to assess their wheelchair for anti-lock brakes. Review of a document titled Fall Screening, dated 02/03/2026, showed a recommendation for patient to use anti-rollback device on wheelchair to prevent fall, notified staff. The document was signed by Staff K, Director of Rehabilitation (DOR). Review of the facility incident report, dated 02/11/2026, showed the facility concluded the fall was the related to Resident 66 attempted to go to the bathroom and slid from the wheelchair onto the floor. Planned interventions to prevent recurrence were continuing to encourage call light use, offer assistance to the bathroom and encourage to attend activities; interventions that were previously initiated on the CP. Review of a document titled Fall Screening, dated 02/12/2026, showed a recommendation for Patient has anti-rollback device on wheelchair to help with safety when standing. Maintenance placed on wheelchair today. Review of a document titled Fall Screening, dated 02/26/2026, showed Patient at baseline, continue nursing supervision and plan of care. Review of the facility incident report, dated 03/03/2026, showed the incident report concluded the fall was the related to Resident 66 attempting to transfer from their wheelchair to the bed. Resident 66 was transfered to the hospital and treated for a hematoma (pooling of blood outside of blood vessels) on their head. Planned interventions to prevent recurrence was to assess for safety upon return from the hospital. Review of Resident 66's Occupational Discharge summary, dated [DATE], showed a recommendation for a Left side brake handle extension, unable to locate. Review of the facility incident report, dated 03/14/2026, showed Resident 66 was found on the floor in the bathroom and unable to state what happened. The incident report concluded the fall was related to Resident 66's preference to not use their call light for assistance and self-transfer to the toilet. A staff witness statement noted Resident 66's bed was locked and in the lowest position. Resident 66 was taken to the hospital and treated for a fracture of their distal clavicle. During an observation and interview on 03/27/2026 at 11:28 AM, Staff J, Occupation Therapist (OT), observed Resident 66 attempted to roll their wheelchair backwards, but they were unable to. Staff J stated the anti-rollback device was not safe or appropriate due to Resident 66's impulse to stand when they could not roll backwards. Staff J stated their recommendation was for a brake handle extension as Resident 66 had a weak left side and was unable to unlock the left side wheelchair brake. Staff J stated nursing was responsible for ordering devices when a resident was not on therapy services. Observation and interview at 03/30/2026 at 9:31 AM, Staff K, Director of Rehabilitation, stated Resident 66 was discharged from therapy in January 2026 but should have been evaluated for therapy after the 01/18/2026, 01/26/2026 and 02/11/2026 falls. Staff K stated Resident 66 was in and out of the hospital and they were unaware of where ball was dropped. Staff K stated Resident 66 was not assessed in the wheelchair after the anti-rollback device was installed on the wheelchair for safety and to determine if the device was appropriate but should have been. During an interview on 03/27/2026 at 2:11 PM, Staff B, Director of Nursing Services (DNS), stated they were unaware of the recommendation for the brake extender; however, they did not believe that contributed to Resident 66's injury. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure the facility's menus were prepared in advance, followed, and reflected input received from the residents and resident group for 3 of 3 sampled days (03/25/2026, 03/26/2026, and 03/27/2026) when reviewed for kitchen. This failure placed residents at risk of dissatisfaction with kitchen services, reduction in food consumed, avoidable weight loss, a decline in clinical condition, and a diminished quality of life. Findings included.Observation and record review on 03/26/2026 at 11:23 AM showed the facility menu for the week with entries for breakfast, lunch, and dinner daily hung in the facility's cafeteria. Review showed beef tip au jus, rice, seasoned peas, wheat roll, margarine, and frosted marble cake were scheduled to be served for lunch on 03/26/2026. Observation showed a sticky note was placed over the lunch menu entry for 03/26/2026 with carrots written by hand. Observation showed similar sticky notes placed over the lunch for 03/25/2026 with No apples, change to pineapple and peaches over the 03/25/2026 lunch entry and Diced potatoes not mashed over the dinner menu for 03/25/2026. Observation on 03/26/2026 at 12:52 PM showed residents were served beef tip au jus, rice, carrots, a piece of bread, and yellow cake for lunch (seasoned peas, wheat roll, and marble cake were not provided per menu). Review of the lunch menu for 03/27/2026 showed chicken fried rice, broccoli, egg roll, and tropical fruit. Observation on 03/27/2026 at 12:06 PM showed apricot was served in lieu of tropical fruit. During an interview on 03/27/2026 at 12:07 PM, Staff JJ, Dietary Manager, stated any substitutions to the menu were reviewed by the facility's registered dietician to ensure nutritional needs were still met and recorded on a substitution log. During an interview on 03/27/2026 at 12:31 PM, Staff JJ, Dietary Manager, stated the facility offered an alternative meal to the posted menu for the day. Staff JJ stated this alternative meal was not posted for residents to view and was based on what extra food was available in the kitchen. Review of the Menu Substitution Record showed on 03/26/2026 carrots were substituted for peas but did not show the substitutions of piece of bread for wheat roll or yellow cake for marble cake. Review showed on 03/25/2026 peaches and pineapple were substituted for baked apples but did not show diced potatoes were substituted for mashed potatoes. Review showed 10 substitutions were recorded for the month of March 2026 and 9 of 10 were due to a lack of product. During an interview on 03/30/2026 at 10:00 AM, Staff JJ, Dietary Manager, stated when a substitute needed to occur, they would have it reviewed by the registered dietician, record it in the Menu Substitution Record, and a sticky note would be put on the menu posted in the facility's cafeteria. Staff JJ stated residents were not informed of substitutions except by this sticky note. Staff JJ stated the alternative meal was not posted for residents, and residents would receive the alternative if the main menu contained items recorded as Dislikes on their tray card. Staff JJ stated the alternative menu was decided by whatever we have in stock and decided on the day it would be served. Staff JJ stated there was no system for residents to choose between the main or alternate meal. During an interview on 03/30/2026 at 10:38 AM, Staff A, Administrator, stated residents should be informed of substitutions to the menu and residents should be able to choose between the main course and the alternative menu item. Staff A stated the facility's menu system did not meet expectations. Reference WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4)

Based on observation interview and record review, the facility failed to implement an infection control program that ensured the surveillance of possible communicable diseases was completed for 1 of 3 months (January 2026) and to ensure the proper handling and processing of soiled linens for 1 of 1 laundry rooms when reviewed for infection control. These failures placed the residents at risk for infections, poor clinical outcomes and a decreased quality of life. Findings included.TrackingReview of the infection control logs for the month of January 2026 showed no infectious organisms were identified and included on the log. Further review showed an entry for Resident 110 dated 01/30/2026 which showed it was not a multidrug resistant organism (MDRO) and did not require special infection control precautions. Review of Resident 110's electronic health record (EHR) showed a laboratory test dated 01/20/2026 which identified Escherichia coli ESBL positive organism [an MDRO] confirmed, contact precautions should be observed with this patient. During an interview on 03/27/2026 at 1:37 PM, Staff E, Infection Preventionist/Registered Nurse (IP/RN), stated the month of January did not include the identified organisms and should have. Staff E stated they did not have access to hospital records and did not know which organisms were present for Resident 110. LaundryDuring an interview on 03/27/2026 at 10:10 AM, Resident 5 stated when they had missing clothing the facility let them go into the laundry room and look for them. Observation and interview on 03/27/2026 at 12:05 PM showed boxes of supplies being stored in the soiled linen sorting room with an open box of gauze bandages. There was one soiled linen barrel present. Staff V, Laundry, stated the soiled laundry room was currently being used for central supply and they sorted the soiled linens in the laundry room. Review of the temperature logs on 03/27/2026 for the month of March 2026 showed the last entry was on 03/24/2026. Staff V stated it should be monitored/logged every shift. During an interview on 03/27/2026 at 12:07 PM, Staff X, Central Supply, stated residents had come into the laundry room and looked through the non-labeled clothes for missing items. During an interview on 03/27/2026 at 12:07 PM, Staff B, Director of Nursing Services, stated soiled linens should be sorted in a separate area from the washing and the temperatures should be monitored daily. During an interview on 03/27/2026 at 1:37 PM, Staff E, RN/IP, stated it was their expectation that soiled linens be sorted separately from the clean linens and the temperature monitoring be completed daily. Staff E stated residents should not have been going through the laundry themselves. During an interview on 03/30/2026 at 11:12 AM, Staff A, Administrator, stated soiled linens being sorted in the washing area, temperature monitoring not being completed, and residents going through the laundry themselves did not meet expectations. Staff A stated it was their expectation that the infection preventionist reviewed all infectious disease labs results to ensure appropriate antibiotics and precautions were in place. Reference WAC 388-97-1320(2)(a)(3)

Based on observation, interview, and record review, the facility failed to ensure safety devices did not restrict residents' ability to move and the resident or resident representative consented to the use of restrictive safety devices for 3 of 4 sampled residents (Residents 66, 105 and 51) reviewed for physical restraints. This failure placed the residents at risk of being unnecessarily restrained and a diminished quality of life. Findings included.Resident 51 Review of the electronic health record (EHR) showed Resident 51 was admitted to the facility on [DATE] with diagnoses to include hospice (end of life care), depression, anxiety and vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain). Resident 51 was not able to communicate their needs. Review of the quarterly minimum data set (MDS, a required assessment), dated 02/24/2026, showed Resident 51 was dependent on staff for completing activities of daily leaving (ADL). Review of the EHR showed Resident 51 last weight was 75.4 pounds on 01/07/2025. Observation on 03/23/2026 at 10:25 AM, showed Resident 51 laid in bed in a fetal position with a fragile, small body frame, with half side rails (metal device approximately three feet long and one foot and a half tall) on both sides of the bed. Resident 51 was surrounded by the side rails in bed. Observation on 03/25/2026 at 8:53 AM showed Resident 51 laid in bed with curled up feet and half size side rails up in the bed. Observation on 03/26/2026 at 11:48 AM showed Resident 51 watching TV in bed with half side rails up in bed. Observation on 03/27/2026 at 9:23 AM showed Resident 51 was assisted by staff to eat breakfast and the side rails were up in bed. Review of a Device and Bed Rail/Bed Enabler Evaluation and consent dated 09/05/2025 showed Resident 51 had Grab/Assist/Mobility Bars/Bed Canes – Bilat (canes are metal device that are the same height as the rails and are 10-12 inches or one foot in length). Review of the care plan problem for falls revised on 10/27/2025 showed Resident 51 had intervention for bilateral grab bars to aid with bed mobility initiated 09/05/2025. During an interview on 03/26/2026 at 1:12 PM, Staff R, Registered Nurse/Unit Manager, stated the process for restraints and devises was to have therapy evaluate residents first and if appropriate the nurses would follow up with consent and assessment. Staff R could not find documentation to explain half side rails use for Resident 51. During an interview on 03/27/2026 at 1:35 PM, Staff B, Director of Nursing Services (DNS), stated any device that could be a potential restraint should have assessment, consent and be periodically reassessed. Staff B stated the use of half side rails without accurate assessment did not meet their expectations. Resident 66 Review of the EHR showed Resident 66 admitted to the facility on [DATE] with diagnoses that included repeated falls, diabetes and dementia (decline in mental ability severe enough to interfere with daily life). Resident 66 was able to make needs known. Review of the 01/19/2026 5-day MDS showed Resident 66 was able to independently wheel 150 feet once seated in a wheelchair/scooter, and the ability to wheel at least 150 feet in a corridor or similar space. Observation on 03/23/2026 at 11:23 AM showed Resident 66 sat in their manual wheelchair which had an anti-rollback device (a safety mechanism, commonly used on wheelchairs, designed to prevent the chair from moving backward unintentionally) attached to both wheels. Resident 66 expressed frustration of not able to self-propel backwards. Review of Resident 66's EHR showed no order or consent for the use of the anti-rollback device. During an observation and interview on 03/27/2026 at 11:28 AM, Staff J, Occupation Therapist (OT), stated they had no knowledge of a referral for the anti-rollback device. Staff J observed Resident 66 attempted to roll their wheelchair backwards, but they were unable to. Staff J stated the anti-rollback device was not safe or appropriate due to Resident 66's impulse to stand when they could not roll backwards. Resident 66 informed Staff J that they did not like the wheelchair because they could not move backwards. During an interview and observation on 03/27/2026 at 12:43 PM, Staff M, Certified Nursing Assistant, stated the anti-rollback device was installed on the wheelchair after Resident 66 had a fall. Staff M stated Resident 66 was unable to self-propel backwards and would instead attempt to stand to move the wheelchair. Staff M stated this was unsafe for Resident 66. During an interview and observation on 03/30/2026 at 9:31 AM, Staff K, DOR, confirmed Resident 66 was restrained from propelling backwards and should not have been. Staff K stated Resident 66 was not assessed in the wheelchair after the anti-rollback device was installed on the wheelchair for safety and to determine if the device was appropriate but should have been. During an interview on 03/27/2026 at 2:11 PM, Staff B, DNS, stated the anti-rollback device was installed incorrectly and that was the reason Resident 66 was unable to self-propel their wheelchair backwards. Resident 105 Review of the EHR showed Resident 105 admitted to the facility on [DATE] with diagnoses to include dementia (decline in mental ability severe enough to interfere with daily life), unsteadiness on feet, and cognitive communication deficit (difficulty communicating, speaking, listening, reading, or writing, because of underlying thinking problems rather than just language issues). Observation on 03/26/2026 at 1:25 PM showed Resident 105 with a wander guard wrist band (a device used to prevent from wandering or eloping by triggering an alarm when approaching an exit) securely fastened to the left wrist. Review of Resident 105's EHR showed no provider orders for the use of the wander guard, no wander guard assessment or informed consent, and the quarterly minimum data set assessment (MDS) dated [DATE] showed a wander/elopement alarm was not used. During an interview and joint observation of Resident 105 on 03/26/2026 at 2:23 PM, Staff C, Registered Nurse/Unit Manager (RN/UM), stated Resident 105 had an elopement risk evaluation dated 03/11/2026 for exit seeking; however, it did not include an evaluation/assessment for a wander guard. Staff C stated they were unable to locate provider orders, an assessment, an informed consent, or function and placement monitoring for the use of a wander guard, and these should have been in place. Staff C stated Resident 105's wander guard was located on the left wrist and would be hard for the resident to remove due to being securely fastened. During an interview on 03/27/2026 at 9:53 AM, Staff B, DNS, stated they were not aware that Resident 105 did not have provider orders, an assessment, an informed consent, or documentation to showed function and placement was checked for the use of the wander guard prior to or at the time of application of the device and there should have been. Reference WAC 399-97-0620(1)

Based on interview and record review, the facility failed to provide Nursing Home Transfer/Discharge Notices and bed hold notices at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 5, 6, 66, and 110) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital, protection of resident's rights during transfer, and diminished quality of life. Findings included. Resident 5Review of the electronic health record (EHR) showed Resident 5 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's (progressive disorder that destroys memory and thinking skills), depression, and atrial fibrillation (heart rhythm disorder where the upper chambers are out of sync with the lower chambers). Resident 5 was transferred to the hospital on [DATE] for injuries to their head. Review of the EHR showed Resident 5 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 01/18/2026 transfer. Resident 6Review of the EHR showed Resident 6 was admitted to the facility on [DATE] with diagnoses to include dementia (brain disorder that impairs memory, thinking and interferes with activities of daily life), diabetes (high blood sugar), and high blood pressure. Resident 6 was transferred to the hospital on [DATE] for vomiting. Review of the EHR showed Resident 6 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 12/13/2025 transfer. Resident 66Review of the EHR showed Resident 66 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation, heart failure and dementia. Resident 66 was transferred to hospital on [DATE] for hip pain. Review of the EHR showed Resident 66 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 12/05/2025 transfer. Resident 110Review of the EHR showed Resident 110 was admitted to the facility on [DATE] with diagnoses to include diabetes, traumatic subdural hemorrhage (brain injury causing bleeding in the brain), and high blood pressure. Resident 110 was transferred to hospital on [DATE] for critical blood test results. Review of the EHR showed Resident 110 did not have Nursing Home Transfer and Discharge Notice or bed hold notice for the 01/27/2026 transfer. During an interview on 03/25/2026 at 10:36 AM, Staff D, Social Service Director, stated when a resident was transferred to the hospital, the nurses sent a copy of the transfer notice and bed hold and the next day the business office manager would follow up. Staff D presented copies of Nursing Home Transfer and Discharge Notices for Residents 110 and 5. The notices had not applicable (n/a) written on the date when the notice was given and not applicable on the space that said notice provided to. During an interview on 03/26/2026 at 8:41 AM, Staff S, Licensed Practical Nurse, stated when a resident was transferring to the hospital, the nurses made a packet that included medical record information plus Nursing Home Transfer or Discharge Notice and bed hold. Staff S stated that it was mandatory and copies were available at the station. Upon reviewing the folder of copies, only Nursing Home Transfer or Discharge Notice forms were available (there were no bed hold form). During an interview on 03/30/2026 at 10:19 AM, Staff A, Administrator, stated the nurses were to present the Nursing Home Transfer or Discharge Notice with a bed hold and then the business office manager was to follow up on completing them. Staff A stated lack of documentation and bed hold for the above four residents did not meet expectations. Reference WAC 399-97 -0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080 -0140(1)(a)-(c)(i)-(iii)

Based on observation, interview, and record review, the facility failed to accurately code the resident assessment for 6 of 20 sampled residents (Residents 11, 32, 51, 33, 10, and 105) reviewed for accuracy of assessments. Failure to accurately code Residents 11 and 32's use of blood thinning medication, Resident 51's use of side rails, Resident 33's use of a breathing device, Resident 10's dental status, and Resident 105's use of a safety device placed residents at risk of unmet care needs, inaccurate information in the electronic health record, and diminished quality of life. Findings included.Resident 11 Review of the electronic heath record (EHR) showed Resident 11 was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body due to tissue death in the brain), dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), high blood pressure and depression. Resident 11 was not able to communicate their needs. Review of the quarterly minimum data set assessment (MDS) dated [DATE] showed Resident 11 was coded for using an anticoagulant (medication that interferes with blood clotting process). Review of the December 2025 and January 2026 medication administration records (MAR) showed Resident 11 was not administered anticoagulant medication. Resident 32 Review of the EHR showed Resident 32 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (final stage of kidney disease), anemia (lack of red blood cells), heart failure and substance abuse disorder. Resident 32 was able to communicate their needs. Review of the admission MDS dated [DATE] showed Resident 32 was coded for using an anticoagulant medication. Review of February 2026 MAR showed no anticoagulant been administered. During an interview on 03/30/2026 at 10:51 AM, Staff O, Registered Nurse (RN)/MDS, stated Residents 11 and 32 had coding errors. During an interview on 03/27/2026 at 1:40 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was for MDS to be coded accurately. Resident 51 Review of the EHR showed Resident 51 was admitted to the facility on [DATE] with diagnoses to include hospice (end of life care), depression, anxiety, and vascular dementia. Resident 51 was not able to communicate their needs. Review of the quarterly MDS, dated [DATE], showed Resident 51 was dependent on staff for completing activities of daily leaving (ADL). Observation on 03/23/2026 at 10:25 AM showed Resident 51 lying in bed in a fetal position with a fragile, small body frame, with half side rails (metal device approximately three feet long and one foot and a half tall) on both sides of the bed. Resident 51 was surrounded by the side rails in bed. Observation on 03/25/2026 at 8:53 AM showed Resident 51 lying in bed with curled up feet and half sized side rails up in the bed. Observation on 03/26/2026 at 11:48 AM showed Resident 51 watching TV in bed with half side rails up in bed. Observation on 03/27/2026 at 9:23 AM showed Resident 51 been assisted by staff to eat breakfast and the side rails were up in bed. Review of the care plan problem for falls revised on 10/27/2025 showed Resident 51 had intervention for bilateral grab bars to aid with bed mobility initiated 09/05/2025 and revised on 10/27/2025. Review of the quarterly MDS dated [DATE] showed Resident 51 was not marked as using bedrails in section P and not marked as having six months or less to live in section J. During an interview on 03/26/2026 at 1:27 PM, Staff O, RN/MDS, stated the coding for Resident 51 's J section was not correct, and section P was unclear to when the side rails were initiated. Staff T stated the half side rails/device should have been on the MDS. Resident 33 Review of the EHR showed Resident 33 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breath) and congestive heart failure (CHF). The resident was able to make needs known. Observation and interview on 03/24/2026 at 11:56 AM showed Resident 33 in bed, there was a bilevel positive airway pressure (BIPAP, a non-invasive form of ventilation) machine at the resident's bedside. Resident 33 stated they wore it when sleeping. Review of the EHR showed a provider's order for BIPAP machine to be worn while sleeping with a start date of 04/14/2025. Review of the administration record for January 2026 showed the resident was wearing the BIPAP daily. Review of the quarterly MDS dated [DATE] showed the resident was not using the BIPAP machine. During an interview on 03/26/2026 at 9:56 AM, Staff O, RN/MDS, stated the MDS was inaccurate and Resident 33 should have been marked for yes for non-invasive ventilator/BIPAP. During an interview on 03/26/2026 at 10:12 AM, Staff B, DNS, stated it was their expectation that the MDS be coded accurately to reflect the resident's care needs. Resident 10 Review of the EHR showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known. During an interview on 03/24/2026, Resident 10 stated they had a dental exam two or more months ago and were told they had broken upper teeth that needed to be pulled. Resident 10 stated it took longer to chew their food because of it. Resident 10 stated they were still waiting for staff to set up a dental appointment for them. Review of the dental visit form dated 08/11/2025 showed Resident 10 had broken teeth or root tips and missing upper and lower teeth and red/irritated gum tissue. It showed handwritten on the form that tooth #4 caused pain and Resident 10 would like tooth extraction/removed. Review of a significant change MDS dated [DATE] that was coded No, for obvious or likely cavity or broken natural teeth and No, for mouth or facial pain, discomfort or difficulty with chewing. Review of the quarterly MDS dated [DATE] showed Resident 10 was coded No for mouth or facial pain, discomfort or difficulty with chewing. During an interview on 03/30/2026 at 2:30 PM, after reviewing Resident 10's EHR, Staff B, DNS, stated the MDS should have been coded for broken and missing teeth. Resident 105 Review of the EHR showed Resident 105 admitted to the facility on [DATE] with diagnoses to include dementia, unsteadiness on feet, and cognitive communication deficit (difficulty communicating, speaking, listening, reading, or writing, because of underlying thinking problems rather than language issues). Observation on 03/26/2026 at 1:25 PM showed Resident 105 with a wander guard wrist band (a device used to prevent from wandering or eloping by triggering an alarm when approaching an exit) securely fastened to the left wrist. During an interview on 03/26/2026 at 2:23 PM, Staff O, RN/MDS, stated Resident 105's care plan had an intervention for a wander guard that was initiated on 03/13/2026. Staff O stated Resident 105's quarterly MDS dated [DATE] was not coded accurately and should have been coded Used daily, for wander/elopement alarm. Staff O stated the MDS needed to be modified. During an interview on 03/27/2026 at 9:53 AM, Staff B, DNS, stated they were not aware that Resident 105's quarterly MDS dated [DATE] was coded Not used for wander/elopement alarm and should have been coded Used daily. Reference WAC 399-97- 1000(1)(a)(b)(4)(a)

