Every finding on record at Landmark Care And Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of nursing staff to provide care and services for 13 of 13 residents (Residents 54, 35, 4, 3, 79, 89, 7, 53, 62, 90, 92, 6, and 23) reviewed for sufficient staffing as evidenced by failures related to Resident Rights, Quality of Care and Pressure Injuries. Additionally, resident interviews, staff interviews and reports from the resident council meeting provided evidence of insufficient staffing without resolution. This failed practice placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health.Findings included .Resident Rights:The facility failed to provide care and services in a manner that maintained and promoted dignity for three residents observed during meal service.Resident 54During an observation on 07/27/2026 at 12:15 PM, Resident 54 was observed attempting to eat their meal in the assisted dining room and were sitting approximately three feet away from the table, attempting to eat their meal with a spoon causing them to spill food on their person and the floor. At 12:40 PM, 25 minutes later, a nursing assistant (NA) came into the dining room and assisted them with their meal.Resident 35During an observation on 07/28/2026 at 9:15 AM, Resident 35 had been served their breakfast tray on their bedside table. The tray table was 6 feet away from where Resident 35 was seated and they were unable to reach the tray. At 9:30 AM, 15 minutes later, a NA came into the resident's room and moved them to their bedside table so they could access their meal.Resident 4During an observation on 07/28/2026 at 9:16 AM, Resident 4's left arm was observed to be paralyzed, and they were attempting to eat with their right hand while the food tray was positioned on the left side of the resident. The position of the tray on the resident's neglected side caused them to drop food on their clothing and the floor.An interview on 07/27/2026 at 12:20 PM with Staff S, NA, stated they were the only one working today in the assisted dining room and were also helping pass meal trays on the south hallway.Quality of Care:The facility failed to ensure care, services and documentation that addressed skin integrity issues were provided in accordance with professional standards of practice.Resident 3Assessment reviews and interviews showed the nursing staff were not adequately assessing, monitoring or providing wound care as required of a surgical wound on Resident 3's right hip.Prevent/Heal Pressure Injuries:The facility failed to ensure pressure injuries did not develop or worsen in the facility.Resident 79During an observation on 07/27/2026 at 9:00 AM, a pressure injury was found on Resident 79's right hip. Further review of assessments and interview with staff showed Resident 79's pressure injury developed in the facility.Resident and Resident Representative interviews:Resident 89During an interview with Resident 89 on 07/27/2026 at 3:26 PM, they stated the call light response time could take up to an hour for anyone to answer. Resident 89 further stated even when the staff do come, they seem rushed and like we are an inconvenience to them.Resident 7During an interview with a Resident Representative (RR) of Resident 7 on 07/28/2026 at 11:21 AM, they stated I don't believe there is enough staff to take care of Resident 7. I took them home last week for a visit and they smelled dirty, so I gave them a shower and found they were not cleaned well in the perineal area and had a small sore on their bottom they were unaware of.Resident 53During an interview on 07/27/2026 at 12:16 PM, Resident 53 stated the facility is frequently short of NA staff. It can take up to an hour to get your call light answered.Resident 62During an interview on 07/27/2026 at 11:44 AM. Resident 62 stated it has taken over 4 hours before to get their call light answered but typically it's 30 minutes to an hour. Resident 62 stated they often have to call the front desk to get someone to come and answer their call light.Resident 90During an interview on 07/27/2026 at 4:26 PM, Resident 90 stated the facility was frequently short of staff, especially at night and on weekends. Resident 90 stated there is a horrible response time to the call lights, usually up to an hour wait time and then when someone does come, they treat you like you are a bother to them and will turn off your call light and say they will be back. Resident 90 stated they rarely come back.Resident 92During an interview on 07/27/2026 at 1:35 PM, Resident 92 stated there were not enough staff working here to take care of the residents. They stated, it takes up to an hour to get your call light answered and then the staff are rushed and impatient with you when they do come. Resident 92 stated there are some good NA's and nurses working here but they have shared they are very frustrated with the staffing issues and those dedicated staff are doing back-to-back 16-hour shifts and are dead on their feet. Resident 92 stated I've heard repeatedly from the staff that they are looking for new jobs because it's just too hard on them to continue working short staffed. Further, Resident 92 stated I am only here for a short stay, but I will not recommend this place to anyone. It has not been a good experience.Staff Interviews:During an interview on 07/30/2026 at 10:00 AM, with Staff DD, nursing schedular, they stated they schedule all shifts for both the Licensed Nurses (LN's) and the NA staff. Staff DD stated the facility administration wants them to schedule the staff by the number of residents in the facility (the census) not by the acuity of residents. (How much care the residents need for their daily ADL care.) Staff DD stated she got concerns all the time from the NA's because many of the residents require two staff members to care for them, which is hard to accomplish if there are not enough staff on the floor to help.During an interview on 07/29/2026 at 2:45 PM Staff Y, NA shower aide, stated the staffing scheduler always tries to have a bath aide on every day unless they are short of NAs on the floor and then they will get pulled and showers are missed for that day. Staff Y stated the bath aides do get pulled frequently, especially on the weekends.In an interview on 07/29/2026 at 2:20 PM, Staff Z, (NA), stated to be honest, I have recently been spoken to for not taking my breaks, but if I do that, I would be behind with resident cares. We are frequently short on staff, and we have a lot of residents who require two staff members, we just do the best we can.In an interview on 07/30/2026 at 10:22 AM, Staff AA, NA, stated they are scheduled to do daily showers and do get pulled frequently from their normal duties. Staff AA stated that it was difficult to do all cares, showers, transfers