Every finding on record at Judson Park Health Center

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer and/or discharge, or as soon as practicable for 3 (Residents 5, 10 & 82), offer a bed hold for 2 (Resident 10 & 82), notify the office of the Long Term Care Ombudsman (LTCO) for 1 (Resident 12), and provide discharge planning for 2 (Residents 1 & 43) of 7 residents reviewed for hospitalizations and discharges. These failures placed residents at risk of being uninformed about their discharge rights, the cost of holding the resident's bed while hospitalized , and a decreased quality of life.Findings included .<Facility Policy>The facility's October 2016, Supplement to Health Facility admission Agreement showed residents who were being discharged to a hospital or other care facility, the facility staff would ensure the resident received written notice of the reason of the transfer, an effective date of transfer, resident rights, and the name and address of the state ombudsman. The admissions agreement showed the facility would provide and document sufficient preparation and orientation made to the resident and provide it in a format the resident could understand to ensure a safe and orderly transfer. The admission agreement showed a written notice of a bed hold would be provided to the resident or their representative before they were transferred to a hospital, that specified the duration of the bed hold policy, payment and policies and permission to return to the facility. <Written Transfer Notification> <Resident 5> According to the 04/29/2025 Discharge – Return Anticipated MDS, Resident 5 discharged to the hospital on that date. Review of Resident 5's records showed a written notification of Nursing Home Transfer or Discharge Notice was given on 04/29/2025. The transfer notice was not signed by the nursing home administrator or designee and there was no signature obtained by the resident or representative to show the form was provided. During an interview on 08/28/2025 at 8:35 AM, Staff F (Charge Nurse) stated it was the responsibility of the nurse to complete the necessary paperwork for transfers to the hospital as it was important to notify the receiving facility and family of the resident’s transfer. Staff F stated they were not able to find a signed nursing home transfer form for Resident 5's discharge on [DATE]. Staff F stated nurses needed to make sure the resident or family were notified and signed the transfer forms. <Resident 10> According to the 07/14/2025 Discharge – Return Anticipated MDS, Resident 10 discharged to the hospital on that date. According to the 07/28/2025 Discharge – Return Anticipated MDS, Resident 10 discharged to the hospital on that date. Review of Resident 10's records showed a transfer/discharge notice note was filled out by the facility on 07/14/2025 and on 07/28/2025. Review of the signature line located on the transfer form showed the facility’s social worker signed the forms, Resident 10 or their representative did not sign the forms to acknowledge they received the notice. In an interview on 08/28/2025 at 8:39 AM Staff F stated the facility did not have to fill out a transfer form and obtain signatures if the resident was discharged to the hospital from the outpatient center. In an interview on 8/28/2025 at 9:08 AM Staff D (Nurse Supervisor) stated nurses completed the transfer paperwork and notify the provider regardless if the resident was sent directly from the facility or another location. Staff D stated if a resident was unable to sign the Nursing Home transfer form, then two nurses should sign to verify that the resident or representative was or was not notified. Staff D stated this was important to make sure everything was provided as required. In an interview on 08/28/2025 at 12:55 PM Staff B (Director of Nursing) stated they expected staff to complete the discharge paperwork when a resident transferred to the hospital. Staff B acknowledged a resident signed transfer discharge paperwork was not in the medical record for Resident 5 and Resident 10 but should have been signed. <Notification of LTCO and rights> <Resident 12> Review of Resident 12's 02/25/2025 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. Record review showed a 02/25/2025 transfer form was completed by staff with documentation the notice of transfer was sent with the resident. This form did not include a statement of the resident’s appeal rights and contact information for the office of the State Long-Term Care Ombudsman. In an interview on 02/28/2025 at 2:18 PM, Staff L (Social Services) stated they were unaware the notice of transfer with included appeal rights needed to be provided to a resident and/or their representative. Staff L stated it was, “not our practice” to provide the notice of transfer to the residents. <Bed Hold> <Resident 10> According to a 07/18/2025 progress note in Resident 10's medical record, showed Resident 10 was in the hospital from [DATE] through 07/18/2025. According to a 08/05/2025 progress note in Resident 10’s medical record, Resident 10 was in the hospital from [DATE] through 08/02/2025. Review of Resident 10's medical record showed no data to support the facility discussed and/or offered a bed hold notice to the resident or their representative for the 07/14/2025 or 07/28/2025 discharges to the hospital. In an interview on 08/28/2025 at 8:35 AM Staff F stated the nurses were to fill out a bed hold form and were responsible for notifying the resident or family of the bed hold. If there was no family and the resident was able, Staff F stated they would have the resident sign the form, otherwise the nurse had to call the family to sign the bed hold forms. Staff F was not able to locate bed hold notices for Resident 10 for the 07/14/2025 and 07/28/2025 discharges. In an interview on 08/28/2025 at 9:08 AM, Staff D stated the nurses were responsible for offering a bed hold notice to residents who were discharged to the hospital. Staff D reviewed Resident 10's record and stated there were not able to locate in the medical record, bed hold notices for Resident 10 for the 07/14/2025 and 07/28/2025 discharges. In an interview on 08/28/2025 at 10:02 AM, Staff B (Director of Nursing) stated nurses were to complete the entire discharge packet with a resident that included the transfer discharge notice and the bed hold forms. Staff B stated it may be uncomfortable for the nurses to relay the bed hold information, but was a requirement they had to do. Staff B stated staff should have offered or discussed a bed hold to the resident or their representative during Resident 10's transfer to the hospital but did not. Staff B stated they were not able to locate the bed hold forms in Resident 10's medical record for the 07/14/2025 and 07/28/2025 discharges. <Resident 82> According to the 07/21/2025 Discharge – Return Anticipated MDS, Resident 82 discharged to the hospital on that date. Review of Resident 82’s record showed no transfer notice or explanation of the facility’s bed hold policy added. In an interview on 08/28/2025 at 10:03 AM, Staff D (Nurse Supervisor) stated they did not see a transfer notice or bed hold was offered to Resident 82. Staff D stated the facility should have provided Resident 82 a transfer notice or bed hold but did not. <Discharge Planning> <Resident 1> According to a 07/13/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 1 had clear speech, was understood, and able to understand others. This MDS showed Resident 1’s overall goal was to discharge to the community and had an active discharge plan. In an interview on 08/22/2025 at 9:35 AM, Resident 1 stated they wanted to discharge and return to their house. Resident 1 stated staff did not talk to them yet about the process or their discharge goals. Review of a 07/09/2025 Social Service History and Initial Assessment showed Resident 1 did plan to return to the community and had some potential barriers to discharge. The assessment showed staff indicated Resident 1 required community services for home health upon discharge. Review of a revised 07/09/2025 discharge Care Plan (CP) showed Resident 1 wished to return home alone and identified interventions to establish a pre-discharge plan with the resident, evaluate progress, and revise plan as needed. Record review showed there was no pre-discharge planning in the record and staff were unable to find documentation when requested that a pre-discharge plan was established with Resident 1. In an interview on 08/28/2025 at 12:30 PM, Staff C (Social Services) stated if a resident had an upcoming discharge, a discharge summary would be started, and the discharge planning and status would be documented by social services in the progress notes. Staff C stated the plan for Resident 1 was to stay at the facility for another two weeks and they were working on a plan. Staff C reviewed Resident 1’s records and stated there should be, but were not any progress notes by social services documenting the discussions with the resident about discharge. <Resident 43> According to an 11/25/2024 admission MDS, Resident 43 had clear speech, was understood, and able to understand others. This MDS showed Resident 43’s overall goal was to discharge to the community and had an active discharge plan. Review of a 03/04/2025 and 05/21/2025 Quarterly MDS showed Resident 43 did not have an active discharge plan. In an interview on 08/22/2025 at 10:08 AM, Resident 43 stated they were frustrated and did not know what the plan was for discharge. Review of an 11/21/2024 Social Service History and Initial Assessment showed Resident 43 did plan to return to the community and had some potential barriers to discharge. The assessment showed staff indicated Resident 43 required community services for home health upon discharge. There was no further documentation from social services regarding Resident 43’s discharge status after the 11/21/2024 initial assessment until 08/15/2025, nine months later, at which time a quarterly social services assessment note was completed with documentation Resident 43 would like to discharge home with spouse, but needed an apartment to accommodate a wheelchair. Review of a revised 06/25/2025 discharge CP showed Resident 43 wished to return to the community when the family could find apartment placement. Staff identified the following interventions: to encourage Resident 43 to discuss feelings and concerns with impending discharge; monitor for and address episodes of anxiety, fear, and distress; and to evaluate and discuss with the resident/family/caregivers the prognosis for independent or assisted living. In an interview on 08/28/2025 at 12:30 PM, Staff C stated it was their expectation quarterly notes be made by social services and discharge planning be documented and updated in the resident’s records. REFERENCE: WAC 388-97-0120(1).

Based on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessments were accurate, revised, or submitted for a Level II PASRR assessment after the 30 day exemption expired for 5 (Resident 1, 2, 8, 12, & 55) of 8 sample residents and 1 (Resident 43) supplemental residents whose PASRRs were reviewed. This failure left residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.**Fix around a bit to include no referral for level 2 with SMIFindings included .<Facility Policy><Resident 1> According to a [DATE] admission Minimum Data Set (MDS – an assessment tool), Resident 1 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication during the assessment period. Review of a [DATE] Level 1 PASRR showed facility staff identified Resident 1 had a Serious Mental Illness (SMI) indicator of a mood disorder, but section IV was marked no Level 2 evaluation was indicated as the resident did not show indicators of an SMI. The facility failed to refer Resident 1 for the required Level 2 PASRR evaluation related to the SMI indicator of a mood disorder identified. In an interview on [DATE] at 12:30 PM, Staff C (Social Services) reviewed Resident 1’s records, confirmed the resident had SMI indicators, and stated a Level 2 PASSR referral should have, but was not completed as required. <Resident 2> According to a [DATE] admission MDS, Resident 2 had multiple medically complex diagnoses including anxiety and required the use of antidepressant and antianxiety medications during the assessment period. Review of Resident 2’s physician orders showed Resident 2 was receiving medication for depression and anxiety since their [DATE] admission. Review of Resident 2’s [DATE] Level 1 PASRR showed the resident had no SMI indicators identified. The Level 1 PASRR did not identify Resident 2 had depression and anxiety and required the use of medications. In an interview on [DATE] at 12:30 PM, Staff C reviewed Resident 2’s records and stated the resident did have SMI indicators and should be referred for a Level 2 PASRR evaluation. <Resident 43> According to a [DATE] Quarterly MDS, Resident 43 had multiple medically complex diagnoses including anxiety. Review of Resident 43’s [DATE] Medication Administration Record (MAR) showed the resident was receiving an antidepressant medication daily for a diagnosis of depression. Record review showed Resident 43 was admitted from the hospital with an [DATE] Level 1 PASRR that showed the resident had an SMI indicator of an anxiety disorder, but no depression diagnosis was identified. Additionally, there was no referral or evaluation completed due to Resident 43's identified SMI prior to Resident 43's admission to the facility as required. In an interview on [DATE] at 12:30 PM, Staff C stated Resident 43 did have SMI indicators and required a Level 2 PASRR evaluation. <Resident 12> According to an [DATE] admission MDS, Resident 12 had multiple medically complex diagnoses including anxiety and depression and required the use of antidepressant medication during the assessment period. Review of Resident 12’s [DATE] MAR showed the resident was receiving an antidepressant and an antianxiety medication. Record review of a [DATE] Level 1 PASRR showed staff identified Resident 12 with an SMI indicator of anxiety and a mood disorder. There was no Level 2 PASRR referral or evaluation completed due to Resident 12’s identified SMI indicators as required. In an interview on [DATE] at 12:30 PM, Staff C stated it was their expectation PASRRs be accurate and Level 2 PASRR referrals obtained as required. <Resident 55> According to the [DATE] admission Minimum Data Set (MDS – an assessment tool), Resident 55 admitted to the facility on [DATE], had a diagnosis of depression, and received an antidepressant medication during the lookback period. Review of Resident 55’s [DATE] PASRR Level 1 showed the resident had a known mood disorder. The PASRR showed the evaluator marked that a PASRR Level 2 was not indicated at the time due to an exempted hospital discharge and the resident was expected to discharge from the facility in less than 30 days. Review of Resident 55’s [DATE] Discharge MDS showed the resident discharged from the facility on [DATE], 65 days after their admission to the facility. In an interview on [DATE] at 1:24 PM, Staff C (Social Services) stated it was their process to send hospital exempted PASRRs for a Level 2 evaluation if the resident stayed past 30 days. Staff C reviewed Resident 55’s record and stated the Level 1 should be sent out but it was not. <Resident 8> According to the [DATE] admission MDS, Resident 8 admitted to the facility on [DATE] and had diagnoses including dementia (a progressive disorder affecting memory loss and the ability to make decisions), anxiety disorder, and post-traumatic stress disorder. The MDS showed Resident 8 received an antipsychotic and an antidepressant medication during the lookback period. Review of Resident 8’s [DATE] PASRR Level 1 showed the evaluator marked “no” indicating the resident did not have dementia. The evaluator marked a PASRR Level 2 was not indicated at the time due to an exempted hospital discharge and the resident was expected to discharge from the facility in less than 30 days. Review of the [DATE] Discharge MDS showed Resident 8 discharged from the facility on [DATE], 49 days after they admitted to the facility. In an interview on [DATE] at 12:30 PM, Staff C stated a new Level 1 PASRR needed to be submitted for residents that were not discharged and remained in the facility beyond the 30 day exempted stay. Staff C stated a new Level 1 PASRR should have, but was not completed as required for Resident 55 and Resident 8. REFERENCE WAC: 388-97-1915 (1)(2)(a-c).

Based on observation, interview, and record review the facility failed to identify and provide care and services in accordance with the resident's goals and professional standards of practice in the areas of non pressure skin conditions for 3 (Resident 40, 53, 1, & 54) of 5 and 1 supplemental (Resident 54) residents reviewed, and monitor and provide notification to the provider for low blood pressure readings for 1 (Resident 10) resident. These failures placed residents at risk for decline in medical status, unmet care needs, and a decreased quality of life.<Facility Policy>According to the facility's undated Care Plan, Comprehensive Person-Centered Care policy, a comprehensive, person centered care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and was developed and implemented for each resident. The policy showed that each resident's care plan would be consistent with resident's rights to receive the services included in the plan of care and would reflect currently recognized standards of practice for problem areas and conditions. <Monitoring Resident Skin> <Resident 40> According to the 08/03/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 40 did not have cognitive impairment and had diagnoses including a fracture. The MDS showed Resident 40 did not have skin impairments. Review of a 07/28/2025 admission progress note showed Resident 40 admitted to the facility with an abrasion to their right elbow. Review of Resident 40’s physician orders showed a 07/28/2025 order directing staff to provide wound care to the resident’s right elbow abrasion and cover with a dressing daily. The order report showed the elbow treatment was discontinued on 08/11/2025. In an observation and interview on 08/22/2025 at 10:42 AM Resident 40 stated they had a bandage on their right elbow. Observation showed a dressing to their right elbow and was dated 08/16/2025.Observation on 08/25/2025 at 12:51 PM with Staff K (Licensed Practical Nurse) showed Resident 40 had the same bandage on their right elbow, dated 08/16/2025, nine days prior. Resident 40 stated they would like the dressing removed. Staff K removed the dressing showing dried skin to the resident’s elbow. Staff K reviewed Resident 40’s physician orders and confirmed there were no active orders directing staff to cover the resident’s elbow. Review of Resident 40’s Treatment Administration Record (TAR) showed a 07/31/2025 order directing licensed staff to complete a weekly skin assessment and document any skin issues. The TAR showed staff completed the skin assessment as ordered on 08/21/2025 and documented there were no skin issues for Resident 40. Review of Resident 40’s assessments showed there was no associated skin assessment with the weekly skin check documentation. In an interview on 08/28/2025 at 9:22 AM, Staff E (Nurse Supervisor) stated it was their expectation staff documented in the TAR the weekly skin check was completed and that the assessment form was completed in the assessments tab. Staff E reviewed Resident 40’s assessments and confirmed staff were not filling out the skin assessment as expected. Staff E stated they expected staff to remove the old, outdated bandage if/when it was noticed on the weekly skin check. <Resident 53> According to the 07/31/2025 admission MDS, Resident 53 had clear speech, could be understood, and understand others. This MDS showed Resident 53 received a blood thinning medication during the assessment period. Review of Resident 53’s 07/26/2025 revised anticoagulant care plan showed interventions to staff to monitor, document, report as needed, adverse reactions to the anticoagulant medication including bruising. Observation on 08/26/2025 at 10:21 AM showed Resident 53 sitting in their room listening to the radio. Resident 53 had a small bruise/discoloration to their right and left cheek and bruising to the back of their right and left hands. Observation on 08/28/2025 at 8:35 AM showed Resident 53 sitting on the edge of their bed. Resident 53 had a small bruise/discoloration to their right and left cheek, bruising to the back of their right and left hands, and a bruise to their upper left arm. Resident 53 stated nobody hurt them, they just got bruises all the time but did not know why or how, stating “these things just show up.” Review of Resident 53’s August 2025 MAR showed an order directing staff to perform a skin check every week on the night shift and to notify the provider for new or worsening skin conditions. The MAR showed staff performed a skin check on the night shift of 08/26/2025 and did not note any new or worsening skin conditions. In an interview on 08/28/2025 at 10:47 AM, Staff B (Director of Nursing) stated it was their expectation staff performed full body skin checks as ordered and capture/document skin impairments. Staff B stated Resident 53’s orders required clarification so staff could document “Y” or “N” for skin issues. Staff B stated they expected staff to monitor the bruising for changes and contact the physician regarding adverse side effects to the blood thinning medication, but they did not. <Resident 1> According to the 07/13/2025 admission MDS, Resident 1 was admitted to the facility after spinal surgery, had a surgical wound, required wound care, and had no rejection of care during the assessment period. In an interview on 08/22/2025 at 9:50 AM, Resident 1 stated they had a surgical incision on their back and the area was healing. Review of a revised 08/21/2025 skin integrity care plan showed Resident 1 had an actual skin impairment related to a surgical incision and gave directions to staff to monitor/document location, size, and treatment of the skin injury. Review of Resident 1’s July 2025 Treatment Administration Records (TAR) showed orders for a weekly skin assessment to be completed by a licensed nurse. This order directed staff to document any skin issues, notify the provider, and refer for a wound consultation. Staff documented the assessments were being completed weekly. Review of Resident 1’s records showed no skin assessments or measurements of the resident’s surgical wound until 08/04/2025, almost four weeks after the last skin assessment was completed on 07/07/2025. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated nursing staff should be completing a skin assessment every week and documenting identified areas. Staff D stated documentation should be in the resident’s records and expected staff to document the appearance and size of any wounds. <Resident 54> According to a 07/07/2025 admission MDS, Resident 54 was at risk for developing pressure ulcers/injuries, was dependent on staff to roll from side to side in bed, had no rejection of care, and was on hospice services (specialized care for people with a terminal illness) during the assessment period. Observations on 08/21/2025 at 10:50 AM showed Resident 54 with a bandage to their left forehead. Review of Resident 54’s July and August 2025 TARs showed orders for wound care to the left face twice weekly and for a skin assessment to be completed by a licensed nurse weekly. This order directed to staff to document skin issues, notify the provider, and refer for a wound consultation. Staff documented a “-“every week for the months of July and August 2025. The TAR did not indicate what was meant by “-“. In an interview on 08/28/2025 at 10:18 AM, Staff E stated the staff completed weekly wound rounds but Resident 54 was not included in the rounds because they were receiving hospice services. Staff E stated nursing staff should be completing weekly skin assessments for Resident 54 and documenting wounds using the wound assessment form. Staff E could not provide documentation showing weekly skin assessments, wound measurements, or refusals by Resident 54. Staff E stated if there was a reason the skin assessment was not completed; the reason should be documented in resident’s records. <Blood Pressure Monitoring> <Resident 10> According to a 08/05/2025 Quarterly MDS, Resident 10 had neurological conditions, a chronic kidney condition, low Blood Pressure (BP) and received dialysis treatment (filtering of the blood treatment due to kidney failure). Review of the revised 03/19/2025 pacemaker care plan showed a goal for Resident 10 to remain free of symptoms of an altered heart output. Staff would monitor and document vital signs and notify the physician for significant abnormalities. The care plan showed staff should monitor for BP readings below the resident’s baseline BP. The care plan did not show what the baseline BP was, and did not provide instructions to staff on what to do when Resident 10’s BP was below their baseline. Review of a 01/23/2025 physician’s order showed Resident 10 took a medication to manage their low BP. Review of the dialysis post visit notes showed on 07/03/2025, 07/08/2025, 07/14/2025, 07/15/2025, 08/15/2025 and 08/18/2025 Resident 10’s BP was low during dialysis. Review of the 07/15/2025 post dialysis note showed the dialysis center documented Resident 10’s BP was low upon arrival to the dialysis center. Review of Resident 10’s BP readings taken by the facility showed the following BP values: 98/60 on 08/23/2025, 85/53 on 08/16/2025, 85/68 on 08/15/2025, 82/50 on 08/09/2025, 85/52 on 08/07/2025, 81/50 on 08/06/2025, and 75/53 on 08/15/2025, the record did not show staff provided interventions or notified the provider of the low BP readings. In an interview on 08/26/2025 at 8:46 AM, Resident 10 stated their BP was always low, but they had a pacemaker. In an interview on 08/27/2025 at 10:54 AM Staff F (Licensed Practical Nurse) stated they knew Resident 10 had low BP, but did not know when to notify the provider when the BP readings were too low. Interview on 08/28/2025 at 9:12 AM, Staff D stated they expected staff to document and notify the provider when a resident experienced a low BP. Staff D stated the provider should be aware of low BP readings and the low BP parameters should be included in the care plan or on the MAR directing staff when to call the doctor. Staff D reviewed Resident 10’s physician’s orders, care plan, and MAR, and stated there were no low BP parameters or instructions on what to do for low BP readings. Staff D could not provide documentation that staff notified the provider or provided interventions when the Resident 10’s BP was low. In an interview on 08/28/2025 at 12:22 PM Staff B stated they expected staff to document and report low BP readings to the provider and stated there should be parameters for the nurses for both high and low BP readings, especially since Resident 10 had a history of low BP. REFERENCE: WAC 388-97-1060 (1).