Based on interview and record review, the facility failed to inform and provide written information on the formulation of advanced directives for 2 of 3 sampled residents (Residents 99 and 15) reviewed for advanced directives. This failure placed the residents at risk of unmet needs and lack of knowledge of their rights to formulate an advanced directive. Findings included.Resident 99Review of the electronic health record (EHR) showed Resident 99 admitted to the facility on [DATE] with diagnoses of diabetes (when the body doesn't process sugars effectively) and foot wounds. The resident was able to make needs known. Review of Resident 99's EHR showed no documentation that the resident was provided with written information on or assistance with completing advanced directives (a legal form appointing a decision maker if the resident is no longer able to make decisions). Resident 15Review of the EHR showed Resident 15 admitted to the facility on [DATE] with diagnoses of end stage kidney disease and was receiving dialysis (a procedure that filters waste from the blood). The resident was able to make needs known. Review of Resident 15's EHR showed no documentation that the resident was provided with written information on or assistance with completing advanced directives. During an interview on 03/27/2026 at 10:20 AM, Staff D, Social Services Director, stated Residents 99 and 15 should have been offered assistance with formulating advanced directives when they were admitted but had not. During an interview on 03/30/2026 at 11:12 AM, Staff A, Administrator, stated it was their expectation that residents be reviewed for advanced directives and offered assistance with obtaining one if needed. Reference WAC 388-97 -0280(3)(c)(i)(ii), -0300(1)(b)(3)(a)-(c)

Based on interview and record review, the facility failed to ensure personal property was protected for 1 of 1 sampled resident (Resident 9) when reviewed for personal property. This failure placed residents at risk loss of property, compromised dignity, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (disease that effects multiple nerves in the body), diabetes (too much sugar in the blood) and dysphagia (difficulty swallowing). Resident 9 was able to make needs known. During an interview on 03/23/2026 at 11:29 PM, Resident 9 stated they were missing two pairs of jeans that were only worn once. Observation on 03/26/2026 at 10:36 AM showed Resident 9 reported to Staff H, Registered Nurse, the missing jeans. During an interview on 03/27/2026 at 11:56 AM, Resident 9 stated they had not been contacted regarding the missing jeans. Resident 9 stated the clothes they were wearing were from the facility's donation closet. During a Resident Council meeting held on 03/26/2026 at 10:00 AM, Council members stated when they sent their clothes to the laundry sometimes, they did not get them back. Council members stated the issues with laundry had been ongoing. Review of the grievance logs from October 2025 through March 2026 showed a total of 27 grievances related to missing clothing. During an interview on 03/30/2026 at 10:59 AM, Staff A, Administrator, stated the expectation was when residents had missing clothing a grievance should be completed by the staff it was reported to so it could be investigated or the resident could receive reimbursement. Reference WAC 388-97-0880(2)

Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled resident (Residents 9) reviewed for personal property and grievances. This failure placed the residents at risk for emotional distress and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (disease that effects multiple nerves in the body), diabetes (too much sugar in the blood) and dysphagia (difficulty swallowing). Resident 9 was able to make needs known. During an interview on 03/23/2026 at 11:29 PM, Resident 9 stated they were missing two pairs of jeans that were only worn once. Resident 9 stated they had not reported the missing clothing to any members of staff. Observation on 03/26/2026 at 10:36 AM showed Resident 9 reported to Staff H, Registered Nurse (RN), the missing jeans. Review of the EHR showed no documentation related to Resident 9's concern. During an interview on 03/27/2026 at 11:23 AM, Staff D, Social Services Director, stated they had not received any grievances related to Resident 9's missing clothing concern. During an interview on 03/27/2026 at 11:56 AM, Resident 9 stated they had not been contacted regarding the missing jeans. Resident 9 stated the clothes they were wearing were from the facility's donation closet. During an interview on 03/30/2026 at 10:59 AM, Staff H, RN, confirmed Resident 9 reported missing clothing and stated they did not complete a grievance. During an interview on 03/30/2026 at 11:36 AM, Staff A, Administrator, stated the expectation was when residents had missing clothing a grievance should be completed by the staff it was reported to so it could be investigated or the resident could receive reimbursement. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to ensure injuries of unknown sources were reported to the State Hotline for 1 of 2 sampled residents (Resident 5) when reviewed for accident hazards. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 5 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (loss of cognitive function), congestive heart failure (when the heart is unable to pump blood efficiently) and depression. Resident 5 was unable to make needs known. Review of the January 2026 accident and incident log showed an entry dated 01/19/2026 for a fall related to Resident 5 on 01/18/2026. The fall was logged as unwitnessed with Small bruises occurring in places generally vulnerable to trauma. The fall was said to be Reasonably related to the resident's condition. The action taken was medical treatment and was not reported to the State Agency according to the incident log. Review of the facility investigation dated 01/18/2026 showed, Floor nurse reported to CNA [Certified Nursing Assistant] that resident had bruising to the right side of the forehead. [Resident 5] had an unwitnessed fall potentially hit their head on the bottom of the overbed table. No pain or concerns noted. Power of Attorney (POA) notified and requested side rails to be put back on resident's bed for safety. Further review showed the facility concluded that the incident was reasonably related to Resident 5's Alzheimer's diagnosis with behavioral disturbances. Abuse and neglect were ruled out. Review of a progress note within the investigation dated 01/18/2026 showed Resident 5 was sent to the hospital due to a black and blue bruise observed on the right side of Resident 5's forehead. Review of a document titled Post-fall Huddle dated 01/18/2026 showed Resident 5 was found with bruising to forehead while sitting in their wheelchair in their room. Resident 5 was unable to recall what happened. The box for unwitnessed fall was checked. During an interview on 03/30/2026 at 10:20 AM, Staff B, Director of Nursing Services (DNS), stated after contacting the staff who worked on the day of the incident it was confirmed that Resident 5 did not have a fall. Staff B stated the incident was an injury of unknown origin and should have been documented on the incident log correctly and reported to the State Hotline. Reference WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to thoroughly investigate the potential for abuse and/or neglect for 1 of 2 sample residents (Resident 9) reviewed for abuse and neglect. This failure placed Resident 9 at risk for psychosocial harm and a diminished quality of life. Findings included .Review of the electronic health record (EHR) showed Resident 9 admitted to the facility on [DATE] with diagnoses that included polyneuropathy (a neurological condition occurring when multiple nerves are damaged), diabetes (too much sugar in the blood), and dysphagia (difficulty swallowing). Resident 9 was able to make needs known. During an interview on 03/23/2026 at 11:24 AM, Resident 9 stated they pressed their call light and after 15 minutes Collateral Contact went to the nurse's station to request assistance which took an additional 30 minutes. During an interview on 03/23/2026 at 11:28 AM, Collateral Contact (CC), stated they were unhappy with the care Resident 9 was receiving. CC stated they worked in long term care and Resident 9's long wait time for a brief change was neglect. Allegation was reported to Staff A, Administrator, on 03/24/2026 at 10:30 AM. Review of the EHR on 03/24/2026 at 3:00 PM, 03/25/2026 at 12:47 PM and 03/26/2026 at 10:40 PM showed no alert charting or documentation related to the allegation neglect. During a joint interview on 03/27/2026 at 11:22 AM, Staff B, Director of Nursing Services (DNS), and Staff A, Administrator, stated Resident 9 was not put on alert for psychosocial well-being to monitor for psychosocial harm but should have been. Staff A, Administrator, stated this did not meet their expectations. Reference WAC 388-97-0640 (6)(a-c)

Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 2 of 20 sampled residents (Residents 10 and 1) reviewed for care plans. Failure to develop care plans that accurately reflected resident care needs related to dental issues placed residents at risk for not receiving needed care and services, negative outcomes, and a diminished quality of life. Findings included.Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include quadriplegia with incomplete damage to the neck (spinal cord damaged causing partial paralysis/partial or complete loss of muscle function and/or feeling to all four limbs and torso/trunk of the body), high blood pressure, and depression. Resident 10 was able to make needs known. During an interview on 03/24/2026 at 9:17 AM, Resident 10 stated they had a dental exam two or more months ago and were told they had broken upper teeth that needed to be pulled. Resident 10 stated it took longer to chew their food because of it. Review of the dental visit form dated 08/11/2025 showed Resident 10 had broken teeth or root tips and missing upper and lower teeth and red/irritated gum tissue. It showed handwritten on the form that tooth #4 caused pain and Resident 10 would like tooth extraction/removed. Review of the current provider order dated 06/20/2025 showed Resident 10 was prescribed a regular diet with regular texture and thin liquids. Review of Resident 10's care plan initiated on 11/14/2024 showed no care plan that identified/reflected current dental status or interventions related to broken and missing teeth. During an interview on 03/30/2026 at 2:30 PM, Staff B, Director of Nursing Services (DNS) stated they were unable to locate Resident 10's dental issues related to broken and missing teeth and need for needed tooth extraction documented in their care plan. Staff B stated the resident's dental status/issues should have been care planned. Resident 1 Review of the EHR showed Resident 1 admitted to the facility on [DATE] with diagnoses that included cholecystitis (inflammation of the gallbladder), chronic kidney disease and rectal cancer (cancer of the anus). Resident 1 was able to make needs known. Observation and interview on 03/24/2026 at 9:59 AM showed Resident 1 had missing and broken upper teeth. Resident 1 stated they had tooth pain and it was starting to effect their ability to eat. Review of the admission MDS dated [DATE] showed Resident 1 was assessed to have Obvious likely cavity or broken natural teeth. Review of Resident 1's care plan initiated 01/08/2026 showed no interventions related to oral care or dental concerns. During an interview on 03/30/2026 at 9:54 AM, Staff B, DNS, stated the expectation was upon assessment Resident 1's oral needs should have been care planned with clear goals and interventions. Reference WAC 388-97-1020(1), (2)(a)(b)

Based on observation, interview, and record review, the facility failed to accurately assess and develop/implement a care plan (CP) for the management of chronic heart problems and failed to timely identify/assess/implement interventions for a related change in condition for 1 of 3 sampled Residents (Resident 51) reviewed for hospitalization . The facility also failed to consistently monitor and document bowel movements (BMs) and implement the bowel program when needed for 2 of 3 sampled residents (Residents 16 and 66) reviewed for bowel management. Resident 51 experienced harm when they had a significant fluid volume overload (too much fluid in the body causing difficulty breathing, increased weight and swelling/edema) and a delay in respiratory interventions resulting in an emergency transfer to the hospital for respiratory failure. The failure placed residents at risk for further decline in their conditions, discomfort, and a diminished quality of life/quality of care. Findings included . Review of the facility's Weight Assessment and Intervention policy, revised March 2022, residents were weighted on admission and at intervals established by the Interdisciplinary Team (IDT). Weights would be documented in the clinical record. Any weight change of 5% or more since the last weight measurement would be retaken the next day for confirmation and if verified, nursing would immediately notify the dietician in writing. Unless notified of a significant weight change, the dietician would review all the resident's weight record monthly to follow individual weight trends over time. Undesirable weight changes would be reviewed by the IDT team to determine level of significance, review status to identify potential contributing factors for the weight change. The resident's individualized CPs would be reviewed and updated to include the identified change in status, identified causes, goals/benchmarks for improvement, and timeframe/parameters for monitoring and reassessment. Review of the facility's Heart Failure-Clinical Protocol policy, revised November 2018, showed the physician would help to identify individuals with a history/diagnosis of heart failure (HF) and clarify as much as possible their severity and underlying cause. The physician would help identify individuals at risk for cardiac decompensation (acute decline / change in condition)- (for example because of a heart rhythm problem or chronic lung disorders). The physician would make recommendations for the nursing plan of care including symptoms monitoring, edema and weight measurement frequency, lab monitoring, and provide parameters for when to report findings, consistent with relevant protocols and professional standards: such as those from the American Heart Association and the American Medical Directors Association. Review of the American Heart Association (Vol.8, No.3) Heart Failure Management in Skilled Nursing Facilities, published 04/08/2015, recommended for residents who were higher risk for decompensation (and with the admission goal to rehabilitate and discharge home or was uncertain), the nursing care plan should adhere to daily weight monitoring (same time of day-preferably first thing in the morning after the first toileting) and fluid volume evaluations. A weight gain of three to five pounds over three to five days should alert licensed staff to perform an advanced assessment of volume status, vital signs, and oxygen saturation, then promptly notify the physician with the findings. Routine daily symptom monitoring should occur for any degree of edema, abnormal lung sounds, cough (especially when lying down), JVD (jugular vein distention-a bulging of major veins in the neck and a key symptom of HF) symptom of too much water in the blood system ), difficulty breathing at rest, when lying flat, and/or at night along with routine weights at the same time every day helped determine exacerbations in HF. <Fluid Volume Overload: Weights and Edema> <Resident 51> In an interview on 04/10/2024 at 11:14 PM, Resident 51 stated they were not weighed routinely and had problems with edema. Resident 51 stated they recently returned from a hospital stay because they had too much fluid on their body. Resident 51 stated they had heart failure and a chronic lung disease, and experienced daily difficulty breathing while lying flat. They required a non-invasive mechanical ventilator via bilevel or continuous positive airway pressure (BiPAP/CPAP: machines that assists with breathing) for their lung problems at night, but they wore it all the time, and only removed it to eat or when they got up in the wheelchair. Review of the Annual Minimum Data Set (MDS), an assessment tool, dated 02/02/2024, showed Resident 51's diagnoses included respiratory failure, diabetes, high blood pressure, fluid volume overload, and swelling to both lower legs. The MDS did not include Resident 51's diagnosis of HF and assessed them as not having a problem with breathing when laying flat. Resident 51 was assessed to require Bipap/Cpap and did not receive oxygen therapy. Resident 51 was assessed to weigh 475 pounds but was not assessed to have a significant weight gain. Review of Resident 51's respiratory CP, dated 01/23/2023, showed they had obstructive sleep apnea (repeatedly stop and start breathing while asleep), COPD (chronic obstructive lung disease), respiratory failure, and the goal was to decrease episodes of respiratory distress with nursing interventions. The CP showed interventions dated 1/23/2023: Bipap/Cpap per physician orders (not personalized with prescription or parameters), oxygen as ordered (not personalized with prescription), and weight per facility protocol- Notify physician of significant weight fluctuations. Review of Resident 51's electric health record (EHR) showed no provider order for routine weight monitoring or frequency. Review of Resident 51's nutritional CP, revised 01/08/2024, showed they were at nutritional risk due to fluid overload and edema including a 01/30/2023 intervention that directed nursing staff to monitor and evaluate for signs or symptoms of significant weight changes or trends and obtain weights as ordered or directed by the licensed nurse. An additional intervention, dated 03/28/2024, read weights and did not specify further. Review of Resident 51's weight record showed they were not weighted consistently since their initial admission on 01/22/2023. Resident 51's recorded weights were: 08/31/2023-415 pounds, 10/17/2023-440 pounds, and 01/25/2024-474 pounds (an 8% weight gain in three months and a 14% weight gain in four months). There were no weights recorded for September 2023, November 2023, or December 2023. Review of the corresponding Progress Notes showed no identification of the significant weight change. Review of the Vascular Specialist consult note, dated 02/19/2024, showed the provider ordered medical grade lower extremity compression therapy (Unna boot) and elevation therapy for the management of chronic lower extremity edema and recurrent venous stasis ulcers (chronic and recurrent wounds of the lower legs, a result of venous insufficiency- the condition of poor blood circulation from the legs back to the heart). Review of the February 2024, March 2024, and April 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no order for weight monitoring frequency or parameters for physician notification, no edema monitoring (except for two days, 03/11/2024 and 03/12/2024), and no medical grade compression therapy was never initiated. In an interview on 04/12/2024 at 1:15 PM, Staff S, Licensed Practical Nurse, stated when residents go to their specialist appointments, they made a point to try to review the consult orders and/or ensure they were reviewed by the provider and expected the orders provided by the specialists to be implemented. Staff S was unable provide documentation to show medical grade compression therapy was started for Resident 51. Staff S stated residents were expected to be weighed monthly unless otherwise specified in their orders or care plans. Staff S stated if a resident had heart failure and problems with edema, their edema should be monitored routinely (daily or weekly) which would include frequent and routine weight monitoring (typically daily, or two to three times per week, depending on the resident's condition), and have parameters for physician notification. Staff S could not provide documentation to show how often Resident 51 should have been weighed to monitor their fluid volume status or how often their edema should have been monitored. <Change in Condition: Respiratory Failure> Review of provider order, dated 01/19/2024, showed oxygen via nasal canula was ordered for 2 liters per minute (lpm) as needed to maintain oxygen saturations above 89%. Review of a Provider Progress Note (PPN), dated 03/01/2024, showed Resident 51's weight was 475 pounds (using the weight from 01/25/2024) with a warning triggered for significant increase in weight. The PPN showed Resident 51's room air oxygen saturation was 89% which triggered for being below 90%. The PPN showed Resident 51 had mild edema on both lower legs. The provider documented Resident 51's COPD was stable and their oxygen sats were greater than or equal to 90%. The documentation showed no adjustments were made to the resident's medical plan. Review of a Nurse Progress Note (NPN), dated 03/11/2024 at 9:53 PM, showed Resident 51's oxygen saturation was around 80% at PM (almost six hours prior to the writing of the NPN). Staff L, Registered Nurse, documented they gave an emergent puff of their inhaler and called the on-call doctor. Staff L did not document a respiratory assessment or an assessment of fluid volume status. Staff L documented Resident 51 did not want the oxygen on [they] wanted to wear their BiPap. Staff L documented the on-call physician requested Resident 51's primary care provider adjust their BiPap prescription to maintain oxygen saturation greater than 90%. Staff L documented Resident 51 reported breathing difficulty earlier in the morning, but now complained of difficult breathing and chest tight. Staff L documented Resident 51's oxygen saturation was between 78% and 86%. The NPN did not document the provider was contacted to report the previous interventions were ineffective at keeping Resident 51's oxygen saturation greater than 90% and that the oxygen saturations were decreasing. Staff L documented Continue to monitor and endorse accordingly. Review of the electronic health record (EHR) showed Resident 51 was not sent to the emergency room at this time (03/11/2024) for evaluation of their low oxygen levels, new onset of increase demand for oxygen, or chest pain. In an interview on 04/12/2024 at 2:15 PM, Staff B, Director of Nursing, stated the facility had a system to help identify and monitor for a change of condition that included the SBAR form (SBAR stands for Situation, Background, Assessment, and Recommendation) for non-emergent concerns. If the concerns were more emergent the nurses were expected to evaluate the resident's condition and call the provider (or on-call) to report their findings. Staff B stated the provider should have been called after there was no improvement in Resident 51's respiratory status on 03/11/2024 and their oxygen saturation persisted below 90% with interventions. Review of a NPN, dated 03/11/2024 at 11:23 PM showed the nurse wrote an SBAR to the provider for the adjustment of the level of the BiPap. Review of new verbal provider order, dated 03/12/2024, written by nursing, showed oxygen two to three lpm to maintain oxygen saturations above 92%. Review of the NPN, dated 03/12/2024 at 1:47 PM showed Resident 51 was on 3 lpm of continuous oxygen with a mask. The nurse documented the Provider would see Resident 51 today. Review of the NPN, dated 03/12/2024 at 11:16 PM showed Resident 51's oxygen saturation was 90% on 3 lpm of oxygen, sometime that evening. After dinner, Resident 51 reported they felt like they could not get enough air and requested to switch to their BiPap. The nurse documented they put both the nasal canula (with oxygen set at 3 lpm) and the BiPap together and their oxygen saturation was 84%-88%. They would continue to monitor and endorse accordingly. There was no documented respiratory evaluation or assessment of fluid volume status. There was no documentation to show they contacted the provider to report the abnormal oxygen saturations readings that were below the ordered parameters. Review of Resident 51's Progress notes did not show a provider note for 03/11/2024 or 03/12/2024, or any new order changes were made. Review of the NPN, dated 03/13/2024 at 6:00 AM showed Resident 51 was sent to the ED at 3:45 AM in respiratory distress and their oxygen saturation was between 84% and 88% that was below the ordered parameters. Review of the hospital Emergency Department (ED) Encounter note, dated 03/13/2024 at 4:38 AM, showed Emergency Medical Services reported to the provider Resident 51's oxygen saturation was 69% at the facility on 4 lpm of oxygen (although the order was for two to three lpm). Resident 51 reported they were short of breath for several days, had worsened lower extremity edema, and chest pain/tightness which would come and go. Review of the SBAR, dated 03/11/2024, regarding Resident 51's situation showed He would like to see a provider for increased coughing and congestion for a few days now. The nurse documented an assessment: no fever, no increased sputum production, wheezing on and off. The nurse made the recommendation to please see the patient today. Next to the Orders section of the SBAR, the Physician wrote patient sent to hospital and signed and dated 03/13/2024 (two days later). Review of the Advanced Heart Failure Consultation note, dated 03/19/2024, showed Resident 51 weight readings from their previous encounters were: 1/17/2023- 466 pounds and 3/16/2024- 493 pounds. The cardiologist consult showed Resident 51 had acute on chronic heart failure with fluid volume overload, removed a total of 15 liters of fluid over the course of six days, started an additional diuretic medication, and increased a blood pressure medication. Review of the hospital discharge summary, dated 3/28/2024, showed Resident 51's weight on 3/28/24 was 454 pounds, a decrease of 39 pounds since 03/13/2024 (expected weight loss from the removal of excess fluid). <Fluid Volume Overload: Post Change in Condition> Review of the quarterly MDS, dated [DATE], showed Resident 51 readmitted to the facility on [DATE] after a hospitalization . Resident 51's diagnoses included pneumonia (a lung infection), respiratory failure, and oxygen dependence. The MDS did not include the diagnosis of HF. Resident 51 was assessed to require non-invasive mechanical ventilation but did not receive oxygen therapy. Resident 51 was assessed to weigh 433 pounds and inaccurately documented Resident 51 did not have a recent significant weight increase. Review of Resident 51's comprehensive CP on 04/08/2024 did not show a CP was developed for cardiac or edema problems after readmitting from the hospital visit. Review of Resident 51's current weight record showed no weight documented for the date of readmission, no daily weights monitoring. The only weight on record showed Resident 51 weighed 469 pounds on 04/03/2024, an increase of 15 pounds in six days based on the hospital discharge weight of 454 pounds on 03/28/2024. In an interview on 04/09/2024 at 10:13 AM, Resident 51 stated they were not weighted routinely, and their edema was less that it had been because they just got out of the hospital after having a bunch of fluid removed from their body. Resident 51 stated before the hospitalization , they kept telling the staff they could not breathe but no one would listen. Resident 51 stated they did have wounds on their lower legs that come and go and get worse when their edema flares. Resident 51 stated they felt like they were starting to have more swelling. Resident 51 stated their lower legs were not routinely wrapped with compression dressings to help manage their edema and vascular problems. Resident 51 stated before the hospitalization they did not routinely use oxygen, only when they needed it connected to their BiPap at night. During the interview, Resident 51 lower legs were observed to not have medical grade compression. Resident 51 was wearing their BiPap with no oxygen connected, and the oxygen concentrator and tubing was sitting under the sink, not in use. 34567 <BOWEL MONITORING> POLICY Review of the facility's Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol policy, dated September 2021, showed the staff and provider would identify individuals with gastrointestinal problems, which included alterations in bowel movements. [BM]. The licensed nurse (LN) would assess and document/report the presence of stool impaction and the onset, duration, frequency, and severity of signs and symptoms. The facility would monitor the individual's response to interventions, including frequency and consistency of bowel movements. The provider would adjust based on identification of causes and the resident's response to treatment. <Resident 16> During an interview on 04/08/2024 at 2:14 PM, Resident 16 stated they experienced constipation (inability to have a bowel movement naturally) that sometimes lasted longer than three days, throughout their stay at the facility. Review of Resident 16's electronic health record (EHR) BM report showed staff documented no BM on the following dates: 03/12/2024, 03/13/2024, 03/14/2024 with a BM documented on 3/15/2024 at 9:17 PM. Additional dates included 04/06/2024, 04/07/2024 with a BM on 04/08/2024 at 8:53 PM. Review of Resident 16's EHR showed several bowel management provider orders dated 02/24/2024 within the resident's March and April 2024 medication administration records (MAR). The BM protocol showed that the LNs were to administer the following orders, as needed, for the resident without a BM: Dulcolax (a laxative that stimulates bowel movements/used to treat constipation), on the evening of the 3rd day, Milk of Magnesia suspension (a laxative) on the morning of the 4th and Dulcolax suppository (in the evening of the 4th day for no BM. The MAR also showed in the evening of the 4th day that the LN had an order for a Fleet enema (a laxative) to be administered to the resident without a BM. The MARs showed an order for Polyethylene Glycol (a medication used in the management and treatment of constipation) to be administered as necessary for constipation. The March and April 2024 MARs showed no documentation that any of the providers orders were administered or documented. Review of Resident 16's care plan dated 02/24/2024 showed resident was ordered a psychotropic (a medication used to affect the brain and causes changes in mood, awareness, thoughts, feelings, and behavior), related to a disease process daily. Interventions included LNs to monitor and document side effects to include constipation. <Resident 66> During an interview on 04/08/2024 at 2:14 PM, Resident 16 stated they had constipation at times during their time at the facility. Review of Resident 66's electronic health record (EHR) showed documentation within the point of care (POC) task section whereas staff had documented longer than three days Resident 16 was without a BM. The staff documented lack of a BM on the following dates: 03/15/2024, 03/16/2024, 03/17/2024, 03/18/2024, 03/19/2024, 03/20/2024 and with a BM not documented until 03/21/2024 at 07:00 PM. Additional dates included 03/22/2024, 03/23/2024, 03/24/2024 03/25/2024, with a BM documented on 03/26/2024 at 07:01 PM. On 03/27/2024 to 03/31/2024 no BM was documented until 04/01/2024. Review of Resident 66's EHR showed several bowel management provider orders dated 02/24/2024 within the resident's March and April 2024 medication administration records (MAR). The BM protocol showed that the LNs were to administer the following orders, as needed, for the resident without a BM: Dulcolax (a laxative that stimulates bowel movements/used to treat constipation), on the evening of the 3rd day, Milk of Magnesia suspension (a laxative) on the morning of the 4th and Dulcolax suppository (in the evening of the 4th day for no BM. The MAR showed in the evening of the 4th day that the LN had an order for a Fleet enema (a laxative) to be administered to the resident without a BM. During an interview on 04/10/2024 at 10:04 AM, Staff R, Registered Nurse/Residential Care Manager (RN/RCM) stated that it was their expectation that the staff start the bowel protocol as ordered by the provider for residents who had constipation for greater than 3 days. During an interview on 4/10/2024 at 10:08 AM, Staff Q, Assistant Director of Nursing (ADON) stated that it would be their expectation that the LNs administer the bowel protocol as ordered for the resident's constipation. Reference WAC 388-97-1060(1)(2)(3)(b)(c).

Based on observation, interview, and record review the facility failed to ensure an environment free of avoidable accidents/hazards for 1 of 7 residents (Resident 1) reviewed for mechanical lift transfers. The failure to assess and develop a safe care plan for the use of a mechanical lift device, ensure staff training and competency in the use of the Named Mechanical Lift system, utilize the mechanical lift according to the manufacturers recommendations, and conduct post-fall resident assessment and investigation procedures resulted in harm to Resident 1 when they were dropped to the floor during an improper mechanical lift transfer, sustained cuts and bruising to their head and body, experienced pain, and created intense sense of fear for Resident 1 surrounding further use of the mechanical lifts. The facility staff's lack of training, failure to observe posted WARNINGS, and improper use of the mechanical lifts as recommended by the manufacturer placed residents at risk for feelings of fear, further hazards, and potential for serious injury/death. Findings included . Review of the facility's Safe Lifting and Movement of Residents policy, revised 2017, showed the facility would assess the resident's individual needs for transfer assistance and document those needs in the care plan, including: preferences for assistance, degree of dependency, weight-bearing ability, and resident's size. Only staff with documented training on the safe use and care of the equipment used would be allowed to lift/move residents. Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to procedures regarding use of the equipment and safe lifting techniques. Review of the facility's Accidents and Incidents-Investigating and Reporting policy, revised 2017, showed all accidents/incidents involving residents and employees would be promptly investigated, reported, and documented. The Incident/Accident Report (IR) would include date and time of the incident, nature of the injury, circumstances surrounding the event, where it took place, the names of witnesses, the resident's account of the event, time/date the physician, administration, and responsible party were notified, the condition of the resident after the incident, any corrective actions taken, and other pertinent data. Review of the Named Mechanical Lift User Manual, dated 2018, showed WARNING (potentially hazardous situation which, if not avoided, could result in death or serious injury): >DO NOT use this equipment without first completely reading and understanding these instructions and any additional instructional material. >Observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. >Slings and accessories designed by other manufacturers are not to be utilized with the Named Lift. >Adjustments for safety should be made before moving the patient. >When using the lifts, the adjustable lift base legs MUST be in a maximum Opened/Locked position before lifting the patient. >DO NOT lock the rear casters (wheels) of the lift when lifting an individual. Casters MUST be left unlocked to allow the lift to stabilize during the transfer. <Resident 1> Review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 01/22/2024, showed Resident 1's diagnoses included diabetes, heart failure, and obesity. Resident 1 required full staff assistance for transfers, had no history of falls, and received a daily anticoagulant medication (a blood thinner). Review of Resident 1's comprehensive care plan, dated 03/23/2024, showed no plan or identified needs for assistance with transfers. The care plan did not direct staff on how Resident 1 was to be transferred from one surface to another. Review of Resident 1's Visual/Bedside Kardex Report (a focused care plan for direct care staff), dated 03/27/2024, showed they required assistance with transferring and mobility but did not indicate the type/level of assist or use of mechanical devices. Review of the facility's IR, initiated 03/25/2024, showed the root cause of the fall was improper use of the mechanical lift by staff. The IR showed the staff did not follow the manufacturer's instructions and warnings to ensure the base legs were always wide open and improperly turned the resident around which created the instability of the lift. The IR showed only Staff F, Certified Nursing Assistant (CNA), was evaluated for competency with the use of mechanical lifts, but the evaluation did not indicate which lift system (the facility utilized two different lift systems). The IR also showed Staff D, Licensed Practical Nurse (LPN), who was the nurse on duty at the time of the fall, did not evaluate Resident 1 for injuries, provide first aid, initiate an investigation, or notify the physician and responsible party of the fall with injury. Review of Resident 1's progress notes showed no documentation for 03/23/2024 or 03/24/2024, including documentation regarding the fall. Review of Resident 1's March 2024 Medication Administration Record (MAR) showed between 03/01/2024 and 03/23/2024, they only required one administration of mild pain reliever for mild knee pain and received opioid pain medication four times. The MAR showed after 03/23/2024, Resident 1 had increased pain levels that required opioid pain medication on 03/23/2024 at 11:14 PM for pain 8/10 (a numerical scale from 0 to 10. 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) and on 03/25/2024 at 1:32 PM for pain 3/10. Resident 1 also received mild pain-relieving medication on 03/24/2024 at 2:46 AM for knee pain 6/10, on 03/25/2024 at 4:06 PM for abdominal side pain 3/10, and on 03/26/2024 at 8:58 AM for pain 4/10 (undocumented location). An observation of the Named Mechanical lift on 03/27/2024 at 10:30 AM showed the lift had product labeling WARNING stickers that said: WARNING-BEFORE using the Patient lift, READ and UNDERSTAND the Owner's Manual for proper operation and safety procedures. DO NOT lock the casters of the Patient lift when lifting an individual. Casters MUST be left unlocked to allow Patient LIFT to stabilize during lifting procedures. USE ONLY Named Lift slings and lift accessories. In an interview on 04/01/2024 at 3:45 PM, Staff E, CNA, stated they had never read the Named Mechanical Lift User's Manual and did not know about the specific WARNINGs for use. Staff E could not verify they were specifically trained to use the Named Mechanical Lift, was not aware that only Named Mechanical lift system slings could be used with the Named Mechanical Lift and could not verify the type/size of sling Resident 1 was in during the fall. An observation, on 3/27/2024 at 11:27 AM, showed Resident 1 sitting on a blue mesh (size large) mechanical lift sling manufactured by a different company than the Named Mechanical Lift, in their wheelchair. Resident 1 had a 3.5 centimeter (cm) linear cut on their forehead, a small green bruise, and a hematoma goose egg on the top of their scalp. The hair covering the hematoma was matted and adherent to the scalp. In an interview on 03/27/2024 at 11:29 AM, Resident 1 stated the facility staff used the Named Mechanical lift with each transfer. Resident 1 was unsure what size sling they required and stated the staff used a different type of sling every day. Resident 1 stated that on 03/23/2024, after their shower, they were taken back to their room to transfer back to bed. Resident 1 stated the staff had them positioned backwards on the left side of their bed; their feet were toward the head of their bed, and their head was at the foot of the bed. Resident 1 stated the staff did not correct their position prior to starting the transfer with the mechanical lift. Resident 1 stated Staff E, Certified Nursing Assistant, lifted them up off the wheelchair and once they were suspended, Staff E began to turn them around while Staff F was standing on the other side (right side) of the bed (not within arm's length), and that was when the lift tipped over. Resident 1 stated they hit their head on the lift's bar which cut their head, something hit the top of their head which caused a painful goose egg which they believed some drainage occurred because it was making their hair stick to their head, and they hurt the left side of their lower back/hip area. Resident 1 stated after they fell , several other staff, which included Staff D, came in to help them get off the floor, and then they all left the room. Resident 1 said no one ever took their vital signs or provided first aid for their injuries to their head. Resident 1 stated they were concerned because they were diabetic and took a blood thinner. Resident 1 stated the nurse that arrived on evening shift didn't know anything about the fall. Resident 1 became tearful and stated since the fall, they have experienced increased pain because of their injuries. Resident 1 stated they were already scared of riding in the mechanical lift, but now they are terrified of it. In an interview on 03/27/2024 at 10:50 AM, Staff B, Director of Nursing, stated they were not made aware of the incident until 03/25/2024, but should have been notified the day of the fall, since they were at the facility around the time of the event and conversed with Staff D. Staff B stated Staff D should have assessed Resident 1 for injuries and evaluate their neurological status immediately after the fall, contacted the physician and responsible party as soon as possible after the fall, placed the resident on Alert Status (increased frequency of nurse monitoring), and initiate a facility IR before the end of shift on 03/23/2024 but did not. Staff B stated they had Staff E and Staff F re-enact the transfer with the Named Mechanical lift and determined they did not correct Resident 1's position prior to starting the transfer and should have had the base legs wide open and the rear casters unlocked but did not. Staff B stated the CNAs should have been trained on the specific Named Lift but were not able to validate which lift system or lift information was used in the training, and could not locate training validation for Staff E. REFERENCE WAC: 388-97-1060 (1)(3)(e)(g)- 0320 (1)(a).

Based on observation, interview, and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for 1 of 1 Residents (Resident 20) reviewed for re-hospitalization . The facility's failure to: recognize and assess risk factors that placed the resident at risk for decline or complications,; develop a person-centered care plan with interventions that met their specific care needs related to arterial ulcers (a wound developed from prolonged inadequate blood flow) caused by Peripheral Artery Disease (PAD-narrowing or blockage of the blood vessels that carry blood from the heart to the legs),; implement physician orders timely,; recognize, and report a change of condition to the vascular surgeon caused harm to Resident 20 who developed wet gangrene (death of body tissue due to lack of blood flow or bacterial infection) and a serious bone/systemic infection that resulted in amputation of part of their foot. Findings included . According to the American Heart Association/American College of Cardiology Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary, dated March 21, 2017 (Volume 135, Issue 12), a comprehensive treatment plan to achieve intact skin and a functional foot included coordinated efforts with vascular medical specialists. To minimize further tissue loss, prompt recognition of foot infection through daily inspections was necessary especially for patients who had diabetes and peripheral neuropathy. Foot infections were to be suspected in patients with pain or tenderness to the area, redness or swelling around the wound, any drainage, foul odor, or white blood cell count greater than 12. <Resident 20> Review of the hospital discharge summary, dated 10/24/2023, showed Resident 20 was in the hospital for five months prior to admission to the facility. The resident's history included partial amputation of half of the left foot due to a serious bone infection and gangrene. In August of 2023, Resident 20 had a right great toe amputation due to bone infection and ischemia (inadequate blood supply to an area due to blockage of the blood vessels that carry oxygenated blood from the heart to rest of the body). Resident 20 underwent vascular surgery in the middle of October 2023 to improve the blood flow to right leg. Vascular studies conducted after the surgery showed they had moderate arterial insufficiency (any condition that slows or stops the blood flow through the arteries that carry oxygen rich blood to the body). Resident 20 discharged from the hospital to the facility with two arterial ulcers: on the right heel and at the base of the right fifth toe. The discharge summary showed directives to continue wound care as directed by the vascular surgeon by scrubbing the heel with saline and apply a dry dressing daily. Review of the 10/30/2023 Admission Minimum Data Set (MDS-an assessment tool), showed Resident 20 had no cognitive problems and diagnoses included diabetes, cardiovascular disease (occlusions of the blood vessels of the heart), Peripheral Vascular Disease (PVD - any condition that slowed the return of blood back to the heart)/Peripheral Artery Disease (PAD), and end-stage kidney failure. Resident 20 was assessed to have two vascular ulcers and no infection of the foot. Review of the alteration in skin integrity care plan, dated 10/24/2023, directed staff to conduct diagnostics and lab tests as ordered by the physician and refer to the Wound Care Specialist (WCS-a wound care group contracted by the facility to provide wound care evaluation and assist with development and implementation of the care plan). The care plan did not show PAD as a risk factor for skin problems and there were no interventions consistent with the nursing care and treatment of PAD ulcers. In an interview on 12/13/2023 at 12:44 pm, Staff C, Assistant Director of Nursing (ADON), stated they conducted the admission evaluation of Resident 20's arterial ulcer at the base of the right fifth toe which was dry, black, intact eschar (dry gangrene) that measured 2.0 cm (centimeters) x 2.0 cm. Staff C stated Resident 20 also had a small arterial ulcer on the top of the fourth toe which healed shortly after admission. Staff C stated the care plan should have included PAD as a risk factor with interventions that would have included: daily monitoring of the foot to ensure the wounds remained clean and dry, protect from injury, assess and treat for pain, and include the name and contact information of the vascular surgeon with directives to report any change in condition of the resident or wound status (any drainage, signs of infection, or new wounds). Staff C stated they did not know if anyone contacted the vascular surgeon to clarify orders and ensure a follow-up appointment was established but should have. In an interview on 12/11/2023 at 10:22 am, Resident 20 stated they went to this facility for wound care of the right foot because they were unable to see or perform their own self-care. Resident 20 stated the facility changed the dressings of their right foot three days a week but was concerned it was not enough. Resident 20 stated while at the facility they asked to see the vascular surgeon twice, but the facility never followed through. Resident 20 stated the day they left the facility, their anxiety was intolerable from the severe pain, and fear they were going to lose their foot. The odor was so bad they asked to see their right foot. Resident 20 stated they were shocked to see the right fifth toe was black and a large, infected wound along the side of their right foot, so they called the vascular surgeon on their own phone. The vascular surgeon told Resident 20 to get to the emergency room (ER) as soon as possible. The facility told Resident 20 they were not able to arrange transportation and offered to establish care with a vascular surgeon locally. Resident 20 called a family member who transported them to theER on [DATE]. Resident 20 stated they were not informed of their condition including: when the wound began to drain, lab results, when the wound began to get larger, and when their toe turned black. Resident 20 stated if they had stayed at the facility any longer, they would have lost more than part of their foot because the facility didn't see their situation as an emergency. Review of Resident 20's October Physician Orders (PO) showed a PO dated 10/24/2023 for wound care treatment to the right foot, to cleanse with wound cleanser, apply a dry dressing, secure with a gauze wrap, and change three times a week. Review of the facility physician history and physical note dated 10/25/2023, Staff G, Physician, documented Resident 20 expressed concerns regarding the frequency of wound care but did not change the treatment orders. Staff G documented the right foot wound was covered with a dry dressing but did not document an evaluation of the right foot arterial ulcers. Review of the Skin Alteration Weekly Review (SAWR) nursing evaluation, dated 11/01/2023, showed the arterial wound on the base of the fifth toe had a small amount of drainage (a change in condition of the wound). The documentation did not show the resident, physician, or vascular surgeon were notified of the change in condition and no changes were made to the treatment plan or the wound care orders. In an interview on 12/13/2023 at 11:29 am, Staff F, Licensed Practical Nurse (LPN), stated when stable, dry, arterial ulcer starts to drain it becomes wet gangrene and must be debrided (removal of dead tissue from the wound bed) as soon as possible and then monitored closely to prevent further tissue damage, bone infection, or risk of amputation. Staff F stated the vascular surgeon must be notified to determine if there are problems with blood flow to the area. Staff F was not able to find documentation in the clinical record to show the resident, physician, and/or vascular surgeon were notified the wound was draining. Staff F stated new wound care orders should have been obtained so the wound could be monitored daily, using the right kind of dressing to protect the wound from excess drainage but was not. A physician note dated 11/2/2023, by Staff G, did not show documentation to support they were notified of the change of condition of the wound. The documentation did not show an evaluation of the right foot wound or a change the treatment plan. Review of a WCS note, dated 11/06/2023, Staff I, Advanced Registered Nurse Practitioner (ARNP), documented Resident 20's right fifth toe wound measured 2.0 centimeters (cm) x 2.0 cm., was followed closely by their vascular surgeon, and was at high risk for complications. The note did not show documentation to support Staff I was notified the wound was draining. Review of a WCS note, dated 11/13/2023, Staff I documented the right fifth toe wound had a moderate amount of drainage and half of the wound was covered with dead tissue which they removed. The wound measured 1.5 cm x 2.1 cm x 0.3 cm deep. Staff I documented the skin around the wound was macerated (softening and damage of skin due to prolonged exposure to moisture). The documentation did not show the vascular surgeon was notified or the treatment plan and wound care treatment orders were changed. Review of the physician note dated 11/14/2023, showed Resident 20 had very high blood sugars (which can be an indication of infection in diabetics), complained about painful muscle spasms, and increased severe pain to their right foot. The documentation did not show an evaluation of the wounds or that the vascular surgeon was made aware of the change of condition. Review of the WCS note, dated 11/21/2023 at 3:38 pm, showed Resident 20 was concerned their right foot wound was infected due to odor during dressing changes that week. The documentation showed the wound size increased to 5.0 cm x 4.0 cm x 0.2 cm, there was redness and maceration around the wound edges, and had deteriorated. The documentation did not show a consultation with the vascular surgeon. Staff I ordered to change the wound treatments to daily dressing changes, collect a culture of the wound, start an antibiotic, obtain x-rays of the right foot and ankle, and draw labs. Review of the November 2023 Medication Administration Record (MAR) showed the first dose of antibiotic was administered on 11/22/23 at 8:00 am, (a delay of 16 hours from the time it was ordered by the WCS ARNP). In an interview on 12/13/2023 at 12:57 pm, Staff C stated antibiotics should be started within four hours of the order. Staff C did not know why there was a delay in starting the antibiotic but Resident 20 should have received their first dose that same day. Review of a nurse progress note (NPN) dated 11/22/2023 at 11:06 am showed the mobile x-ray company was called to order the x-ray (19 hours after it was ordered by the WCS ARNP). The clinical record did not show documentation to support when mobile x-ray arrived to take the x-ray, when the results were received, what the results were, or who was notified of the results. The clinical record did not provide x-ray results for the right foot while at the facility. Review of a lab report, dated 11/23/2023 at 8:28 am, showed Resident 20's blood was not collected until 11/22/2023 at 9:17 am, a delay of 18 hours from the time the WCS ARNP wrote the order. The lab result was flagged as Critical and showed an elevated WBC count of 17.0 (normal is 3.8-10.1), indicating infection. Review of the clinical record did not show documentation to support that the resident, the ARNP, or the vascular surgeon were notified of the abnormal lab results. The lab showed it was not reviewed by a provider until 11/27/2023 at 11:48 am. Review of the November 2023 Treatment Administration Record (TAR) showed the order to change the wound dressings to daily was not started until 11/23/2023, a delay of two days from the date the WCS ARNP changed the treatment order. The TAR showed no signature for a dressing change on 11/22/2023. Review of a PO dated 11/23/2023 at 10:40 am directed staff to obtain STAT (a directive to medical personnel during an emergent situation which means instantly or immediately). Review of a lab report dated 11/25/2023 at 3:17 pm showed the blood for the STAT lab (ordered on 11/23/2023 at 10:40 am) was not collected until 11/25/2023 at 1:15 pm, 51 hours after the order was written for STAT labs. The STAT labs results were sent to the facility on [DATE] at 2:45 pm and showed the WBC was now 18.7 (higher than the last result). In an interview on 12/13/2023 at 12:55 pm, Staff C stated STAT means as soon as possible. Staff C stated the STAT labs were not done timely and should have been done within four hours of the order. Review of a wound culture lab report dated 11/28/2023 at 12:24 pm, the day after Resident 20 transferred to the hospital, showed the specimen was collected on 11/23/2023 at 8:00 am, 40 hours after it was ordered by the WCS ARNP and 24 hours after Resident 20 started the antibiotic. In an interview on 12/13/2023 at 12:15 pm, Staff F, stated they were unable to collect the wound culture specimen on 11/21/2023 during wound rounds because they were out of culture swabs and had to wait until the lab sent them more. Staff F stated the wound culture was not collected timely or before the antibiotic was started but should have been. Review of an SBAR (Situation, Background, Assessment, Response-a universal reporting tool used to report and document changes in resident status) dated 11/23/2023 showed Resident 20 had elevated blood sugars, was sleeping most the day, asked for an increase in pain medication, and to be referred to their vascular surgeon. The SBAR was signed reviewed by Staff K, ARNP, four days later, on 11/27/2023. In an interview on 12/13/2023 at 1:00 pm, Staff K stated due to the nature of the concerns that were written on the SBAR, the staff member should have called the provider that same shift, as soon as possible, to prevent delay in treatment. Review of the NPNs between 11/24/2023 and 11/26/2023 showed no documentation to support staff closely monitored Resident 20's change of condition, that the resident was notified of their abnormal lab and diagnostic results, or that the change of condition was reported to the vascular surgeon. Review of a physician note dated 11/27/2023 at 8:27 pm, Staff K documented Resident 20 notified the vascular surgeon of their change of condition and was directed to go to the ER. Staff K documented Resident 20 reported their right fifth toe turned black and was painful. Staff K documented Resident 20 reported not feeling well and continued to have elevated blood sugars. In an interview on 12/13/2023 at 1:18 pm, Staff L, Physician, indicated wet gangrene was a medical emergency and 27 days of wet gangrene on a diabetic foot with PAD was too long to wait before evaluation and intervention by a vascular and/or infectious disease specialist. Review of hospital history and physical dated 11/27/2023 at 1:23 pm, showed Resident 20 was admitted to the hospital for an infected gangrenous right fifth toe and sepsis (systemic blood infection). Resident 20 was started on intravenous antibiotics for the severe infection and had arterial diagnostic studies that determined acute bone infection and ischemia (lack of oxygenated blood flow) to the right foot. In an interview on 12/11/2023 at 10:48 am, Resident 20 stated the vascular surgeon met them in the ER, scheduled them for immediate surgery to correct the blood flow to their right leg, got started on intravenous antibiotics, but was too late and had to have two toes and part of the right foot amputated. Resident 20 stated if they would have got to the vascular surgeon in time, the most likely would have avoided the amputation. (Refer to F580 and F658) Reference WAC 388-97-1060 (1)(2)(3)(b)(4).