Based on interview and record review the facility failed to obtain and/or renew guardianship papers, and/or failed to provide assistance in the formulation of an Advanced Directive (AD - a document describing a resident's wishes for care if they became incapacitated) for 6 of 20 residents (Residents 5, 49, 9, 1, 2 & 54) reviewed for guardianship/advance directives. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end-of-life care.Findings included .<Facility Policy>According to the facility's revised September 2022 Advanced Directives policy, the resident had the right to formulate an advanced directive (AD) and advance directives were honored in accordance with state law and facility policy. The policy showed prior to an admission, the social services director or designee would inquire about the existence of any written AD and provide written information concerning the right to formulate an AD. If the resident had an AD upon admission, the documents would be obtained and maintained in the medical record and the care plan would be updated with residents AD preferences. The interdisciplinary team would annually review the residents AD and record this in the medical record. <Resident 5> According to the 07/17/2025 Annual Minimum Data Set (MDS - an assessment tool), Resident 5 had non-Alzheimer’s dementia (a progressive impairment of memory and abstract thinking) and generalized weakness. Review of Resident 5's revised 03/19/2025 impaired cognitive function Care Plan (CP), showed Resident 5’s CP goal was to be able to communicate basic needs. Interventions showed staff were to ask yes or no questions in order to determine the residents’ needs. Advanced Directives or who to call for health concerns were not shown in the CP. In an observation on 08/22/2025 9:02 AM, Resident 5 stated their daughter was their Durable Power of Attorney (DPOA), but they were not sure if the facility had the paperwork to show this or not. Record review of a 08/04/2025 physician's note showed the DPOA was consulted. Record review showed there was no DPOA paperwork found in Resident 5’s record. <Resident 49> According to the Quarterly 05/30/2025 MDS, Resident 49 had non-Alzheimer’s dementia and other neurological conditions. Review of the revised 05/9/2025 advance directives, full code CP, showed Resident 49’s code status was a full code. Interventions on the CP showed staff were to discuss code status and advance directives preferences with Resident 49 on a quarterly basis and to ensure the resident had an appropriate order from the attending provider regarding their advance directive preferences. Review of a DPOA acknowledgement form dated 08/15/2024 and signed by a resident representative showed a box was checked to indicate the resident representative provided a current copy of the advance directive documents or was in the process of providing a copy to the facility. Review of Resident 49’s medical record did not show an advanced directive or durable power of attorney was on file in the resident’s medical record. In an interview on 08/28/2025 at 8:47 AM Staff C (Social Services) stated ADs was completed by the admissions nurse. <Resident 9> According to a 06/16/2025 Quarterly MDS, Resident 9 had moderate memory impairment, had a life expectance of less than six months, and was on hospice (specialized care for people with a terminal illness) services. Review of Resident 9’s revised 06/27/2025 advance directive CP showed the resident’s advance directive preferences would be followed based on the resident’s preferences. Interventions showed directions to staff to discuss the advance directive preferences with the resident or the responsible party on a quarterly basis and as needed. Record review showed an 11/03/2023 hospice admission consent form which indicated Resident 9 had made a Power of Attorney (POA). No POA paperwork was found in Resident 9’s records. <Resident 1> According to a 07/13/2025 Admissions MDS, had multiple medically complex diagnoses including fractures and other multiple traumas, high blood pressure, pneumonia (an inflammation of the lungs caused by an infection, thyroid disorder, and depression. In an interview on 08/22/2025 at 9:55 AM, Resident 1 stated they had a living will and their youngest child was their POA. Review of Resident 1’s revised 06/27/2025 advance directive CP showed the resident’s advance directive preferences would be followed based on the resident’s preferences. Interventions showed directions to staff to discuss the advance directive preferences with the resident or the responsible party on a quarterly basis and as needed. Review of a 07/07/2025 Durable POA Acknowledgement form showed Resident 1 was informed of the benefits of a POA and provided a current copy of their advance directive documents or were in the process of providing them shortly. Review of a 07/09/2025 Social Service History and Initial Assessment showed staff did not mark Resident 1 had a POA and documented the resident stated their son was their, “living will.” The section on the form, asking if the financial POA, medical, and/or living will documents were on file, was left blank by staff. No POA or advance directives paperwork was found in Resident 1’s records. <Resident 2> According to a 07/27/2025 admission MDS, Resident 2 had multiple medically complex diagnoses, had moderate memory impairment, and was taking psychotropic medications during the assessment period. Review of a 07/21/2025 DPOA Acknowledgement form showed Resident 2 was informed of the benefits of a POA and provided a current copy of their advance directive documents or were in the process of providing them shortly. This form was signed by Resident 2’s son with “POA” written next to their signature. Resident 2’s son also signed other admission paperwork as well. Review of a 07/24/2025 Social Service History and Initial Assessment showed staff marked Resident 2 did not have any POA and no documents were on file. Review of Resident 2’s records showed the emergency contact information for the resident, but did not include the son, who was identified as the POA on the admission paperwork. No POA or advance directives paperwork was found in Resident 2’s records. <Resident 54> According to a 07/07/2025 admission MDS, Resident 54 had moderate memory impairment, had a life expectancy of less than six months, and was on hospice services. Review of Resident 9’s revised 07/13/2025 advance directive CP showed the resident’s advance directive preferences would be followed based on the resident’s preferences. Interventions showed directions to staff to discuss the advance directive preferences with the resident or the responsible party on a quarterly basis and as needed. Review of Resident 54’s records showed the emergency contact information for the resident included a son and was identified as the resident’s POA. No POA or advance directives paperwork was found in Resident 54’s records. Review of a 07/08/2025 Social Service History and Initial Assessment showed staff documented Resident 54’s son stated they were the POA and no paperwork was on file. There was no documentation the POA documents were requested from the family and none were located in Resident 54’s records. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated advance directives should be readily available in the resident’s records and were important so staff would know who to contact to make decisions when a resident was unable. In an interview on 08/28/2025 at 12:30 PM, Staff C (Social Services) stated advance directives were usually done by admissions and reviewed quarterly during care conference. Staff C stated if a resident has advance directives, it was their expectation the documents be in the resident records so staff know who to contact in an emergency. In an interview on 08/28/2025 at 1:42 PM, Staff G (Admissions Liaison) stated it was the responsibility of the social worker to get the advanced directives (AD). If the AD was not in the medical record, then the facility did not have a copy of it. Staff G stated an AD acknowledgement form was contained within the admission packets and the facility asked resident’s or families to complete the forms in the packets, but they did not always provide a copy of the AD to the facility. Staff G stated staff do not provide follow up to make sure the AD or DPOA paperwork got turned in. Staff G acknowledged the facility did not have advance directives in the medical record for Resident's 1, 2, 5, 9, 49 & 54. Staff G stated AD were important and should be available because they were used to honor preferences for the resident and provide information on who to call or should be contacted regarding resident concerns. REFERENCE: WAC 388-97-0280(3)(c)(i-ii).

Based on observation, interview, and record review the facility failed to conduct care conferences to ensure person-centered care for 3 (Residents 43, 4, & 53) of 4 residents reviewed for care planning, and failed to ensure Care Plans (CPs) were updated and/or revised, as needed for 2 (Residents 2 & 10) of 20 sample residents whose CPs were reviewed. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included. <Facility Policy>Review of the facility's Resident Participation - Assessment/Care Plans policy, revised 02/2025, showed the resident and/or their representative had the right to participate in the their assessments and the development of the their CP. The policy showed facility staff would support the resident's and/or resident representative's participation in the care planning process by holding meetings at a time of day when residents and/or representatives were available and when residents were functioning at their best. The policy showed staff would provide advanced notice of CP meetings and the social services director or designee was responsible for notifying the resident/representative of the CP meeting and maintaining records of notices.<Care Conferences> <Resident 43> According to a 05/21/2025 Quarterly MDS, Resident 43 had clear speech, was understood, and able to understand staff. In an interview on 08/22/2025 at 10:08 AM, Resident 43 stated they had not had a care conference and expressed frustration they did not know what the plans were for their care. Record review showed a care conference progress note from 11/21/2024 with no further documentation in Resident 43’s records regarding any care conferences until 08/14/2025, almost nine months later. The 08/14/2025 progress note showed staff documented they called Resident 43’s family to schedule a quarterly care conference. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated care conferences should occur quarterly, and it was their expectation the care conference be documented on a progress note in the resident’s records. In an interview on 08/28/2025 at 2:18 PM, Staff L (Social Services) reviewed Resident 43’s records and stated they did not see that a care conference was done quarterly and stated, “it might have been dropped.” Staff L stated care conferences were important, so all departments and the resident knew what was going on and could follow up with any concerns identified. <Resident 4> According to the 07/08/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 4 was cognitively intact, had clear speech, could understand and be understood by others. The MDS showed Resident 4 had diagnoses including a hip fracture, malnutrition, and a blockage in their throat. The MDS showed Resident 4 had weight loss, was not on a prescribed weight loss regimen, and received more than 51 percent of their nutrition via a surgically placed tube in their stomach. In an interview on 08/22/2025 at 11:45 AM, Resident 4 stated they did not recall having a care plan meeting since their admission to the facility on [DATE]. Review of Resident 4’s progress notes and assessments showed no information regarding a care conference for the resident. A 07/04/2025 “Social Service History & Initial Assessment” showed the social services assessed the resident’s history, advanced care planning, cognitive abilities, and the residents discharge plans. This assessment did not discuss therapy goals, activity preferences, or have input from the dietary or nursing departments. <Resident 53> According to the 07/31/2025 admission MDS, Resident 53 had clear speech, was understood, and could understand others. The MDS showed Resident 53 had diagnoses including heart disease, a major infection, wounds to their lower legs, and a disease that caused major fluid buildup to their lower legs. Review of Resident 53’s progress notes and assessments showed no information regarding a care conference for the resident. A 07/27/2025 “Social Service History & Initial Assessment” showed the social services assessed the resident’s history, advanced care planning, cognitive abilities, and the residents discharge plans. This assessment did not discuss therapy goals, activity preferences, or have input from the dietary or nursing departments. In an interview on 08/26/2025 at 11:52 AM, Staff L (Social Services) stated it was their practice to schedule care conferences for newly admitted residents within 72 hours of their admission. Staff L stated care conferences were documented on a care conference assessment form and that this form was implemented a “couple of weeks ago.” Staff L stated care conferences included resident care managers, the social worker, therapy, nursing staff, and the dietary department. Staff L reviewed Resident 4 and Resident 53’s records and confirmed there was no care conference assessment or documentation showing the residents were provided a care conference <Care Plan Revision> <Resident 2> According to a 07/27/2025 admission MDS, Resident 2 had multiple medically complex diagnoses including fractures, falls prior to admission, and required major surgery for a hip replacement. Review of a revised 08/20/2025 “actual fall” CP showed staff identified interventions including: checking the resident’s range of motion “(specify#)” times daily; and for neurological checks “x (FREQ).” Staff did not identify the number of times the range of motion checks should occur daily or the frequency of the neurological checks. In an interview on 08/27/2025 at 1:15 PM, Staff D stated CPs were important, so staff knew what kind of care to provide for a resident. Staff D stated it was their expectation staff update, and revise CPs as needed to reflect the current care needs of the residents. REFERENCE: WAC 388-97-1020(2)(c)(d), -1020 (2)(f), (4)(b).

Based on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (a process to determine what mental health services residents required after a Level 1 PASRR determined mental health services were necessary) were obtained for 3 (Residents 5, 10 & 26) of 8 residents whose PASRRs were reviewed. This failure placed residents at risk of not receiving necessary mental health care and services. Findings included .<Facility Policy>According to the facility's admission Criteria policy, revised in March 2019, all new admissions and readmissions were screened for Mental (MD), Intellectual (ID) or Related Disorders (RD) per the PASSR process. According to the policy, if the Level I screening indicated an individual may meet the criteria for MD, ID, or RD the resident was referred to the state PASRR representative for the Level II evaluation and determination screening process. The social worker would be responsible for making referrals to the appropriate state-designated authority.<Resident 5> According to the 07/17/2025 Annual Minimum Data Set (MDS - an assessment tool), Resident 5 had cognitive impairment and depression. According to a 03/25/2025 progress note, Resident 5 was on alert for behavior issues. According to a 05/26/2025 progress note, staff documented Resident 5 had confusion and hallucinations. Review of the 05/05/2025 PASSR Level I form showed Resident 5 had serious mental illness indicators for mood and anxiety. No level II referral evaluation was indicated on the form. <Resident 10> According to the 08/05/2025 Quarterly MDS, Resident 10 had a chronic kidney condition and hepatic encephalopathy (a condition occurring when the liver was unable to rid the blood of toxins, causing changes in brain function). The MDS showed Resident 10 did not exhibit any behaviors. Review of the revised 08/13/2025 Target behavior CP showed Resident 10 had behavior problems including cursing towards staff, kicking and hitting other residents, and refusals of medications. Review of a 06/15/2025 progress note showed Resident 10 left the facility and was found at a nearby bus stop. Review of a 08/03/2025 progress note showed Resident 10 refused a skin check when readmitted , said profanities to the nurse, and told them to leave the room. Review of a 08/06/2025 progress note showed the resident exhibited behavioral issues including attempting elopement from the building, verbal abuse toward staff, inappropriate language, attempting to punch staff, and discarding a portion of their prescribed medication in the trash. Review of the 07/19/2025 Level 1 PASSR screening showed Resident 10 had no serious mental illness indicators and did not exhibit any serious functional limitations in the past 6 months. The record did not show an updated Level 1 screening or Level II referral was made after the Level I PASSR on 07/19/2025. In an interview on 08/21/2025 at 1:52 PM Resident 10 stated facility staff person accompanied them to appointments because the facility was afraid that they would attempt to leave the facility again. Resident 10 stated a couple of months ago they went out of the facility to go shopping in a nearby city and the police were called. In an interview on 08/28/2025 at 12:22 PM Staff D (Nurse Supervisor) stated they were not aware that Resident 10 had any psychological issues, as they believed Resident 10 acted out knowingly and purposefully. In an interview on 8/28/2025 at 1:18 PM Staff C (Social Services) stated they were not aware of any behavioral issues with Resident 10 that would require a Level II PASSR referral. Staff C stated they were unsure of the PASSR Level II process for changes of condition and did not redo the PASRR process with a change of condition for Resident 10 but should have. <Resident 26> According to the 07/15/2025 Quarterly MDS, Resident 26 had a condition where their brain function was impaired due to disturbances in their metabolism. Review of the 07/17/2025 “Impaired cognitive function related to probable moderate dementia” CP showed staff were to speak in simple directive sentences. The CP did not show Resident 26 had any behavioral issues. Review of a 07/12/2025 provider progress note showed Resident 26 had intermittent confusion. Review of 08/05/2025 social services note showed Resident 26 mentioned to their family on 08/01/2025 that their roommate became pregnant by an employee and they moved to an island to have a baby. After investigation by the facility, it was determined that the allegation was unsubstantiated. Review of 08/08/2025 provider progress note showed if medically appropriate, the provider would consider an antipsychotic medication due to the severity of Resident 26’s delusional thoughts. Review of an 08/14/2025 provider progress note showed Resident 26 had a diagnosis of moderate, unspecified dementia with psychotic disturbance and recent delusions. Review of the 04/14/2025 Level 1 PASRR screening showed Resident 26 had no serious mental illness indicators or any dementia or delirium diagnosis. The Level I screening showed a Level II evaluation was not indicated. The medical record did not show an updated Level 1 PASSR screening completed or Level II PASSR referral made after the 04/14/2025 Level 1 screening. In an interview on 08/28/2025 at 8:48 AM, Staff C stated they reviewed PASSR forms during care conferences and after 72 hours of admission. Staff C stated PASSR evaluations were important as staff should be aware of their behavior. Staff C stated they were unsure of the requirements to rescreen residents after a change in condition and the Level II PASSR process, and unsure when they needed to be completed. Staff C stated Level 1 screenings should have been completed and Level II referrals made after identification of serious mental health indicators for Residents 5, 10 or 26 but were not. REFERENCE: WAC 388-97-1915(4).

Based on observation, interview, and record review the facility failed to ensure prompt dental services were provided for 1 (Resident 43) of 1 sample residents reviewed for dental services. This failure placed the residents at risk for unmet dental needs and a diminished quality of life.Findings included .<Resident 43> According to a 11/25/2024 admission Minimum Data Set (an assessment tool) Resident 43 had clear speech, was able to understand others, and make themselves understood. This MDS showed Resident 43 was assessed with obvious or likely tooth decay or broken teeth and had mouth or facial pain and discomfort or difficulty with chewing. In an interview on 08/22/2025 at 10:09 AM, Resident 43 stated they needed to see a dentist for their “really bad teeth.” Resident 43 stated they had some teeth that were cracked down to the gum which caused discomfort at times when eating. Resident 43 stated they had one tooth with a hole and they had to pick food out of their tooth every time they ate. Resident 43 stated they saw a dentist when they first admitted at the facility and did not hear anything afterwards. Observations at this time showed Resident 43 with broken upper and lower teeth. Review of a revised 02/27/2025 dental Care Plan (CP) showed Resident 43 had broken, natural teeth, tooth decay, occasional pain, and difficulty chewing. This CP gave directions to staff to coordinate arrangements for dental care and transportation as needed/as ordered. Review of Resident 43’s physician orders showed a 11/19/2024 order for a dental consult as needed and showed the resident could be seen and treated by a dentist. Record review showed the facility’s visiting dentist saw Resident 43 on 01/27/2025 and noted several broken and decayed teeth needing attention. A referral for x-rays, evaluation, and extraction for all Resident 43’s upper teeth was recommended. There was a handwritten note on the consultation documenting Resident 43 had an abscess (a tooth infection causing a pocket of pus to form) on one of their teeth. The note showed Resident 43 wanted extractions and a full upper denture. Record review showed a 01/31/2025 referral request form for Resident 43 requesting the x-rays, evaluation, and extractions. This form did not identify where the referral request was sent. In an interview on 08/27/2025 at 9:09 AM, Staff H (Unit Coordinator) stated they were responsible for scheduling appointments and faxing referrals to providers. Staff H stated they usually obtained a fax confirmation showing the referral was received by the provider and then added the appointment to their calendar. Staff H reviewed their records and was unable to find a fax confirmation or a dental appointment for Resident 43. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated that timely dental follow up was important to avoid delays and stated dental issues could negatively impact a resident’s daily life. Staff D stated it was their expectation staff followed up with recommendations for dental referrals timely. Staff D confirmed there was nothing in Resident 43’s records after the request form from 01/31/2025, almost seven months earlier, to demonstrate staff scheduled the dental appointment. REFERENCE: WAC 388-97-1060(1); (3)(j)(vii).

Based on interview and record review, the facility failed to identify triggers that might prompt a recall of previous traumatic events, and develop care planned goals and interventions for a resident who was a trauma survivor for 1 of 1 residents (Resident 67) reviewed for trauma informed care (a framework for understanding and responding to the effects of trauma). This failure placed the resident at risk for re-traumatization, psychological harm and a diminished quality of life.Findings included .<Facility Policy>Review of a revised August 2022 Trauma-Informed Care policy showed an individualized Care Plan (CP) would be developed that addressed past trauma, triggers identified to decrease exposure that may re-traumatize the resident, and establish resident-care strategies.<Resident 67>According to an 08/18/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 67 had a diagnosis of depression, moderate memory impairment, and no behavioral symptoms.Review of an 08/21/2025 care conference progress note showed Resident 67 reported being punched by staff during care. Staff documented the resident would be placed on alert, and new CP interventions implemented.In an interview on 08/26/2025 at 8:59 AM, Resident 67 stated they felt safe in the facility, nobody hurt them, and had no concerns about staff.In an interview on 08/26/2025 at 9:30 AM, Staff B (Director of Nursing) stated Resident 67 had a history of trauma and they were working with the resident's family regarding the 08/21/2025 reported incident.Review of a 12/07/2024 Trauma-Informed Screening form showed staff documented Resident 67 experienced abuse when they were younger and could experience mood swings, confusion, disorientation, and depression. The assessment listed prevention strategies that could be used to prevent trauma symptoms which included: redirection; one to ones, reapproach, communication, allow participation in decision-making, and to ensure physical and/or emotional safety and security.Review of a 07/24/2025 spiritual care progress note showed recommendations for a Trauma-Informed CP to be implemented and identified specific interventions for Resident 67 to help prevent re-traumatization.Review of Resident 67's comprehensive CP showed it did not include a Trauma-Informed CP or address the resident's trauma history, identify any triggers, or prevention strategies to help prevent trauma symptoms.In an interview on 08/28/2025 at 2:08 PM, Staff B stated it was important to make sure a resident felt safe in the facility and stated it was their expectation staff develop a CP with individualized triggers and interventions to avoid re-traumatization when a resident experienced past trauma. Staff B stated staff did not but should have initiated a trauma-informed CP for Resident 67 once it was identified on the 12/07/2024 Trauma-Informed Screening form.REFERENCE: WAC 388-97-1060 (1)(3)(e).

Based on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 2 of 2 residents (Resident 27 & 6) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); ensure staff used appropriate Hand Hygiene (HH) during resident care for 4 of 4 residents (Resident 27, 6, 37 & 54) who were observed for care; ensure staff followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 of 1 resident (Resident 37) reviewed for TBP; and ensure the facility was free of uncleanable surfaces for 1 of 1 residents (Resident 2). These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases. <Facility Policy>According to the facility's February 2023 Infection Prevention and Control Program policy, the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help to prevent the development and transmission of communicable diseases and infections. The policy showed staff would use standard precautions during resident care, unless the resident was on transmission-based precautions (TBP), then staff would use personal protective equipment (PPE) as indicated by the identified precaution. The policy showed for standard precautions staff would perform hand hygiene, even if gloves were used before and after contact with the resident, after contact with blood or bodily fluids, and after removing PPE. <Enhanced Barrier Precautions-EBP) <Resident 27> According to a 06/02/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 27 had history of a traumatic brain injury, had a gastrostomy (tube inserted into the stomach for feeding) and had deficiencies with their immune system. Review of 05/27/2025 tube feeding Care Plan (CP), showed Resident 27 was on EBP due to a feeding tube placement. Observation on 08/21/2025 at 1:12 PM showed a sign on Resident 27’s door that resident was on EBP and staff were to wear a gown, gloves and mask when providing personal care. Observed Staff M (Certified Nursing Assistant - CNA) provide incontinent care to Resident 27. Staff M was observed to clean Resident 27 after changing their soiled incontinent pad. Staff M did not remove soiled gloves or wash hands before putting on moisturizing ointment on Resident 27’s skin or before helping Resident 27 look through their drawers for their glasses or when using the bed remote to lower their bed. Resident 27 stated they had ongoing diarrhea and were being fed through a tube. <Resident 6> According to the 07/23/2025 quarterly MDS, Resident 6 had a neurological condition, required a feeding tube to eat, and used an indwelling catheter (tube inserted in the urinary tract from the bladder) due to urinary blockage. Review of the 08/09/2024, MRSA (Methicillin-Resistant Staphylococcus Aurea) CP, Resident 6 was on EBP due to their feeding tube and a history of multiple drug-resistant organisms that were resistant to multiple antibiotics for treatments. Observation on 08/25/2025 at 8:45 AM, Resident 6 had a sign on their door for EBP. Observed Staff O (CNA) provide care to Resident 6 after changing their soiled incontinent pad. Staff O did not wear a mask and did not change their gloves or wash their hands before putting Resident 6’s clean pants and socks on. Observed Staff O discarded their soiled gown and gloves in the trash, did not sanitize or wash their hands and then left the room to obtain assistance with resident’s care. In an interview on 08/25/2025 at 9:28 AM Staff O stated they did not wash their hands when they left Resident 6’s room but should have for infection control. In an interview on 08/28/2025 at 9:12 AM Staff D (Nurse Supervisor) stated proper hand hygiene was needed for all personal care activities and for all residents on EBP. Staff D stated staff were expected to follow instructions on the EBP form provided and staff should wear gloves, gowns, masks, when taking care of a resident on EBP. <Transmission Based Precautions – TBP> <Resident 37> Observations on 08/21/2025 at 9:05 AM showed a contact enteric precautions (a set of safety measures to prevent the spread of infections that are transmitted through the intestines and by direct or indirect contact with a person or their environment) sign posted by the door outside of room [ROOM NUMBER] with directions to staff to put on a gown and gloves when entering room and to wash with soap and water upon leaving room. Review of Resident 37’s physician orders showed an 08/21/2025 order for enteric contact isolation due to pending C-Diff (a highly contagious bacteria that causes diarrhea) results. On 08/22/2025 the facility received the lab results showing Resident 37 was positive for having a C-diff infection. Observations on 08/21/2025 at 10:34 AM showed housekeeping staff inside room [ROOM NUMBER], without a gown or gloves on, while cleaning the side of the room by the window. At this time, a staff member from the therapy department, without putting on a gown or gloves, entered the room and brought Resident 37 some water. Observations on 08/21/2025 at 12:28 PM showed staff entering Resident 37’s room carrying their lunch tray, moved items on their bedside table for the tray, and exit the room using only hand sanitizer. Staff did not put on a gown and gloves prior to entering the room and did not use soap and water for hand hygiene upon exiting. On 08/21/2025 at 12:29 PM, Staff T (Certified Nursing Assistant - CNA) entered Resident 37’s room and began assisting the resident with opening their milk container, exited the room, without performing hand hygiene, and picked up a carton of thickened liquids being kept on a beverage delivery cart to pour fluids for another resident. Staff T then went to another room, used hand sanitizer prior to entering, but had not washed their hands with soap and water after exiting Resident 37’s room, who was on a TBP. Observations on 08/26/2025 at 12:23 PM showed Staff V (CNA) and Staff W (CNA) enter Resident 37’s room, without putting on a gown and gloves, to deliver a lunch tray and beverages to the resident. Both staff used hand sanitizer, but did not wash their hands with soap and water, upon exiting as indicated on the sign posted at the door. Observations on 08/27/2025 at 8:35 AM showed Resident 37 remained on a TBP and Staff U (Physical Therapy Assistant) entered their room, without putting on a gown and gloves, set a laptop down inside the room on a counter, and stated, “let me go get my gown on and come back.” Staff U went back into the hall and put on a gown and gloves. In an interview on 08/27/2025 at 9:01 AM, Staff U stated a gown, and gloves should be put on prior to entering a room when someone is on contact enteric precautions. In an interview on 08/28/2025 at 12:04 PM, Staff X (Infection Preventionist) stated it was their expectation staff adhere to the directions posted on the TBP signs to help prevent the spread of infections. Staff X stated for contact enteric precautions, staff should put on a gown and gloves prior to entering the room and wash their hands with soap and water upon exiting the room. <Wound Care> <Resident 54> Observations on 08/28/2025 at 9:56 AM showed Staff N (Nurse Supervisor) providing wound care to an open area on Resident 54’s backside. Staff N removed the old dressing, put cleansing solution on some gauze, and began cleaning the wound and surrounding area. With the same soiled gloves, Staff N opened and applied a skin preparation (a protective barrier to prevent damage from adhesive bandages) to the surrounding area of the wound, and covered wound with a new foam bandage. Staff N, while wearing the same soiled gloves, touched the bed remote and picked up one of Resident 54’s pillows to position under the resident’s knees. Staff N removed their gloves, did not perform hand hygiene, touched the door handle to exit the room, went into the room next door to say hello to family, exited that room, and entered a third room, all before performing hand hygiene. In an interview on 08/28/2025 at 12:04 PM, Staff X stated it was their expectation staff perform hand hygiene during wound care after removing soiled dressings and prior to applying a clean dressing. Staff X stated staff should also perform hand hygiene after removing gloves and when moving between resident rooms. <Cleanable Surfaces> <Resident 2> Observations on 08/22/2025 at 12:41 PM showed Resident 2 sitting in their wheelchair with cracked, peeling material noted to both arm rests. In an interview on 08/28/2025 at 12:04 PM, Staff X stated wheelchair armrests were not cleanable once they are cracked and peeling and should be replaced to decrease the spread of bacteria and improve the ability to sanitize the surfaces. REFERENCE: WAC 388-97-1320 (1)(a)(c),(2)(b).