Based on interview and record review, the facility failed to permit 1 of 6 residents (Resident 1) reviewed for hospitalization to return to the facility after a facility-initiated transfer to the emergency room (ER). The facility's failure to provide bed hold information in writing upon transfer to the hospital, provide appropriate discharge/transfer notice and rights to an appeal prior to the facility-initiated transfer and discharge, and failure to permit Resident 1 to return to the facility and resume residence after the ER visit caused physical and psychological harm to Resident 1 who experienced unnecessary pain, anxiety, fear, humiliation, and re-traumatization. Findings included . <Policy> Review of the facility's policy, Transfer or Discharge Documentation, revised December 2016, showed each resident would be permitted to remain in the facility and not be discharged or transferred unless it was necessary for the resident's welfare and their needs could not be met in the facility; transfer/discharge was appropriate because their health had improved and they no longer required the level of care the facility provided; the health and/or safety of individuals in the facility was endangered due to clinical or behavioral status of the resident; if the resident failed to meet their financial obligations after reasonable and appropriate notice; or if the facility ceased to operate. A resident who chose to exercise their right to appeal a transfer/discharge notice would not be transferred/discharged during the appeal process unless the failure to do so would endanger the health or safety of the resident or other individuals. When a resident was transferred or discharged the facility would document in the medical record: the basis for the discharge; that appropriate notice was provided to the resident and/or representative; the date and time of the transfer/discharge; the new location of the resident; mode of transportation; a summary of the resident's overall status. If they were transferred/discharged because their care needs could not be met, the resident's attending physician would document the specific needs that could not be met, the facility's attempt to meet those needs, and the receiving facility's service(s) that were available to meet those needs, that the facility could not. <Resident 1> Review of the 08/25/2023 Annual Comprehensive Minimum Data Set (MDS-an assessment tool), Resident 1 had no cognitive problems, made consistent and reasonable decisions regarding tasks of daily life, and had no behaviors or rejection of care. Resident 1 had no indicators of a mood problem. Resident 1's diagnoses included stroke (a brain injury caused by loss of blood supply), loss of movement of some parts of their body, anxiety, depression, and chronic pain syndrome. Resident 1 required extensive assistance for activities of daily living (ADLs). Resident 1 was assessed to have pain and received scheduled and PRN (as needed) medication. Review of Resident 1's 08/25/2022 Trauma Informed Care screen showed three indicators of past trauma. Review of the 08/25/2023 Trauma Informed Care screen showed more than 10 indicators of past trauma and Resident 1 did not feel safe. Review of Resident 1's 11/23/2022 Trauma care plan showed they had trauma in their past and would be free of trauma while at the facility. A 02/23/2023 trauma care plan intervention showed Resident 1 received treatment from Behavioral Health Service (BHS). Review of a Physician Order (PO) dated 02/01/2023 at 4:23 PM by Staff D, Medical Director, showed they accepted to oversee Resident 1's medical care and were listed as primary Physician. Review of a PPN dated 08/21/2023 by Staff E, Physician, showed they tapered down Resident 1's pain medication without involving Resident 1 in the pain management plan. Resident 1 told Staff E they wanted a different provider. Review of POs for Resident 1's pain medication prescriptions from September and October 2023 showed they were ordered by Staff D. In an interview on 10/24/2023 at 3:35 PM, Resident 1 stated their pain was not managed well by Staff E and they no longer had trust in them. Resident 1 stated they told Staff E they wanted a different provider, but one was never provided so they assumed Staff E was still their provider. Resident 1 stated they were transferred to the hospital on 10/06/2023 because the facility was out of their prescribed scheduled pain medication and the physician refused to re-new their prescription. Resident 1 stated they were treated for chronic pain for many years and was not asking for more pain medication. Resident 1 felt they were on a tolerable lowest effective dose. Resident 1 stated they told the nurse they were in horrible pain and the nurse came into their room and told them they would need go to the hospital ER for pain medication. Resident 1 stated they initially did not want to go to the ER because they knew they would have a long wait time and they did not need anything from the ER that the facility couldn't already provide. Resident 1 stated a staff member called 9-1-1. Resident 1 stated they felt pressured to go to the ER and they were in excruciating pain, so they went with the paramedics. Resident 1 stated they were assessed in the ER and provided with the same dose of pain medication they were previously prescribed at the facility. Resident 1 stated they had not experienced a change of condition or acute illness. Resident 1 stated they were notified by a social worker in the ER that the facility refused to allow them to return. Resident 1 stated they were surprised, humiliated, and felt retaliated against. Resident 1 stated they immediately experienced increase fear and worsened anxiety because they did not know what they were going to do about their living situation because the hospital had no reason to admit them. Resident 1 stated they felt traumatized because they were forced to live in an observation holding room of the ER, where everything was covered in plastic, for six days. Resident 1 stated the first two days were spent lying on an uncomfortable transport stretcher, then the ER staff brought them an actual bed for the remaining four days. Resident 1 stated they felt almost suicidal because they did not want to go to another skilled nursing facility and start over. Resident 1 stated they were not provided a bed-hold notice upon transfer to the hospital, they were not given a discharge notice prior to transfer to the hospital or after the facility-initiated discharge. Resident 1 stated they had never been told by facility staff the facility could not meet their care needs. Resident 1 stated they had no change in their care requirements. Review of Resident 1's clinical record showed no documentation to support the facility notified Resident 1, in writing, of their bed-hold rights upon transfer to the hospital or provided a written Notice of Transfer/Discharge and rights to appeal. There was no documentation to show the facility could not meet Resident 1's care needs as they had for the past year. Review of Resident 1's narcotic ledger (NL-an accounting mechanism used to track and document narcotic use) showed a quantity of 35-5 mg tablets (a four-day supply) was ordered by Staff D and filled on 10/06/2023 (the day Resident 1 was transferred to the ER for pain medication). The 35 unused tablets were destroyed on 10/13/2023. Review of the 10/06/2023 Discharge Return Anticipated MDS showed Resident 1 had an unplanned discharge. The MDS showed Resident 1 had no behaviors, no rejection of care, no change in ADL care needs, and no change in special treatments, procedures, or programs. Review of an ER Physician Progress Note (PPN) dated 10/07/2023 at 12:10 PM showed they tried to consult with Staff D, via phone at 8:23 AM. At 11:38 AM, they called Staff D's call center to request an on-call provider contact them for arrangements to return Resident 1 to the facility since Resident 1 had no acute medical concerns. At 12:10 PM, the on-call Provider called back after talking to the facility and reported the facility was adamant, they would not accept Resident 1 back to the facility because Resident 1 refused all care with exception of opiate pain medication. Review of the ER Physician Treatment Plan dated 10/07/2023 showed they were concerned for Resident 1 who was vulnerable, bedbound, and required skilled nursing care. The ER physician documented the facility transferred Resident 1 to the ER without emergent medical concerns or acute illness which they believed was an inappropriate use of emergent care resources. Review of Resident 1's 10/18/2023 Admission MDS showed they transferred from the hospital to a new skilled nursing facility on 10/12/2023 (six days after the facility-initiated transfer and discharge). Resident 1's mood assessment score showed a significant increase in symptoms of depression. Resident 1 had no behaviors, no rejection of care, and did not require any new special treatments, care, or procedures. In an interview on 10/24/2023 at 4:00 PM, Staff G, Physician Assistant at the new skilled nursing facility, stated Resident 1's care was as basic as it gets for nursing home care with no special care requirements. Review of a PPN dated 10/20/2023 by Staff D (14 days after Resident 1 discharged ), showed Resident 1 was not suitable for re-admission to the facility because their needs for medical management and residential care exceeded the facility's abilities because they had no physician who was credentialed to oversee Resident 1's medical care needs, Resident 1 was a threat to staff due to aggressive and abusive behaviors, Resident 1 expressed intent to harm others, and Resident 1 rejected alternative treatments to include medications to manage their alleged pain. Staff D's PPN did not show documentation to support Resident 1 had a change in care needs, what specific care needs the facility could not provide Resident 1 (or any resident who required the same level of care and similar diagnoses), alternatives attempted to try to meet Resident 1's care needs, and what services the receiving facility would need to provide to Resident 1 that the facility could not. In an interview on 10/23/2023 at 4:18 PM, Staff D stated they were unsure if the facility had made any attempt to assist Resident 1 to find another provider after they fired Staff E. Staff D did not know if Staff E officially notified Resident 1, they would no longer provide their medical care. Staff D, primary Physician of record, stated it was their decision to not accept Resident 1 back based on what they were told by the facility administration, consultation with Staff E, and limited historical chart review. Staff D stated they did not consider Resident 1's status on 10/06/2023 at the ER to make their decision to not accept Resident 1 back to the facility. Staff D stated their knowledge of Resident 1's care was limited to clinical chart review and interviews with facility staff and Staff E. In an interview on 10/20/2023 at 4:30 PM, Staff A, Administrator, stated they sent Resident 1 to the ER because they threatened to harm themselves by self-medicating for pain and refused to relinquish any medication they may have had. Staff A stated they were unsure if Resident 1 had any medication in their belongings. Staff A stated they were unsure if the facility had provided Resident 1 with bed-hold information upon transfer to the hospital. Staff A stated they had not provided Resident 1 with a Notice of Transfer/Discharge with the required information that the facility could not meet Resident 1's care needs and what those needs were, what alternatives were attempted to try to meet those care needs, and what special services the receiving facility would need to provide Resident 1 that the facility could not. (Refer to F-625 and F-697) Reference WAC 388-97-0120 (1)(b)(2) (a-e) (3)(a)(c).