Based on observation, interview, and record review the facility failed to ensure food was properly stored and labeled for 2 of 2 kitchens reviewed for kitchen safety. These failures left residents at risk for spoiled or contaminated foods, and food-borne illness.Findings included .<Facility Policy>According to the facility's revised 01/2025 Food Storage policy and Resident Food Services policy, all food, non-food items, and supplies used in food preparation would be stored in a manner to prevent contamination and maintain the safety and wholesomeness of the food. Food items would be labeled with a manufacturer's expiration date or the date of receipt. This policy showed staff would restrain all facial hair with a beard/hair net restraint. <Skilled Nursing kitchen >Observation of the facility's dry food storage on 08/21/2025 at 8:45 AM showed opened boxes of snacks containing nacho chips, cheese crackers, and popcorn packages. These packages did not have a label with an expiration date on the box or individual packages. Three cartons of unopened frozen orange juice were observed in the walk-in freezer and were not labeled with expiration dates.<Main Kitchen >Observation of the main kitchen on 08/21/2025 at 9:42 AM showed the following items were not labeled with an open or expiration date: two tubs of bacon jam, one container of cream cheese, uncooked eggs loosely stored in a canister, and three bags of corn tortillas. An opened package of ham lunch meat was past the labeled expiration date.Observation of the walk-in freezer on 08/21/2025 at 10:00 AM showed one bag of frozen french fries, one bag of frozen bagels, and one bag of frozen chicken quarters were not labeled with an expiration date. Observation on 08/21/2025 at 10:05 AM of small refrigerator in the main kitchen showed one container of chopped lemons that was not covered or labeled with an open or expiration date. Observed approximately a quarter of a canister containing several butter packets that were not labeled with an open or expiration date. Observation on 08/21/2025 at 10:05 AM showed the main kitchen dry storage room had a box of mayonnaise packets that did not have an expiration date on the individual packages or the box.In an interview on 08/21/2025 at 10:22 AM Staff P (Visiting Food Service Supervisor) stated all bottles should be labeled when they were opened and have an expiration date but were not.In an interview on 08/28/2025 at 10:23 AM Staff Q (Director of Nutrition Systems) stated all food should be labeled and dated. If the food came from their food supply vendor, the staff should place a sticker with the received date on the food containers. If the food was unopened, the facility would use the manufacturer's date, if the manufacturer date did not show, the food must be labeled.<Facial [NAME] Covering>Observations on 08/21/2025 and 08/26/2025 at 10:49 AM showed three kitchen cooks (Staff P, Staff R - Cook, and Staff Z - Regional Chef) had facial beards and were not wearing beard nets to cover their face while preparing food.In an interview on 08/26/2025 at 10:49 AM Staff Q acknowledged Staff P, Staff R, and Staff Z had facial beards that were not covered and stated every time staff enter the kitchen, they needed to wear a hair net or facial cover for their beard. Staff Q stated this was important as foreign objects could enter the food being prepared.REFERENCE: WAC 388-97-1100(3).

Based on observation, interview, and record review the facility failed to ensure effective pain management was provided to residents, consistent with professional standards of practice. The failure to offer non-pharmacological interventions to residents experiencing pain or investigate causes of pain for 3 of 5 sampled residents (Residents 6, 49 & 40) reviewed for pain management, placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life.Findings included .<Facility Policy>Review of the facility's revised April 2025 Pain Assessment and Management policy showed procedures that helped staff identify pain in residents, helped with development of interventions consistent with the resident's goals and needs, and helped to address the underlying causes of pain. The policy shows staff were to conduct a comprehensive pain assessment whenever there was a need or significant change in condition and when there was an onset of new or worsening pain and to offer pain management interventions along with non-pharmacological intervention in conjunction with medications. The policy showed the facility would address and treat the underlying causes of the pain to the extent possible by developing and implementing both non-pharmacological and pharmacological interventions and approaches to pain management.<Resident 6> According to the 07/23/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 6 had a neurological condition, required a feeding tube to eat, and used an indwelling catheter (tube inserted in the urinary tract from the bladder) due to a urinary blockage. In an interview on 08/22/2025 at 9:49 AM, Resident 6 stated they had a suprapubic catheter (catheter surgically placed in the bladder, above the belly button) that sometimes clogged, but the staff took care of it. Resident 6 stated they were having surgery later this week to remove kidney stones. Review of the 02/25/2025 Catheter Care Plan (CP) showed staff would monitor and document fluid intake and urinary output as per facility policy and report pain/discomfort related to the catheter. The CP did not show Resident 6 had a history of kidney stones or interventions to relieve their kidney stone pain. Review of Resident 6’s physician orders showed an 08/01/2024 order for a narcotic pain medication. This order directed staff to administer 5 Milligrams (MG) every four hours as needed for “other chronic pain.” Review of the August 2025 Medication Administration Record (MAR) showed on 08/26/2025 Resident 6 received the narcotic pain medication at 2:15 AM, 7:30 AM and 1:02 PM. In an interview on 08/26/2025 at 8:59 AM, Resident 6 complained of pain and stated the nurse gave them their pain medication, but they were still in pain. In an interview on 08/26/2025 at 12:11 PM, Resident 6 stated the pain medication dulled their pain but did not really help relieve the pain, and staff did not provide or offer other interventions to help with the pain. Interview on 08/27/2025 at 10:59 AM, Resident 6 stated their pain on 08/26/2025 was caused by their catheter tubing being clogged and kinked. Resident 6 stated once the nurse was able to fix the kink, urine immediately began to flow into their catheter bag and Resident 6 felt better. Interview on 08/28/2025 at 9:24 AM Staff D (Nurse Supervisor) stated the nurses should check the catheter for kinks in the morning and monitor for urine flow. Staff D stated there were no nonpharmacological pain interventions listed on Resident 6’s CP or medication record but there should be, so nurses knew to offer Resident 6 other options instead of medications. Staff D stated staff could have discovered the source of Resident 6’s pain earlier instead of providing additional pain medications. In an interview on 08/28/2025 at 12:48 PM Staff B (Director of Nursing) stated the nurses should have assessed Resident's 6 pain first. The nurses should have assessed how intense the pain was, the location of the pain, and offered nonpharmacological interventions. Staff B stated this should have led the nurse into resolving the kink of the catheter bag first, rather than providing more pain medications. <Resident 49> According to the 08/20/2025 Annual MDS, Resident 49 had medically complex conditions, received pain medication, and non-medication interventions for pain. Review of the revised 02/18/2025 Pain CP showed Resident 49 had a fracture to their right arm. Interventions showed pain was alleviated and relieved by rest and medication. No other non-pharmacological interventions were listed on the CP to resolve Resident 49’s pain. In an interview on 08/22/2025 at 9:35 AM, Resident 49 stated they had a fall at the facility and broke their right wrist. Resident 49 stated there was some healing, but they could not do a lot of things because of the pain. In an interview on 08/25/2025 at 12:18 PM, Resident 49 stated they always had pain, and they received a muscle relaxer but that did not help with their ongoing pain. Resident 49 stated staff did not offer other interventions to help with the pain. Review of Resident 49’s physician orders showed a 10/24/2024 order for a muscle relaxer to be administered as needed every 8 hours. The order did not specify where the resident’s pain was or what the muscle relaxer was for. Review of Resident 49’s August 2025 MAR showed staff provided the muscle relaxer medication for pain but staff did not document where or what type of muscle pain Resident 49 experienced. In an interview on 08/28/2025 at 9:41 AM, Staff D stated there were no nonpharmacological interventions listed in Resident 49’s MAR and staff were providing the muscle relaxer for Resident 49’s arm and wrist but were not documenting nonpharmacological interventions. Staff D stated the MAR should show what the medication was intended for and provide non-pharmacological interventions, but staff did not. In an interview on 08/28/2025 at 12:44 PM, Staff B stated nonpharmacological interventions should be provided to residents in pain as the facility's providers were working to get rid of narcotic pain medications. Staff B stated they expected for short and long term pain, the staff assessed the pain and provided non pharmacological interventions. Staff B stated these instructions should be listed on the MAR to include what interventions worked for the resident’s pain and the order should specify what the pain medication should be used for but was not for Resident 49. <Resident 40> Review of the 08/03/2025 admission MDS showed Resident 40 received scheduled and as needed pain medications during the assessment period. The MDS showed Resident 40 did not receive non-medication interventions for their pain. The MDS showed Resident 40 was experiencing a pain level of “8” out of “10” on the pain scale during the time of the assessment. Observation and interview on 08/22/2025 at 10:42 AM showed Resident 40 sitting in their wheelchair in their room. Resident 40 had a large brace on their right leg extending from their thigh down to their shin. Resident 40 stated they had a fall at home and broke their leg. Review of the 07/30/2025 revised, “…acute/chronic pain” CP showed Resident 40 had pain related to a leg fracture. The CP directed staff to report as needed side effects of pain medication, report signs and symptoms of non-verbal signs of pain, and report complaints of pain or requests for pain treatment. The care plan did not include directions to staff to offer or provide non-pharmacological interventions for pain. Review of Resident 40’s 08/2025 MAR showed the resident had a 07/28/2025 order directing staff to monitor the resident’s pain every shift, a 07/29/2025 order for an over-the-counter pain reliver to be administered three times per day, a 07/29/2025 order for a pain reliving cream to be applied three times daily, and an 08/04/2025 order for a pain patch to be applied daily. The MAR showed no orders directing staff to provide non-pharmacological interventions for Resident 40’s pain. In an interview on 08/28/2025 at 9:31 AM, Staff E (Nurse Supervisor) reviewed Resident 40’s records and confirmed there were no directions to staff to offer the resident non-pharmacological interventions for their pain but stated there should be orders for non-pharmacological interventions. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for 1 (Resident 43) of 8 residents reviewed for accidents, and failed to ensure the potential risks of an air mattress were assessed prior to implementation for 1 supplemental resident (Resident 1). These failures placed residents at risk for falls, injury, discomfort, and frustration. Findings included. <Facility Policy>According to the facility's revised March 2018 Falls - Clinical Protocol Policy, after assessing a resident was at risk for falls, the facility would identify pertinent interventions to try to prevent future falls.<Resident 43>According to a 05/21/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 43 had multiple medically complex diagnoses and had a recent history of falls, one with major injury. This MDS showed Resident 43 had limitations in functional Range of Motion (ROM) to one of their arms and both sides of their legs, and required partial assistance from staff to roll side to side in bed.In an interview on 08/22/2025 at 10:20 AM, Resident 43 stated they have had several falls and fractured their wrist on a table next to their bed during a nightmare. Observations at this time showed an overbed table at Resident 43's bedside, a floor mat to the left side of the bed, and the resident was lying in a low bed with a raised edged mattress.Review of a revised 05/20/2025 falls Care Plan (CP) showed Resident 43 was at high risk for fall and injuries and had a history of falls related to nightmares. The established goal was that Resident 43 would not sustain serious injury through the review date. Interventions identified were: a raised edged mattress; to place floor mats on both sides of the bed during hours of sleep; the bed in lowest position.Review of a revised 05/20/2025 actual fall CP gave directions to staff to use floor mats on left side of the bed during hours of sleep.According to Resident 43's physician orders, a 03/25/2025 order showed directions for right and left side floor mats at bedtime to decrease injury from falls. There were no orders regarding the use of the floor mats during the day or for the raised edged mattress on Resident 43's bed.Record review showed no assessment or consent was found for the raised edged mattress currently in use.Review of a 03/04/2025 progress note showed Resident 43 obtained a fracture to their right wrist.According to a 03/05/2025 facility incident report, Resident 43 was having a nightmare and struck their wrist on the side of their table. Staff identified one intervention to prevent recurrence was to move all furniture two feet from the bed while sleeping. Review of Resident 43's comprehensive CP did not show staff added that injury prevention intervention on to the CP.In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated it was their expectation that fall and injury interventions be implemented to help prevent further falls or injuries and so staff are aware of what interventions should be in place. Staff D stated CPs should be updated and interventions clarified as needed. Staff D reviewed Resident 43's records and stated the physician orders and interventions needed to be updated. Staff D stated staff were only using a fall mat on the left side of the bed and that it should be in place at all times. Staff D stated all safety devices should have physician orders, be assessed for risks, and consent from the resident obtained prior to use. Staff D was unable to locate physician orders, a consent, or a safety device evaluation for Resident 43's raised edged mattress.<Resident 1>According to a 07/13/2025 admission MDS, Resident 1 had clear speech, was understood, and understands others. This MDS showed Resident 1 had a limitation in functional ROM to one of their arms and required substantial assistance from staff to roll from side to side, and had a history of falls with fracture.Observations on 08/22/2025 at 9:20 AM and 08/25/2025 at 8:36 AM showed Resident 1 lying in bed on an air mattress with their knees bent outward to the sides and their feet flat against the foot board. In interviews during the observed times, Resident 1 stated they were frustrated about their bed because it was too short and narrow for them. Resident 1 stated, I'm a tall guy and I'm afraid I could easily fall off the edge. Resident 1 stated it got worse when they changed them to an air mattress and stated they reported their concerns to staff.Review of a revised 07/10/2025 falls CP showed Resident 1 had a high potential risk for falls and injury with a goal that Resident 1 would not sustain serious injury through the review date. A revised 08/21/2025 skin integrity CP showed an intervention for a low air loss mattress was initiated for Resident 1 on 07/02/2025.Record review showed no assessment, evaluation, or consent was documented prior to the initiation of the air mattress for Resident 1.In an interview on 08/28/2025 at 10:18 AM, Staff E (Nurse Supervisor) stated an air mattress was considered to have safety risks and should have an assessment, evaluation, orders, and consent prior to implementing. Staff E reviewed Resident 1's records and was unable to locate an evaluation, assessment, or consent was obtained. Staff E stated their expectation was that a bed to be the appropriate size for the resident's comfort and safety. On 08/28/2025 at 10:47 AM, Staff E observed Resident 1's bed while Resident 1 stated, it needs to be longer, I have to keep my legs bent. Staff E confirmed Resident 1's air mattress and bed needed to be assessed.REFERENCE WAC: 388-97-1060 (3)(g).

Based on observation, interview, and record review the facility failed to ensure 1 of 23 sample residents (Resident 54) and one supplementary resident (Resident 1) reviewed for pressure injuries (injuries to the skin and underlying tissue caused by prolonged pressure) received the necessary care and services, consistent with professional standards of practice, to prevent new ulcers from developing, identify and treat PUs. Failure to complete weekly skin assessments, implement interventions, and describe and measure wounds placed residents at risk for skin deterioration, increased discomfort, new pressure injuries, and a diminished quality of lifeFindings included.<Facility Policy>According to the facility's revised April 2018 Pressure Ulcers/Skin Breakdown. policy the facility would assess residents' risk for pressure injuries and obtain orders from the physician for wound treatment. The policy showed the physician would identify pertinent medical interventions and during wound rounds evaluate and document the progress of wound healing.<Resident 54>According to a 07/07/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 54 was at risk for developing pressure ulcers/injuries, had no open wounds, was dependent on staff to roll from side to side in bed, had no rejection of care, and received hospice services (specialized care for people with a terminal illness) during the assessment period.Observations on 08/21/2025 at 10:37 AM showed staff providing care to Resident 54. An undated dirty foam dressing was observed on the Resident 54's tailbone area.Observations on 08/28/2025 at 9:44 AM showed Resident 54 lying in bed with a pillow under their knees and their heels resting on their mattress.Review of a revised 08/01/2025 skin impairment Care Plan (CP) showed Resident 54 had an actual impairment to skin of their tailbone area. The CP directed staff to monitor and document the location and size of the skin impairment, and the treatment provided.Review of a 07/01/2025 physician's order showed directions to staff to always float (lift from a surface) Resident 54's heels while in bed for skin integrity.Observations on 08/28/2025 at 9:44 AM showed Staff N (Nurse Supervisor) providing wound care to Resident 54's tailbone area. The old dressing was removed, revealing a small opening on the surface of the skin. Staff N cleansed the area and applied a new dressing, without measuring the wound. Staff N positioned a pillow under Resident 54's knees and rested both heels directly on the mattress.According to a 08/01/2025 nursing progress note, staff noted a Stage 2 (a partial-thickness skin loss) wound to Resident 54's tailbone area which they cleaned and covered. The note showed staff repositioned the resident, notified hospice, and wound care treatment orders would be implemented and added to the Treatment Administration Records (TAR). There was no description of the appearance or measurements of Resident 54's newly identified wound.Review of an 08/01/2025 facility investigation showed staff identified a Stage 2 pressure injury on Resident 54's tailbone area and documented the nurse supervisor assessed the skin, but no wound measurements were included in the investigation.Review of an 08/04/2025 hospice progress note showed Resident 54 had a new Stage 2 pressure injury on their tailbone area that was assessed, cleaned, and dressed. There was no description of the appearance or measurements of Resident 54's newly identified wound.Review of an 08/04/2025 hospice order scanned into Resident 54's records on 08/07/2025, showed direction to cleanse, dry, and apply a foam dressing to the wound twice a week and as needed when soiled. Staff hand wrote noted on the order on 08/06/2025.Review of Resident 54's August 2025 TAR showed the wound treatment orders were not implemented until 08/11/2025, eleven days after staff identified the tailbone wound, and five days after the order was noted by staff.In an interview on 08/28/2025 at 1:33 PM, Staff B (Director of Nursing) it was their expectation skin assessments were completed on the assessment form and full measurements obtained when any open areas were identified. Staff B stated wound treatment orders and skin interventions should be implemented immediately to decrease the risk of complications. Staff B stated staff should document the assessment and measurements of Resident 54's wounds weekly and as needed. Staff B stated staff should have obtained treatment orders on 08/01/2025 when the open area was identified but did not.<Resident 1>According to a 07/13/2025 admission MDS, Resident 1 admitted to the facility after spinal surgery, had a surgical wound, and required wound care. This MDS showed Resident 1 required substantial assistance from staff to roll side to side in bed and was at risk for developing pressure ulcers.Review of a 07/18/2025 pressure ulcer/injury Care Area Assessment showed Resident 1 had a potential for impairment to skin integrity related to decreased functional bed mobility.Review of a revised 08/21/2025 potential for impairment of skin CP showed a goal that Resident 1 would maintain or develop clean and intact skin by the review date. This CP gave directions to staff for an air mattress and to monitor/document the location, size, and treatment of the skin injury.Review of Resident 1's physician orders showed a 07/14/2025 order to offload (lift from a surface) both resident's heels while in bed for blanchable (whitening of skin when pressed to indicate blood flow remain) redness.Observations on 08/22/2025 at 9:50 AM and 08/25/2025 at 8:36 AM showed Resident 1 lying in bed with their heels on the surface of the bed.In an interview on 08/28/2025 at 10:18 AM, Staff E (Nurse Supervisor) stated it was their expectation staff followed physician orders and offloaded heels to decrease the risk of pressure ulcers and complications.In an interview on 08/28/2025 at 3:00 PM, Staff B stated it was important to have pressure reducing interventions in place and being followed by staff to try and avoid skin breakdown.REFERENCE: WAC 388-97 -1060 (3)(b).

Based on observation, interview, and record review the facility failed to ensure activity programs met the needs for 5 (Residents 1, 54, 2, 9, & 20) of 7 residents reviewed for activities. The failure to provide meaningful activities left residents at risk of boredom and a diminished quality of life. Findings included.<Facility Policy>According to the facility's revised 2018 Activity Evaluation policy, an activity evaluation would be completed for each resident and the results incorporated into the resident's Care Plan (CP). This CP would facilitate the resident's participation in the activities of their choice.<Resident 1> According to the 07/13/2025 admission Minimum Data Set (MDS – an assessment tool) it was very important to Resident 1 to listen to music, be around pets, participate in group and favorite activities, and attend religious services. Review of the 07/16/2025 “somewhat dependent on staff for meeting emotional, intellectual, physical, and social needs…” CP Resident 1 had a goal to participate in activities of their choice one-to-two times a week, as able. This CP showed staff should invite Resident 1 to scheduled activities and provide the resident with materials for independent pursuits as needed. The CP identified Resident 1’s preferred activities as listening to music (country, oldies, easy listening), being around animals, socializing, watching television and movies, playing video games, spending time with friends and family, being outdoors, and religious practices. In an interview on 08/28/2025 at 10:52 AM Resident 1 stated in terms of having enough to do, “lying in bed all day doesn’t [NAME] it.” Observation on 08/25/2025 at 11:01 AM on the third floor showed activities staff helping eight residents gather in a circle for a balloon activity. Resident 1 was not among the eight residents. According to the 07/9/2025 Resident preferences Evaluation, Resident 1 enjoyed listening to music (country, oldies, easy listening), being around animals, socializing, watching television and movies, playing video games, spending time with friends and family, being outdoors, and religious participation. Review of the activities documentation showed in July 2025 the facility provided Resident 1 a one-to-one activity one occasion, and in August 2025 was again provided a one-to-one activity on one occasion only, and documented the resident participated in “independent pursuits” on two occasions. <Resident 54> According to the 07/07/2025 admission MDS, it was very important to the Resident 54 to participate in their favorite activities, going outside, and participating in religious services. According to the 07/04/2025 Activities Care Area Assessment (CAA) leisure was an important part of a resident’s wellbeing. This CAA showed staff should focus on providing Resident 54 their preferred activities and should encourage family visitation and spiritual support. According to the 07/07/2025 “dependent on staff and family for meeting emotional, intellectual, physical, and social needs…” CP, Resident 54 had a goal to participate in activities of their choice two-to-three times a week, as able. The CP showed staff should invite Resident 54 to scheduled activities and provide assistance to get to the activities. The CP showed staff should Review of the activities charting showed no individual or group activities provided to Resident 10 in the 30-day period from 07/29/2025 through 08/27/2025. There were no documented refusals Observation on 08/21/2025 at 11:31 AM Resident 54 was observed lying in bed, dressed. Resident 54 wanted to get up and do something. There were no individual activities available at Resident 54’s bedside. Observation on 08/22/2025 from 10:02 AM through 10:59 AM, showed Resident 54 in bed with the television off. Observation on 08/25/2025 at 11:01 AM on the third floor showed activities staff helping eight residents gather in a circle for a balloon activity. Resident 54 was not among the eight residents. <Resident 2> According to the 07/27/2025 admission MDS, Resident 2 stated it was very important to them to have reading material available, to listen to music, keep up with the news, do things in groups, participate in their favorite activities, go outside when the weather is good, and participate in religious services. In an interview on 08/22/2025 at 7:54 AM Resident 2 stated they did not attend group activities. Resident 2 stated they loved to read but their poor vision prevented them. Resident 2 stated they would like to go to “meetings” but did not while at the facility. In an interview on 08/22/2025 at 11:59 AM, Resident 2 stated they did not attend any activities that day. Resident 2 stated they hoped “there was a bridge group or something.” Resident 2 stated they did not attend activities on the third floor and asked if the activities provided on that floor were good. Observation on 08/25/2025 at 11:01 AM on the third floor showed activities staff helping eight residents gather in a circle for a balloon activity. Resident 2 was not among the eight residents. According to the 07/28/2025 “somewhat dependent on staff for meeting emotional, intellectual, physical, and social needs…” CP, Resident 2’s goal was to attend their activities of choice one-to-two times weekly. The CP showed staff should invite Resident 2 to scheduled activities and provide assistance to participate. The CP showed Resident 2 should attend a religious service on Tuesdays as available and identified the resident’s preferred activities as reading (current events), listening to music, keeping up with the news, using their phone to access internet, card games (bridge), word puzzles, being around friends and family, watching television or movies, being outdoors, and religious practices. According to the 07/31/2025 Health Center Activity-Life Enrichment Assessment, Resident 2 saw the benefit of activity participation, and enjoyed independent activities, card and board games, going outside, movies, music, politics, puzzles, socializing, and religious services. Review of the activities charting showed no individual or group activities provided to Resident 2 in the 30-day period from 07/29/2025 through 08/27/2025. There were no documented refusals <Resident 9> According to the 06/16/2025 Quarterly MDS, Resident 9 stated their preferred activities of reading, listening to music, being around animals, and participating in religious services were very important to them. According to the 10/10/2024 psychosocial wellbeing CAA psychosocial wellbeing was an area of concern for Resident 10 who showed little pleasure in doing things outside their room and chose to stay in their room all the time. According to Resident 9’s 10/13/2024 “dependent on staff for meeting emotional, intellectual, physical, and social needs…” CP, Resident 9’s goal was to attend activities of their choice one-to-two times a week. The CP showed Resident 9 needed staff assistance to attend activities should receive one-to-one visits in their room if unable to attend. The CP showed Resident 9 would attend a religious service on Tuesdays as needed/requested, and their preferred activities were reading, listening to music (including [NAME]), being around animals, keeping up with the news, going outside, spending time with friends and family, watching television shows and movies, cooking and baking, reminiscing, people watching, bird watching, and one-to-one visits. The CP showed staff should invite Resident 9 to scheduled activities, and provide the resident with materials to do individual activities as desired. Review of a 06/16/2025 Health Center Activity-Life Enrichment Assessment showed Resident 9 saw the benefit of and wished for more activities. The assessment showed Resident 9 needed reminders and assistance to attend activities, and sometimes enjoyed being around others. Review of the activities charting showed no individual or group activities provided to Resident 9 in the 30-day period from 07/29/2025 through 08/27/2025. There were no documented refusals Observation on 08/22/2025 at 12:35 PM, on 08/22/2025 at 1:01 PM, on 08/25/2025 at 8:31 AM and on 08/25/2025 at 2:12 PM showed Resident 9 in bed with no television, movie, or music playing. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated the activities staff notified nursing what activities were scheduled on the calendar and communicate what assistance they needed to ensure resident were able to get to the scheduled activity. Staff D stated nurse’s aides and management helped get residents to activities. Staff D stated not many resident from the second floor made it up to the activity area on the third floor. In an interview on 08/27/2025 at 12:36 PM Staff S (Activity Coordinator) stated the activities process started with Staff S’s doing the activities portion of the MDS assessment, and then discussing activity preferences with the resident as part of the Life Enrichment Assessment. This information was used to develop the activities CP. Staff S stated the facility’s nurse’ aides and activity assistant were responsible for helping residents get to activities. Staff S stated most scheduled activities occurred on the third floor but there was an activity cart on the second floor with recreational supplies. Staff S stated if residents liked group/social activities, they expected those residents to be invited and assisted to come as needed. Staff S stated activity participation and refusals to participate should be documented in the activities charting. Staff S stated they expected the activity CP to be updated to reflect residents’ current interests/abilities. Staff S stated there was no record of any activity participation or refusals to participate for Residents 54, 2, or 9 over the 30-day period from 07/29/2025 through 08/27/2025. Staff S stated they was no record of Resident 1 participating in groups or refusing to participate in July or August 2025 <Resident 20> According to the 08/13/2025 admission MDS, Resident 20 had adequate hearing, clear speech, was understood and could understand others. The MDS showed the resident was cognitively intact. The MDS showed it was very important for Resident 20 to have books, newspapers, and magazines to read, listen to music, be around pets, keep up with the news, and do things with groups of people. Review of Resident 20’s “… somewhat dependent on staff for meeting emotional, intellectual, physical, and social needs CP, revised 08/13/2025, showed a goal the resident would attend/participate in activities of choice two to four times per week. The care plan directed staff to invite Resident 20 to scheduled activities and showed the resident required assistance to get to facility activities. The care plan showed Resident 20’s preferred activities included reading, listening to music, being around animals, socializing, doing word searches, and being outdoors. In an observation and interview on 08/22/2025 at 9:43 AM, Resident 20 stated the facility staff did not invite them to activities and that they were not aware of what activities were occurring. Resident 20 stated they read anything the facility brought them because they were “so bored.” Resident 20 stated their son recently brought them a flyer showing the facility had dogs visit a couple times per week and stated, “I would love to pet a dog.” Resident 20 stated they received the facility’s daily newssheet occasionally but not daily. Observation on 08/26/2025 at 2:10 PM showed activities staff starting the 2:15 PM bingo activity at 2:10 PM, stating “I don’t think anyone else is coming”, five minutes before the posted time. Unidentified residents were observed getting off the elevator going to the activity, concerned that bingo started before the scheduled time. Observation and interview on 08/26/2025 at 2:14 PM showed Resident 20 in their room reading a book. Resident 20 stated staff did not invite them to the bingo activity. Review of Resident 20’s 30-day activity documentation showed the resident did not refuse to participate in any activities. The documentation showed the resident participated in one-on-one/keep in touch activities or “independent pursuits.” In an interview on 08/28/2025 at 10:05 AM, Staff S stated they and the activity assistants notified residents of activities. Staff S stated they also relied on the nursing assistants, especially on the second floor, to invite residents and assist them to activities. Staff S stated the daily newssheet was only passed out on Saturdays, not daily. Staff S stated it was their expectation all residents were invited to activities and that activities started at the posted times. REFERENCE: WAC 388-97-0940 (1).

Based on observation, interview, and record review the facility failed to ensure proper storage and labeling of medications in 1 of 1 medication storage rooms (Cascade Hall), 2 of 3 medication carts (Cascade Hall and Shoreline Hall), and ensure medications were secured for 1 of 1 residents (Resident 2) reviewed for medication storage. These failures placed residents at risk of receiving expired medications, ineffective treatment, missing medications, and a diminished quality of life.Findings included.<Facility Policy>According to the facility's Medication Labeling and Storage policy, revised 02/2023, all medications would be labeled with an expiration date. The policy showed multi-dose vials that were opened would be dated and discarded within 28 days.<Cascade Hall Medication Room>Observation on 08/21/2025 at 9:11 AM of the Cascade Hall medication storage room showed an open bottle of tuberculosis (infectious, airborne disease affecting the lungs) testing solution with an open date of 07/08/2025. The bottle was not discarded after 28 days. Observation at that time showed a box containing an open vial of tuberculosis testing solution. This vial did not have an open date to direct staff when the bottle was opened or when it needed to be discarded.In an interview on 08/21/2025 at 9:11 AM, Staff BB (Assistant Director of Nursing) confirmed the bottles of tuberculosis testing solution should be discarded.<Cascade Hall Medication Cart>Observation on 08/21/2025 at 1:24 PM of a medication cart on the Cascade Hall showed an injectable medication used to treat a blood sugar disorder with an open date of 06/14/2025. Observation at that time showed a blood sugar control solution with an open date of 11/2025. The instructions on the control solution directed the user to use the solution within three months of opening.In an interview on 08/21/2025 at 1:24 PM, Staff CC (Licensed Practical Nurse - LPN) confirmed the injectable medication should be discarded after 28 days of opening and the testing solution was expired.<Shoreline Hall Medication Cart>Observation on 08/21/2025 at 1:55 PM of a medication cart on the Shoreline Hall showed an injectable medication used to treat a blood sugar disorder with an open date of 07/07/2025. In an interview at that time, Staff K (LPN) confirmed the medication should be discarded after 28 days.In an interview on 08/28/2025 at 1:33 PM, Staff B (Director of Nursing) stated it was their expectations no medications should be opened without a date opened added to the label. Staff B confirmed the tuberculosis testing solution should be discarded after 28 days of opening and the injectable blood sugar medication should be discarded after 28 days of opening. Staff B confirmed the testing solution should be discarded after three months as specified in the manufacturer's instructions. <Medications at Bedside><Resident 2>Observations on 08/22/2025 at 11:59 AM showed one bottle of a prescription eye drop medication used to decrease the pressure in the eyes and one bottle of a prescription eye drop medication used for chronic dry eye disease caused by inflammation. The bottles were sitting on a medication tray on Resident 2's overbed table.Observations on 08/22/2025 at 12:41 PM showed the same two eye drop medication bottles still unsecured at Resident 2's bedside. In an interview at this time, Staff AA (Registered Nurse) confirmed the medications and stated they should not be left unsecured in a resident's room.REFERENCE: WAC 388-97-1300(2), -2340.

Based on observation, interview, and record review the facility failed to ensure physician orders were clarified for 4 (Residents 4, 40, 2, & 43,), order parameters were followed for 1 (Residents 53), and staff were signing only for tasks that were completed for 2 (Residents 1 & 2) of 20 sample residents reviewed. These failures placed residents at risk for medication errors, unmet care needs, and other negative health outcomes.Findings included .<Facility Policy>According to the facility's Medication and Treatment Orders policy, revised 07/2016, medication would only be administered upon the written order for the medication. Medication orders would include the dosage staff were to administer.<Clarifying Physician Orders> <Resident 4> Review of Resident 4’s 08/2025 Medication Administration Record (MAR) showed the resident had two 07/02/2025 orders directing staff to administer an as needed; over-the-counter pain medication. The first order directed the staff to administer 10.2 milliliters (mL) of the medication every four hours as needed for pain. The second order directed staff to administer 20.3 mLs of the pain medication every four hours as needed for pain. These orders did not include parameters for Resident 4’s pain level so staff knew which order to administer. In an interview on 08/28/2025 at 10:22 AM, Staff B (Director of Nursing) reviewed the pain medication orders and stated the orders needed to be clarified to include pain level parameters so staff knew which dose to administer to Resident 4. <Resident 40> Review of Resident 40’s 08/2025 MAR showed an order directing staff to administer a suppository every 24 hours as needed if a laxative given prior to the suppository was ineffective. Further review of Resident 40’s MAR showed there was no order regarding the laxative medication. In an interview on 08/28/2025 at 9:30 AM, Staff E (Nursing Supervisor) reviewed Resident 40’s suppository order and confirmed the order required clarification. <Resident 2> Review of Resident 2’s August 2025 MAR showed an order for a blood pressure medication to be administered twice daily. This order gave directions to staff to hold the dose if Resident 2’s heart rate was less than 60. There was no documentation staff were obtaining Resident 2’s heart rate prior to administration of the dose. In an interview on 08/28/2025 at 1:33 PM, Staff B stated it was their expectation staff check a resident’s heart rate prior to administering the medication as directed by the physician and the order needed to be clarified. <Resident 43> Review of Resident 43’s August 2025 MAR showed an 11/22/2024 order for a liquid supplement to be administered twice daily and a second 03/07/2025 order for another liquid supplement to be administered twice daily for weight loss. Neither of these orders gave directions to staff the amount of liquid supplement they were to administer. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated the physician orders needed to be clarified and the amount to administer should be included in the order. <Medications Administered Outside of Parameters> <Resident 53> Review of Resident 53’s 08/2025 MAR showed a 07/25/2025 order directing staff to administer a blood pressure medication twice daily to the resident. The order directed staff to hold the blood pressure medication if the resident’s systolic blood pressure (measure of the pressure in the arteries when the heart contracts to pump blood) was less than 100 or if the resident’s heart rate was less than 60 beats per minute. This MAR showed on four occasions staff administered the blood pressure medication to Resident 53 when their heart rate was less than 60 beats per minute. In an interview on 08/28/2025 at 11:15 AM, Staff B stated they expected staff to follow parameters as stated on medication orders. <Signing For Tasks Not Completed> <Resident 1> In an interview on 08/25/2025 at 8:36 AM, Resident 1 stated after back surgery, they used to wear a chest brace, but stated they were no longer using it. Resident 1 stated it was “quite a while” since they wore it last. Observations at this time showed Resident 1 was not wearing a brace. Review of Resident 1’s August 2025 Treatment Administration Record (TAR) showed staff were documenting twice daily they were removing the resident’s chest brace immobilizer to monitor skin underneath. In an interview on 08/28/2025 at 1:33 PM, Staff B stated it was their expectation staff not sign for tasks they did not complete. <Resident 2> Review of Resident 2’s August 2025 MAR showed staff were documenting twice daily the resident was on contact precautions for an infection. The MAR included six medications that did not include the diagnosis to be treated: three medicated eyedrops, a blood thinner, a medication to treat inflammation, and a medication to treat high cholesterol or itching. Observations on 08/21/2025 at 9:05 AM and 08/22/2025 at 7:52 AM showed no contact precautions sign at Resident 2’s door. In an interview on 08/28/2025 at 12:04 PM, Staff X (Infection Preventionist) stated Resident 2 was not on contact precautions and the order should be discontinued. Staff X stated staff should not document a task was completed, if it was not. In an interview on 08/28/2025 at 1:33 PM Staff B stated it was important for mediation orders to identify the condition being treated so staff knew why the resident needed the medication. Staff B stated medication should not be prescribed without an indication for use. REFERENCE: WAC 388-97-1620 (2)(b)(i)(ii), (6)(b)(i).

Based on interview and record review, the facility failed to ensure nurses signed timely for the care provided for 1 (Resident 1) of 20 sample residents reviewed, and failed to ensure provider notes were added timely to the resident's record for 1 (Residents 9) of 1 resident reviewed for hospice and one supplemental resident (Resident 54). These failures placed residents at risk for an incomplete record of their care, unmet care needs, and delays in treatment. Findings included.<Resident 1>According to a 07/13/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 1 had multiple medically complex conditions including a thyroid (an organ that helps regulate metabolism) disorder.Review of the August 2025 Medication Administration Record (MAR) showed Resident 1 had a thyroid medication scheduled to be administered every day by staff at 6:30 AM. This MAR showed nurses left the boxes blank with no initials indicating the medications were administered as ordered on 08/20/2025 and 08/21/2025.In an interview on 08/28/2025 at 10:56 AM, Staff Y (Medical Records) stated it was important to have complete and accurate resident records. Staff T stated MARs should not be left blank.<Resident 9>According to a 06/16/2025 Quarterly MDS, Resident 9 had moderate memory impairment, a life expectancy of less than six months, and received hospice (specialized care for people with a terminal illness) services.Review of Resident 9's records on 08/27/2025 showed the last hospice note in the resident's records was from 08/04/2025, over three weeks previously. There was no record of a hospice visit after that date.In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated hospice visited Resident 9 frequently and stated their expectation was for the visit notes to be readily available in the resident's record, so they were accessible to all care staff and providers. Staff D reviewed Resident 9's records and was unable to locate any hospice notes after the 08/04/2025 visit.<Resident 54>According to a 07/07/2025 admission MDS, Resident 54 had moderate memory impairment, a life expectancy of less than six months, and received hospice services.Review of Resident 54's records on 08/27/2025 showed the last hospice note in the resident's records was from 08/04/2025, over three weeks previously. There was no record of a hospice visit after that date.In an interview on 08/28/2025 at 1:33 PM, Staff B (Director of Nursing) stated it was their expectation hospice notes were added to a resident's records timely so any orders or updates could be processed within 24 hours and any pertinent information added into the resident's care plan.REFERENCE: WAC 388-97-1720 (1)(a)(i-iv)(b).

Based on observation, interview, and record review the facility failed to initiate, investigate, and resolve grievances for 1 of 1 sampled residents (Resident 49) reviewed for grievances. This failure placed residents at risk for emotional distress, unresolved frustration, and a diminished quality of life.Findings included .<Facility Policy>According to the facility's revised 10/20/2023 Resident and Family Grievance policy, the team member who received a grievance from a resident or family member would complete a grievance form or assist in completing the form. The form would be forwarded to the social services department, resident services direct, and the executive director. The policy showed the receiving team members would take steps to resolve the grievance and record the information and actions taken to resolve the grievance as quickly as possible and to notify the resident of the progress of the resolution. <Resident 49>According to the 08/20/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 49 could understand and be understood by others, had neurological conditions, and memory impairment. The MDS showed Resident 49 needed partial to moderate assistance with personal hygiene. Review of the revised 03/13/2025 activities of daily living performance deficit care plan showed Resident 49 had impaired balance and muscle weakness and needed assistance with personal care.Review of the facility's grievance reporting log did not show a grievance report completed for Resident 49. In an observation and interview on 08/22/2025 at 9:21 AM, Resident 49 stated they could not get to their clothing in the room's closet because their roommate (Resident 17) blocked the room closet with their clothes hanging on the door of the closet. Resident 49 stated they could barely wash their hands or use the bathroom because the room sink was crowded with Resident 17's hygiene products and the bathroom door was blocked with Resident 17's clothing items. Resident 49 stated Resident 17's bed was pushed over the room divider curtain towards their bed and was now taking over even more of their personal space. Observed Resident 17's bed was pushed up against the room divider curtain and pushed up against Resident 49's items, very near Resident 49's bed. Observed, the handwashing sink was cluttered with bottles of toiletries, cups and brushes that limited access to the handwashing sink. Resident 49 stated they were frustrated because they told the nursing staff on several occasions but nothing had been done about this and no one had got back to them regarding these issues. Observation on 08/25/2025 at 9:21 AM showed Resident 17's room was cluttered with clothing on the floor and clothing was hanging on the closet door and bathroom door. The room sink was overcrowded with bottles of soap, lotions, brushes, and other toiletries.Observation on 08/26/2025 at 2:15 PM showed Resident 17 was by the room handwashing sink near Resident 49's bed. Resident 17 placed more items on the counter of the sink and items into the resident drawers near sink.In an interview on 08/26/2025 at 2:17 PM Staff J (Certified Nursing Assistant) stated they were not aware there was an issue or complaint by Resident 49 about Resident 17 taking over much of the space in their room. Staff J stated they were aware that Resident 17 had a lot of items that were disorganized in the room. In an interview on 8/28/2025 at 8:47 AM Staff C (Social Services) stated they were waiting to declutter Resident 17's room when Resident 17 was better able to handle moving things in their room because they would get upset. Staff C stated they were aware of Resident 49's concerns but did not think this issue constituted completing a grievance report and they did not go back to Resident 17 to discuss a resolution. After reviewing the facility's grievance process, Staff C stated a grievance report should be completed by the staff but was not. Staff C said it was important to fill out a grievance report because it would start a grievance process so others would be aware of the issue and staff could work to resolve the problem and provide feedback to Resident 49. In an interview on 08/28/2025 at 9:30 AM Staff D (Nurse Supervisor) stated they were aware of a clutter issue in Resident 17's room, and stated it was a difficult situation to manage. Staff D stated they were not aware of a grievance by Resident 49 and did not see a grievance form completed by the staff. Staff D stated the staff should have filled out a grievance form and the staff should have documented Resident 49's issue but did not.In an interview on 08/28/2025 at 12:59 PM, Staff B (Director of Nursing) stated staff were expected to fill out a grievance form anytime a resident had a concern or complaint. Staff B stated this would allow staff to track and follow the grievance for a resolution and provide customer service such as getting back to the resident on the resolution. Staff B stated a grievance form should be completed for Resident 49 but was not. REFERENCE: WAC 388-97-0460.

Based on observation, interview, and record review the facility failed to ensure residents were free from unnecessary psychotropic medications for 3 (Residents 55, 1, & 2) of 5 residents reviewed for unnecessary medications. Staff failure to monitor residents for target behaviors, provide nonpharmacological interventions, and obtain consent for psychotropic medications placed residents at risk for receiving unnecessary medications and other negative health outcomes.Findings included .<Facility Policy>According to the facility's Psychotropic Medication Use policy, revised 02/2025, the facility would utilize behavioral and non-pharmacological approaches to minimize the need for psychotropic medications. This policy showed psychotropic medications would be considered when non-pharmacological approaches were attempted but did not relieve the resident of their medical symptoms. The policy showed prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and the physician would review non-pharmacological alternatives, rationale for the recommendation, potential risks and benefits, and the resident/representative's right to accept or decline the treatment. The policy showed staff would monitor the resident's response to treatment including a behavior flow sheet. <Resident 55> According to the 06/29/2025 admission Minimum Data Set (MDS – an assessment tool), Resident 55 had a diagnosis of depression and received an antidepressant medication during the lookback period. Review of Resident 55’s August 2025 Medication Administration Record (MAR) showed the resident received an antidepressant medication daily. This MAR showed no orders indicating staff identified and documented target behaviors related to Resident 55’s depression and there were no orders directing nonpharmacological interventions. Review of Resident 55’s 06/23/2025 comprehensive Care Plan (CP) showed staff did not identify nonpharmacological interventions or target behaviors related to the resident’s depression. In an interview on 08/28/2025 at 9:33 AM, Staff E (Nurse Supervisor) reviewed Resident 55’s record and confirmed staff were not monitoring the resident for target behaviors or implementing nonpharmacological interventions. <Resident 1> According to the 07/13/2025 admission MDS, Resident 1 had multiple medically complex diagnoses including depression and required the use of an antidepressant medication during the assessment period. In an interview on 08/22/2025 at 9:20 AM, Resident 1 stated they struggled at times with not wanting to give up on their therapy progress and expressed feelings of frustration. An observation at this time showed Resident 1 was tearful off and on during the interview process. Review of a revised 08/22/2025 antidepressant CP directed to staff to administer the antidepressant medication as ordered and to monitor/document the side effects and effectiveness every shift. Review of Resident 1’s August 2025 MAR showed the resident was receiving an antidepressant medication daily with no behavior monitoring being documented by staff. In an interview on 08/27/2025 at 1:15 PM, Staff D (Nurse Supervisor) stated behavior monitoring was important to justify if the medications were needed or not, and to help evaluate the effectiveness of the antidepressant medication. Staff D stated behavior monitoring should be documented on the MAR, reviewed Resident 1’s records, and confirmed there was no behavior monitoring for the use of the antidepressant medication. <Resident 2> According to a 07/27/2025 admission MDS, Resident 2 had multiple medically complex diagnoses including anxiety and required the use of antidepressant and antianxiety medications during the assessment period. Review of both revised 07/29/2025 antidepressant and antianxiety CPs showed directions to staff to administer the psychotropic medications as ordered and to monitor/document the side effects and effectiveness every shift. Review of Resident 2’s August 2025 MAR showed the resident was receiving an antidepressant daily and an antianxiety medication three times daily. No behavior monitoring was being documented by staff for either medication. Additionally, no consent for the antianxiety medication was found in Resident 2’s records. In an interview on 08/28/2025 at 10:18 AM, Staff E stated if a resident was receiving psychotropic medications, it was their expectation a consent was obtained, and staff would monitor and document behaviors. Staff E stated behavior monitoring was important to identify how often the resident experienced behaviors and/or if the medication doses need to be adjusted. Staff E reviewed Resident 2’s records and was unable to find behavior documentation for the psychotropic medications. In an interview on 08/28/2025 at 1:22 PM, Staff N Reviewed Resident 2’s records and was unable to provide the consent for the antianxiety medication. REFERENCE: WAC 388-97-0620 (2)(d), (4)(b).