Based on observation, interview, and record review the facility failed to ensure residents received effective pain management consistent with professional standards of practice and according to residents' goals/preferences for 7 of 11 residents (Residents 1, 2, 3, 4, 5, 6, & 7) reviewed for pain. The facility's failure to re-evaluate Resident 1's pain after medication change and ensure they had an adequate supply of medication to administer their scheduled and PRN (as needed) pain medication caused harm when Resident 1 experienced unnecessary extreme pain and was transferred the emergency room (ER) for pain medication administration. The facilities failure to properly assess resident's pain, involve residents in development and modification of a person-centered pain care plan, notify residents of changes to their pain management plan, re-evaluate the effectiveness of changes made, identify and utilize person centered non-pharmacological interventions, consider adjunctive pain modalities, provide referrals to pain management specialists, and administer pain medications as ordered placed residents at risk for poorly managed pain, decline in mood, decline in activities of daily living (ADL's), and diminished quality of life/quality of care. Findings included . <Policy> Review of the facility's policy Pain Assessment and Management, revised [DATE], showed the facility would commit to ensuring each resident was comfortable and their pain management regime would result in a reduction of their pain to a level that was acceptable to them based on their clinical condition and goals for treatment. The Interdisciplinary Team (IDT) would implement their facility process to assess pain, effectively recognize the presence of pain, address underlying causes, develop, and implement a pain management care plan, monitor effectiveness, and modify the plan as needed. <Resident 1> Review of the [DATE] Annual Comprehensive Minimum Data Set (MDS-an assessment tool) showed Resident 1 had no cognitive problems, made consistent and reasonable decisions regarding tasks of daily life, and had no rejection of care. Resident 1's diagnoses included stroke (a brain injury caused by loss of blood supply), mobility problems of the legs, spinal problems, anxiety, depression, and chronic pain syndrome. Resident 1 required extensive assistance for ADL's and was unable to walk. Resident 1 received both scheduled and PRN pain medication, and a Pain Assessment Interview should have been conducted but was not. Review of Resident 1's [DATE] pain care plan showed Resident 1's goals for pain management were to limit interruptions in normal daily activities and require fewer pain medications to achieve pain relief. The pain care plan interventions dated [DATE] directed staff to: evaluate the effectiveness of Resident 1's pain management plan quarterly and as needed; assess for pain every shift; implement non-pharmacological interventions and evaluate effectiveness prior to administration of PRN medications; and showed Resident 1 was able to reliably communicate their need for pain medication. A pain care plan intervention dated [DATE] showed Resident 1 preferred to direct pain medication use and would request medication from the licensed nurse as needed. The care plan did not provide individualized person-centered approaches to pain management such as non-pharmacological interventions they used in the past to help with pain relief. Review of the [DATE] hospital Discharge Summary (DS) showed Resident 1 had abnormal labs that indicated rheumatoid arthritis (an autoimmune and inflammatory disease that causes painful swelling of the affected body parts) and was recommended to follow-up with a rheumatology specialist after discharge from the hospital. Resident 1 was also evaluated by a neurologist who noted the diagnostic images used to conduct the consult were poor quality due to interference from hardware placed during previous neck and spine surgeries. The provider documented Resident 1 used CBD topical ointment (cannabidiol- an active ingredient in medical marijuana some find effective in the treatment of chronic pain and other medical conditions but does cause a high impairment or addiction) daily for pain management at home and was ambulatory with the use of a walker or cane. In an interview on [DATE] at 4:00 PM, Staff E, Physician, stated they were not aware of the recommendation for rheumatology. Review of a [DATE] Physician Progress Note (PPN) by Staff E showed Resident 1 reported back pain ,d+[DATE] (a standardized pain assessment scale used to determine pain intensity- zero means no pain and 10 means worst possible pain) and muscle spasms due to a three-hour delay in pain medication administration. Staff E documented they reviewed the neurology consultation from the hospital prior to admission and added to Resident 1's plan to refer to a pain management specialist. Review of a [DATE] PPN by Staff E showed Resident 1 continued to complain about pain medications not administered timely or as scheduled. Staff E documented they discussed tapering off the opioid pain medication which Resident 1 disagreed with. Staff E documented Resident 1 stated they were in pain and the current dosing frequency-when given timely-lowered the intensity of their pain but did not make the pain go away. Staff E's plan showed they would continue pain management with no mention of a pain clinic and follow-up with neurology. Review of a [DATE] PPN by Staff E showed Resident 1 had a past medical history of chronic pain syndrome, neck and back pain, opioid dependence, and osteoarthritis (a painful swelling disorder of the joints). Staff E documented Resident 1 stated their pain continued to affect their mobility and they continued to receive their scheduled pain medications late, depending on the nurse who was on shift. Staff E and Resident 1 discussed and agreed on the pain management plan. Staff E documented to follow-up with neurology. Review of a Physician Order (PO), dated [DATE] at 7:00 AM, showed a referral for Resident 1 to go to neurology for ongoing weakness and deconditioning. Review of a [DATE] PPN by Staff E showed Resident 1 stated they were doing fine in general, but continued to experience dental pain and was waiting to see a dentist. Staff E ordered an oral gel for tooth pain, continued plan for pain management, and follow-up with neurology. A Review of Resident 1's [DATE] Medication Administration Record (MAR) showed Resident 1 was scheduled to receive their schedule II opioid pain medication two-5 milligrams (mg) tablets (10mg total) every six hours routinely, and one 5 mg tablet every 12 hours PRN for breakthrough pain. Resident 1 reported daily pain levels between 4-,d+[DATE] with the scheduled medication routine and requested a PRN dose twice (they used two of the 62 PRN doses available). Review of a [DATE] PO showed Resident 1's scheduled pain medication frequency was increased from every six hours to every eight hours and one tablet every 12 hours PRN for breakthrough pain. Review of the [DATE] PPN by Staff E showed a review of Resident 1's neurology findings from the prior year and documented to follow up with Neurology (for the fifth time since [DATE] when they first made the referral). Staff E documented Resident 1 was upset with the recent change in their pain medication frequency from every six hours to every eight hours because Staff E did not notify Resident 1 prior to making the change. Staff E documented Resident 1 said they were taking three times as much pain medication when they were treated at a previous clinic for pain, and now was talking less pain medication than what they were prescribed when they discharged from the hospital in August of 2022. Staff E notified Resident 1 they were referred to a pain clinic on [DATE] (five months after the first documented pain specialist referral). Staff E documented Resident 1 said they wanted a different physician to oversee their care. In an interview on [DATE] at 4:30 PM, Staff E stated they discussed with Resident 1 the goal to decrease their intake of opioid pain medication in May. Staff E stated they did not notify or discuss with Resident 1 regarding decreasing the frequency of pain medication on [DATE] but should have. Staff E stated they notified Staff D, Resident 1's Primary Physician of record and Medical Director, Resident 1 wanted a different provider. Staff E was unsure what steps the facility took to obtain a new provider to oversee Resident 1's care. Staff E stated they were not sure why their referrals for the pain clinic and neurology were not carried out and should have followed-up with the facility. Resident 1 was not seen by a neurologist for over a year. Review of Resident 1's August and [DATE] MARs showed they continued to experience pain daily and did not show any non-pharmacological interventions were attempted to help alleviate Resident 1's Pain. Resident 1 had orders for Tylenol, but it was never offered. Resident 1's PRN opioid pain medication usage increased; In August of 2023 they used 44 of their 62 available PRN doses and in September they used 41 of 60 available PRN doses. In an interview on [DATE] at 3:45 PM, Resident 1 stated they felt they were finally getting a hold on their pain management in July of 2023 and barely used their PRN's. Resident 1 stated their pain got worse after Staff E changed the frequency. Resident 1 stated they were not notified of the change which effected their trust in Staff E, so they requested a new provider. Resident 1 stated they didn't want more pain medication, they just wanted what they were ordered, administered as timely as possible, and to be consulted about their pain management before making any changes. Resident 1 stated some staff were already so delayed in administration of the medications; the frequency change made it worse. Resident 1 stated they did not feel they were taken seriously about their pain. Review of Resident 1's clinical record showed no documentation to support Resident 1's pain was adequately evaluated prior to or re-evaluated for effectiveness after the frequency change on [DATE]. The clinical records did not show the facility followed through after Staff E wrote repeated referrals for neurology and the pain management clinic. In an interview on [DATE] at 4:00 PM, Resident 1 stated they were not evaluated at a pain clinic or seen by a neurologist during their stay at the facility and believed it would have helped their pain. Review of a Nurse Progress Note (NPN), dated [DATE] at 4:54 PM, showed the nurse requested a re-fill of Resident 1's schedule II opioid pain medication from Staff D, the day before the supply exhausted. The nurse documented Staff D wanted to speak with the Staff B, Director of Nursing Services (DNS), before they would authorize a refill due to Resident 1's refusal of care from Staff E. Review of a NPN, dated [DATE] at 10:06 AM, showed Resident 1 requested their routine schedule II opioid pain medication and described their pain as extreme. The nurse informed Resident 1 their pain medication supply was out, and they had no valid prescription from Staff D. In an interview on [DATE] at 4:10 PM, Resident 1 stated their last pain medication at the facility was received on the evening of [DATE]. Resident 1 stated they did not get their [DATE] morning and afternoon dose and by the time they were sent to the ER, they were in excruciating pain. Resident 1 stated they told facility staff they would self-medicate (with their CBD cream) if their pain medication was not provided, and after that, they were pressured to go to the ER for pain medication. Review of Resident 1's Narcotic Ledger (NL-an accounting mechanism used to track and document narcotic usage) page 125 showed the last pill from their supply was administered on [DATE] at 9:10 PM. The remaining balance of the card showed zero. Review of Resident 1's [DATE] ER MAR showed they were administered pain medication at 5:07 PM (20 hours after their last pain medication). The pain medication was the same medication and dose they were scheduled to receive routinely at 8:00 AM and 2:00 PM from the facility but did not. Review of an ER PPN, dated [DATE], showed the provider spoke with Staff E, Assistant Director of Nursing (ADON), who reported Resident 1 was prescribed ,d+[DATE] mg tablets (the incorrect amount and dose according to the NL) of their opioid pain medication on [DATE] and 'already used most, and only had two tablets remaining' (inaccurate according to the NL). Staff E reported to the ER provider Resident 1 threatened to self-medicate for pain but did not say what they would use and refused to allow staff to search their belongings. Staff C also reported to the hospital provider that Resident 1 refused to go to the pain clinic because they requested stretcher transport. It was documented that Staff E told the provider the facility was not able to accept Resident 1 without them finding another physician with facility privileges. Review of Resident 1's NL pages 103,110,114,119,120,125, and 126 showed the pharmacy issued a total quantity of ,d+[DATE]mg tablets between [DATE] and [DATE]. The first tablet was not administered until the evening of [DATE]. For the facility to have enough medication to administer Resident 1's routine pain medication as ordered (six tablets per day) and have two tablets on hand for PRN administration (for a total of eight tablets per day), from [DATE] to [DATE], the facility needed to have a quantity of ,d+[DATE] mg tablets. This showed Resident 1 did not request the second PRN pain medication they had available to receive 14 times during that time frame. As of [DATE] at 9:10 PM, Resident 1 had no more medication left. Review of Resident 1's NL Page 132 showed a card of ,d+[DATE]mg tablets (a four-day supply), ordered by Staff D, filled by the pharmacy on [DATE] (the day Resident 1 was transferred to the ER), and logged into the NL [DATE] (three days later). The bottom of the NL page showed the 35 tablets were destroyed on [DATE]. Review of a PO, dated [DATE] at 4:23 PM, showed Staff D accepted to oversee Resident 1's medical care as their primary physician. Further review of Resident 1's POs did not show an order to direct staff to find a physician for Resident 1, to transfer care to another physician from Staff D, or that Resident 1 was provided with a notice they would no longer have a provider to oversee their care after a reasonable timeframe. In an interview on [DATE] at 4:30 PM, Staff D stated Resident 1 did not have a provider to oversee their medical care after they notified Staff E they no longer wanted them as their provider. Staff D stated on [DATE] they were asked to send in a new prescription for Resident 1's pain medication and requested to speak with the DNS first. Staff D stated they did not evaluate Resident 1's PRN pain medication usage to determine the effectiveness of their pain regime and did not conference with facility administration to problem solve the concern of Resident 1's request for a new provider. Staff D was unsure if the facility took any steps to obtain a provider for Resident 1 outside of the facility provider group. Staff D stated Resident 1's needs could not be met at the facility, and they were sent to the ER. Staff D stated Staff E did not refer Resident 1 to a pain clinic because their clinical judgement found it was not necessary. Staff D was asked about their role in the care of Resident 1 given they were the provider of record and Medical Director of the facility. Staff D stated Staff E was the facility Physician who conducted Resident 1's evaluation and managed their care. Staff D stated their knowledge of Resident 1's care was limited to clinical chart records, Staff E's interview, and facility staff interviews. Staff D stated they were not aware of the status of Resident 1 after they transferred to theER on [DATE]. <Resident 4> Review of Resident 4's [DATE] Admission MDS showed no problems with cognition, diagnoses included cirrhosis (liver failure), kidney failure, and diabetes. Resident 4 received scheduled pain medication, no PRN pain medication, and their Pain Assessment Interview was incomplete. Review of Resident 4's [DATE] pain care plan showed they took pain medication would be reviewed quarterly and as needed, staff were directed to assess the pain characteristics and assess effectiveness of routine medication and PRN medication within one hour of administration. The care plan directed staff to observe and report physical indicators of pain and Resident 4 was reliable to indicate their pain care needs. The care plan was not person-centered, did not include individualized non-pharmacological interventions Resident 4 found to be effective, other pain modalities, goals and preferences, or their expectation for acceptable pain relief. Review of a History & Physical note, dated [DATE] by Staff E, showed Resident 4 had a history of a fracture of their spine and complications from liver failure that included severe ascites (accumulation of fluid in the abdominal spaces that in severe cases can be painful) and required repeated procedures to drain the fluid. Staff E documented Resident 4 stated they had back pain ,d+[DATE]. There was no documented evaluation of pain characteristics, length of time they had the pain, their acceptable level of pain, or how they managed the pain in the past. Staff E documented the hospitalist sent a referral for Resident 4 to follow up with hepatology (branch of medicine that deals with diseases of the liver). Review of a PPN, dated [DATE] by Staff E, showed Resident 4 had multiple trips to the ER for shortness of breath and pain. Staff E documented on [DATE], Resident 4 was seen in the ER for shortness of breath from excess fluid and was unable to complete their full dialysis session the day prior due to back pain. Resident 4's Representative (RR) expressed concern about Resident 4's pain management and asked if their pain medication could be increased. Staff E told the RR 10 mg every eight hours was a high dose for their condition and the main goal was to identify the cause of their pain and have appropriate interventions instead of increasing pain medication (although the main causes for Resident 4's pain were already identified to be from their end stage liver and kidney disease and previous fractured back). Staff E documented they suggested if the current pain regime was not effective Resident 4 would be referred to a pain clinic. Staff E also repeated the referral to follow up with hepatology. A Review on [DATE] of Resident 4's POs showed no order for referral to a pain clinic. Review of Resident 4's clinical record showed no documentation to support they were seen at the pain clinic or hepatology. Review of Resident 4's [DATE] MAR showed two PRN orders for Tylenol (not recommended for patients with cirrhosis) and a [DATE] PO for an schedule II opioid pain medication 10 mg every eight hours PRN for severe pain. The opioid pain medication was administered multiple times daily and Resident 4 consistently reported pain levels greater than ,d+[DATE]. The MAR showed no non-pharmacological interventions were attempted prior to administration of the PRN medications. In an interview on [DATE] at 2:30 PM, Resident 4 stated they broke their back several years ago and they were in constant pain. Resident 4 stated Staff E changed their pain medication frequency from every six hours to every eight hours without their knowledge and refused to change it back. Resident 4 stated they told Staff E they were still in pain. Resident 4 stated over half of their day was spent at a pain level of 8-,d+[DATE]. Resident 4 stated they were not offered other non-pharmacological interventions by staff and stated they spent most of their day in bed. Resident 4 stated they were not evaluated at a pain clinic and was unsure if they were seen by hepatology. In an interview on [DATE] at 4:14 PM, Staff E stated they thought they had talked about referral to a pain clinic with Resident 4. Staff E stated they needed to review Resident 4's record and they would re-evaluate their pain management plan and follow up on their referrals. <Resident 5> Review of the [DATE] Quarterly MDS showed Resident 5 had no problems with cognition and diagnoses included blood clots, heart failure, vascular disease, diabetes, and kidney failure. Resident 5 received scheduled and PRN pain medication and their Pain Assessment Interview was incomplete, but they reported their worst pain an ,d+[DATE] during that timeframe. Review of Resident 5's comfort care plan revised [DATE] showed they desired to remain comfortable through their end-of-life process and directed staff to assess their pain regime and coping strategies, coordinate with the physician to ensure they remained comfortable, to administer pain medication as ordered and notify the physician for breakthrough pain immediately. Review of a PPN, dated [DATE] and signed by Staff E [DATE] at 7:01 PM, Resident 5 refused to start dialysis due to kidney failure and signed new advance directives for end-of-life care, no cardiopulmonary resuscitation (CPR), and wanted to be on comfort measures only. Staff E did not document an assessment or plan for pain management. Review of a social services note, dated [DATE] at 2:46 PM, showed Resident 5 stated they called hospice because the pain in their kidneys was unbearable and their Schedule II opioid pain medication of 5 mg three times daily was not enough to make their pain tolerable. The writer documented Resident 5 stated the physician did not spend enough time with them to understand their concerns or why they requested their pain medication be increased. Review of a PPN, dated [DATE] and signed by Staff E on [DATE] at 7:59 PM, showed the medication list did not include updated pain medication orders, Resident 5 stated their pain level was ,d+[DATE], experienced a change of condition, and Staff E suggested they take pain medication one hour prior to their wound care to help with the pain. Staff E's PPN did not show documentation to support they thoroughly evaluated Resident 5's pain concerns with their kidney's or their other pain concerns. Review of a PO, dated [DATE], showed Resident 5's schedule II pain medication was tapered down from 5 mg every 10 hours PRN to 5 mg every eight hours PRN for pain, although Resident 5 continued to complain of moderate to severe pain. Review of a PPN, signed and dated [DATE] by Staff D, showed Resident 5 stated they had pain to their kidney and abdominal area, described as sharp, wrenching, constant, and ,d+[DATE]. Staff D documented Resident 5 stated their pain medication provided some mild-moderate relief. Staff D documented their assessment and plan for abdominal pain would be to order an x-ray and follow up as needed. Review of a PO, dated [DATE], showed Resident 5's schedule II pain medication changed from 5 mg every eight hours PRN to every four hours PRN FOR FOUR DAYS THEN CHANGE TO ONE TAB EVERY SIX HOURS THEREAFTER. Review of Resident 5's September and [DATE] MARs showed a [DATE] PO for the schedule II pain medication 5 mg every six hours PRN pain FOR FOUR DAYS THEN CHANGE TO ONE TAB EVERY SIX HOURS THEREAFTER. The September MAR showed the medication was never scheduled for routine administration every six hours on [DATE] (as ordered) but remained PRN. Resident 5 requested the medication multiple times daily and consistently reported their pain 6-,d+[DATE]. Non-pharmacological interventions (the same interventions ordered for Residents 1, 2, 3, & 4) were not attempted. Review of a PPN, dated [DATE] by Staff E, showed Resident 5 wanted to start dialysis treatment because of feeling tired and being in constant pain. Staff E's PPN did not provide documentation to support they thoroughly evaluated Resident 5's constant pain. In Staff E's assessment and plan, Resident 5 took the schedule II pain medication every six hours PRN for pain related to an amputation of their limb, and did not address Resident 5's abdominal and kidney pain. Review of a PO, dated [DATE], showed Staff E tapered down Resident 5's schedule II pain medication to 5 mg every eight hours PRN despite Resident 5's continued multiple daily complaints of moderate-severe uncontrolled pain. In an interview on [DATE] at 12:50 PM, Resident 5 stated their pain was not managed and they stated they got three pain pills a day, but they had to ask for them. Resident 5 stated their acceptable pain level was 6-,d+[DATE] which they considered moderate pain and rarely was less than a ,d+[DATE] throughout the day. Resident 5 stated if they could get their pain to a 7-,d+[DATE], they can grit their way through it. Resident 5 stated they were frustrated with how their pain was managed, the stigma of pain management, and fear of addiction. Resident 5 stated I depend on the medication for relief due to my medical conditions, I am not addicted to it. Resident 5 stated earlier in the week, they had a medical procedure to insert a catheter into a vein in their chest and asked if they could have one extra dose prior to the procedure, but the on-call provider the nurse contacted refused to authorize a one-time dose and told the nurse to apply ice to the area. Resident 5 stated the procedure was very uncomfortable. In an interview on [DATE] at 4:20 PM, Staff E stated they were unsure which provider was contacted regarding the additional dose for the procedure but would investigate it and they would re-evaluate Resident 5's pain regime. <Resident 7> Review of the [DATE] Annual Comprehensive MDS, Resident 7 had significant cognitive impairment, diagnoses of vascular disease, and dementia. Resident 7 received scheduled pain medication, no PRN medication, and a staff assessment for pain was not conducted. Review of Resident 7's [DATE] pain care plan showed they had indicators of pain that included facial expressions, other non-verbal signs of pain, and a pressure injury. The established goal for Resident 7 was they would verbalize adequate pain relief and ability to cope with unrelieved pain (except they had severe cognitive deficits due to dementia). The care plan showed three generic care plan interventions to observe for discomfort through either verbal or facial expression, assess characteristic of pain including location and severity on the ,d+[DATE] scale, and listed some non-verbal indicators to monitor for. The care plan was not individualized, had unrealistic goals which indicated they would have unrelieved pain, and did not include use of a pain scale appropriate for dementia care. Review of Resident 7's [DATE] revised behavior care plan showed they had behaviors that included: aggression toward staff, disrobing, self-transfers to the floor, and crawling on the floor. The care plan did not direct staff to identify their behaviors as potential indicators of pain. Observations on [DATE] at 11:45 AM and 4:40 PM showed Resident 7 crawling on the floor from their room to the hallway, pushing their wheelchair, and hollering. During both observations, staff were aware of Resident 7's actions, but no staff were observed to intervene with Resident 7 to evaluate if they were hurting or had some other unmet care need. Review of Resident 7's [DATE] MAR showed they received scheduled Tylenol 1,000 mg three times daily for chronic pain, a lidocaine patch daily, a schedule IV narcotic pain medication every morning, and staff consistently documented pain level 3-,d+[DATE] (via the verbal pain scale). A PO, dated [DATE], directed staff to attempt non-pharmacological interventions (which were the same interventions as Residents 1, 2, 3, 4, 5, & 6) prior to administration of PRN medications but none were documented. Review of Resident 7's schedule IV NL, Page 36, showed they did not receive the medication on [DATE], [DATE], [DATE], [DATE], and [DATE]. In an interview on [DATE] at 5:10 PM, Staff B stated they would investigate why Resident 7 was not administered the scheduled doses of pain medication. <Resident 3> Review of the [DATE] Admission MDS showed Resident 3 had no problems with cognition, they received scheduled and PRN pain medication, and reported their worst pain an ,d+[DATE]. Review of Resident 3's [DATE] MAR showed they had orders for: a schedule II extended-release opioid medication twice daily for back pain related to chronic pain syndrome, a schedule II opioid pain medication every six hours PRN for severe pain, a scheduled medication for neuropathy, a PRN medication for neuropathy, scheduled Tylenol 1,000 mg three times daily (for a total of 3,000 mg), and Tylenol 650 mg every six hours PRN -not to exceed the maximum daily dose of 3,000mg /24 hours from all Tylenol sources, and two different muscle relaxants PRN for muscle spasms. Review of Resident 3's October PRN opioid medication showed they requested the medication two to four times daily for pain levels of 6-,d+[DATE]. No non-pharmacological interventions were documented as attempted prior to the administration of the PRN opioid pain medication. Despite multiple daily use of their PRN opioid pain medication, on [DATE], Staff E decreased their order from one tablet every six hours to one tablet every 22 hours for seven days and then discontinued completely. The clinical record provided no documentation to support the facility or Staff E assessed Resident 3's pain management regime to determine why they continued to have breakthrough pain when they were on an extended-release opioid medication or the consequences of discontinuation of their PRN pain medication while they continuously reported breakthrough pain. Review of Resident 3's NL page 13 showed a quantity of ,d+[DATE] mg schedule II extended-release opioid tablets to be administered twice daily. The prescription did not indicate how far apart the medication should be administered. The facility scheduled the medication for 8:00 AM and 8:00 PM. According to the NL Resident 3 was not provided their scheduled dose on [DATE] at 0800 AM. Review of Resident 3's NL page 12 showed a quantity of seven-5mg instant release schedule II opioid tablets for PRN administration which was discontinued on [DATE]. An entry on [DATE] at 0800 AM showed Resident 3 was administered one 5mg tablet of instant release pain medication (two days after Staff E discontinued the medication). This indicated a medication error occurred when the nurse gave a 5 mg instant release tablet instead of their scheduled extended-release medication. Review of Resident 3's [DATE] MAR showed they complained of pain ,d+[DATE] on [DATE] at 3:49 PM and was given 650 mg of Tylenol for ,d+[DATE] (severe) pain. At 8:00 PM they were administered their evening extended-release pain medication as scheduled and at 9:00 PM they were given 1,000 mg of Tylenol for pain ,d+[DATE] (for a total of 3,650 mg of Tylenol which exceeded the maximum daily dose). The failure to administer the correct medication for their morning dose likely contributed to their severe breakthrough pain and they no longer had an order for the opioid PRN medication to treat moderate-severe pain, and was administered Tylenol (used for general pain and fever) which exceeded the maximum daily limit. In an interview on [DATE] at 12:45 PM, Staff B, Director of Nursing stated they were not aware of the medication error and would investigate it. In an interview on [DATE] at 3:00 PM, Resident 3 stated their pain was not managed. Resident 3 stated their scheduled pain medication was usually administered late, they were not referred to a pain specialist or offered other treatments for pain management such as contracture management and splinting for their contracted limb. In an interview on [DATE] at 4:15 PM, Staff E stated they were unsure of Resident 3's pain [TRUNCATED]

Based on interview and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a POLST (Physician's Orders for Life Sustaining Treatment) that indicated the resident wanted to receive life-sustaining care and services. This failure resulted in the resident's wishes not being followed and placed other residents at risk of not receiving needed emergency medical interventions for unexpected emergencies. The facility corrected the above deficient practice prior to the abbreviated survey. This constituted a past noncompliance immediate jeopardy. This was a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) Immediate Jeopardy (non-compliance that has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation and is no longer outstanding. Findings included . Record review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) Emergency Response, revised February 2018, showed that 6. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR Unless: (a) it is known that a Do Not Resuscitate (DNR) order specifically prohibits CPR and /or external defibrillation exists for that individual; or (b) there are obvious signs of irreversible death (e.g., rigor mortis). Emergency Procedure: If an individual is found to be unresponsive: briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Instruct a staff member to activate the emergency response system (code) and call 911. Instruct staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support BLS sequence of events. 8. Continue with CPR/BLS until emergency medical personnel arrive. Code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops. Code status includes but is not limited to Full Code (implement lifesaving interventions such as CPR). Review of the American Heart Association (AHA) guidelines dated 2015 showed that the standard of practice for CPR was to give two minutes of CPR for an unresponsive person that was not witnessed when the condition change occurred, get emergency assistance (911), and resume CPR. Review of the Physician Orders for Life-Sustaining Treatment (POLST) form dated [DATE], showed that Resident #1 signed the document and chose to have CPR initiated in the event of having no pulse and was not breathing. The document showed this was discussed with Resident 1 and signed by the Practitioner on [DATE]. Record review showed Resident 1 admitted to the facility on [DATE]. According to the [DATE] Admission Minimum Data Set (MDS- an assessment tool), Resident 1 was alert and oriented, required extensive two-person assist with activities of daily living. A [DATE] 5:24 AM progress note showed Resident 1 was found unresponsive during check and change by Certified Nursing Assistants (CNAs). Vital signs were assessed, and no pulse rate was found. The family was notified and requested not to call the funeral home until they got to the facility. In a phone interview on [DATE] at 3:40 PM Staff D, CNA stated that on [DATE] around 4:00 AM, Staff D went to check on the resident and found him unresponsive. Staff D stated they immediately notified Staff E, Registered Nurse, RN at the nurse station. Staff E came and checked on the resident and went back to the nurse station. When asked if they knew the resident's code status, Staff D said No. When asked how to find the resident code status, Staff D stated that there was a green binder at the nurses' station which had all of the residents' POLST and when asked if they checked on Resident 1's code status. Staff D said No. It should be noted that the facility included resident code status in multiple locations in the medical record and all of those accurately reflected the resident's code status. In a phone interview on [DATE] at 3:42 PM Staff E stated that they were notified by Staff D that Resident1 was unresponsive. Staff E stated that they checked the resident's code status on the green binder at the nurse station and saw that the POLST was written Do not Resuscitate (DNR). Staff E then went to Resident 1's room and checked the resident's pulse and confirmed that the resident had expired. Staff E returned to the nurse station and notified the family who requested not to send the body to the funeral home until they came to the facility. When asked how to know the resident's code status, Staff E stated, You check in the green binder at the nurse station, on the resident's electronic chart under special instruction and under miscellaneous tab under scanned documents. When asked if they verified the three areas about Resident 1's code status, Staff E, RN said No when asked if they initiated CPR for Resident1 or called code blue or called 911, Staff E said No. When asked if they notified the physician and the facility Director of Nursing and administrator, Staff E stated No. Staff E further stated that she notified the oncoming shift Resident Care Manager (RCM) and assumed that they would notify the physician and management. In an interview on [DATE] at 1:39 PM Staff C Assistant Director of Nursing (ADON) stated that when they arrived at the facility, they were notified by a staff that the resident had passed on (approximately nine-and one-half hours from when the resident was found unresponsive). Staff C checked in the resident's file and found out that the resident was full code status. Staff C then reviewed the resident's nursing progress notes and did not find any information about CPR initiation or notification to the physician or facility management. When asked what staff were to do in the event a resident was found unresponsive, with no pulse and no respiration: Staff C, ADON stated that they would check the resident's code status, and if a full code, call a code, start CPR, and have another staff get the phone and call 911. In an interview on [DATE] at 2:13 PM Staff B Director of Nursing/Regional Nurse Consultant stated that CPR was not initiated on Resident 1 with full code status. Staff B further stated that the physician had not been notified at the time of resident's death. When asked the expectation Staff B, DNS stated that the facility staff was to initiate CPR and call code blue, call 911 and notify the physician on the resident's change of condition. In an interview on [DATE] at 2:40 PM Staff A stated that the correct POLST had not been reviewed when the resident was found unresponsive, and the facility policies had not been followed. The facility implemented the following interventions on [DATE], which corrected the deficiencies: - Physician notification and following physician orders. -Coroner office notification -One on one training to the staff about change of condition, code status, identification and implementation resident's code status, physician notification, State agency notification. -All staff training about change of condition, code status, Full code/DNR responses, Physician, management notification, Documentation -Facility Audit of all resident's POLST and advance directives. This was a Past Non-Compliance Immediate Jeopardy situation and is no longer outstanding. Reference (WAC) [DATE] (1)