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 5 (Resident 43, 2, 5, 10, & 26) of 20 sampled residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included .<Resident 43> <Falls> According to a 05/21/2025 Quarterly MDS, Resident 43 had a functional limitation in range of motion to their upper extremity on one side and both sides to their lower extremities. This MDS showed Resident 43 had two or more non-injury falls, two or more injury falls, and one fall with major injury since the prior MDS on 03/04/2025 Review of the facility incident report log showed Resident 43 had two documented incidents, one on 03/05/2025 and one on 03/24/2025. No other incidents were documented on the log. Review of the 03/05/2025 incident report showed Resident 43 obtained a wrist fracture after having a nightmare and striking the edge of a table near their bed. No fall was indicated on the 03/05/2025 incident report. Review of the 03/24/2025 incident report showed Resident 43 had a fall from their bed and had no injuries. In an interview on 08/27/2025 at 1:00 PM, Staff I (MDS Coordinator) stated they calculate falls on the MDS by reviewing the resident’s records and adding up the falls since the previous assessment period. Staff I reviewed Resident 43’s records and stated the 03/05/2025 MDS falls section was inaccurate and needed to be modified. <Depression> According to the 05/21/2025 Quarterly MDS, Resident 43 had multiple medically complex diagnoses, did not have an active diagnosis of depression, but received an antidepressant medication during the assessment period. Review of a 04/01/2025 physician visit note showed an assessment that indicated Resident 43 had depression and was to continue on the current dose of an antidepressant. Review of Resident 43’s physician orders showed the resident was receiving an antidepressant medication for depression since their admission on [DATE]. In an interview on 08/27/2025 at 1:00 PM, Staff I reviewed Resident 43’s records and stated depression should have, but was not triggered as an active diagnosis on the 05/21/2025 assessment and needed to be modified. <Resident 2> According to a 07/27/2025 admission MDS, Resident 2 had multiple medically complex diagnoses, did not have an active diagnosis of depression, but received an antidepressant medication during the assessment period. Review of a revised 07/29/2025 antidepressant Care Plan (CP) gave directions to staff to administer the antidepressant medication as ordered and to monitor/document the side effects and effectiveness every shift. Review of Resident 2’s August 2025 MAR showed the resident was receiving an antidepressant for a diagnosis of depression daily since their admission to the facility. In an interview on 08/27/2025 at 1:00 PM, Staff I stated an MDS should be accurate and include the resident’s active diagnoses. <Resident 5> According to the 07/17/2025 Annual MDS, Resident 5 had cognitive impairment and depression without behaviors. No mood behaviors were noted on the MDS. Review of progress note dated 03/25/2025 showed Resident 5 was on alert for behavior issues. Review of the 05/05/2025 PASSR I form, Resident 5 had serious mental illness indicators for mood and anxiety. Review of progress note dated 05/26/2025, showed staff documented Resident 5 had confusion and hallucinations. In an interview on 8/28/2025 at 1:18 PM Staff I stated they were not aware of Resident 5’s behaviors but stated an update to the MDS should have been done. <Resident 10> According to the 08/05/2025 Quarterly MDS, Resident 10 had multiple chronic conditions. The MDS showed Resident 10 had not exhibited any behaviors. Review of a progress note dated 06/15/2025 showed Resident 10 had an attempted elopement and was found outside of the facility on the sidewalk at the bus stop and the police were notified. Review of a 08/03/2025 progress note showed Resident 10 refused a readmission skin check, used profanities toward the nurse and told the nurse to get out of their room. Review of 08/06/2025 progress note showed Resident 10 exhibited behavioral issues, including an attempted elopement from the building, verbal abuse toward staff and used inappropriate language, attempted to punch staff and discarded a portion of their prescribed medication in the trash. In an interview on 08/21/2025 at 1:52 PM, Resident 10 stated a staff member had to escort them whenever they left the facility because the facility was afraid they would leave. Resident 10 stated on one occasion they got out of the facility to go shop in a nearby city and the facility called the police on them. In an interview on 08/28/2025 at 12:22 PM Staff D (Nurse Supervisor) stated they were not aware that Resident 10 had any psychological issues, and thought Resident 10 acted out knowingly and on purpose and was the reason the assessment was not updated. In an interview on 8/28/2025 at 1:18 PM Staff I stated they were not aware of Resident 10’s behaviors and any unwarranted behaviors, elopement or threatening others and staff should have triggered a behavior risk alert, and this would have triggered Staff I to update the MDS. Staff I stated social services was responsible for completion of the behavior section on the MDS and an updated MDS should be done for Resident 10 but was not. <Resident 26> According to the 07/15/2025 Quarterly MDS, Resident 26 had a condition where the brain's function was impaired due to disturbances in the body's metabolism. The MDS showed Resident 26 exhibited no behaviors and Resident 26’s short- and long-term memory was ok. Review of an 07/12/2025 provider progress note showed Resident 26 had intermittent confusion. Review of 08/05/2025 social services note, showed Resident 26 had mentioned to their family on 08/01/2025 that their roommate had hallucinations about their roommate. Review of 08/08/2025 provider progress note showed if medical workup was unremarkable, the provider would consider an antipsychotic medication due to severity of delusional thought content. Review of 08/14/2025 provider progress note showed Resident 26 had a diagnosis of moderate unspecified dementia with psychotic disturbance and recent delusions. In an interview with Resident 26’s family on 08/26/2025 at 2:34 PM, the family stated the allegation about their roommate was not valid as Resident 26 was not a reliable source due to confusion. In an interview on 8/28/2025 at 1:18 PM Staff I stated they did not make any changes in the MDS due to Resident 26’s behaviors and confusion. Staff I stated if a psychological evaluation was ordered and there were changes in Resident 26’s behaviors and cognition a change in the MDS should be made but was not. In an interview on 08/28/2025 9:43 AM Staff D stated they and the MDS nurse were responsible for updating the MDS assessment. Staff D stated the MDS should be updated and revised for Resident 26's behaviors and cognition but was not. REFERENCE: WAC 388-97-1000 (1)(b).

Based on observation, interview and record review, the facility failed to ensure each resident had the required equipment to prevent accidents, for 1 of 3 residents (#1) reviewed for falls. The facility failed to implement safety interventions when the resident did not wear required foot wear consistent with the resident's individualized needs and care plan, for going outside to an appointment to prevent accidents. This failure resulted in harm for Resident #1, who experienced a fall and sustained a right [MEDICAL CONDITION]. Findings included: RESIDENT #1 Resident #1 admitted to the facility on [DATE], after an acute hospitalization . The resident's [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) an assessment tool dated 06/06/19, showed the resident required assistance of staff for all Activities of Daily Living (ADLs) including, dressing (putting on proper footwear-nonskid shoes) and one person assistance with mobility, for the resident's safety. Review of Resident #1's Care Plan (CP) dated 05/20/19, instructed staff to ensure Resident #1 had appropriate foot wear (Non-skid shoes). Observation on 07/29/19 at 8:30 AM showed, Resident #1 laying in her bed with substantial darkened bruises covering most of the resident's face. Further observation showed, the resident had a surgical incision to the right hip area, and substantial bruising to lateral and posterior right thigh. On 07/29/19 at 9:30 AM in an interview, Resident #1 said she fell outside the facility's entrance, when she was being assisted from a hope link van by the van driver, after a doctor's appointment. Review of progress notes dated 06/16/19, 06/22/19, 06/23/19, 06/29/19 , 07/15/19 and 07/17/19 showed Resident #1 was forgetful at times was confused, and required assistance with ADLs including putting on proper foot wear. Review of a recorded camera video dated 07/19/19 at 1:19 PM, showed Resident #1 being assisted from a white transportation van by the van's driver after a doctor's appointment. The resident was wearing slippers, inconsistent with the resident's care plan which, instructed staff to ensure the resident had proper footwear (nonskid shoes). The van had three stairs about one foot from the ground. According to the van driver interviewed on 07/29/19 at 7:00PM, when the driver turned his back in an attempt to enter the facility to bring out the resident's walker, Resident #1 tripped on the house slippers, lost balance and fell to the ground, hitting the right hip first, and then, the face. On 08/02/19 at 11:00 AM, Staff I, a Certified Nurse's Aide (CNA) who was assigned to provide care for the resident, was asked why the resident left for the doctor's appointment in slippers and not with the required equipment (non skid shoes). Staff I did not respond and later stated that, the resident required proper foot wear when going to the doctor's appointment. On 08/12/19 at 11:30 AM., Staff B, DNS, was asked who was expected to assess the resident's equipment when going outside the facility, Staff B said, Staff D, the assigned nurse at the time of transportation to the doctor's appointment was responsible for ensuring the resident's safety, but she did not. On 08/02/19 at 1:00 PM., Staff A, the facility's Regional Executive Director and Staff C, the Interim Director of Nursing acknowledged the identified failed practice and Staff C, further said, the facility was in the process of re-educating staff on how to prevent further accidents by ensuring adequate supervision of staff, to make sure residents have all the proper and required equipment, such as shoes, walker, gait belt, etc. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure three (#s 6, 24 & 281) of five residents reviewed, received the necessary care and services in accordance with professional standards of practice. Failure to ensure Resident #6, one of three residents reviewed for non-pressure skin issues, was assessed and received adequate monitoring or interventions, caused this resident to go over six months without treatment of [REDACTED]. In addition, the facility failed to ensure residents were assessed, monitored, and received the treatment they were assessed to require for one (#s 281) of three sample residents reviewed for [MEDICAL CONDITION] management; one (#24) of three residents reviewed for positioning. These failures placed residents at a potential risk of decline in medical status and unmet care needs. Findings include: RESIDENT #6 Resident #6 admitted to the facility on [DATE] and according to the [DATE] Admission Minimum Data Set (MDS-an assessment tool), the resident admitted to the facility with care needs related to infection, multiple fractures, stroke, [MEDICAL CONDITION] and mood disorder. According to the [DATE] MDS, the resident had surgical wounds. Review of Physician Ordered Life Sustaining Treatment documents revealed the resident was to receive CPR (Cardio [MEDICAL CONDITION] Resuscitation) as part of life sustaining care. Further record review revealed, Resident #6 recently had a feeding tube placed to provide nutrition in the presence of insufficient oral intake. Observation on [DATE] at 9:02 a.m. revealed Resident #6 had a dark, black scab on the left aspect of the bridge of the nose approximately 1.0 cm (centimeter) by 1.0 cm. In an interview at that time, the resident was unable to answer questions about the nose wound. According to the Nursing Admission assessment dated [DATE], staff identified multiple skin issues, including a Left nare biopsy (a medical test commonly performed by a surgeon involving sampling of cells or tissues for examination to determine the presence or extent of a disease) site which measured 0.5 x 0.5 cm. An associated note indicated, A healing scab was noted on the bridge of the nose. No sign of infection noted. Review of all Care Plans (CPs) revealed no past or current care plan which addressed Resident #6's nose wound. In an interview on [DATE] at 8:04 a.m., Staff F (Registered Nurse, MDS coordinator) confirmed the absence of any CP that addressed the resident's nose wound. Review of (MONTH) (YEAR) Treatment Administration Records (TARs) revealed a [DATE] order which directed staff to, Monitor biopsy site to left nare measuring 0.5 cm x 0.5 cm. Notify MD if not resolving . Staff documented monitoring took place each day until [DATE] when this order was discontinued. During this time there were no ordered treatments of this wound. There were no objective assessment of this wound which might indicate appearance, drainage, surrounding area, or size. There was no progress note on [DATE] indicating the wound had resolved, nor was there rationale as to why the wound was no longer monitored. There was no subsequent mention of the nose wound until [DATE] when, according to the TAR, staff re-implemented an order of, Monitor the scab on the bridge of the nose measuring ,[DATE] cm by ,[DATE] cm every shift for signs of infection. Staff continued to document each shift there was no sign of infection. Record review revealed no objective assessment of the wound, and no notification to the physician of it's non-healing status. Nursing staff continued to document each shift that the scab was monitored until [DATE], when staff were now directed to, Monitor stable scab on the bridge of the nose every day shift every Fri for Stable scab. Record review revealed no objective assessment of the wound since admission and no indication nursing staff questioned the wound's non-healing status. In an interview on [DATE] at 12:24 p.m., when asked why the wound was categorized as a stable scab, Staff E (Registered Nurse - Resident Care Manager) replied, It stays the same, it just stays there. When asked if, based on the lack of observed healing, it was a non-healing wound Staff E stated .Oh, I see what you are saying. When asked how anyone could definitively prove the wound was unchanging when there were no measurements, Staff E stated, I guess we should have included in the orders for measurement each week. I would assume it's automatic. When asked the etiology of the wound, Staff E stated, It was a biopsy When asked, if the non-healing wound was related to a biopsy, could the healing, or lack thereof, be impacted if any lesion removed [MEDICAL CONDITION], Staff E stated, If it [MEDICAL CONDITION], it might not heal. When asked about the results of the biopsy, Staff E reviewed the record and confirmed there were no biopsy results. When asked if facility staff could obtain the results of the biopsy, Staff E indicated she could. When asked about the process for a non- healing wound, Staff E stated, She wasn't seen by (the contracted wound company). When asked, How long do you wait for no signs of improvement before you notify the physician? Staff E replied, A month. Staff E indicated Resident #6 had transferred to her unit from another floor in the facility and stated, I wish we had pictures of what the wound looked like previously. Staff E confirmed the wound didn't improve for over six months stating, (it) should have (healed within six months). Staff E was asked to provide any indication facility staff identified the wound was not healing and would benefit from referral to a physician, no information was provided. Upon request on [DATE] at approximately 12:40 p.m., Staff E measured the wound on Resident #6's nose. In an interview during this observation Staff E described the nose wound as a, 0.7 x 0.4 x 0.1 cm irregularly shaped, scabbed over (wound) that was, not really red around it. There was a small open area in the center of the scab and Staff E stated, I could see some yellow, no drainage; hard under the scab is yellow . On [DATE] at approximately 2:30 p.m, Staff E provided a biopsy result dated [DATE], which revealed a [DIAGNOSES REDACTED]. The 0.8 x 0.3 cm tan ovoid shave of skin which was, ulcerated and inflamed for which the margins are involved (Involved margins [MEDICAL CONDITION] cells come right out to the edge of the removed tissue (biopsy). When asked, in an interview on [DATE] at 2:38 p.m., what margins are involved meant, Staff E replied, It means it's (cancer) still there. A subsequent [DATE] progress note by Staff E indicated, Results received from .Dermatology for left nose biopsy. Results revealed [DIAGNOSES REDACTED]. (Physician) was informed and recommended to follow up with dermatology if needed or if daughter wants to pursue the follow up .daughter confirmed that she knew about the benign form [MEDICAL CONDITION] on Resident #6's nose. She states that the plan was to take her back to have a procedure done but due to the stroke, she put it off . In an interview on [DATE] at 9:05 a.m., Staff E indicated the resident's daughter believed the [DIAGNOSES REDACTED] was benign. When asked if she clarified with the daughter that [DIAGNOSES REDACTED] is malignant, not benign, Staff E stated that she had not. In an interview on [DATE] at 8:51 a.m., when asked if staff should have requested the resident's biopsy results prior to survey staff request, Staff B stated, Yes. When asked if it was reasonable to expect that an [MEDICAL CONDITION] left untreated for [REDACTED]. According to progress notes dated [DATE], Res(ident) left side of nose scab with slight dried bloody drainage. MD was informed with orders to apply triple antibiotic ointment until seen by wound doctor. Facility staff failed to monitor an identified wound, failed to consider it's origin (biopsy site) or identify the wound's non-healing status or pursue biopsy results given the wound's, stable (non healing/recalcitrant) status. These failures caused a delay in identification and treatment interventions for the wound [MEDICAL CONDITION]. POSITIONING RESIDENT #24 Resident #24 admitted to the facility on [DATE], and according to the [DATE] Quarterly MDS, the resident required end of life care and was totally dependent on staff for all activities of daily living. According to this document, Resident #24 had severe cognitive impairment. Observation on [DATE] at 11:07 a.m. revealed Resident #24 up in a wheelchair. The resident's lower legs, above the ankles, were supported by a pillow, but the resident's feet hung down unsupported, toes pointing toward the ground. Similar observations of unsupported, dangling feet, were noted when the resident was up in the wheelchair (w/c) on: [DATE] at 8:19 a.m. and 9:27 a.m., when the resident was in the assisted dining room with feet/heels on a pillow but toes flexed forward toward the ground; [DATE] at 9:44 a.m. in her room, the w/c tilted back slightly, feet hanging unsupported; and [DATE] during the breakfast meal in the assisted dining room. On [DATE] at 7:59 a.m., Resident #24 was observed similarly, up in a w/c in the assisted dining room, a pillow behind the calf area. Observation on [DATE] at 8:10 a.m., revealed Resident #24 up in a w/c in the assisted dining room, a pillow behind the calves, feet unsupported with toes pointing toward ground. This observation was confirmed by Staff M (Registered Nurse) who stated that the resident's feet were not, but should be supported, unless the family indicated otherwise. In an interview on [DATE] at 9:11 a.m., Staff E (Resident Care Manager - RCM) indicated Resident #24 was positioned appropriately because in the care guide, staff were directed to, put a pillow under her feet. A subsequent observation at approximately 9:14 a.m., Staff E went to see the resident and confirmed the resident was in the w/c with a pillow beneath the calves bilaterally. The resident's legs extended out past the foot pedals. Upon removing the pillow, the resident's legs remained straight out, unsupported. Staff E attempted to bend the resident's legs so the feet would rest on the foot pedals, but was unable to bend the resident's knees. At this time, Staff E confirmed the resident's feet should be, but were not supported, additionally indicating the resident should be pulled up in her wheelchair. [MEDICAL CONDITION] MANAGEMENT RESIDENT #281 Resident #281 admitted to the facility on [DATE]. Review of the Nursing Admission Assessment, completed on [DATE], revealed the resident was assessed to have [MEDICAL CONDITION] present .all over body . The assessment did not include grading of the [MEDICAL CONDITION] e.g. ,[DATE]+ (a standardized method for grading [MEDICAL CONDITION]). The Baseline Care Plan also identified the resident had [MEDICAL CONDITION] all over but failed to provide direction to staff on when and how to monitor the [MEDICAL CONDITION] or when to notify the physician. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. On [DATE], an order was obtained to double the [MEDICATION NAME] to 20 mg a day. Record review revealed no indication or documentation that facility staff were assessing or monitoring the resident's [MEDICAL CONDITION]. In an interview on [DATE] at 1:33 p.m. when asked if it was the expectation that residents identified with [MEDICAL CONDITION], and receiving a diuretic, had their [MEDICAL CONDITION] monitored Staff L (Assistant Director of Nursing) stated, Yes you monitor ([MEDICAL CONDITION]) and it is daily at least .it should be documented on the TAR (Treatment Administration Record) or in the progress notes and (staff) notify the (Physician) if it ([MEDICAL CONDITION]) is increased. Staff L went on to explain that the facility used ,[DATE]+ (standardized method for grading [MEDICAL CONDITION]) to grade [MEDICAL CONDITION]. When asked if there was any indication staff had been monitoring Resident #281's [MEDICAL CONDITION] Staff L stated, No. When asked how much [MEDICAL CONDITION] (,[DATE]+) the resident had upon admit Staff L stated, It (the assessment) was not specific, it was generalized. When asked if that would detract from staff's ability to determine if the [MEDICAL CONDITION] was worse and if the Physician required notification Staff L stated, yes. Reference WAC [DATE](1)