Based on observation, interview and record review, the facility staff failed to ensure timely implementation of pain control measures for one of two residents (Resident 236) reviewed for pain management. Failure to timely obtain and provide as needed (PRN) pain medication and implement non-pharmacological interventions to minimize the resident's pain caused harm to resident 236 when his pain went unrelieved for over seven hours. Findings included . Review of the facility's pain management policy, dated March 2020, documented Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. <PAIN CONTROL 07/01/2022> Resident 236 admitted to the facility on [DATE]. Review of a vascular surgery progress note, dated 06/26/2022, showed the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident experienced post-operative complications which resulted in formation of large hematomas (a solid swelling of clotted blood within the tissues) to his bilateral (both) groin and scrotum. A vascular surgery progress note, dated 06/29/2022, showed Resident 236 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the note the resident's pain was effectively controlled with [MEDICATION(S)] (an opioid pain medication) 5 to 10 milligrams (mg) every three hours PRN. Review of Resident 236's 07/01/2022 nursing admission assessment showed staff identified bruising to the resident's thighs. There was no documentation or indication that staff assessed and/or identified that the resident's groin and scrotum remained swollen and painful due to the large underlying hematomas. In an interview on 07/06/2022 at 10:08 AM, Resident 236 stated that when he admitted to the facility the pharmacy was unable to deliver his pain medication, so he was suffering half of the night. During an observation and interview on 07/07/2022 at 9:28 AM, Resident 236 again reported, The day I admitted , I requested pain medication and [staff] told me there was no one here to get the medications so I would have to wait. The resident reported he was in tremendous pain due to a three-hour ambulance ride that was bumpy and painful. Resident 236 stated, You know about this and motioned toward his groin. Observation of the area showed the resident's groin and scrotum had extensive bruising and swelling. On 07/08/2022 at 2:22 PM, Collateral Contact (CC) 1 stated, I was aware that they (facility) did not have [Resident 236's] medications for pain. They said there was no prescription. My daughter called [the hospital] and had them send a prescription over but then the facility said it was too late to get it filled .My daughter keeps notes on all of that, you should ask her for the notes. During an interview on 07/12/2022 at 9:09 AM, CC 2 stated on 07/01/2022 she and CC 3 were at their mother's house when Resident 236 called them at 8:05 PM. CC 3 stated, He said he was in an excruciating amount of pain and wanted to go back to the hospital. He told us he had only received [acetaminophen] and it was the worst pain he had ever experienced in his life. After that phone call we called the facility [at 8:25 PM] and spoke with Staff N, Registered Nurse (RN), who said she knew dad was in pain, but there was no script for the [MEDICATION(S)], so the pharmacy would not dispense it. She said she would call the hospital to try and get something. CC2 said that they contacted the facility again around 10:00 PM and the [MEDICATION(S)] still had not been administered, but the nurse on duty informed them the doctor was in the process of calling the script into the pharmacy. In an interview on 07/12/2022 at 4:40 PM, CC3 stated that she and CC2 received a call from Resident 236 at 8:05 PM and he was crying saying he was in pain and had not received anything but acetaminophen. CC3 stated, I need you to know that is only the second time I have seen or heard [Resident 236] cry. CC3 stated she called the facility and was told Resident 236 arrived without a prescription and there was a call out to the doctor. CC3 stated that [Resident 236] was in distress, so we called back again around 10:00 or 10:30 PM to ensure everything had been taken care of, and at that time they had not obtained the [MEDICATION(S)] yet, but said the doctor was on the phone with the pharmacy. Review of Resident 236's 07/01/2022 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Fax Transmittal, dated 07/01/22 at 3:39 PM, showed a signed prescription for '[MEDICATION(S)] 5 milligrams every 3 hours as needed for moderate or severe pain' was faxed from the facility to the pharmacy. Review of Resident 236's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurses' note, dated 07/01/2022 at 10:44 PM, written by Staff N, Registered Nurse showed, Call also received from [hospital doctor] who gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 236's Electronic Health Record showed after the residents family informed the facility of his pain at 8:25 PM, no documentation or indication that Resident 236's pain was assessed, that the location, intensity, or contributing factors were identified, nor was there any indication facility staff attempted to identify and implement non-drug interventions, to minimize the resident's level of discomfort . Review of Resident 236's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the order for ibuprofen 600 mg every 8 hours x 24 hours, which was obtained to help control Resident 236's pain until the ordered [MEDICATION(S)] was available, was never transcribed or administered. During an interview on 07/13/2022 at 10:29 AM, Staff B, DNS explained that Resident 236 admitted without a script for the [MEDICATION(S)] order, which created a delay in obtaining the medication. When queried how the original [MEDICATION(S)] prescription from the hospital, dated 07/01/2022, got into Resident 236's EHR, Staff B, DNS, stated that they were still investigating. Review of the facility's investigative documents provided on 07/15/2022, showed the facility investigation concluded Resident 236's pain was well controlled. According to the facility's investigative timeline at 7:30 PM Staff BB began inquiring about Resident 236's [MEDICATION(S)] order with the pharmacy and the pharmacy reported they did not have a script for Resident 236's [MEDICATION(S)]. According to the investigative documentation Staff BB informed Resident 236 about the pharmacy not having a script for his [MEDICATION(S)], and the resident was agreeable to take acetaminophen. Review of Resident 263's EHR showed no documentation was present to support the statement. <PAIN CONTROL 07/07/2022> During an interview on 07/07/2022 at 8:53 AM, Resident 236 complained about pain management and stated, I called for my pain meds at 5:40 AM [this morning, 07/07/2022], when they did not come, I called again and Staff J, Registered Nurse (RN), came in .and I finally got my [[MEDICATION(S)]] at 8:00 AM. My pain level was a 7 at 5:40, by 8 am it was a 9-10, it hurt. I have already talked to [Staff A, Administrator] this morning and told them to get me out of here today. I cannot keep going through this every day. One of my biggest complaints is getting [pain] medications in the morning .they say there is no nurse [to administer them.] Review of Resident 236's July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Despite the resident reporting pain of seven out of ten at 5:40 AM, review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation that facility staff attempted to identify and implement non-drug interventions to minimize the resident's level of discomfort. During an interview on 07/07/2022 at 9:24 AM, Staff J, RN. stated, [Resident 236] told me that he asked for a pain medication, but it took too long, and the nurse's aide never came back. I told him between six and seven there is a shift change. Staff J indicated after shift change report was received, he medicated the resident. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to identify indicators of acute change in a condition including vital signs and failed to complete a thorough physical assessment and monitoring of residents with changes in condition for five of 27 residents (Residents 3, 8, 11, 16, and 26) reviewed for change of condition. This failure resulted in Resident 16's hospitalization and subsequent death. Findings included . RESIDENT 16 Review of admissions record dated [DATE], showed Resident 16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse's note dated [DATE] at 2:02 PM, showed Staff D, LPN, documented that Resident 16 had a change of condition. The resident was lethargic, unable to swallow, and had decreased oral intake. Further record review showed Resident 16 was not placed on alert after a change in condition was identified, and vital signs were not obtained every shift for three days after [DATE]. Interview with Staff S, MD (Medical Doctor), on [DATE] at 12:40 PM, stated vital signs should be done every shift for three days when there is a change of condition. Review of a nurse's note dated [DATE] at 2:28 PM showed Resident 16 had some confusion noted. The nurse did not describe if this was a new onset of confusion or the resident's baseline. The assessment did not include whether the resident was alert and oriented to self, place, time, and circumstances. Without this information, the facility could not ensure thorough monitoring. During observation and interview on [DATE] at 11:00 AM, Resident 16 was lying in bed on his left side facing toward the window. Resident 16 appeared weak, spoke softly, but was awake and able to answer questions appropriately. He stated he goes to [CONDITION(S)] treatment each Tuesday, Thursday, and Saturday. Resident 16 stated that the facility sent him to a [CONDITION(S)] center with a shuttle service. Review of a nurse's note dated [DATE] at 11:59 AM, showed Staff D, LPN, identified Resident 16 was non-verbal. Facility sent Resident 16 to [CONDITION(S)] center when he was non-verbal with a shuttle service. The facility did not complete a physical assessment and obtain vital signs to rule out a change in condition. In an interview on [DATE] at 4:47 PM, Staff D, LPN was asked if she knew if Resident 16 had a change in condition on [DATE] prior to being sent to [CONDITION(S)]. Staff D, LPN stated maybe he had a change of condition. Staff D, LPN was unable to find vital signs and said they should have been done before sending resident to [CONDITION(S)]. During an interview on [DATE] at 4:00 PM, Collateral Contact A, (CCA) stated that Resident 16 was not responding when picked up at the facility on [DATE] at around 11:00 AM. CCA also stated that the facility staff were asked about Resident 16's condition, and two facility staff members told CCA that Resident 16 was safe for travel and not to worry about the resident's condition. CCA was unable to recall the staff member's name or description. Further record review showed no assessment or evaluation was conducted regarding Resident 16's non-verbal condition before sending him out for [CONDITION(S)] treatment. A review of the [CONDITION(S)] communication record dated [DATE] showed no vital signs were obtained before [CONDITION(S)]. According to multiple interviews with anonymous witnesses on [DATE] at 2:20 PM and [DATE] at 3:20 PM, Resident 16 arrived at [CONDITION(S)] unresponsive on [DATE] around 11:30 AM. The [CONDITION(S)] center staff were familiar with Resident 16 and noticed that was not his usual condition. The [CONDITION(S)] team called 911, and Resident 16 was transported to the emergency department. Review of hospital record dated [DATE], showed Resident 16 had [CONDITION(S)] (damage to the brain) due to [CONDITION(S)] activity. During observation and interview on [DATE] at 7:45 PM, the anonymous witness (hospital nurse) stated that Resident 16 arrived in the Emergency Department unconscious, was admitted to the Intensive Care Unit, and subsequently died in the hospital on [DATE]. During an interview on [DATE] at 5:45 PM, Staff FF, LPN, Charge Nurse, was asked about protocol for vital signs before and after [CONDITION(S)]. Staff FF, LPN, said she was not aware of any policy or protocol about vital signs check. However, according to her nursing experience, vital signs should be checked before and after [CONDITION(S)]. RESIDENT 11 Review of admission records dated [DATE], showed Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 11's care plan initiated on [DATE], showed the intervention to monitor status after [CONDITION(S)]. Review of a Nursing Progress note dated [DATE] 3:06 PM, showed that Resident 11 had three episodes of short duration seizures [MEDICATION(S)] less than 30 seconds, as evidenced by his eyes closed, rigid movements, and not responding to his name on [DATE]. In addition, the progress note indicated that a therapist witnessed the [CONDITION(S)] episodes during the therapy session, and the Rehabilitation Director reported these [CONDITION(S)] episodes to the Director of Nursing Services (DNS) on [DATE]. Review of nursing notes dated [DATE] at 6:29 PM, showed Resident 11 had seven [CONDITION(S)] episodes and was sent to the Emergency Department (ED) for an evaluation at 6:15 PM. Resident 11 returned from the ED on the same day at 11:10 PM. There was no neurological assessment and/or post-[CONDITION(S)] monitoring before or after the resident returned from the ED. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift look for stares, does not respond to name, mild jerking movements, space out, closes eyes, looking sides, becomes rigid. The order was discontinued on the same day and was not renewed. Review of nursing notes dated [DATE], showed Resident 11 had ten [CONDITION(S)] episodes and was sent to the ED again at 4:20 PM. Resident 11 returned from the ED on [DATE] at 12:30 AM. No frequent neurological monitoring was initiated when the resident returned to the facility. Review of nursing notes dated [DATE], showed Resident 11 fell at 4:45 PM. Review of nursing notes dated [DATE] at 10:17 PM showed Resident 11 was placed on alert for increased confusion. Further record review showed Resident 11 was not assessed until [DATE] at 1:23 PM, or 15 hours later when he developed severe shortness of breath and was sent to the ED again. Resident 11 returned from the ED on the same day at 8:06 PM. A review of the nurse's notes showed Resident 11 was not assessed until [DATE] at 7:28 AM, or 11 hours after he sustained a fall with a [CONDITION(S)]. During an interview on [DATE] at 4:55 PM, Staff B, Registered Nurse, DNS (RN, DNS), was informed of missing nursing assessment including neurological monitoring for Resident 11. Staff B, RN, DNS, stated she was in the process of implementing standardized neurological monitoring, and a neurological flow sheet would be implemented. RESIDENT 26 Review of admission record dated [DATE], showed Resident 26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on [DATE] at about 3:30 PM, Resident 26 was observed in his room sitting on the bed. The resident was unable to participate in an interview. Review of Resident 26's Care Plan dated [DATE] showed, the staff should monitor status after [CONDITION(S)] and report significant assessment data to MD (Medical Doctor). Review of the nurse's notes dated [DATE], showed Resident 26 had a medical emergency. Staff found the resident unconscious, stiff with jerking arm movements resembling [CONDITION(S)] activity. The symptoms lasted for three minutes. A physician was contacted and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review showed, following the medical emergency episode, Resident 26 was not assessed for eight hours, or until [DATE] at 5:36 PM, when he was found on the floor shaking with blood on his gown and a laceration to his head. During an interview with Staff D, LPN, and Staff GG, RN on [DATE] between 4:00 PM and 4:08 PM about assessment after seizures. Both staff nurses reported they did not know where policies and procedures were located for monitoring seizures and how to complete neurological assessments. Staff GG, RN, stated that the nurse should complete a head-to-toe assessment and start neurological checks after the resident had a [CONDITION(S)], and based on her nursing experience. The facility did not implement Resident 26's care plan. RESIDENT 3 Review of the admissions record dated [DATE], showed Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 3's care plan initiated on [DATE], showed Resident 3 had compromised cardiovascular status and had an intervention to monitor/document/report as needed any signs and symptoms for cardiovascular complications such as: shortness of breath, increased heart rate. Observation and interview on [DATE] at 11:00 AM revealed Resident 3 in bed on his left side, holding the oxygen cannula in his mouth. Resident 3 said he felt his heart racing and asked staff to check his pulse but they refused. Resident 3 further stated that when finally an unnamed staff member checked his heart rate, the oximeter showed 168 beats per minute (a normal heart rate range from 60 to 100 beats per minute for adults). Resident 3 also stated that he had been sent to the hospital for Cardioversion (restoring heart rhythm) a few times since admitted to this facility. Review of a nurse's note dated [DATE] showed The patient`s heart rate increased to 180 after the shower due to SVT and was transferred to the ED for evaluation and treatment at 3:00 PM. Review of a nurse's note dated [DATE] showed the resident returned from the hospital following a cardioversion. Further record review showed the resident was not placed on alert (assessment and vital signs monitoring once a shift for three days) after the ED visit. Review of a nurse's note dated [DATE] showed Resident 3 had another SVT episode with heart rate of ,d+[DATE] beats per minute, and was sent to ED again at 3:11 PM. Review of a nurse's note dated [DATE] showed Resident #3 returned from ED at 1:30 AM. Record review did not find alert documentation following ED visit. Review of Resident 3's vital sign record dated [DATE], showed the resident had a heart rate at 121 beats per minute at 3:48 PM. This abnormal heart rate was not addressed. Nursing notes did not show that staff rechecked Resident 3's heart rate by auscultation and notified or consulted with a provider. Interview with Staff S, MD, on [DATE], at 12:40 PM, stated vital signs should be done every shift for 3 days when there is a change of condition or when a resident is a new admission. RESIDENT 8 Review of the admissions record dated [DATE], showed Resident 8 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 8's care plan initiated on [DATE], showed Resident 8 had compromised cardiovascular status and had an intervention to monitor/document/report as needed any signs and symptoms for cardiovascular complications such as: shortness of breath, weakness and/or fatigue, increased heart rate, lethargy and disorientation, and monitor vital signs. Review of Resident 8's blood pressure record from [DATE] to [DATE], showed Resident 8's blood pressure baseline was averaging ,d+[DATE] mmHg. Review of Resident 8's blood pressure record dated [DATE], showed a high blood pressure reading of ,d+[DATE] mmHg at 1:59 PM, and on [DATE], ,d+[DATE] mmHg at 2:00 PM. Further record review did not find follow up on abnormal blood pressure. Review of a nursing progress note dated [DATE], showed Resident 8 was sent to the emergency roiagnom on [DATE] and was diagnosed with an acute stroke. The facility did not implement Resident 8's cardiovascular care plan. Interview with Staff S, MD, on [DATE] at 12:40 PM, stated vital signs should be done every shift for three days when there is a change of condition or when a resident is a new admission. Reference (WAC) [DATE](1)