Based on observation, interview and record review, the facility failed to ensure six (#'s 35, 6, 4, 69, 39 & 27) of seven sample residents reviewed for Mobility/Limited Range of Motion (ROM), received the splinting and ROM services they were assessed to require to improve and/or maintain range of motion and/or prevent further decline. These failures placed residents at risk for unmet care needs and resulted in harm to Resident #35, who experienced a decline in ROM and development of a contracture. Findings include: Refer to CFR 483. sufficient staff RESIDENT #35 Resident #35 admitted to the facility on [DATE] and according to the 12/16/17 Admission Minimum Data Set (MDS - an assessment tool) was assessed with [REDACTED]. According to the 04/03/18 Significant Change, 06/25/18 Quarterly and 09/18/18 Quarterly MDSs, the resident was assessed with [REDACTED]. Observations on 10/30/18 at 10:44 a.m. revealed Resident #35 lying on his left side with the right leg in a tucked position. The resident appeared to have a contracture to the right lower extremity. No splints were noted at this time or during any subsequent observation. Observations on 10/31/18 at 9:50 a.m. revealed the resident in bed with the head of bed elevated, Staff M (Registered Nurse - RN) at the bedside. The resident's legs were covered with a sheet and were not observed. Observations on 10/31/18 at 10:36 a.m., revealed Resident #35 in bed with the left leg hanging straight off the left edge of bed, the right leg bent at the knee with the right foot toward the back of the thigh. Observations on 11/01/18 at 8:14 a.m. and 9:36 a.m. revealed Resident #35 lying in bed with the right leg pulled up midway toward the resident's chest, foot pulled up toward the resident's buttock. Observations on 11/01/18 at 10:50 a.m. revealed the resident lying in bed, on his left side, left leg extended with the right leg tucked up, foot toward the back of his thigh. Review of therapy records revealed Resident #35 received therapy services in January, (MONTH) and (MONTH) of (YEAR). Record review revealed a 10/27/18 referral to, PT/OT for contracture management. Record review revealed no supporting progress note which explained the rationale behind this intervention nor did it reference the location of said contracture(s). In an interview on 11/01/18 at 12:15 p.m. when asked if there should be documentation regarding why the resident was referred to therapy, Staff B (Director of Nursing) stated, Yes. According to Staff B, an on-call nurse put the order in for the therapy referral. RIGHT KNEE SPLINT According to Staff N (Physical Therapist - PT), in an interview on 11/01/18 at 2:12 p.m., a therapy note on 01/30/18 indicated, Assessment of patient response: rt (right) knee extension is 6 degrees from neutral . requires AAROM (Active Assisted ROM)/PROM (Passive ROM) to RLE (right lower extremity): plan for next session .training for positioning of RLE in order to decrease risk of contracture development. When asked to explain this, Staff N indicated Resident #35's right knee, at the time, was within normal range, and based on the 01/30/18 PT assessment the resident was at, high risk of contracture development. According to Restorative Nursing Aide (RNA) documentation dated 03/28/18, therapy assessed the resident to require and developed a program for, Dynapro knee splint and static AFO (Ankle Foot Orthotic). Apply splint to right knee and AFO to right ankle once a day in the morning for 2 hours to prevent contractures. According to RNA documents these splints were applied through 05/12/18 when the program was abruptly discontinued for no documented reason. Further record review revealed the resident discharged to the hospital for an acute illness on 05/13/18, and returned to the facility on [DATE]. Record review revealed no indication the splinting programs for the right lower extremity were ever re-implemented. In an interview on the morning of 11/02/18, Staff B indicated that it appeared the computer system automatically canceled the splint application program when the resident was discharged to the hospital. Staff B confirmed at this time the resident did not receive the right knee splint and AFO he was assessed to require for over five months. In a joint interview with Staff H, N and O (Occupational Therapist) on 11/01/18 at 1:59 p.m., all indicated, after reviewing therapy notes, that Resident #35 did not have contractures during the period of (MONTH) through (MONTH) (YEAR), and the programs developed by therapies were to prevent contractures. In an interview on 11/02/18 at 2:22 p.m. (via phone) Staff N (PT) indicated she had treated the resident previously, having developed the right leg splint program in (MONTH) (YEAR). Staff N stated Resident #35 did not have a contracture to the right knee at that time. Staff N stated, based on her assessment on 11/01/18, the resident had a significant right knee contracture. Upon further discussion, Resident #35 had gone from a 6 degree range of motion limitation (within normal limits), with the resident's leg almost fully extended, to a 100 degree limitation in range of motion of the knee, with the foot pulled up toward the buttock. When asked if this was a significant decline in range of motion from her previous assessment, Staff N stated, Yes when asked if this could be related to the lack of splint application and lack of consistently implemented ROM, Staff N stated, Yes. RIGHT RESTING HAND SPLINT A Telephone Order (TO) dated 01/29/18 directed staff to don a, right resting hand splint for 4 hours in the a.m. (morning) and four hours in the p.m. (evening) to promote functional position of forearm, hand/decrease contractures. According to Treatment Administration Records this program was initiated on 01/31/18 and continued to be implemented until 02/20/18, when the resident was discharged to the hospital for a medical issue. Upon return from the hospital on [DATE], there was no indication the right resting hand splint was ever re-implemented or assessed as no longer needed. In an interview on 11/02/18 at 10:18 a.m., Staff D (Medical Records) was requested to provide any documentation to support the right hand splint was ever implemented after the 02/25/18 readmission. Staff D reviewed the record and stated, I can't find anything. In an interview on 11/02/18 at 10:15 a.m., Staff H (Director of Rehab) was asked to provide any documentation to support the resting hand splint was ever reassessed as no longer beneficial. Staff H indicated no such documentation could be found. In an interview on the morning of 11/02/18, Staff B indicated that it appeared the computer system automatically canceled the splint application program when the resident was discharged to the hospital. Record review and interview with Staff B confirmed, Resident #35 went over seven months without the hand splint he was assessed to require. RANGE OF MOTION PROGRAM According to a Restorative Nursing Referral form dated 03/31/18, a Restorative Nursing Assistant Program (RNP)was developed for, PROM (Passive Range of Motion) for RLE (Right Lower extremity) with hamstring stretches and TA (Total Assist) stretch x 5 reps with 30 sec(onds) hold at end range to prevent contractures. However, record review revealed no indication this program was implemented. Instead, on (MONTH) 2, (YEAR), according to computerized Actvities of Daily Living (ADL) documents, staff transcribed the implementation of the following program: NAC (Nursing Assistant Certified) task: ROM exercise during ADL assistance for upper extremities and lower extremities. In an interview on 11/01/18 at 12:48 p.m., Staff B confirmed the program for standard ROM during ADL assistance did not reflect the RNP developed by therapy. For (MONTH) (YEAR), the RNA (Restorative Nursing Assistant) documented this program was implemented on three occasions in the month, with one refusal. According to (MONTH) (YEAR) aide documentation, Staff Q (Restorative Aide) documented ROM exercises during ADL assistance for upper extremities and lower extremities was refused three times from 05/05 through 05/09/18. The program was not offered again in the month of (MONTH) after 05/19/18. Record review revealed the resident discharged to the hospital for an acute illness on 05/13/18 and returned to the facility on [DATE]. In an interview on the morning of 11/02/18, Staff B indicated that it appeared the computer system automatically canceled the ROM program when the resident was discharged to the hospital on [DATE]. A progress note on 06/01/18 indicated, Patient unable to participate effectively in restorative program. He refuses to participate. NAC task added to perform ROM during ADL care. In an interview on 11/01/18 at 12:48 p.m., Staff B was unable to explain why an NAC working on the floor would be better able to perform ROM services, if the Restorative Aide, whose specific job was to implement ROM programs, was unable to do so. Review of (MONTH) (YEAR) ADL documents revealed facility staff implemented a 15 minute ROM program on one of 60 opportunities. Review of (MONTH) (YEAR) ADL documents revealed facility staff implemented a 15 minute ROM program on one of 62 opportunities. Review of (MONTH) (YEAR) ADL documents revealed facility staff implemented a 15 minute ROM program on two of 62 opportunities. Review of (MONTH) (YEAR) ADL documents revealed facility staff implemented a 15 minute ROM program on four of 60 opportunities. In an interview on 11/01/18 at 1:01 p.m., Staff B reviewed Resident #35's ROM program documentation and stated, It looks like it's functional maintenance; the aides are doing it, not the restorative aides. After reviewing the CNA documentation of the resident's ROM, when asked if ROM once every 10 days was sufficient to prevent a decline in ROM, Staff B said, No DIRECT CARE STAFF In an interview on 11/01/18 at 10:37 a.m., Staff R (Certified Nursing Assistant - CNA) indicated she provided care to Resident #35 and stated, He is cooperative usually but sometimes he has behaviors. When asked if the resident refused care, Staff R stated, Oh, sometimes he will refuse care every day. When asked if the resident had any splints or braces, Staff R replied, Not yet, he doesn't have any. When asked if he had a ROM program, Staff R replied, Yes, he has a program, since he came to this floor .They encourage us to stretch his leg, his right leg is bent, when he is in the chair we have to stretch his leg; his knee is bent. I think that is part of the therapy, we try to put the (right) foot on the foot rest. When asked about the program she provided to the resident, Staff R demonstrated the ROM program she provided for Resident #35, which did not reflect all joints or all planes and did not reflect ROM for the resident's unaffected (left) side as directed by the program. Staff R indicated she did not do any ROM for the left extremities despite directions to provide, ROM .for upper extremities and lower extremities. Failure to ensure direct care staff demonstrated competency of required tasks resulted in Resident #35 not recieving services as intended and contributed to a decline in ROM. In an interview on 11/02/18 at 10:50 a.m., Staff B agreed Resident #35 experienced a decline in range of motion, that the right hand splint was discontinued when the resident discharged to the hospital in (MONTH) (YEAR) and was not re-implemented, and the right foot/leg splint/AFO was discontinued and not re-implemented after re-admission from the (MONTH) (YEAR) hospitalization . RESIDENT #6 According to the 04/27/18 Admission MDS, Resident #6 admitted to the facility with [DIAGNOSES REDACTED]. Staff determined the resident had upper and lower extremity limitations in ROM on one side; no ROM or splint application, no restorative; did receive therapy. According to the 07/17/18 MDS, the resident had active ROM on three days of the assessment period, but no splint application. According to (MONTH) (YEAR) TARs, nursing staff were directed to apply right resting hand splint and BLE (bilateral lower extremity) splints at 6:00 a.m. and 6:00 pm and remove at 10 AM and 10 PM . Observations revealed facility staff failed to place the splints for the four hours as directed, or document reasons for not following application instructions (i.e., resident experiencing pain/redness). Observations on 10/30/18 at 8:45 a.m. and 9:06 a.m. revealed Resident #6 lying in bed without a hand or leg splints. Similar findings were identified on 10/31/18 at 7:45 a.m., 8:05 a.m. and at 9:40 a.m. when the resident was noted without splints applied. Staff were noted to apply the LE splints at 12:33 p.m., which were noted as off at 1:47 p.m. and 2:20 p.m. Observations on 11/01/18 at 8:32 a.m., and 9:01 a.m. revealed no hand or leg splints applied. At 9:46 a.m., the resident was noted with the right hand splint, but no LE splints applied. At 10:20 a.m. the resident was observed with both hand and LE splints applied. Subsequent observations at 11:29 a.m., 12:35 p.m. and 2:09 p.m. revealed the resident had no splints applied. In an interview on 11/02/18 at 10:50 a.m., Staff B indicated she had spoken with Staff H, and therapy staff prefer that Licensed Nurses apply the splints. In an interview at this time, observations of the resident's splints not being applied as directed were shared. Staff B indicated the timing was important for splint application (for Resident #6) and the leg splints should not be more than 4 hours, but the hand splint should be as directed. Failure to ensure consistent application of splints placed the resident at risk for worsening contractures. RESIDENT #4 Resident #4 admitted to the facility on [DATE] and according to the 07/16/18 Admission MDS, the resident was assessed as cognitively intact, receiving OT and PT services and requiring extensive one person assistance with locomotion. According to the 10/03/18 Restorative Nursing Referral, the RNP should include: seated lower and upper extremity, standing LE there(apuetic) ex(ercise)/ROM 15 reps, 2 sets, can use 2# weights with LE, UE. However, according to the RNP implemented by RNAs, the program did not include the specified, Standing LE there/ex which were to be done with two sets of 15 repetitions. Additionally, the RNP which originated from therapy did not include how many times a week the program should be implemented, but was transcribed to be performed, 3-6 times a week. In an interview on 11/07/18 at 9:32 a.m., Staff H indicated when a RNP is written, it should include the number of days it should be implemented. When asked why some residents received programs three days a week, and others four days a week, Staff H deferred to nursing as to why 3-6 times a week was chosen as the frequency. When asked if it was better, to improve ambulation, to have three or six days a week of a walking program, Staff H replied, More days are better. RESIDENT #39 According to the 09/14/18 Quarterly MDS, Resident #39 suffered from (R) right [MEDICAL CONDITION] and required physical assistance of 1-2 person with activities of daily living i.e. dressing and hygiene. A review of a Restorative Nurse referral dated 03/30/18 revealed the resident developed (R) ight [MEDICAL CONDITION] at birth. The RA program indicated the staff were to perform AROM (active range of motion) on RUE (right upper extremity), using 2 lb weight for(10 reps), also perform (L)eft lower extremity exercises in a supine position for (10 reps) and (two sets). A review of the RA documentation revealed Resident #39 wasn't receiving RA or therapy services he was assessed to require. In an interview on 11/02/18 at 9:08 a.m., Staff E (RN- Resident Care Manger) said, I don't see any documentation that would indicate he's still receiving RA services. I think after he returned from the hospital, he somehow fell off our radar, and we forgot to restart his rehab program. In an interview on 11/06/18 at 10:34 a.m.,Staff H (OT- Rehab director) said, in (MONTH) of this year, Resident #39 requested therapy services to regain his ability to ambulate in the hall. However, it doesn't look like we've been working with him for rehab. According to Staff H, the resident had an OT eval on 11/03 or 11/04/18, and the plan was to have PT complete an evaluation to determine the resident's strengths and weakness and develop and treatment plan. On 11/07/18 at 8:14 a.m., Staff B(RN- Director of Nursing) said, due to a glitch in the software program, we weren't prompted to re-initiate the resident's rehab program when he readmitted to the facility. Therefore, he did not receive the services he was previously assessed to require. RESIDENT #27 Resident #27 admitted to the facility on [DATE] and according to the 12/16/18 quarterly Minimum Data Set (MDS - an assessment tool) was assessed with [REDACTED]. According to the care plan revised 10/27/18 reflected Restorative nursing services: goal to maintain independence and prevent decline. Intervention, active range of motion program right upper extremity and right lower extremity (RUE/RLE), Passive range of motion on left upper extremity and left lower extremity (LUE/LLE) 3-6 times a week. In multiple observations and interview made during survey process and on 10/30/18 at about 9:00 a.m. revealed Resident #27 lying on his back. No splints were noted at this time or during any subsequent observation. Resident #27 revealed he missed multiple times his restorative program because staff were pulled to the floor to work as nursing assistants. No restorative programs in the evenings and on the weekends. Interview with staff Q, Restorative aide on 11/01/18 at about 01:59 p.m. revealed she get pulled to work on the floor every other day to work as nursing assistant and restorative tasks are not done. Staff Q further said she only work 6-2 p.m. and all restorative program are scheduled at that time frame. Splints are applied by restorative aides and nursing assistants depending on the care plan and orders. REFERENCE: WAC 388-97-1060(3)(d)

Based on observation, interview and record review, the facility failed to have safe systems in place for hot beverages prior to serving residents. The facility failed to provide adequate supervision for 1 of 4 residents reviewed for injuries and accident hazards. This failed practice resulted harm, a substantial injury, of a second degree burn for Resident (#20) who [MEDICAL CONDITION] bilateral upper thighs from hot chocolate. Findings include: Review of facility Hot Beverages policy revised 10/26/18 reflected 1. The kitchen staff is responsible for checking and documenting the hot beverage temperatures at each meal just prior to the hot beverages leaving the kitchen. 2. The temperature for hot beverages at resident contact should not exceed 150 degree Fahrenheit. Resident #20 was admitted to the facility with multiple medical [DIAGNOSES REDACTED]. The last significant change Minimum Data Set (MDS) an assessment tool, dated 08/16/18, indicated the resident needed limited supervision and one person physical assist with eating, and extensive assist with transfers, dressing, hygiene and Review of the resident's 08/17/18 Activity of daily living care plan reflected, Eating -offer assist only as resident allows, prefers to eat independently. Review of facility incident investigation analysis dated 10/25/18 revealed, .Resident 20 is alert with confusion due to [DIAGNOSES REDACTED]. Review of staff W, witness statement dated 10/26/18 revealed staff W served Resident #20 a cup of hot chocolate, and went to the kitchen to get tickets to start serving lunch. When returned she found Resident #20 had spilled the hot drink on herself. The clothes were warm to touch, she went and notified the nurse. Progress Notes (PNs), dated 10/26/18 at 09:09 a.m. by Staff E, Residential Care Manager (RCM) Reflected . reddened area to bilateral inner thighs were noticed with fluid filled blisters of various sizes with one blisters to left thigh. The physician was notified and orders received prescribed [MEDICATION NAME] 1% cream (topical anti-microbial medication used in the treatment of [REDACTED]. Plan of care revised to include drinking hot beverages using closed lid mug. Resident skin will be checked every shift x 72 hours and physician to be notified of any further changes. Record review of skin assessment on 10/26/18 revealed, . reddened area to bilateral inner thighs with fluid filled blisters of various sizes with one blister to left posterior thigh. In an observation with Staff K, Licensed Practical Nurse (LPN) on 11/02/18, the resident had fluid filled blisters of different sizes and one open blister to left posterior thigh. The resident didn't remember what happened to her when asked. Record review of wound consult document dated 11/01/18 revealed the wound was identified as a burn with partial thickness, the right medial thigh measured 1.9cm length, 1.9cm width and 0.1cm deep. The left medial thigh measured LxWxD (3.8 cm length, 5cm width and 0.1 cm deep). According to an interview with staff E, RCM on 11/05/18 at about 11:30 a.m. staff E, was notified about the incident in the dining room and on assessment the resident had sustained burn to her inner thighs. On investigation the staff had served Resident #20 hot chocolate per usual preference and went to the kitchen to get tickets to start serving lunch. The resident was left unsupervised with hot beverage and didn't know if the hot beverage temperature was checked before being served to the resident. In an interview wth staff B, Director of Nursing (DNS) on 11/05/18 at about 11:55 a.m. Staff B indicated the hot water was obtained from the kitchen, the water temperature was not checked on the day of the incident but the temperature was checked the following and the temperature went down. According to staff B, the expectation was to ensure residents were supervised and hot beverage temperatures are checked before being served to residents. In an interview with Staff A, Administrator on 11/05/18 at about 1:45pm indicated the hot water was obtained from the coffee machine in the kitchen and the water temperature was not checked prior to leaving the kitchen. The new dietary service company does not check the water temperature prior to serving the residents. Staff A, expected water temperatures to be checked prior serving the residents, and all residents need to be supervised according to the care needs. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review it was determined the facility failed to prevent, identify, monitor and/or implement preventative measures for pressure ulcers. Failure to implement the interventions identified as required for Resident #152 caused harm as evidenced by the development of a recurrent Stage II pressure ulcer. Failure to timely assess and monitor an existing pressure ulcer which staff were aware of placed Resident #9 at risk for delayed treatment to promote wound healing and detracted from staff's ability to monitor wound progression. Findings include: RESIDENT #152 Resident #152 admitted to the facility on [DATE]. According to the Nursing Admission assessment dated [DATE], staff identified the resident had only one pressure ulcer (PU), on the right trochanter (hip) which measured 4.0 x 9.9 centimeters (cm). According to the 01/23/16 Admission Minimum Data Set (MDS) assessment, the resident was assessed to require extensive two person assistance with bed mobility and transfers and had two Stage II pressure ulcers. The associated Care Area Assessment (CAA) indicated, Resident admitted with a Stage 2 Pressure Ulcer to a right trochanter (hip area) that is 6 x 10 x 0.1 cm. Resident also with open area to coccyx, that is 7 x 4 x 0.5 cm, base pink in color. This CAA further indicated the resident, .has declined in ADLs (Activities of Daily Living) and requires extensive assist with bed mobility and is at increased risk for skin issues . Proceed with POC (Plan of Care) and continue to provide pressure reduction mattress and wheelchair pad, (every) two hours. A facility investigation dated 01/24/16 revealed facility staff identified, resident noted to have an open area to coccyx region 7 cm by 4 cm by 0.5 cm. No (signs/symptoms) of infection noted base pink in color no tunneling. This investigation indicated staff should clean with normal saline pat dry apply [MEDICATION NAME] (every) shift until resolved. Actions taken included direction to staff to, turn resident (every) 2 hours and prn (as needed) while in bed (and) encourage resident to relieve coccyx area pressure . Weekly wound assessment notes dated 02/04/16 revealed wound on coccyx has resolved. According to the 02/12/16 MDS, the resident continued to require extensive two person physical assistance with bed mobility and now had one Stage II PU (trochanter) and remained at risk for PUs. The 03/16/16 MDS reflected the resident required two person extensive assistance for mobility and now had one unstageable PU (trochanter) which measured 3.0 x 3.0 cm. According to the resident's ADL directive, staff were to monitor and report any changes in condition of Resident skin and turn and reposition with skin care as needed and as resident will allow. Another intervention indicated, Resident may use Tilt-in-space wheelchair to assist with central positioning and off-loading of pressure to coccyx/buttock. A PU care plan dated as revised on 01/26/16, indicated the resident had 2 Pressure ulcers to right hip and coccyx and has potential for pressure ulcer development . It was not updated to reflect the coccyx PU had resolved as identified in the 02/12 and 03/16/16 MDSs. Observations on 04/22/16 at 7:50 a.m., 9:44 a.m. and 2:41 p.m. all revealed the resident lying in bed, positioned on his back. Observation on 04/25/16 at 7:32 a.m. revealed the resident wearing a hospital gown, lying in bed on his back. Similar observations were noted at 8:14 a.m., 8:39 a.m., and 9:01 a.m. At 9:52 a.m., the resident was noted sleeping in bed on his back. The head of bed was elevated approximately 30 degrees. At 10:44 a.m., the resident was lying on his back in bed. The oxygen tubing was positioned on his right check, not in his nares. The resident was similarly noted on his back, with no discernable change in position at 11:03 a.m. and 11:26 a.m. At 12:33 p.m., the resident was lying in bed on his back, and now wore a long sleeve shirt. The resident's oxygen cannula was noted on his forehead. At 12:49 p.m., the resident remained lying in bed on his back. At 12:59 p.m., Staff Q (a nursing assistant student) left the room with the resident's lunch tray. The resident was on his back with the head of bed elevated. The resident was noted on his back in bed at 1:05 p.m., 1:31 p.m. and 2:06 p.m. with no positioning that would effectively relieve pressure from the coccyx/buttock. Observation on 04/26/16 at 7:50 a.m. revealed Resident #152 lying in bed on his back, positioned slightly to the right. At 8:48 a.m. the resident was noted lying in bed on his back with the head of bed elevated. Similar observations of the resident lying on his back with no effective change in position were noted at 9:00 a.m. and 9:19 a.m. In an interview at 9:19 a.m., Staff I (Licensed Nurse) stated, He is lethargic, he was a little better, he had pneumonia . he is very weak, his vital signs are gradually getting better, we feed in bed, he is not getting up for a few days. Staff I indicated she left the facility the previous day at 5:00 p.m. and the resident had not been out of bed. Record review revealed no direction to staff not to get the resident up or contraindication to utilize the Tilt-n-space wheelchair to assist with central positioning and off-loading of pressure to coccyx/buttock as directed by the ADL guide. In an interview on 04/26/16 at 9:39 a.m. Staff R (Restorative Aide) stated, you know he's changed a lot in the last week or so . lately they haven't been getting him up at all, he used to sit up by the elevators . Observation on 04/26/16 at 10:35 a.m. revealed Staff K (Certified Nursing Assistant) change the resident's clothes from a hospital gown to a shirt. The resident's brief was saturated and the bed was wet. At 10:38 a.m., Staff K stated, I need help and left the room. Staff K returned approximately four minutes later with Staff S (a student nursing assistant) to complete the resident's care. As the resident was turned to the left, a red, beefy open area was clearly noted on the coccyx area, which upon brief glimpse appeared to be approximately 1.5 cm x 1.5 cm. Observations on 04/26/16 at 11:02 a.m., 11:20 a.m. and 12:26 p.m. revealed similar observations of the resident in bed lying on his back. At 1:11 p.m., the resident was lying in bed on his back, the head of bed was elevated and Staff K was at the bedside assisting the resident with lunch. At approximately 1:19 p.m., Staff G (Nurse supervisor) entered the room to assist the resident further with lunch. At 1:28 p.m., the resident was observed lying in bed with the head of bed lower than previously noted. At 1:46 p.m. on 04/26/16 the resident was lying in bed on his back with no position change noted. At 1:57 p.m. Staff R initiated performing range of motion with the resident while he was in bed. On 04/26/16 at 3:16 p.m., the resident was lying in bed flat on his back. Record review on 04/27/16 at 7:33 a.m. revealed no indication facility staff were aware of or treating any skin issue associated with the resident's coccyx. At approximately 7:35 a.m., Staff C was asked to perform a skin assessment for Resident #152. Staff C indicated the medication nurse (Staff J) could do the skin assessment. In an interview at approximately 7:40 a.m., Staff J indicated she could do the skin assessment after medication pass, between 10:00 and 10:30 a.m. Observation on 04/27/16 at 7:36 a.m. revealed the resident lying in bed on his back. No lights were noted lit on the resident's air overlay mattress machine which made it impossible to determine what the settings were set at. The mattress had a firm surface to the touch, which did not appear to alternate. Similar observations were noted at 8:52 a.m. and 9:24 a.m. Observation on 04/27/16 at 9:28 a.m. revealed Staff H enter the resident's room with supplies to perform a bed bath. Staff H indicated, they wanted me to do a bath before his skin assessment. Staff H, with assistance from Staff X (student Nursing Assistant), performed a bed bath. Staff H was noted to remove a pillow, which did not effectively change the resident's position off the coccyx, from beneath Resident #152's lower back/buttock area. At 10:06 a.m., upon changing the resident's brief, an open area was identified to the resident's coccyx area, which was then reported to Staff J, who was, at the time, passing medications to Resident #152's roommate. Upon observing the wound, Staff J indicated she should measure it and left the room. At 10:13 a.m., Staff G described the wound as a Stage II PU which was 4 cm long, teardrop shaped with a width ranging from 1.0 cm to 1.5 cm. Staff G indicated there was probably 30% slough located at the top of the wound with the rest of the wound bed noted as a pink/red color. In an interview on 04/27/16 at 10:50 a.m., Staff C (Resident Care Manager/Assistant Director of Nursing) indicated he was not aware Resident #152 had a Stage II PU to the coccyx and that no staff had reported any skin issues to him. Staff C was unable to explain why facility staff were not aware of a PU identified by survey staff, during care provided by facility staff, the previous day. Subsequent documentation provided by the facility indicated, Statements from staff indicate that the day shift staff on 04/26/16 did not visualize the coccyx area for this resident because a CNA student was providing the care and the resident's coccyx was out of the employee's view. Statements from the evening shift CNAs indicated the CNAs were unable to fully visualize the resident's coccyx because he was extremely resistant to care. Staff C, on 04/27/16 at 10:50 a.m., was asked how staff ensured appropriate settings for the air overlay mattress, as there were no such directions to staff in either the Care Plan, resident record, or Treatment Record. Observation with Staff C on 04/27/16 at 10:55 a.m. confirmed the air overlay mattress was on the softest setting (one out of 10), was set at neutral therapy (not alternating air pressure), had no time range, and low air loss. Staff C stated he would check to see what the settings should be as he did not know. In an interview on 04/27/16 at 2:09 p.m., Staff C stated, We have to provide education on how to (program the air overlay mattress) because there was no specific order to set the bed on, soft or firm, it wasn't set on alternate it was on normal . we have to show people how to operate that thing . At 3:08 p.m. the settings were noted at a medium setting (six out of ten), ten minute hold time, and was now set for alternating air pressure. Failure to ensure the air overlay mattress was set to the accurate setting detracted from its intended therapeutic effect to prevent pressure ulcers. Documentation provided by the facility on 04/29/16 indicated, the (air overlay) . has pressure relieving properties even when the pump is off or not set to rotation therapy and that the mattress, aid(s)in the prevention/treatment of [REDACTED]. Facility staff failed to provide turning and repositioning as care planned. Additionally, AccuMax Quantum PVC mattress documents clearly reflect, When connected to the control unit (pump), the Accumax with airPort provides alternating pressure, which can help improve pressure redistribution and reduce PU incidence. The facility failed to utilize the equipment available to maximize pressure redistribution. In an interview on 04/27/16 at 3:59 p.m., Staff B indicated she spoke to multiple staff and that they had a hard time positioning Resident #152 with a pillow, that he would always move to the right. However, current observation revealed facility staff had since implemented positioning blocks which provided positioning/pressure relief to the buttocks/coccyx area, and that there was no indication nursing assistants reported to the nurse that they were unable to properly position the resident. Had line staff reported difficulties maintaining proper positioning, facility staff could have implemented additional interventions to assist the resident in maintaining positioning to either side timely. Failure to ensure adequate offloading of pressure to the resident's coccyx/buttock area resulted in the development of a recurrent Stage II PU. RESIDENT #9 Resident #9 admitted to the facility on [DATE]. According to the admission assessment dated [DATE], the resident had [DIAGNOSES REDACTED]. This MDS indicated the resident required extensive two person physical assistance with bed mobility and transfers and had functional limitation in range of motion on both lower extremities. The MDS identified the resident had one stage I (intact skin) pressure ulcer, a skin tear and moisture associated skin damage. The functional assessment completed on 03/26/16 reflected two different surgical areas and no PUs. According to admission skin assessments dated 3/26/16 (date of admission), the resident had a [MEDICAL CONDITION]/[MEDICATION NAME] and a right knee front surgical incision but did not identify a PU. A Resident Occurrence Report dated 04/02/16 indicated the resident was identified with a 1 cm x 1 cm open area on ankle, red min(imal) drainage which was identified as a skin tear. However, a synopsis of Statement indicated the resident's wound was, due to pressure from boots. Staff failed to consistently label the wound (skin tear versus PU) accurately. Additionally, this report indicated there were new orders dated 04/03/16 directing, Do not wear the boots. Elevate bilateral lower extremities using pillows. Facility staff failed to identify the resident had both boots and a right leg immobilizer, which was later identified as the cause of the pressure ulcer. According to the 04/04/16 skin assessment, the resident had a total risk score of 14 (indicating moderate risk of developing pressure ulcers). According to this assessment, the resident was determined to have a rll (right lower leg) wound and Lt (left) foot side (scab), which was a newly identified wound without identified etiology, and right ankle (outer) wound open which was a new wound not previously mentioned on the skin assessments. None of these skin issues had measurements or consistent descriptors of what types of wounds they were (pressure, vascular, surgical), and there was no explanation of how these new skin conditions developed. Additionally, review of Treatment Administration Records (TARs) revealed an order dated 03/29/16 which directed staff to monitor redness to posterior right calf . until healed. There was another order dated 04/04/16 directing staff to treat a medial right calf wound and to ensure proper placement of leg brace to prevent pressure ulcers. A treatment order dated 04/13/16 directed staff to treat a Right lower leg wound. There was no indication if the ankle, the medial and posterior calf wounds, and right lower leg wounds were one in the same or different wounds. A progress note dated 04/04/16 indicated, she has pressure sore on her buttocks both butt cheeks also a wound on her left lower leg. There was no other indication in the record the resident had a wound to the left lower leg. In an interview on 04/26/16, Staff D indicated staff, .were probably referring to the right leg. Failure to ensure skin assessments were accurate detracted from staff's ability to determine location and progression of wounds. An email dated 04/06/16, written by Staff D (charge nurse) and sent to Staff L (MDS Coordinator), indicated for Resident #9 Her sacral area is reddened and excoriated. On the right buttock side it has a purple area and at risk for breakdown. The purple area measures 3 cm long x 1.5 cm wide. There is also a dark red area measuring 3 cm x 1 cm that is on the left buttock area. There is no depth to the area. She also has a pressure sore on her calf but (Staff G) said she saw it yesterday and says it's just a reddened area. So I would call it a Stage I. There was no indication facility staff identified if these purple/reddened areas were blanchable, which detracted from staff's ability to accurately rule out a Stage I PU. There was no assessment in the record by Staff G dated for 04/05/16 which indicated the assessment of 04/04/16 was incorrect or if the resident actually had two stage II wounds (buttock and calf/ankle). Review of the resident's care plan (CP) on 04/22/16 revealed the resident had a problem of open area to left ankle due to pressure from boots. There was no other indication in the record the resident had a wound to the left ankle. In an interview on 04/26/16 at 9:10 a.m. Staff C confirmed the CP did not accurately reflect the resident's wound which was located on the posterior calf. Additionally, the CP was not updated to reflect the resident's coccyx wounds. Facility staff did not update the CP to indicate the resident had pressure ulcer development to the coccyx area until 04/22/16, after review by survey staff. In an interview on 04/26/16 at 1:15 p.m., Staff L was asked where she obtained evidence the resident had the skin tear which was referenced on the 04/02/16 MDS. Staff L referred to a 04/02/16 progress note which indicated the resident had 1 x 1 cm open area, stating, I considered that a skin tear. In an interview on 04/26/16 at 8:09 a.m., Staff C stated the right leg wound, .wasn't really the ankle, she had a leg brace (immobilizer) and it was too tight and it caused pressure, it wasn't really (the) ankle. According to a skin assessment dated [DATE], the resident was at low risk to develop pressure ulcers. This assessment identified, coccyx redness and a right ankle outer wound but no measurements. A skin assessment dated [DATE] determined the resident was at moderate risk to develop a PU and identified, right heel redness, left heel redness a coccyx pressure ulcer and right lower leg rear pressure. Staff documented on this assessment, wound to right lower leg looks worse, slough to wound bed, surrounding skin red small serosenguinous drainage Bilateral red heels . There was no indication staff determined if the heels where blanchable, which would determine if they were PUs or precursors to PUs. There was no attempt by staff to reconcile if the right lower leg rear was the same as the right ankle outer. Again, staff failed to identify the length, width or depth of these wounds. It was not until the 04/13/16 wound assessment that wounds were consistently identified as to location and measured as follows: right buttock PU was 2.5 cm x 1.0 cm and unstageable, and the right lower leg (rear) PU as 2.0 x 2.0 cm and unstageable. An 04/21/16 weekly wound assessment identified the right lower leg (rear) as 1.5 cm x 1.5 cm unstageable and the right buttock PU as 2.0 cm x 1.0 cm with a depth of 0.1 cm and determined to be a Stage II PU. In an interview on the morning of 04/26/16, Staff D indicated she was dependent on line staff to identify and report PUs so they could be included on the weekly wound assessments. In an interview on the morning of 04/26/16, Staff C reviewed the weekly skin assessments and confirmed they were confusing stating, I was only aware of the buttock and the right calf wounds (as he pointed to the lateral right calf approximately four inches above lateral maleolus). Failure to consistently assess as to the blanchability of reddened areas detracted from staff's ability to identify PUs. Failure to consistently/accurately describe and care plan wounds as to their location detracted from staff's ability to track and trend these wounds and placed the resident at risk for unidentified or worsening/untreated skin conditions.

Based on observation, interview and record review the facility failed, for one of three residents (Resident #1) reviewed for pressure ulcers, to accurately assess resident's skin, monitor skin conditions, identify and treat pressure ulcers and supervise the delivery of care to prevent unnecessary physical harm. This failure caused Resident #1 to develop a Stage III pressure ulcer on the left buttock. Findings included: FACILITY POLICY According to the facility's April 2007 Pressure Ulcer/Skin Breakdown - Clinical Protocol, 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that had not yet ulcerated. The physician will help the staff define the type. of ulceration. The physician will help identify factors contributing or predisposing residents to skin breakdown. clarify relevant medical issues. authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleaning and debridement approaches, dressings. medical interventions related to wound management. document the progress of wound healing. modify the care plan. The December 2007 Pressure Ulcer Treatment policy stated, Review the resident's care plan to assess for any special needs. Deep tissue injury may be difficult to detect. Stage I: Intact skin with non-blanchable redness. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough. or eschar (tan, brown or black) in the wound bed. There was no instruction to any staff, in either of the pressure ulcer policies, about steps one would take if identification of a pressure ulcer was made. There was no instruction on when and whom to notify, when and how to monitor wounds or use of facility forms such as the Ongoing Ulcer Assessment form. Resident #1 Resident #1, reviewed as a closed record, admitted to the facility on [DATE] from a local acute care hospital according to the admission documents and hospital records. Staff documented on the admission 01/26/15 Functional Assessment the only identified skin issues were, 8. Scab: on his back pin point, 10. Surgical Inc. (incision) a. Old: Lt Clavicle, 13. Discolored: back of arm from post IV (intravenous). Staff documented the location of thepin point scabs on the four human figures located on the Functional Assessment sheet. Staff also documented on the human figure reflecting a person's posterior presentation, Red and an arrow pointing to the coccyx and redness in between buttock cheeks, with an arrow pointing to this area. On 05/28/15 at 12:30 p.m., Resident #1 was observed in the day room at the local hospital eating lunch. Resident #1 was not interviewable. According to the facility's 05/18/15 14:43 p.m. nursing note, Resident #1 discharged to a local hospital for further medical evaluation and treatment on 05/18/15. The discharge was prearranged and did not require an emergency service or treatment. Shortly after Resident#1 transferred to the hospital (less than an hour), Resident #1 was noted with a stage III pressure ulcer on the left buttock. Both the physician and the admitting nurse documented the stage of pressure ulcers as Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.). Nursing staff documented, Stage III pressure ulcer with slough present. No infection. 1X1cm(centimeter), on the Daily Patient Reassessment form. The 05/18/2015 physician's note included, Demonstrated a stage 2-3 small 0.5 cm circular ulcer on the left buttocks. There was mild [DIAGNOSES REDACTED] present. The Manager, of the hospital where Resident #1 was discharged , said in an interview on 05/22/2015 at 12:25 p.m., .It was a stage III.it didn't develop here (the resident came with it). It (the pressure ulcer) was located on the inner aspect of the left buttock between the coccyx and the ileum. On 05/26/2015 at 4:00 p.m., this manager said the wound could be construed as unstageable because of the slough and eschar. The hospital nursing staff documentation and review of photographs of the left buttock pressure ulcer that was close to the ileum and was taken within 24 hours of the admission revealed a portion of the wound bed was black/brown (eschar (tan, brown or black) in the wound bed) surrounded by a much larger area of [DIAGNOSES REDACTED] (redness), suggesting more extensive tissue damage. There was no verbal or written communication to the hospital from the facility indicating Resident #1 had a stage III pressure ulcer on his left buttock. An interview with multiple staff on 05/26/15 indicated that no facility staff had knowledge about the stage III pressure ulcer on the left buttock. According to the 02/02/15 Minimum Data Set (MDS), Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Staff assessed the resident to require extensive assistance of two staff for bed mobility, transfers, toileting and personal hygiene. A 01/27/15 Skin Assessment sheet reflected a score of 14. Instruction to staff on this assessment included, Patients with a score of 16 or less are considered to be at risk of developing pressure ulcers. (15 or 16=Low Risk, 13 or 14=Moderate Risk, 12 or less=High Risk). Subsequent 02/23/15 30 day, 03/23/15 60 day and 05/05/15 quarterly MDS assessments indicated Resident #1 had no skin issues and no pressure ulcers. The 05/05/15 MDS was completed just 13 days before Resident #1 discharged . In an interview on 05/26/15 at 5:00 p.m. Staff B and C were asked for documentation to support staff monitored Resident #1's skin. The facility provided Follow-up Quarterly Reports that instructed Nursing Assistant (NA) staff to, Document if skin is intact, skin is reddened or has open area, Report any new openings to Registered staff. Q (every) shift. These report indicated 14 NA Staff (Staff C-Q) observed Resident #1's skin more than 383 times from January 26, 2015 through May 18, 2015. On nine of these observations staff recorded Resident #1 had reddened skin, but did not indicate where the redness was located. In an interview on 05/26/15 at 5:00 p.m., Staff B and C were asked where the facility monitored skin issues identified by Nursing Assistants. No documentation was received to support Registered Staff were consulted about the redness on the occasions it was noted by the NAs. Staff C did provide the Ongoing Ulcer Assessment form for other residents but not for Resident #1. Staff C said Resident #1 had no pressure ulcers. The facility was asked to provide a list of staff who provided Resident #1 with care during the two days prior to discharge. Staff R, a Licensed Nurse, provided a written statement that included, I. discharged (Resident #1) to (hospital) for further assessment. Before discharge, I assessed the resident (with) no open areas in his skin. no sores noticed. There was no indication in the resident's record this staff documented the alleged skin assessment. In response to the question about Resident #1's skin and if there were any open wounds, pressure ulcers or other skin conditions, Staff F reported, in an interview on 05/26/15 at 11:30 a.m., No. If you had seen a skin problem to whom would you report? Staff F replied, Report to the nurse. Staff B reported, in an interview on 05/26/15 at 4:40 p.m., that Staff D, an NA, showered Resident #1 on the day of dischrge and there were no skin issues. According to the facility's 05/18/15 14:43 p.m. nursing note, Resident #1 discharged to a local hospital. The facility did not develop adequate policies and procedures addressing assessment, identification or treatment of [REDACTED].#1's skin, provide Registered or Licensed Nursing supervision or follow-up for reddened areas, did not monitor reddened areas from the time of admission to discharge, did not identify pressure ulcers and did not treat pressure ulcers.

Based on observation, interview and record review the facility neglected to accurately assess resident's skin, monitor skin conditions, identify and treat pressure ulcers and supervise the delivery of care to prevent unnecessary physical harm for one of three (Resident #1) residents reviewed for pressure ulcers. This failure caused Resident #1 to develop a Stage III pressure ulcer on the left buttock. Findings included: According to the facility's November 2012 Abuse Prevention Policy, Neglect means failure to provide goods and services necessary to avoid physical harm. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of resident care and services to ensure that care is provided as needed by the residents. Neglect occurs when a facility fails to provide necessary care for residents. Resident #1, reviewed as a closed record, admitted to the facility on [DATE] from a local acute care hospital with multiple [DIAGNOSES REDACTED]. According to the 02/02/15 Minimum Data Set (MDS), Resident #1 to require extensive assistance of two staff for bed mobility, transfers, toileting and personal hygiene. A 01/27/15 Skin Assessment sheet reflected a score of 14. Instruction to staff on this assessment included, Patients with a score of 16 or less are considered to be at risk of developing pressure ulcers. (15 or 16=Low Risk, 13 or 14=Moderate Risk, 12 or less=High Risk). According to the facility's 05/18/15 14:43 p.m. nursing note, Resident #1 discharged to a local hospital for further medical evaluation and treatment on 05/18/15. The discharge was prearranged and did not require an emergency service or treatment. Shortly after Resident#1 transferred to the hospital (less than an hour), Resident #1 was noted with a stage III pressure ulcer on the left buttock. Both the physician and the admitting nurse documented the stage of pressure ulcers as Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.). Nursing staff documented, Stage III pressure ulcer with slough present. No infection. 1X1cm(centimeter), on the Daily Patient Reassessment form. The 05/18/2015 physician's note included, Demonstrated a stage 2-3 small 0.5 cm circular ulcer on the left buttocks. There was mild [DIAGNOSES REDACTED] present. The Manager, of the hospital where Resident #1 was discharged , said in an interview on 05/22/2015 at 12:25 p.m., .It was a stage III.it didn't develop here (the resident came with it). It (the pressure ulcer) was located on the inner aspect of the left buttock between the coccyx and the ileum. On 05/26/2015 at 4:00 p.m., this manager said the wound could be construed as unstageable because of the slough and eschar. The hospital nursing staff documentation and review of photographs of the left buttock pressure ulcer that was close to the ileum and was taken within 24 hours of the admission revealed a portion of the wound bed was black/brown (eschar (tan, brown or black) in the wound bed) surrounded by a much larger area of [DIAGNOSES REDACTED] (redness), suggesting more extensive tissue damage. There was no verbal or written communication to the hospital from the facility indicating Resident #1 had a stage III pressure ulcer on his left buttock. An interview with multiple staff on 05/26/15 indicated that no facility staff had knowledge about the stage III pressure ulcer on the left buttock. In an interview on 05/26/15 at 5:00 p.m. Staff B and C were asked for documentation to support staff monitored Resident #1's skin. The facility provided Follow-up Quarterly Reports that instructed Nursing Assistant (NA) staff to, Document if skin is intact, skin is reddened or has open area, Report any new openings to Registered staff. Q (every) shift. These report indicated 14 NA Staff (Staff C-Q) observed Resident #1's skin more than 383 times from January 26, 2015 through May 18, 2015. On nine of these observations staff recorded Resident #1 had reddened skin, but did not indicate where the redness was located. In an interview on 05/26/15 at 5:00 p.m., Staff B and C were asked where the facility monitored skin issues identified by Nursing Assistants. No documentation was received to support Registered Staff were consulted about the redness on the occasions it was noted by the NAs. Staff C did provide the Ongoing Ulcer Assessment form for other residents but not for Resident #1. The facility was asked to provide a list of staff who provided Resident #1 with care during the two days prior to discharge. Staff R, a Licensed Nurse, provided a written statement that included, I. discharged (Resident #1) to (hospital) for further assessment. Before discharge, I assessed the resident (with) no open areas in his skin. no sores noticed. There was no indication in the resident's record this staff documented the alleged skin assessment. In response to the question about Resident #1's skin and if there were any open wounds, pressure ulcers or other skin conditions, Staff F reported, in an interview on 05/26/15 at 11:30 a.m., No. If you had seen a skin problem to whom would you report? Staff F replied, Report to the nurse. The facility did not develop adequate polices and procedures addressing assessment, identification or treatment of [REDACTED].#1's skin, provide Registered or Licensed Nursing supervision or follow-up for reddened areas, did not monitor reddened areas from the time of admission to discharge, did not identify pressure ulcers and did not treat pressure ulcers. The facility failed to provide necessary care resulting in neglect. The facility failed to follow their policies or the nursing home guideline also know as The Purple Book to prevent neglect.