Based on observation, interview, and record review, the facility failed to prevent the development of pressure injury for one of three residents (Resident 16). This failure resulted in harm when Resident 16 developed unstageable pressure injuries to both heels. Findings include . RESIDENT 16 Review of the admission Minimum Data Set (MDS, a comprehensive assessment tool) dated 01/05/2021, showed Resident 16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS document showed Resident 16 was admitted without a pressure injury. Review of the Braden scale (an assessment tool to predict pressure injury risk) dated 12/29/2020, showed Resident16 scored at 11, indicating he was at high risk for developing a pressure injury. The risk included limited sensory perception, moisture, completely immobile, and had friction and shearing problems. Review of Resident 16's care plan for pressure ulcer risk dated 12/31/2021, showed no intervention to relieve pressure to the feet. Observation on 03/17/2021 at 10:20 AM, Resident 16 was in bed on his left side. Resident 16's feet were resting on the mattress and were not floated. Review of the nursing progress notes date 01/15/2021, Resident 16 was found with unstageable deep tissue injury to both heels. The left heel measured 7x5 cm and the right heel was 3x1.5 cm. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment order dated 01/15/2021, showed Skin prep daily and cover with foam dressing and monitor until healed. Review of the nursing progress note dated 01/18/2021, 01/19/2021, and 01/21/2021, showed there was no nursing assessment describing wounds and Resident 16's response to treatment. Review of a wound care specialist note dated 01/22/2021, showed a recommendation to apply skin prep and cover with foam dressing every other day and monitor until healed. Review of the Treatment Administration Records (TAR) dated January 2021 and February 2021, did not show above wound care recommendations had been implemented. Review of a nurse's progress note dated 02/04/2021 at 3:31 PM, showed the left heel wound measured 3x2 cm and the right heel measured 4.5x4.5 cm. The right heel increased in size, and the wound had drainage. The drainage description did not include color, amount, odor, or consistency. Review of a nurse's progress note dated 02/05/2021, 02/06/2021, 02/08/2021, and 02/09/2021, Resident 16 continued having wound drainage. The documentation did not include color, smell, consistency, and volume. Review of a progress note dated 02/10/21 at 8:44 AM, showed right heel measured 4.5x5x1 cm. Review of a progress note dated 02/11/21 at 12:25 PM, showed the right heel wound was 4.5x3x1 cm. Review of a progress note dated between 02/09/2021 and 03/17/2021, showed the following wound measurements: 02/09/21 Right heel: 4.0x5 cm Left heel: 3x2 cm 02/15/21 Right heel: 4.5x3 cm Left heel: 3x2 cm 02/24/21 Right heel: 4.5x3 cm Left heel: 3x2 cm 02/28/21 Right heel: 4.5x3 cm Left heel: 4.5x2cm 03/09/21 Right heel: 4.5x3 cm Left heel: 4x2 cm 03/17/21 Right heel: 4.0x3 cm Left heel: 4x2 cm Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 03/31/2021 at 4:34 PM, Staff D, LPN, stated the appointment for Resident 16's vascular referral had not been scheduled because the clinic did not call back. In an interview on 03/31/2021 at 3:49 PM, Staff D, LPN was asked how the resident developed pressure injuries to both heels. Staff D, LPN, stated Resident 16 wore tennis shoes to [CONDITION(S)]. Staff D, LPN, also stated that weekly skin rounds had not been done at the facility since January 2021. In an interview on 03/25/2021 at 3:40 PM, a Collateral Contact stated that Resident 16 had no heel protectors on his feet when picked up from the facility to go to [CONDITION(S)] on 03/18/2021. Reference (WAC) 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to initiate interventions to prevent significant weight loss for five of six residents (Resident 6, 12, 13, 16, and 26) reviewed for nutritional status and weight loss. These failures resulted in harm to Resident 16 and 26 and placed other residents at risk for a continued decline in nutritional status and related complications. Findings include . RESIDENT 16 Review of admission Minimum Data Set (MDS, a comprehensive assessment tool) dated 01/15/2021, showed Resident 16 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 3/17/2021 at 7:00 AM showed breakfast was being served. Interview on 03/24/2021 at 5:20 PM Collateral Contact LL, from [CONDITION(S)] center stated meals or snacks were not provided. Outside food was not allowed and the patients need to eat prior to [CONDITION(S)]. Interview on 3/29/2021 at 8:00 PM Collateral Contact MM, stated Resident 16 frequently asked her to bring in food because he was hungry. Collateral Contact MM also stated that he missed lunch on [CONDITION(S)] days. Additionally, Collateral Contact MM said when staff delivered meal trays and resident was asleep they would not wake him up for meals. Resident 16 would not eat after 7:00 AM until 5:00 PM when dinner was served on [CONDITION(S)] days. Observation and interview on 03/17/2021 at 11:20 AM, showed Resident 16 was in bed. The resident had a darkened banana on a bedside table. The resident stated he disliked bananas and the resident felt he should not have bananas. On 3/31/2021 at 4:01 PM Staff D, LPN said resident went to [CONDITION(S)] on Tuesday, Thursday and Saturday. Resident left around 12:00 PM and returned around 5:00 PM. Staff D, LPN said resident missed lunch on [CONDITION(S)] days. The facility could not send lunch sack with him to [CONDITION(S)] due to COVID-19. Review of a [CONDITION(S)] center monthly nutritional summary dated 03/19/2021, showed Resident 16's nutritional status was malnourished . as evidenced by inadequate oral intake and significant unintentional weight loss. Review of the resident's food intake record dated from 03/01/2021 to 03/18/2021 showed, during 30 out of 58 meals, he ate less than 50 percent (%). Review of Resident 16's new admission nutrition assessment dated [DATE], showed Resident 16's self-feeding ability fluctuated. This note indicated the resident was at nutritional risk. The Registered Dietician (RD) recommended adding [MEDICATION(S)] Renal (nutritional supplement for additional calories) daily. Review of the medication administration records (MAR) dated January 2021, showed Resident 16 was not started on the supplement until 01/30/2021, 26 days after the recommendation was made. Review of a Registered Dietician's (RD) note dated 02/18/2021 at 9:16 AM, showed Resident 16 was underweight and had 7.8 % significant weight loss in one month. The same note showed Resident 16 disliked the facility food. The RD recommended to liberalize his diet (from the renal diet into general diet) and start Prosource (protein supplement) daily to help with wound healing. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 16's food intake record from 03/01/2021 to 03/18/2021, showed during 30 out of 58 meals, he ate less than 50%. Review of a RD assessment dated [DATE], showed Resident 16 had ongoing low food intake and continued to dislike the food. The RD also noted that prior recommendations for liberalizing his diet was not completed. The RD recommended again liberalizing the diet and increasing a protein supplement [MEDICATION(S)] to twice a day for poor intake. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 16's weight records, showed Date Weight 01/04/2021 136.2 lbs (pounds), 03/17/2021 125.9 lbs. The resident had a significant weight loss of 10.3 lbs, or 7.5 percent (7.5%) in less than three months. During an interview on 3/25/2021 at 3:19 PM Staff BB, RD said she was not sure if Resident 16's weight loss was unavoidable or avoidable. RESIDENT 26 Review of Resident 26's Quarterly MDS assessment dated [DATE], showed Resident 26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 26 was at nutritional risk due to development delay and needed extensive assistance with eating. Review of a hospital record dated 03/23/21 showed resident is fearful of returning to his former residence. Resident 26 indicated the hospital food was better than nursing home food. Care plan initiated in November 2020 identified Resident 26 had a nutrition risk. Resident 26 was on a regular diet. The nutrition care plan did not identify resident's food preferences. Review of Resident 26's weight record dated from 11/18/2020 to 03/16/2021, showed Date Weight 11/23/2020 216.8 lbs 12/21/2020 204.4 lbs 01/26/2021 196.4 lbs 02/23/2021 188.2 lbs 03/16/2021 179.0 lbs Review of a RD assessment dated [DATE], showed Resident 26's average intake was 60%, and he had been experiencing vomiting after meals. The resident had an unplanned severe weight loss of 15.1% in three months. The RD recommended fortified hot cereal, extra butter, and 120 ml of 2 cal MedPass (nutrition supplement) daily. Review of Medication administration records (MAR) dated February 2021 and March 2021 showed the RD recommendations were not carried out. Review of RD assessment dated [DATE], showed Resident 26 had lost an additional 5.3% weight loss in one month, an unplanned severe weight loss. The same assessment described Resident #26 met the criteria for severe malnutrition in the context of chronic disease, and it was recommended to inform the provider and add the diagnoses. The RD also recommended adding a Magic Cup (a nutritional supplement) at bedtime for weight loss and poor intake. Review of Resident 26's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . RESIDENT 12 Review of an admissions MDS assessment dated [DATE] showed, Resident 12 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 12 required extensive one-person assistance with eating. Observation on 03/17/2021 at 10:20 AM showed Resident 12 sat in a wheelchair in her room. The resident was unable to participate in an interview. Observation on 03/23/2021 at 6:50 PM, showed Resident was not assisted with meal and no cueing was provided. Resident 12's dinner tray was removed with two untouched hotdogs on the plate and one half-full glass of milk and one half-full glass of red color liquid. Review of the meal intake record dated between 03/16/2021 to 03/23/2021 showed Resident 12 ate less than 25 percent during four meals, ate 26 to 50 percent of meals during six meals, and ate 76-100 percent during four meals, and ate 76 to 100 percent during one meal. There was no meal consumption recorded on 03/18/2021 and 03/20/2021, and only one meal was recorded on 03/19/2021. Review of 2020 Weight Summary between 09/21/2020 to 03/22/2020 showed Resident 12 weight 184.6 Lbs on 09/21/2020 and 156.2 Lbs on 03/22/2020. Resident lost 28.4 Lbs or 15.3 percent (15.3 %) of body weight within six months. Review of Resident 12's weight record dated from 09/07/2020 to 03/22/2021, showed Date Weight 09/07/2020 187.3 lbs 10/15/2020 188.0 lbs 11/02/2020 181.5 lbs 12/11/2020 181.0 lbs 01/28/2021 170.2 lbs 02/22/2021 151.0 lbs 03/22/2021 156.2 lbs Review of Nutrition/Dietary Note dated 08/13/2020 showed Resident 12 had no open skin areas. The dietician recommended changing the resident's diet in the care plan to match the orders, Regular, texture, TL- finger foods (care plan says NCS) and advised to determine significant weight changes to stabilize weight. Review of the Nutrition assessment dated [DATE], showed Resident 12 had developed right heel unstageable pressure injury (extensive tissue damage due to pressure) on 09/07/2020. The dietician recommended adding large protein portions to the diet for wound healing. Review of the dietician's note dated 12/31/2020, showed the RD recommended to start house health shakes 4 oz (118 cc), BID (twice a day) - suggest at AM and HS (bed-time) snack. Document % (percent) accepted in MAR. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nutrition/dietary assessment dated [DATE], showed Weight change: -3.2% x 1 mo (non-sig), -9.2% x 3 mo (sig), -10.1% x 6 mo (sig). and that Resident 12 appears to need full assist with meal intake. The dietician recommended the facility to consider if finger foods are still needed. Further record review did not find follow-up nutritional evaluation after 01/28/2021 when a resident had unplanned significant weight loss. The nutrition care plan did not include individualized approaches including food preferences. Resident 12 lost 13.8 lbs between 01/28/2021 to 03/22/2021, or eight percent (8%) in two months. RESIDENT 6 Review of the admission MDS assessment dated [DATE], showed Resident 6 was admitted on [DATE] after a hip surgery. Resident 6 had severe cognitive impairment and needed one-person assistance with eating. The resident was a nutritional risk due to blood loss during surgery and had an increased nutritional need for wound healing. Review of a hospital record dated 09/15/2020, showed Resident 6 had inadequate energy intake and required supplemental nutrition. Review of Resident 6's weight record dated from 09/22/2020 to 10/30/2020, showed 9/22/20 158 lbs 9/23/20 157 lbs 9/24/20 157 lbs 10/16/20 146 lbs 10/30/20 147 lbs Record review of 09/21/2020 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/21/2020 Registered Dietician recommended the following 1. Magic Cup supplement at bedtime. 2. House Shake in the morning 3. Multivitamin A review of orders and administration records showed the above orders were not transcribed. Resident 6 did not receive Magic Cup during his entire stay. The house shake supplements and multivitamins were not given between 09/21/2020 through 10/16/2020 for six weeks. On 10/01/2020, according to the progress notes, Resident 6 tested positive for COVID-19. On 10/22/2020, RD progress notes showed Resident 6 average meal intake is 42%, and he had an unplanned significant weight loss of 8.2% in one month. The same progress note showed the resident's body mass index (BMI) was currently below optimal for advanced age. The RD described that order for Boost (supplement) three times a day was not currently supplied by the facility or documented in the October 2020 and November 2020 MAR. The care plan did not reflect individualized interventions for weight loss, including food preferences. RESIDENT 13 Review of admissions record dated 01/13/2021, showed resident 13 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident needed assistance with meal set up. Resident 13 had an unplanned significant weight loss of 9.6% in one month. Observation and interview on 03/17/2021 at 8:15 AM, showed Resident 13 sat in bed, with a breakfast tray on a bedside table. The resident was rolling her shirt with her fingers and not eating. At 8:36 AM Staff I, Nursing Assistant Certified (NAC), removed the resident's tray. Staff I, NAC stated resident ate 30% of breakfast. Staff I, NAC, did not inquire if the resident wanted additional food or a supplement. Review of a Dietician note dated 01/21/2021, showed Resident 13's usual body weight was 130 lbs. Review of Resident 13's weight record dated from 01/22/2021 to 02/16/2021, showed 01/13/2021 128.2 lbs 02/16/2021 115.8 lbs There was no documented supporting evidence showing the resident was evaluated for significant weight loss. The care plan did not include food preferences and why the resident was not eating. A review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations and interviews on 03/23/2021 between 7:00 PM and 7:30 PM, showed evening snacks delivered to the nurses' station. Staff Z, Charge Nurse, Licensed Practical Nurse (CN, LPN), stated there was no Magic Cup on the evening snack/supplement tray. Staff Z, CN, LPN, stated Magic Cups have not been available for at least a month. In an interview on 3/23/2021 at 7:30 PM, Staff Y, Dietary Staff (DS), stated that the previous dietary manager had stopped ordering Magic Cups a while back . approximately in November [2020] or December [2020] last year. Staff Y, DS, stated the kitchen was substituting Magic Cups with yogurt or pudding. In an interview on 03/25/2021 at 3:19 PM, Staff BB, RD stated that her expectation was for follow-up on RD recommendations within three days. The facility process was to do weekly weights. The RD also stated yogurt was not equivalent to a Magic Cup. Staff BB, RD was asked if Resident 13 weight loss was avoidable or unavoidable. Staff BB, RD said she did not know. Interview and record review was completed on 03/31/2021 between 4:00 PM and 4:30 PM with Staff D, LPN, related to nutritional management for Residents 6, 12, 13, 16 and 26. Staff D, LPN stated that there was no follow-through for these residents on Registered Dietician's recommendations. Reference: WAC 388-97-1060(3)(h)

Based on observation, interview, and record review, the facility failed to provide effective pain management for one of three residents (Resident 3). This failure resulted in mental and physical distress. Findings included . RESIDENT 3 A review of the admissions record dated 01/08/2021 showed Resident 3 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had chronic and acute pain. A review of the care plan initiated on 01/09/2021 described Resident 3 had the potential for chronic and acute pain due to arthritis, infection, and wounds. The care plan described the resident's goal was to allow participation in therapy and participate in the activity of daily living. The care plan did not identify resident-specific goals related to tolerable or acceptable pain level. Observations on 03/17/2021 at approximately 10:00 AM and 03/31/2021 at 5:30 PM, revealed Resident 3 grimacing and squirming in a fetal position in his bed. His knees were contracted up to his abdomen and a urinary catheter tubing was noted between his legs. The resident could not extend his legs and could not separate both knees. Observation and interview on 03/31/2021 at 5:30 PM revealed red shiny skin between Resident 3's legs from rubbing. Resident 3 said the staff was unable to clean between his legs and clean his catheter because it was very painful to separate the legs. Resident 3 said he was not medicated before being cleaned and tried to clean himself. Additionally, Resident 3 said he has not worked with therapy to manage contractures due to severe pain. Resident 3 said therapy staff gave him a wedge to keep the legs separated to prevent further contractures but he could not use it because it was painful. In an interview on 4/01/2021 at 2:08 PM, Staff HH, Director of Therapy (DOT), stated that therapy could not work with Resident 3 to manage contractures because it caused him so much pain. Therapy notes dated 01/25/2021 showed Resident 3 had limited progress in therapy due to severe lower extremity spasms resulting in significant pain. On 03/31/2021 at 5:30 PM Resident 3 stated he could tolerable a pain level of four, on a zero to ten pain scale (four to six is moderate pain). Resident 3 said he was in constant pain, could not sleep, felt frustrated, and sometimes cursed and yelled out in pain. Resident 3 said when he complaints about his pain to staff there is no response. Resident 3 said he felt mistreated because his pain was ignored. Resident 3 said he had an appointment with the pain clinic in February 2021 but the facility canceled it because they could not arrange for proper transportation requiring a stretcher. A review of the pain assessment dated [DATE] showed Resident 3's pain was 9/10 related to leg spasms, [CONDITION(S)], nerve pain, and pressure ulcer. Resident pain at nine out of ten (almost constant excruciating unbearable pain). The same assessment showed Resident 3's pain management goal included sleeping without interruption, participate in therapy Another pain assessment dated [DATE] showed Resident 3 experienced excruciating and unbearable pain, rated at nine out of ten. The resident was bracing, had facial grimaces had resistance to movement, and had increased agitation, anxiety, anger, and aggression. This assessment concluded, No change needed continue the plan. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Records (MAR) for three months January 2021, February 2021, and March 2021 showed Resident 3's pain was inadequately managed. Resident 3 experienced pain severity between seven to 10 (moderate to severe pain occasions) on 107 occasions. A review of nursing progress notes showed Resident 3 experienced physical and mental distress related to untreated pain: -On 01/28/2021 at 12:16 AM, Resident 3 cursed loudly due to contracture pain. The same note stated resident had a pain management appointment scheduled on 02/01/2021. -On 02/01/2021, Resident 3 complained of increased spasm and pain. The note stated the charge nurse would consult with the physician on 02/02/2021. A review of nursing notes on 02/02/2021 did not find a physician consultation. -On 02/03/2021 at 7:49 PM, Resident 3 was very upset because the pain management appointment was canceled. There was no documentation showing efforts were made to reschedule the pain clinic appointment. A review of a psychiatric mental health provider's note dated 02/16/2021 at 3:41 PM showed Resident 3 had ongoing agitation, irritability, and the resident reported he hated being at the facility. The resident could not sleep and stated he was barely sleeping every other day and life is miserable. Review of a psychiatric mental health provider's note dated 3/18/2021 showed Resident 3 was verbally abusive and stated, I want to sleep . leave me alone. The resident continued feeling irritable and was minimally engaged. In an interview on 3/31/2021 at 5:38 PM, Staff GG, Registered Nurse (RN), stated Resident 3 was under-medicated because of his prior history of substance abuse. Staff GG, RN said the physician was not proving new orders for pain. Reference (WAC) 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure care and services were provided for two of six residents (Resident #s 43 and 47) when reviewed for range of motion/mobility. Failure to evaluate, monitor, and treat identified decreased range of motion in Resident #43's left hand resulted in harm and the development of a contracture (a permanent shortening of muscle and loss of joint mobility). Findings included . Review of Resident #43's quarterly Minimum Data Set (MDS, a required assessment tool) dated 10/24/19, showed that the resident admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS showed that Resident #43 had memory impairment and impairment to upper and lower extremities (shoulder, elbow, wrist, hand and hip, knee, ankle, foot) on one side of the body and did not receive therapy or restorative services. Observation on 12/11/19 at 12:09 PM showed Resident #43's left fingers curled in a fist position. Observation on 12/12/19 at 12:31 PM, showed Resident #43 laid in bed with her left hand positioned with fingers curled in a fist position. When asked if she could straighten her left hand, Resident #43 lifted her left arm slightly and attempted to straighten her fingers and was unable to straighten the last three digits of her left hand. Review of the admission nursing assessment dated [DATE] showed that Resident #43's left arm range of motion and grasp/strength was within normal limits in all joints with general weakness. Review of the care plan dated 04/24/19 showed that Resident #43 had deficits in activities of daily living with a goal to improve function through therapies or restorative to highest rehabilitation potential. The care plan did not show that Resident #43 had a left hand contracture or a specific intervention put into place to prevent a left hand contracture. Review of the Occupational Therapy note dated 04/26/19 showed that Resident #43 had decreased functional grasp of the left hand secondary to [MEDICAL CONDITION] (swelling) and reduced passive range of motion (PROM, joints moved through the range of motion with no effort from the resident). Review of the neurological assessment (to evaluate for any abnormalities in the nervous system that can cause problems with daily functioning) dated 05/19/19 showed that Resident #43's left grip and strength (rating 0 to 5, with 0 = none and 5 = full strength) had an evaluation of 4. Review of the progress note dated 05/21/19 showed that Resident #43 had completed therapy services with restorative recommendation for omnicycle (exercise equipment) and group exercise. It further showed that Resident #43 was cognitively unable to follow programs and showed no sign of interest. Review of the care plan dated 04/24/19 showed that Resident #43 had a deficit in mobility with an intervention dated 05/21/19 to participate in active range of motion (AROM) group exercises for all joint planes. Review of the neurological assessment dated [DATE] showed that Resident #43's left grip and strength had an evaluation of 2, and that the medical doctor and the Director of Nursing Services (DNS) was not notified. It further showed that Resident #43 had no changes from baseline; however, previous neurological assessment dated [DATE] showed Resident #43's left grip and strength was evaluated at 4. This assessment showed a decrease in Resident #43's left hand function. During an interview and observation on 12/18/19 at 1:17 PM, Staff F, Licensed Practical Nurse (LPN), approached Resident #43 and attempted to assist the resident to straighten the fingers of her left hand; however, she was unable to straighten the last three digits. Staff F, LPN, stated that when Resident #43 first came to the facility she use to be able to move the fingers of her left hand better than now and was unaware that the resident could not straighten her last three fingers. During an interview on 12/18/19 at 2:29 PM, after reviewing Resident #43's therapy notes, Staff E, Director of Rehabilitation (DOR), stated that once occupational therapy identified Resident #43 had a decrease in functional grasp and reduced PROM of the left hand, there should have been measurements of the left hand obtained. Staff E, DOR, further stated that there should have been follow up to assess whether Resident #43's PROM had increased or decreased. In addition, Staff E, DOR, stated that Resident #43's therapy notes had no documentation that the resident had been seen by therapy to treat a hand contracture nor documented left hand measurements. During an interview on 12/19/19 at 10:12 AM, after reviewing Resident #43's Neurological assessment dated [DATE], Staff G, LPN/Charge Nurse (LPN/CN), stated that the assessment should have had documentation that there was a change from baseline and the medical doctor and the DNS should have been notified. During an interview on 12/19/19 at 12:55 PM, when asked what should happen once a resident was identified with decrease in ROM in a body part such as a hand, Staff B, DNS, stated that she expected that the resident be assessed, the decline documented, an order obtained for therapy to evaluate and treat to ensure interventions were put into placed to decrease and prevent further decline. Staff B, DNS, further stated that therapy should assess the resident and if decrease in ROM or suspected contracture, then measurements should be obtained, documented and care plan revised. In continued interview on 12/19/19 at 12:55 PM, Staff B, DNS, stated that Resident #43's neurological assessment dated [DATE] was inaccurate because there was a change in ROM to the left hand from baseline. In addition, Staff B, DNS, stated that she was not aware of Resident #43's decline in ROM. RESIDENT #47 Review of Resident #47's quarterly MDS dated [DATE] showed that the resident admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #47 was alert, oriented and able to make needs known. The MDS further indicated that the resident had no functional limitation in ROM. During an observation and interview on 12/13/19 at 8:24 AM, Resident #47 was able to demonstrate how she grabbed the bed rails. Resident #47 stated that she had to ask for two staff to help her turn in bed because it was hurting her shoulders every time she grabbed the rails. Review of the document titled, Therapy to restorative nursing communication, dated 09/27/19 showed that Resident #47 was discharged from therapy and the program recommendations were for the resident to do right shoulder AROM using a cane with the exercise repeated 10 times and right shoulder stretching at 30 seconds hold, repeated three times. According to the recommendation, the risk of not participating in the exercises could lead to a decrease in ROM and increased pain. During an interview on 12/18/19 at 9:04 AM, Staff M, Restorative Aide, stated that Resident #47 attended the group exercises; however, it was hard to get the resident to participate in the exercises. Individual one-on-one therapy had been provided to the resident before but the resident refused to participate and blamed the aides for not getting her up. Review of the restorative program provided to Resident #47 from 11/19/19 to 12/18/19, showed that the resident attended two sessions of group exercises out of the 30 days. There was no documentation of Resident #47's refusal to participate or the reasons why the resident was not able to participate in the exercises. During an interview on 12/18/19 at 9:10 AM, Staff N, LPN/Restorative Nurse, stated that he provided oversight to the restorative nursing program and conducted the resident's quarterly restorative assessment. Review of Resident #47's last quarterly restorative assessment showed it was conducted seven months ago on 05/08/19. During an interview on 12/18/19 at 10:35 AM, Staff B, DNS, stated that the expectation was for the restorative staff to document any refusal or reason as to why the resident did not attend the program and for the quarterly restorative assessment to be conducted timely by the restorative nurse. During an interview on 12/18/19 at 11:29 AM, Staff E, DOR, stated that when a resident discharged from therapy, the expectation was for restorative nursing to help assist the resident with the recommended exercises. Reference: WAC 388-97-1060 (3)(d)