Based on observation, interview and record review it was determined that the facility failed to ensure residents received care they were assessed to require. The facility failed to ensure three (#s 16, 50 & 93) of three residents reviewed for non-pressure skin conditions and one (#179) supplemental resident had skin issues identified and/or monitored. Failure to ensure staff provided timely interventions related to the identification of a new wound for Resident #16 delayed treatment and monitoring, which constituted harm. In addition, five (#s 6, 124, 51, 143 & 173) residents did not receive bowel care as ordered. These failures placed residents at risk for untreated and worsening skin issues, infection, pain and constipation. Findings include: FACILITY POLICY According to the Skin Assessment and Interventions to Maintain Skin Integrity policy, the facility is, committed to assisting residents to maintain optimal skin integrity. Assessment, protection of skin integrity, treatments and monitoring will be provided. The policy indicated . all residents receive a weekly skin assessment on shower day and if an alteration in skin or ulcer is found, treatment orders are obtained per medline wound care guidelines. This policy further indicated that Bruises will be monitored on the TAR (Treatment Administration Record) for three days-if healing, discontinue monitoring. RESIDENT #16 According to the 02/12/15 significant change Minimum Data Set (MDS), Resident #16 required extensive one person physical assistance with bed mobility, dressing and personal hygiene. According to the resident's aide directives, staff were to document if skin is intact, skin is reddened or has open areas. Report any new openings to Registered Staff (each shift) and Turn and reposition with skin care (every) two hours if skin is intact/ every one hour if skin integrity is not intact. Hospice Aide documents dated 05/05/15 indicated, Both heels are soft to the touch. Sores on top of the toes are very red. An additional Hospice memo dated 05/05/15 indicated, Triage call from (Staff F) wanting (Hospice) to look at (patient) heels and toes. A skin assessment performed by Staff D (Licensed Nurse) on 05/21/15 at 11:51 a.m. at the surveyor's request revealed multiple skin issues. Staff D described a wound on the resident's second left toe as, .a pressure area on a bony prominence . Staff D described the wound as having slough and a scab which made the pressure ulcer unstageable. The pressure ulcer, located on the distal metatarsal, was measured as approximately 1.0 by 1.0 centimeters (cm) and the scab was partially removed from the wound bed. In an interview on 05/21/15 at 11:51 a.m. Staff H (Hospice Aide) stated, The (left) toe (ulcer) has been there for a few weeks . In an interview on 05/22/15 at 9:05 a.m., Staff F (Licensed Nurse) indicated she was aware of the left toe open area stating, I know it was about two and a half weeks ago, the aide was giving a shower and she told me about it (open area). I talked to the hospice nurse and she said she would be going in and she came in and she saw it and she decided to do whatever they did; they did something, I think they give her the boots, I am a float nurse, there is a big thing over the bed, I don't know about the doctor (being aware of the left toe wound), but the hospice nurse did (know about the open area) . When asked if she made a progress note regarding the wound to the left toe, Staff F replied, Yes we do, we should. Record review revealed no progress note related to the identification of the left toe ulcer, nor any evidence staff were aware of, treating or monitoring the wound to the left second toe. In an interview on 05/21/15, Staff D was asked to provide any evidence in the record staff had identified, monitored, or treated the open area to the left second toe. No information was provided. According to documentation provided by facility staff on 05/26/15, the hospice nurse believes it (open area) to be stasis and not pressure. This document also reflected the hospice nurse, .indicated that a dressing treatment would have been contraindicated to the [DIAGNOSES REDACTED]. Facility staff provided documentation that the resident was seen by the Advanced Registered Nurse Practitioner (ARNP) on 05/26/15 who documented, Nursing staff reported a small open wound on the 2nd toe of her left foot x 1 week and described the wound as a diabetic ulcer 2nd toe left foot. The ARNP also ordered triple antibiotic ointment to the left second toe and Prostat, a high protein liquid supplement. There was no documentation to support why the hospice nurse, who had been aware of the ulcer, had not implemented such interventions. In an interview on 05/28/15 at 9:16 a.m., the ARNP indicated he was first made aware of the left toe wound on 05/26/15. When asked if he would expect to be notified of skin issues upon their identification he stated, Usually I am. He stated he would expect to be notified upon identification of any skin issues so interventions could be implemented to prevent wound decline. The ARNP indicated the Prostat was ordered to promote wound healing. Failure to timely notify the ARNP or physician of the wound when staff became aware of it resulted in delayed implementation of interventions to promote wound healing. During the skin assessment, an additional area was was noted to Resident #16's right posterior calf measured as 13.5 cm by 5 cm and described by Staff D as a deep red/purple bruise. A fluid filled blister was observed centrally located in the bruised area and measured as 3 cm x 2 cm. A progress note from 05/20/15 identified a blister to the resident's right lower extremity but did not provide any measurement, treatment or intervention for the wound nor was there mention of the bruising. In an interview on 05/21/15 at 2:09 p.m., Staff D indicated the right calf blister, should be measured, care planned and noted in the record . In an interview on 05/28/15 at 9:16 a.m., the ARNP who examined Resident #16 on 05/26/15 indicated he would expect to be notified upon identification of any skin issues so interventions could be implemented to prevent wound decline. When asked about the blister to the resident's posterior right leg, the ARNP indicated he was not made aware of this wound and thus did not look at it. Facility staff failed to provide an objective measurable assessment or interventions for the right calf blister identified in a 05/20/15 progress note. The facility failed to notify the ARNP/physician so that interventions to promote wound healing could be implemented. These failures placed Resident #16 at risk for worsening wounds, pain and infection. RESIDENT #50 According to the 02/14/15 MDS, Resident #50 originally admitted to the facility in February 2012 and had a BIMS score of 7, reflective of severe cognitive impairment. According to this MDS, Resident #50 was usually understood and usually able to understand conversation. Observation on 05/18/15 at 10:18 a.m. revealed the resident had a lesion on the left cheek which was black in color with a similar lesion on the right forehead near the eyebrow line. According to the Centers for Disease Control, (www.cdc.gov/cancer/skin.com), A change in your skin is the most common sign of [MEDICAL CONDITION]. The CDC described five signs of melanoma: a mole or spot that is asymmetrical, has borders that are irregular, has uneven color, has a diameter that is larger than the size of a pea, or that is evolving. Staff D (Licensed Nurse) performed a skin assessment, at the surveyor's request, on 05/21/15 at 9:42 a.m. Staff D described the left cheek lesion as, a mole . not open, dry, 1.5 centimeter (cm) by 1.1 cm, dark brown, with irregular (asymmetrical) borders, it is raised not smooth, bumpy, not uniform in color, different shades of a dark brown, no drainage, dry and intact. Staff D described the lesion proximal to the right eyebrow as, a mole, 0.5 cm by 1.0 cm, dark brown, not open, raised dry, irregular borders, varied color tone, dark brown to light brown and varied height. Review of care plan documents revealed no mention of the observed [MEDICAL CONDITION]. In an interview on 05/19/15, Staff D was asked to provide any documentation in the record staff were aware of these [MEDICAL CONDITION] or of any baseline assessment that had been done. In an interview at 05/19/15 at 1:50 p.m., Staff D stated, I can't find anything. When asked why these [MEDICAL CONDITION] weren't care planned or monitored, Staff D stated, we wouldn't monitor them unless they changed . Staff D concurred that without a baseline assessment, it would be difficult to determine if there was any change in the [MEDICAL CONDITION]. RESIDENT #93 Resident #93 was observed 05/18/15 at 1:36 p.m., with bruising to her right 4th finger between her distal knuckles. Her arms were covered with sleeves at the time and could not be viewed. Review of the Kardex from the computer system, which was only dated with the resident's admission date of [DATE], revealed staff were directed to Monitor and report any changes in condition of Resident skin. Create alert if new area is observed. 2x/w (two times per week) & PRN (as needed) on bath days. Sunday and Thursday day shift. This indicated the resident had a skin check on 05/17/15. Review of the May 2015 TAR and nursing notes on 05/17/15 did not indicate any new skin issues. A current Weekly Skin Checklist could not be found. The most recent one was dated 05/10/15. There was no indication the bruising was identified or being monitored. On 05/21/15 at 8:30 a.m., Staff L, CNA, was asked where the most recent Weekly Skin Checklist(s) were kept. She explained they were kept in a separate binder. Upon locating this binder Staff L looked for Resident #93's. She was unable to find a Weekly Skin Checklist more recent than 05/10/15. On 05/21/15 at 8:39 a.m. Resident #93 was being taken to the shower room by Staff AA, CNA. At 11:08 a.m., Resident #93 was observed in bed lying on her left side. Her right arm was visible. Along with the bruising to her right 4th finger, five other bruises were observed. There were three to the forearm and two on the upper arm. Her right elbow also had a skin tear. There was no indication in the record that any of these areas were identified or monitored. At 11:22 a.m., Staff AA, who bathed Resident #93, indicated a skin check was done during the shower and stated she had informed the resident's nurse of the skin tear to her right elbow. Additional record review revealed a treatment order had been added 05/21/15 to Monitor s/sx (signs and symptoms) of infection on right elbow skin tear, bilateral arm bruising. There was no specific description of the bruises (e.g. number, location, measurements) that would allow staff to be able to objectively determine if a skin issue was worsening, getting better or if a new one had developed. On 05/22/15 at 10:00 a.m., Staff C, Assistant Director of Nursing, was asked what he expected staff to do if they saw an injury/skin issue of unknown origin such as a bruise or skin tear. Staff C stated We would do an investigation . and indicated staff would then monitor the area(s). The resident was not available for observation at this time, however, the bruising was described to Staff C who indicated if there were multiple bruises staff should be descriptive with treatment orders to monitor such as Monitor hand or more specific on the finger. Staff C was informed that bruising to the right finger was first observed on 05/18/15 and there was nothing in the record until 05/21/15 that indicated it was identified. Staff C was asked how staff were supposed to determine if an area was getting better, worse or that a new bruise occurred if there was not a more specific description of the location than bilateral arm bruising. He was unable to explain. RESIDENT #179 According to the 05/04/15 MDS, Resident #179 was understood and able to understand conversation and required one person extensive assist with dressing, toilet use and personal hygiene. In an interview on 05/19/15 at 12:33 p.m. the resident indicated she had a bruise on her buttock from a fall she had experienced. She indicated the bruise was apparent within a day or so . of the fall. A progress note, dated 05/15/15, revealed the resident was discovered sitting on the floor in her room. She slid down from wheel chair to floor after using bathroom. The resident was described as alert and oriented. .no injury or skin tears noted at this time. There was no indication facility staff re-assessed the resident for latent injury post fall until the resident experienced another fall three days later. According to a progress note dated 05/18/15, Found resident in her chair. She told me she was trying to reach the pen on the floor while she slipped out of her chair and hit the floor with her back . assessment was done. she was able to move her extremities without any limit. No skin tear noted during assessment . A progress note dated 05/19/15 at 5:31 a.m. indicated, Noted diffusing bruise on left buttock r/t (related to) fall . A progress note dated 05/20/15 at 6:09 a.m. indicated, left bottom bruise diffusing . but offered no other description of the bruise. During a skin assessment, requested by the surveyor, on 05/22/15 Staff D identified what was described as an approximate, six inch by six inch dark red bruise to the resident's left buttock. In an interview on the morning of 05/22/15, Staff B indicated, We wouldn't measure it (the bruise) but would monitor it to see if it was getting better. However, with rotating staff, unless there was at minimum, a baseline description of the bruise, it would be impossible for staff to determine any static change in the bruise. BOWEL PROTOCOL According to the facility's bowel protocol, staff were directed to give 120 cubic centimeters of prune juice on day shift if no bowel movement (BM) for 48 hours. Thirty milliliters of Milk of Magnesia (MOM) was to be given on evening shift if no BM following prune juice. A [MEDICATION NAME] Suppository was to be inserted rectally on night shift if no BM following administration of MOM. Staff were directed to notify the physician if no BM results from suppository. RESIDENT #6 Review of the resident's bowel record revealed staff documented he did not have a bowel movement (BM) from 10:00 a.m. on 04/21/15 until the day shift on 04/26/15, a total of 14 shifts or 4 1/2 days. Similarly, there was no indication of a BM for three days between 04/29, 30 and 05//01 and no BM was recorded on 05/10, 11, 12, 13, 14, or 15/15. a total of more than 6 days. Review of the April and May Medication Administration Records (MAR) and TAR revealed staff did not implement any interventions related to the lack of a BM. Staff failed to provide prune juice, Milk of Magnesia (MOM) or a suppository as directed by physician's orders [REDACTED]. In an interview on 05/20/15 at 12:45 p.m. Staff B stated the nursing assistants documented BMs in the computerized record. She explained the night shift ran a report nightly to identify who had not had a BM in 48 hours and then would start interventions. She was unable to explain why there was no indication interventions were implemented despite multiple days of no BM for Resident #6. RESIDENT #124 Similar findings were identified for Resident #124 who went without a BM from 04/24/15 to 04/28/15 without receiving MOM as directed in the POs. RESIDENT #51 Similar findings were identified for Resident #51. According to her 05/05/15 MDS, the resident required extensive two person assistance for transfers and toilet use. Review of bowel records revealed staff indicated she did not have a BM on 04/29, 30, 05/01, 02, 03 or 04/15, a total of more than six days. Review of the MAR and TAR revealed staff did not implement any of the ordered interventions, nor was there any indication the physician was notified of the resident's apparent constipation. In an interview on 05/20/15 at 12:50 p.m., Staff B stated Resident #51 was on narcotic pain medication which could cause constipation. In addition, she stated the resident had not been eating, so it was possible she did not need to have a BM. Staff B stated staff should document that assessment and notify the physician to determine if interventions were warranted. She was unable to explain why that had not been done. RESIDENT #143 A PO dated 11/29/14 directed staff to administer MOM every 48 hours as needed for constipation . evening shift . if no BM following prune juice. Review of the bowel record revealed the resident went from day shift on 12/11/14 to 12/15/14 with no bowel movement and no evidence either prune juice or MOM was administered. RESIDENT #173 Similar findings were identified upon review of the closed record for Resident #173. Review of the bowel record revealed staff documented the resident did not have a BM on 04/11, 12 or 13, until the evening of 04/14 with no interventions. In addition, staff did not administer prune juice until the morning of 04/18/15 despite no record of a BM for the previous three days (04/15, 16 or 17). Similarly, while staff documented the resident did not have a BM on 05/03, 04, 05, or 06, they failed to implement any interventions until prune juice was given on the afternoon of 05/06/15.

Based on observation, interview and record review it was determined that the facility failed to prevent, identify, monitor and/or implement preventative measures for pressure ulcers. Failure to implement the interventions identified as required for Resident #16 caused harm as evidenced by the development of pressure ulcers. Failure to monitor and provide interventions for existing pressure ulcers which staff were aware of placed Resident #16 at risk for delayed treatment to promote wound healing and detracted from staff's ability to monitor wound progression. In addition, the facility failed to implement interventions after a pressure ulcer was discovered for Resident #173. These failures placed residents at risk for worsening or unhealed pressure ulcers, infection and pain. Findings include: FACILITY POLICY According to the facility policy on Skin assessment and interventions to maintain skin integrity, all residents receive a weekly skin assessment on shower day and if an alteration in skin or ulcer is found, treatment orders are obtained per medline wound care guidelines. Staff were directed to complete a skin Ulcer Assessment Tool for all pressure ulcers, a separate tool for each area of breakdown. The weekly skin assessment tool utilized by the facility directed staff to indicate on diagram using numbers next to the condition the presence of any of the following: cut, dry flaky, abrasion, bruise, skin tear, incision, rash, red area, open area, scratch, blister .other. The facility Pressure Ulcer Treatment policy described a Stage II pressure ulcer as partial thickness loss of dermis . may present as an intact or open/ruptured serum-filled blister. This policy described an unstageable pressure ulcer (PU) as full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (tan, brown or black) in the wound bed. RESIDENT #16 According to the 02/12/15 significant change Minimum Data Set (MDS), Resident #16 was assessed as being at risk for the development of PUs, but had no current PUs. This assessment determined the resident had pressure reducing devices for both the bed and chair. According to this MDS, staff assessed the resident required extensive one person physical assistance with bed mobility, dressing and personal hygiene. According to the resident's aide directives, staff were to document if skin is intact, skin is reddened or has open areas. Report any new openings to Registered Staff (each shift) and Turn and reposition with skin care (every) two hours if skin is intact/ every one hour if skin integrity is not intact. A progress note dated 03/09/15 indicated, (Received) notice that resident has a new open area on coccyx . explained importance of eating well and following guidelines provided for changing position. will order Vitamin A, Vitamin C and zinc to help promote wound healing . Progress notes dated 03/11/15 indicated, per RN resident's wound has healed . will d/c the Vit A, Vit C and zinc. There was no indication of the size or stage of this wound in the resident's record. Record review revealed a weekly skin checklist, dated 05/16/15, which identified redness in the groin area but no other skin issues. According to computerized records dated 05/13/15 and 05/20/15, staff were asked if the resident had redness or open areas to which staff documented, Intact. Observations on 05/19/15 at 8:21 a.m., 9:50 a.m., 10:40 a.m., 12:38 p.m., 1:09 p.m. and 1:37 p.m. revealed Resident #16 lying in bed on her back. The resident was noted with a foot cradle (a device which keeps bed sheets off the feet) on the bed and blue boots to her feet. While staff were noted to periodically provide care to the resident, no significant change in position was provided. Observations on 05/20/15 at 8:05 a.m., 8:36 a.m., 9:00 a.m., 10:30 a.m., 11:24 a.m., 12:29 p.m., 1:39 p.m. and 1:50 p.m. revealed Resident #16 lying in bed on her back. Similar observations of the resident lying in bed on her back without position changes were noted on 05/21/15 at 7:43 a.m., 8:44 a.m., 9:38 a.m., 10:24 a.m. and 11:40 a.m. In an interview on 05/20/15 at 1:22 p.m., Staff J (Nursing Assistant) stated, the boots and the (foot) cradle are new from hospice. Record review revealed no Physician's Orders, care plans or aide directives which addressed the use of either the boots or foot cradle. A skin assessment performed by Staff D (Licensed Nurse) on 05/21/15 at 11:51 a.m. at the surveyors request revealed an open area was identified on the resident's coccyx, which Staff D described as a pressure ulcer having, red wound bed with no drainage that was measured as 0.3 cm in length and 0.2 cm in width. (This description is indicative of a Stage II pressure ulcer.) This pressure ulcer was on the coccyx, just at the pressure ulcer identified on 03/09/15 was. Facility staff failed to provide the turn and reposition as care planned for Resident #16 caused the coccyx PU to reoccur. Facility staff also failed to identify, report and assess skin issues till skin assesment requested by the surveyor. These failures placed Resident #16 at risk for worsening wounds, pain and infection. RESIDENT #173 Review of the record revealed Resident #173 admitted to the facility on [DATE] for care needs related to a repaired [MEDICAL CONDITION]. According to admission records, she admitted with a pressure ulcer to the coccyx. She was discharged back to the hospital on [DATE] due to a non-healing pressure ulcer to the coccyx that had become infected. She subsequently passed away at the hospital and was thus unavailable for interview or observation. According to a progress note dated 04/29/15, staff identified an intact blister (a Stage II pressure ulcer) on the resident's right heel. This note indicated interventions of moon boots, direction to float the resident's heels while in bed, and monitoring of the blister would be placed on the Treatment Administration Record (TAR) for implementation by staff. However, none of these interventions were placed on the TAR until 05/05/15, a full week after the blister was discovered. In addition, none of the interventions were added to the care plan or care directive. There was no indication the resident's heels were floated prior to the discovery of the blister, despite her risk factors, which included immobility and a pressure ulcer that was being treated to her coccyx. In an interview on 05/22/15 at 8:37 a.m., Staff B reviewed the resident's closed record. She stated there was direction in the care plan to turn / reposition the resident every two hours, as well as a physician's order, dated 04/26/15, to elevate the resident's legs while in bed overnight. She stated while the order specified overnight, she thought it could be interpreted to be done anytime the resident was in bed. When asked the purpose of elevating the resident's legs, Staff B explained it was due to [MEDICAL CONDITION] in her lower extremities. When asked if elevating a resident's legs meant pressure would be removed from her heels Staff B acknowledged it did not, for the elevation could be implemented simply by raising the foot of the bed, while her heels could have remained against the mattress. Staff B stated she could not explain why the blister was not put on the MAR indicated [REDACTED]. She acknowledged that for a resident with risk factors, interventions needed to be implemented prior to the development of a pressure ulcer, and immediately upon identification of a pressure ulcer, monitoring and treatment needed to be initiated.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer for Resident #118 or deterioration of pressure ulcers for Resident #90, two of three residents reviewed for pressure ulcers . In addition, for Resident #118, the facility failed to revise and implement treatments which promoted healing of the pressure ulcer. These failures resulted in harm to both residents who developed pressure ulcers while in the facility. Findings Include, but are not limited to: In review of the facility policy "Skin assessment and interventions to maintain skin integrity" it was identified under the section "Basic Protection of skin integrity: Daily skin observations during care by the Nursing Assistant, who reports problems to the Licensed Nurse." In addition the policy identified "New admissions are assessed weekly times four by the Licensed Nurse and documented on the TAR (Treatment Administration Record)." RESIDENT #118: Resident # 118 was admitted to the facility in mid 02/11 after a fracture to the hip. The admission comprehensive assessment (Minimum Data Set) dated 02/22/11 showed the resident required extensive to total assistance with Activities of Daily Living (ADL) and was at "moderate risk" of developing pressure ulcers. The Care Area Assessment (CAA) associated with the 02/22/11 MDS identified risk factors for pressure ulcer were related to dementia, confusion, anxiety, impaired mobility and identified the approach of "float heels in bed" as a preventive measure. The resident's February TAR did not include full body skin assessment information. The progress notes during this period of time did not include any information related to skin condition. During observation of the resident in bed on 06/6/11 at 3:54 p.m.; 06/07/11 at 8:57 a. and 2:06 p.m.; and 06/08/11 at 10:30 a.m., no "heel protector to right foot" was observed. In addition staff was aware of the resident not wearing a heel protector during the time in bed. During the observation on 6/07/2011 at 8:02, Staff S, said "She doesn't keep it on."; at 8:57 a.m., Staff DD looked for the prescribed "heel protector" and was unable to locate it. The CNA stated, "She doesn't leave it on anyway." In an interview with Staff CC on 06/07/11 at 2:28 p.m. she also reported "... (the resident) kicks off the boot." The resident's daughter on 06/08/11 at 10:31 a.m. stated, "(she) didn't like it, wouldn't leave it on." The daughter identified a boot found in the resident's room as a "new" one; not like the one which was usually there. Observation of the resident on 06/06/11 at 3:54 p.m. when asked about her heel, she responded "Yes" to the question "Does it (your heel) hurt?" On 06/07/11 at 8:52 a.m. the resident was sitting in her wheelchair lifting her right foot off of the floor and stated "...I've got a sore here..." At 8:57 a.m., while lying in bed, the resident said, "It is sore, it still hurts. I don't know what to do with it." On 06/08/11 at 10:31 a.m. the resident reported her heel hurts when she has her shoes on. The pressure ulcer on the heel was observed with Staff I on 06/08/11 at 10:31 a.m. It was necessary to use a mirror to observe the black eschar (Dead or devitalized tissue) on the heel. On 03/02/11, 14 days after admission, the facility's "Skin Ulcer Assessment Tool--Newly Found Ulcer" documented a 2 cm by 2 cm pressure ulcer. The Facility's "Ongoing Ulcer Assessment" form sheet noted the "Ulcer type as decub/pressure (decubitus), facility acquired, on the right heel, unstageable, purple in color, ... no pain and with the current treatment--float heels, monitor q (every) shift and lotion q shift until resolved." (Unstageable related to the condition of the skin and depth of the pressure ulcer. If the base of the ulcer is not visible, the wound is classified as unstageable.) In a conversation with the resident's daughter on 06/08/11 at 10:31 a.m. she reported "it (the pressure ulcer) happened here, she was immobile for about 6 weeks after she was admitted . She wouldn't keep the boot (prescribed treatment) on her foot." In an interview with the Director of Nursing (DNS) on 06/08/11 at 1:40 p.m. when ask how the pressure ulcer developed, she identified possible "casual factors" for the development of the pressure ulcer as "1) deep tissue damaged due to surgery--didn't (wasn't) present on admit or 2) staff/family reported the resident repeatedly rubbed her right foot/heel back and forth on the bed initially after admit." She did not think the rubbing of the foot was the cause, but was unable to clearly identify why the skin broke down. The DNS reported the resident's physician was notified on 03/07/11, during a routine visit about the pressure ulcer (5 days after its discovery). The "Ongoing Ulcer Assessment" sheet documented weekly checks. On each check through 06/1/11 the size increased. For example: on 03/31/11 the size increased to 2.4 cm by 2.0 cm and was unstageable; 04/20/11 the size increased to 2.5 cm by 2.4 cm; 05/20/11 2.7 cm x 3.0 cm; and on 06/01/11 the size was, 2.2 cm x 2.4 cm in size. Each time (except on 03/09/11) the pressure ulcer was staged as "unstageable." A section on the "Ongoing Ulcer Assessment" contained the following: "Is this the 4th week with the same TX (treatment)?" Starting on 03/23/11 through 06/01/11, "Yes" was marked. A "Yes" response indicated, "...need to change treatment." The current Physician Orders for June 2011, showed the same treatments: "[MEDICATION NAME] to ... heels until resolved, start date 4/3/11" and "Offload ankles/feet while in bed and wear heel protector to right foot, start date 03/7/11." The facility failed to prevent a pressure ulcer from developing on a newly admitted resident resulting in an unstageable ulcer which increased in size from 03/02/11 through 06/01/11. Treatments were not revised nor implemented in a consistent manner and the pressure ulcer increased in size. RESIDENT # 90 Resident # 90 was admitted to the facility 01/28/10, with multiple medical [DIAGNOSES REDACTED]. On 06/06/11 during repeated observations at 7:45 am, 8:31 am, 9:30 am, and 10:22 am, Resident # 90 was found lying in the same position, directly on her right hip. On 06/07/11 at 10:47 am, two pressure ulcers, both stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pick wound bed) were observed with Staff G during dressing change. The pressure ulcer located on the right hip measured 1.1 cm (centimeter) by 1 cm. A second pressure ulcer located on the right inner heel measured 1.6 cm by 2.8 cm.. Review of the care plan, dated 02/18/10, showed interventions included monitoring the resident for skin breakdown, and also directed staff to: "Turning per protocol, position to keep off the open area." On 06/10/11 at 2:00 pm, the DON reported the facility standard for providing assistance with repositioning was every two hours. There were no other interventions to prevent skin breakdown on the care plan. The current "Ongoing Ulcer Assessment" documented weekly evaluations of the pressure ulcer characteristics on the right hip. The assessment noted on 06/01/11, indicated the resident had a stage I (non blanchable reddened skin) which had developed in severity to a stage II on 06/08/2011. On 06/09/11 at 1:00 pm, the Resident Care Manager (RCM) was interviewed about the resident's skin issues. She reported that in the past the resident had an unstable pressure ulcer on her heel that resolved in 12/22/10. She stated the resident experienced recurrent pressure ulcers on her heel and that staff routinely monitored the area daily when applying the "skin prep." At 2:00 pm, the RCM accompanied a surveyor to observe the resident's right heel. A previously unreported Stage II pressure ulcer was observed. The RCM commented the Licensed nurses need more training on identifying pressure ulcers. The documentation of the previous "ongoing ulcer assesment" were later provided. The monitoring sheets indicated the resident's right heel previously had a pressure ulcer staff described as a blister on the right heel between 03/29/10 and 05/28/10. The pressure ulcer opened again as an unstageable pressure ulcer on 07/16/10 and heeled on 12/22/10. Not ensuring Resident # 90 received assistance with turning and repositioning as care planned resulted in a Stage I pressure ulcer on the right hip progressing to a Stage II. In addition, the facility had knowledge of a previously heeled chronic pressure ulcer on the resident's heel, but failed to identify interventions were in place to prevent further skin breakdown on the resident's right heel.