Based on observation, interview and record review the facility failed to ensure residents were free from accidents and hazards: 1. Failure to ensure 20 out 66 rooms (#'s 101, 102, 106, 108, 110, 112, 117, 120, 204, 211, 213, 222, 301, 302, 305, 307, 309, 313, 314, & 315) had items placed away from baseboard heaters per manufactures guidelines, placed residents in immediate jeopardy related to potential fire hazard and/or resident injury for burns. 2. The facility failed to ensure one of four residents (Resident # 137) reviewed for falls, had all potential contributing factors and risks related to falls identified including sufficient supervision, appropriate interventions, and revision of care plans were completed after each fall. This failure placed the resident at risk for subsequent falls with potential for serious injury. 3. The facility failed to secure three out of three oxygen rooms (halls 100, 200, & 300) reviewed for accident hazards. Failure to ensure oxygen rooms were secured placed residents at potential risk for injuries when coming in contact with oxygen tanks. Findings included . HEATERS Resident rooms were heat regulated with the use of a self-adjusted thermostat, on the wall, inside each room. 100 Hall An observation on 10/23/17 at 10:33 AM, room 117 had a baseboard heater under the window, near a bed. A nightstand was approximately four inches from the front of the heater. The heater was hot to the touch. The resident in the bed by the window was sitting on the edge of her bed next to the nightstand. An observation on 10/23/17 at 11:40 AM, showed rooms 101, 110, 112, and 120 had chairs less than six inches from the heater. An observation on 10/23/17 at 11:41 AM, room 102 had a bedside table up against the heater, room 106 had a folding chair a few inches in front of the heater, and room 108 had a small book-shelf less than six inches away from the heater. An observation on 10/23/17 at 11:45 AM, room 112 had storage shelves placed a few inches away from the heater. During an interview on 10/23/17 at 11:25 AM, Staff S, Housekeeping, stated that depending on how hot the residents liked their room, the heaters were hot to touch at times. When asked how close items could be to the heaters, Staff S, Housekeeping, replied, I'm not exactly sure how close stuff should be. In an interview on 10/23/17 at 11:46 AM, Staff C, Registered Nurse (RN), stated that the heaters did get hot. Staff C, RN, stated that she was not sure of the distance items needed to be away from the heaters. During an interview on 10/23/17 at 11:55 AM, Staff D, Nursing Assistant Certified (NAC), stated that the heaters did get hot, and thought items should not be closer than 10 to 12 inches from the heater. During an interview on 10/23/17 at 12:02 PM, Staff T, Housekeeping, stated that the heat could be turned to whatever temperature that residents wanted between comfort zone or hotter. When asked how close could items be to the heaters, Staff T, Housekeeping, stated that at least eight inches, and also stated I always try to pull stuff away from the heaters, if things are too close. During an interview on 10/23/17 at 12:11 PM, Staff A, Administrator, stated that items should be about a foot away from the heaters and nothing should touch them. Staff A, Administrator, stated that the facility did not have a written policy for the heaters and did not have a copy of the manufacturers guidelines at that time. Staff A, Administrator stated that staff were aware items needed to be 12 inches away from the heaters and that he and maintenance performed environmental checks almost daily. During an interview and observation on 10/24/17 at 2:59 PM, Staff A, Administrator, went to room 112 and observed shelving close to the heater. Staff A, Administrator immediately moved the shelving over to ensure it was six inches away from the side of the heater. Staff A, Administrator, stated that the manufacturer guidelines were for items to be spaced a foot away from the front, a foot above, and six inches to the side of the baseboard heaters. An observation on 10/24/17 at 4:00 PM, room 120 had a bed side table with a plastic bag attached to the side touching the top of the heater. An observation on 10/24/17 at 4:01 PM, room 119 had a wheelchair and bed side table pushed up against the heater. In an interview on 10/24/17 at 4:06 PM, Staff Z, RN/Charge Nurse (CN) 100 hall, stated that she was in-serviced, signed off, and understood the baseboard heater policy. Staff Z, RN/CN, stated that items should not be closer than 12 inches from the front and 6 inches from the side. When informed of items that touched heaters in rooms 119 and 120, Staff Z, RN/CN, stated that the residents were just assisted into bed. Staff Z, RN/CN, than told the aides to keep items away from the heaters. An observation on 10/24/17 at 4:09 PM, showed the items that had touched the heaters in rooms 119 and 120, were removed by an aide. 200 Hall An observation on 10/23/17 at 10:39 AM, room 204 had a chair touching the baseboard heater. An observation on 10/23/17 at 10:41 AM, room 213, a front-wheeled walker touched the baseboard heater. An observation on 10/23/17 at 10:42 AM, room 211 had a walker within a few inches of touching the baseboard heater. An observation on 10/23/17 at 10:44 AM, room 222, a wood frame chair touched the baseboard heater. An observation on 10/23/17 at 12:46 PM, room 207, the baseboard heater measured a temperature of 137 degrees Fahrenheit and the exposed coil measured above 300 degrees Fahrenheit. During an interview on 10/23/17 at 11:48 AM, Staff Y, Licensed Practical Nurse (LPN)/CN, stated that the heater in each room was controlled individually by a thermostat and staff would adjust it per resident request. In an interview and observation on 10/23/17 at 11:55 AM, Staff X, LPN, stated, In theory, the staff turn it (the thermostats) on, but residents can turn it on too, because it is in their rooms. Staff X, LPN, walked to a nob on the wall, and turned it easily. 300 Hall An observation on 10/23/17 at 10:35 AM, room 301 had a cardboard box touching the right side of the baseboard heater. An unidentified aide was in the room talking with the resident. An observation on 10/23/17 at 10:36 AM, in room 302, a wood table touched, a television electrical cord, and cable cords dangled approximately an inch away from the baseboard heater. The heater was cool to the touch at the time. Resident #35, lying in bed, stated that the room sometimes got too warm. An observation on10/23/17 at 10:40 AM, room 315 had a television stand and table pushed up against the base board heater. The resident sat in her wheelchair in close proximity to the television. An observation on 10/23/17 at 10:52 AM, in room 314, a wood chair touched the baseboard heater. The heater was near the bed by the window. An observation on 10/23/17 at 10:55 AM, in room 301, a cardboard box observed earlier, was still touching the right side of the heater. In addition, a clear plastic storage box with various items was placed approximately two inches from the front of the heater. Heat emanated from the front of the heater and was warm to the touch. An observation on 10/23/17 at 11:08 AM, room 306 had a table with metal legs located within approximately two inches from the baseboard heater. The heater was hot to the touch, and the room was warm. The thermostat was located inside the room, next to the door frame and the privacy curtain, on the wall. The device had a dial, with small, faded numbers printed on it to show whether the heater was on. An observation on 10/23/17 at 11:08 AM, in room 307, the back of a night stand, and two legs of the front wheeled walker, was approximately one inch in front of the baseboard heater. An observation on 10/23/17 at 11:10 AM, in room 309, the back of the wood framed bookshelf touched the heater. An observation on 10/23/17 at 11:29 AM, the temperature of the top of the heater in room 306, measured 132.5 degrees Fahrenheit. In an interview on 10/23/17 at 11:46 AM, Staff C, RN, stated that the heaters did get hot. She also stated that she was not sure of the distance items needed to be away from the heaters. During an interview on 10/23/17 at 11:48 AM, Staff E, LPN, stated that each resident on the 300 hall had a heater in their room. Staff turned the heaters on for the residents who were not able to do if for themselves. When asked if the heaters got hot to the touch, Staff E, LPN, stated that she was not aware and had worked in the facility for seven years. Staff E, LPN, stated that the policy and procedure for the heaters were to keep things away from them however, was uncertain of the distance. When asked about the cardboard box that was touching the side of the heater, Staff E, LPN, stated, That is ok as long as it is not blocking the register. All items are supposed to be away from it. In an interview on 10/23/17 at 11:53 AM, Staff E, LPN, stated that she moved the cardboard box in room 301 for safety. She let the staff in the room know to keep the box away from the register. In observation, the plastic storage box was still placed in front of heater/register, approximately 3 inches. In an interview on 10/23/17 11:55 AM, Staff F, NAC, stated that if the resident was not mobile, then staff turned the thermostats on for them. Staff F, NAC, was not aware if the heaters got hot to the touch, but was instructed to keep things away from them. Staff F, NAC, did not know the distance items were to be kept away from the heaters. During an interview on 10/23/17 at 12:01 PM, Staff H, LPN, stated that staff monitored to ensure items were not touching the heaters by walking up and down the halls and glanced in their rooms. There was no routine checks, just to monitor as staff passed the rooms. Staff H, LPN, stated that the resident in room 315 was able to manage the thermostat by herself, and was not aware of any other resident who was capable. Most of them are in chairs. During an interview on 10/23/17 at 12:04 PM, Resident #79 stated that she was able to operate the thermostat when the room got cold. In an interview on 10/23/17 at 12:11 PM, Staff A, Administrator, stated that they did not have a written policy regarding the distance items should be away from the baseboard heaters and was unable to locate the manufacturer's recommendations. In further interview, Staff A, Administrator stated that he did not know the last time the heaters were serviced to ensure they were in safe operational order. On 10/23/17 at 5:07 PM, the facility provided documents titled, Product Information, with a print date of 10/23/17, Maintaining Your Heater, dated December 2015, Operating Instructions, dated December 2015, and copy of the product information guide obtained from the internet, on a 2017 standard electric baseboard heater, similar to a type found in the facility. None of the documents provided, included recommended safety guidelines. Review of the document titled, Audit Sheet Resident Room, showed a column that addressed items too close to the heater. The audit included one room chosen in the facility, completed approximately on a weekly basis. No items were identified too close to the heater between 07/02/17 and 10/19/17. The audit did not describe or include what too close meant. On 10/24/17 at 8:30 AM, the facility provided a list of 21 residents who were cognitively impaired, able to independently self-propel or maneuver a wheelchair, and/or walk with/without an assistive device. Of those 21 residents, 11 residents were identified by the facility as exhibiting wandering, rummaging or exit seeking behaviors. Two residents were identified as wandering in a dangerous place. One resident sustained [REDACTED]. All 20 residents in the rooms identified with items within a few inches or directly touching the heaters, were identified with either cognitive impairments or required assistance of staff for mobility, or both. During an interview on 10/24/17 at 4:50 PM, Staff A, Administrator, stated that when the heaters were inspected, a visual inspection was completed; to see if there were any obvious broken pieces, debris on or inside the unit. The inspection did not include the manufacturer's recommendations that Staff A, Administrator, could recall, or when it was last maintained per the guidelines. On 10/25/17 at 3:05 PM, Staff A, Administrator, provided a copy of the manufacturer's guidelines for both types of baseboard heaters similar to those found in the facility. The guidelines included to keep all items 12 inches away from the front and top of the heaters, and six inches from either side. It was recommended that the heaters be inspected every two years. FALLS Refer to F225 for additional information. RESIDENT #137 Review of the Admission Minimum Data Set (MDS, a required assessment tool) dated -04/11/17 showed Resident #137 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident exhibited short and long term memory loss, decreased attention, fluctuating periods of lethargy (tiredness), and wandering behaviors. Resident #137 required assistance from staff for cues and supervision to stay on task and safety due to decreased attention and impulsivity. Resident #137 triggered for a fall risk care area assessment. The facility identified risk factors to include a history of falls with fractures prior to admission. Resident #137 was incontinent, unsteady gait/balance, hearing and visual impairments. An observation on 10/24/17 at 12:15 PM, in the Rose Dining Room, Resident #137 repeatedly fell asleep in her wheelchair at the table during lunch, with few cues from staff to stay awake. Resident #137 was removed from the dining room with less than 25% of her meal eaten. An observation on 10/27/17 at 10:28 AM, Resident #137 was in the Solarium alone, asleep in her wheelchair, with her glasses on. When attempted to wake her by using her name and touching her arm, the resident did not respond and did not reposition or move. An observation on 10/27/17 at 10:37 AM, Resident #137 remained asleep in the same position in the Solarium. The resident's glasses had fallen off her face and were in her lap. Resident #115 was the only other person in the room, who also had cognitive impairments and was dependent on staff for mobility. An observation on 10/27/17 at 10:56 AM, Resident #137 slept in her wheelchair in the Rose hallway near the nurses' station, in front of the double fire doors. Staff was not in line of sight. An observation on 10/30/17 at 9:52 AM, Resident #137 self-propelled her wheelchair down the 100 hall, past the small chapel. An observation on 10/31/17 at 8:34 AM, Resident #137 self-propelled her wheelchair with her feet, untied shoe, and held on to the railing, down past the nurses' station toward the central supply room. At 8:35 AM, an unidentified nursing assistant saw the resident, stopped and tied her shoe, and brought her to the television room across from the Rose nurses' station. Resident #137 asked the aide if she was going to put her to bed. The aide said she could not because she was in the dining room, and walked away. Resident #137 sat outside the television room door. At 8:38 AM, Resident #137 propelled herself past the nurses' station and down the 100 hall. An observation on 11/01/17 at 9:28 AM, Resident #137 had a worried look on her face and appeared agitated, as evidenced by repeatedly calling out, Wait a minute, while she pulled herself in the wheelchair down the hallway, holding onto the handrail. She appeared to be looking for someone, but was not following anyone. Review of the care plan dated 08/31/17, showed Resident #137 was at risk for falls. The goal was to minimize injury through next review date. Interventions included: keeping walker out of reach, anticipate needs, encourage to stay in highly supervised areas, ensure appropriate footwear, use call light to alert staff to needs, frequent checks, green tape to wheelchair and leaf to outside the bedroom door to alert staff to high fall risk protocol, night light to bathroom to improve visibility when the resident attempted unassisted ambulation, offer activities to distract and redirect from unsafe mobility attempts, offer to lay down after lunch, toileting program with specific times included in the schedule, and remind resident to ask and wait for assistance. Review of the facility's forms titled, Reporting Log Forms dated June 2017 through October 2017, showed Resident #137 sustained 12 falls between 06/25/17 and 10/17/17. Resident #137 had already sustained six falls prior to 06/25/17. Of the 12 falls, five occurred in her room at bedside, three occurred in her bathroom next to the toilet, two took place in the television (TV) room across from the nurses' station, one was in the hall outside her room, and one was sustained in a utility room in the facility. Four falls resulted in injuries. All 12 falls were unwitnessed. Falls in the Bathroom Record review of incident reports of falls that occurred in the bathroom, dated 07/01/17 at 1:00 AM, 07/12/17 at 1:00 AM, 10/7/17 at 11:30 PM, showed the falls were unwitnessed. All falls were determined to be related to Resident #137's condition, as the [DIAGNOSES REDACTED]. Review of the incident investigations of the falls that occurred in the bathroom, the facility documented they reviewed all prescribed medications and diagnoses, and determined they did not impact her need to use the bathroom. The facility did not review or analyze the resident's need to urinate frequently, or verify the care plan was followed. Resident #137's care plan was updated to include to ensure resident wore non-skid socks, and placed a night light in the bathroom. The facility failed to reassess risk factors and potential need for increased assistance, to include supervision, which resulted in subsequent unwitnessed falls. Falls at Bedside Review of the incident reports of the falls that occurred at bedside, in Resident #137 room on 06/25/17 at 11:20 AM, 07/27/17 at 9:15 AM, 08/15/17 at 3:00 PM, 09/10/17 at 8:30 PM, and 10/17/17 at 4:10 PM, showed all falls were unwitnessed, and the resident was either getting out of bed or getting self into bed. All falls were determined to be reasonably related to the resident's condition. No new interventions were initiated after each fall. Falls in High Traffic Areas Record review of the incident reports for the falls that were sustained on 07/10/17 at 8:45 AM, 09/08/17 at 9:45 AM, and 09/18/17 at 9:55 AM, showed all falls were unwitnessed in areas identified as supervised areas, to include the Rose Wing Television room, and the hall outside Resident #137's room. Each investigation identified a period of time after breakfast where the resident had not been observed for an unidentified period of time. The falls occurred in a location determined as a supervised area. However, the resident sustained [REDACTED]. The facility failed to comprehensively assess all risk factors that may have contributed to the falls, to include daily routine or level of supervision, and no new interventions were initiated. A therapy evaluation was requested after the 09/18/17 fall. Fall in Utility Room Record review of incident report of an unwitnessed fall sustained on 09/24/17 at 2:15 PM, showed Resident #137 was found in the utility room on the floor, next to her wheelchair. The fall was determined to be related to her condition of dementia, with poor safety awareness, and impulsivity. The facility was not aware why or how Resident #137 got into the utility room. The facility failed to comprehensively assess all risk factors that may have contributed to the falls, to include daily routine or level of supervision, and no new interventions were initiated. Staff K, LPN, stated there were no new interventions put in place after each fall for Resident #137. When asked what the physician's input was on the repeated falls for Resident #137, Staff K, LPN stated the physician would just ask to obtain lab work. A lot of times the physicians looked to us for interventions. In an interview on 11/01/17 at 3:06 PM Staff K, LPN, continued to state, Resident #137 was supposed to be in a highly supervised area, and her room would not be that place. She was not supposed to be in her room unless she was in bed or cares were being performed. In an interview on 11/02/17 at 10:34 AM, Staff B, RN, Director of Nursing Services (DNS), stated she was familiar with Resident #137. She was very busy and squirrely, and not very safe. OXYGEN 100 HALL An observation on 10/24/17 at 8:43 AM, showed the door to the Rose wing oxygen room by the nurses' station was not secured/locked. This surveyor found the door easy to open. The room stored six tanks placed in vertical wooden compartments attached to the wall, four tanks placed in free standing portable oxygen cylinder carts, not secured to the wall, and one small oxygen tank that hung from a hook attached to the wall placed in a cloth holder. Chains were attached and dangling from the wall, but not in use. During an interview on 10/25/17 at 9:20 AM, Staff M, LPN, stated that the oxygen rooms were not locked and that she did not think that they needed to be locked. When asked how staff monitored residents to ensure they will not enter the oxygen rooms, Staff M, LPN, stated that staff can see the residents from the nurses' desk and in the hallways and would redirect residents as needed. During an interview on 10/25/17 at 9:38 AM, staff K, LPN, stated that the oxygen rooms were not locked. Staff K, LPN, stated that the doors to the oxygen rooms were heavy and not easy for a resident to open, and located by a nurses' station, a high visible area. 200 HALL An observation on 10/23/17 at 10:37 AM, showed the oxygen storage room had no locking mechanism. The oxygen tanks were placed in vertical wooden compartments attached to the wall and in free standing portable oxygen cylinder carts in various sizes that were not secured to the wall. Some tanks had the oxygen valve installed that showed the tanks were full and ready for use. During an interview on 10/25/17 at 9:20 AM, Staff W, NAC, stated that the nurses are responsible for oxygen the aides do not touch oxygen. In an interview on 10/25/17 at 9:25 AM, Staff M, LPN, stated that the oxygen storage rooms did not need to be locked. When asked if there were residents who wander on this hall, Staff M, LPN, stated yes. Review of the facility policy Oxygen Therapy Protocols dated October 2017, did not indicate if the oxygen rooms were required to be locked or precautions needed to prevent residents from entering the oxygen room. In interview on 10/25/17 at 9:38 AM, Staff B, Director of Nursing Services (DNS), stated that oxygen was considered a medication and that medications should be locked for the safety of residents. 300 HALL An observation on 10/25/17 at 9:11 AM, the oxygen room door, located across from the nurses' station, had a locking device in the doorknob, but was not locked. The oxygen room contained four oxygen tanks in wooden compartments attached to the wall, one tank in a portable cylinder cart sitting in the middle of the room, and two large tanks were in portable frames toward the back of the room. Several tanks had the regulators attached, ready for use. Chains were attached and dangling from the wall, but not in use. In an interview on 10/25/17 at 9:13 AM, Staff G, NAC, stated there were three oxygen rooms in the facility, all located by a nurses' station. Nursing assistants were not allowed to enter the oxygen rooms, and only nurses deal with oxygen. Staff G, NAC stated that she was unsure if the oxygen room should be locked or unlocked. When asked how staff monitored the halls to ensure residents did not enter the oxygen room, Staff G, NAC, stated that there was usually the presence of staff in the halls to assist the residents to get where they were supposed to go. In an interview on 10/25/17 at 9:21 AM, Staff H, LPN, stated that the oxygen company delivered the tanks approximately once a week. The licensed nurses were in charge and the only ones able to enter the oxygen rooms. When asked for the oxygen storage policy, Staff H, LPN, stated she did not believe the room was required to be locked. Staff H, LPN, identified Resident #112 as a wandering resident on the hall. When asked how the facility ensured residents did not enter the oxygen rooms, Staff H, LPN, stated that the aides and licensed nurses, assigned to the hall, helped monitor and redirect residents to where they were supposed to be. WAC 388-97-1060 (3) (g)

Based on observation, interview, and record review, the facility failed to provide care and services in an environment that humanized and individualized each resident, when staff did not respond to call lights in a time consistent with each resident's needs, for four of 20 sampled residents (#1, #2, #11, #14, #16). This failure resulted in a decreased quality of life for the residents. Findings include: Review of Resident #1's 5/13/16 revised care plan revealed, the resident required two people to assist with transfers, using a mechanical device (sit to stand lift). In interview on 5/23/16 at approximately 3:54 p.m., Resident #1 said four residents needed to use the sit to stand lift for transferring to the bathroom. According to Resident #1, there were times when the resident waited 30 minutes for staff to respond to the call light. Resident #1 said when other residents needed the lift, Resident #1 had to wait longer for assistance to the bathroom. When asked what she did if she needed to wait for assistance, Resident #1 said I wet my Depends. Resident #1 said staff have told her it was ok to go in her pants, however, Resident #1 said she did not like doing that. Review of Resident #2's 10/2/15 revised care plan revealed, staff were required to anticipate the resident's needs, and encourage to use the call light. In addition, the resident required extensive assistance with transferring from bed to the wheelchair. Observations on 5/23/16 at approximately 4:30 p.m., revealed the resident's wheelchair was placed across the room, and he motioned to the Department staff to help with transferring to the wheelchair. The Department staff used the call light to call for help. After twenty minutes, when there was no response, the Department staff summoned the caregiver to assist Resident #2. When asked how it made him feel to wait for someone to help, Resident #2 said it did not feel good to wait. In interview at 4:50 p.m., Staff F and Staff L said they did not have enough staff, as there were expected to be three caregivers, and instead there were two. In a random interview at 4:55 p.m., Resident #14 said sometimes she waited for a long time for assistance. Resident #14 said a caregiver told her to just go ahead and pee in your pants. When asked how it made her feel, Resident #14 said she felt totally dependent on other people. In a random interview at approximately 5:00 p.m., Resident #16 said the call light did not always work, so she waited a long time for assistance. Resident #16 said once a day or once every other day, the call light did not work and she waited a long time, longer than 15 minutes, according to Resident #16. Review of Resident #11's 8/5/2015 toileting care plan revealed, the resident required assistance with toileting. Staff were expected to anticipate the resident's needs, and encourage the resident to use the call light. According to the care plan, Resident #11 needed toileting upon rising, prior to and after meals, and at bedtime. Observations on 5/24/16 at approximately 5:55 a.m., revealed Resident #11 sitiing in a wheel chair, her call light had already been on, and the resident had been waiting for help. In interview, Resident #11 said her call light had been on since 5:40 a.m. When asked what happened if she did not get help sooner, the resident said I just wet my pants. When asked how it made her feel, Resident #11 said there was nothing dignified about it. Resident #11 said usually a half hour was the wait limit. At 6:11 a.m., Staff N responded to Resident #11's call light. When the Department staff indicated there were no caregivers around, Staff N said she was in another hall. According to Staff N, there were supposed to be four caregivers, however, there were only three during the night shift.

Based on observations, record review, and interview, the facility failed to provide adequate supervision to ensure correct positioning of a wheel chair for 1 of 4 residents (Resident #1) reviewed for falls. This failure resulted in harm to Resident #1 when she fell from a wheel chair which was left in an upright position and without footrests. The resident sustained [REDACTED]. Findings include: On 9/7/11, Resident #1 was observed in a wheel chair tilted at 30 degrees. Observations revealed swelling and dark purple bruising on the right side of the resident's forehead. The bruising extended above and below the resident's right eye to her cheekbone. Small scabs were noted on the tip of the resident's nose and right nostril in addition to small dark purple bruises above the resident's lip. The resident was not able to provide information about her fall. Record review revealed Resident #1 admitted during 6/2011 with medical [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] revealed the resident was totally dependent on staff for transfer, bed mobility, and positioning. Review of a facility investigation dated 9/1/11 revealed Resident #1 was found lying on her right side on the floor next to her wheel chair. Facility assessment noted a hematoma above the resident's right eye on her forehead, a bruised nose, and two 0.5 centimeter (cm) lacerations under her right nostril. On 9/2/11, a bruise was noted on the resident's right knee; facility assessment determined it was reasonably related to the fall on 9/1/11. Review of the facility's analysis of the incident revealed documentation the resident had poor sitting balance secondary to her stroke. The fall was due to poor sitting balance and the wheel chair being left in an upright position and without footrests. Resident #1 was not able to maintain her balance when sitting in an upright position. On 9/8/11 at 11:10 a.m., the investigator and Staff A (care manager) observed Resident #1's wheel chair. Observations revealed a plastic tag on the back of the wheel chair that indicated the degree of tilt was 30 degrees. Staff A stated facility practice required a tag on tilt wheel chairs as a visual reminder for staff. Staff A stated the tag was in place at the time of the resident's fall because she personally checked it after the incident.