and Hoyer transfers in a shift. Staff AA stated on the south hall most rooms require 2 staff members to assist the residents. If we get pulled from doing showers, all NAs are expected do their own showers on top of everything else. We already don't have enough time to get all the tasks done and then we will get told to go home when the census drops.During an interview on 07/30/2026 at 10:24 AM, Staff D, Director of Nursing, (DNS) stated they are currently recruiting for more nursing staff but felt the recent resignations of some of the nurses and call ins are what has caused a lot of the problems as far as low staffing levels go. The DNS stated they frequently have to work the floor themselves because they don't have enough LNs to cover the shifts.Resident Council Meeting:During an RC meeting on 07/28/2026 at 1:00 PM, Resident 6 stated that the residents who come to the resident council meetings monthly consistently shared concerns about there not being enough staff to take care of them. Resident 6 stated the long waits for call lights to be answered was the worst, it often takes up to an hour to get it answered and then the staff answering them acts like they are doing you a favor.During the same RC meeting Resident 23 stated having enough staff to care for them was their major concern. They stated the weekends were the worst, followed by night shift and they were frequently told to expect long call light wait times on any shift because they were short staffed. Resident 23 stated I don't my call light answered for up to an hour or more, I used to feel safe here but don't any longer. Any of us could fall, or choke, or have a heart attack, and nobody would even come and check on us before we were dead.Reference: WAC 388-97-1080 (1), -1090 (1)

Based on observation, interview, and record review the facility failed to ensure residents received wound care treatment and management in accordance with professional standards of practice regarding a surgical wound which was not consistently/adequately assessed, monitored, or had the ordered wound care dressing changes completed for 1 of 3 residents (Resident 3) reviewed for non-pressure related skin issues. These failures placed residents at an increased risk for unmet care needs, untreated skin impairments, and a diminished quality of life. Findings included .Review of the facility's undated policy titled, Documentation of Wound Treatments, showed the facility would complete accurate documentation of wound assessments and treatment. The policy showed that wound assessment would be completed on admission and weekly. The documentation would include measurements (like length, width and depth of the wound), descriptions of the wound characteristics (wound bed color, skin tissue color surrounding wound, presence/amount of wound drainage, odor and pain) and each treatment or dressing changes performed. Additionally, the policy showed that documentation would include the wound progress towards healing, effectiveness of current interventions, modification of treatment, and notification to the physician regarding wound treatment or changes. The facility's policy utilized references from Lippincott Nursing Procedures 8th edition.Review of professional nursing guidelines, Lippincott Nursing Manual of Nursing Practice 11th edition, and Lippincott Nursing Procedures 8th edition, both dated 2019, showed postoperative surgical wounds dressing changes should be completed per the surgeon's instructions along with being assessed at least every shift, which included the type of surgical wound, how it was held together (like staples, sutures or surgical glue), the wounds appearance (like redness, swelling, irritation, drainage, and if the sides of surgical wound closely aligned or touching) and the type of dressing used. The postoperative surgical wound guidelines for bathing/showering showed that a surgical wound could get wet three days after operation if the initial dressing had already been changed. Additionally, the guidelines showed, .Because many practitioners prefer to change the first postoperative dressing themselves to check the incision, don't change he first dressing unless you have specific instructions to do so . and if the wound had drainage and required a dressing change an order and communication with the practitioner would be necessary.Review of Resident 3's medical records showed that they were admitted on [DATE] with diagnoses including a fracture of the neck of right femur (long hip and thigh bone) with hemiarthroplasty (a surgery that replaces half of the hip joint), bladder infection, multiple heart complications and anxiety. The 06/25/2026 comprehensive assessment showed was cognitively intact, able to make their needs known and had a surgical wound that required dressing changes.Review of Resident 3's hospital transfer orders, dated 06/19/2026 showed the resident was to follow-up with the orthopedics (a specialized medical branch focused on correcting and treating bones, joints and muscles) department in two weeks to monitor the surgical wound healing. The orders showed restrictions of keeping the wound covered while bathing and that for wound care, Follow current wound care recommendations .Review of Resident 3's progress notes showed;06/19/2026 at 2:50 PM, admission note stated the resident was alert, cognitively intact and had a right femur neck fracture that required surgical intervention.06/19/2026 at 10:11 PM, daily skilled assessment note stated, .Skin Observation: Resident noted to have a surgical wound. Surgical incision .No clarification of wound care orders or communication with practitioner nor an assessment of Resident 3's surgical wound/dressing had been noted.Review of Resident 3's wound care orders showed;Starting on 06/19/2026 at 7:00 PM nursing staff were to document assessments of the resident's right femoral neck fracture hemiarthroplasty incision two times a day.Starting on 06/20/2026 the right surgical hip incision was to be cleansed with wound cleanser (a special solution used to clean out the wound bed), rinsed with a normal saline solution, pat dry, apply skin prep to peri wound (skin area surrounding the wound) and cover with bordered dressing (a gauze pad surrounded by adhesive tape border). Additionally, the order showed the dressing was to be changed every day or if soiled (made dirty or unclean) or displaced.Review of Resident 3's June 2026 and July 2026 shower schedule documents showed they had received showers on 06/20/2026, 06/23/2026, 06/26/2026, 06/30/2026, 07/03/2026 and 07/07/2026. All shower documented noted Residents right hip surgical incision wound.Review of Resident 3's progress notes for their June 2026 and July 2026 shower days showed that on 06/20/2026, 06/23/2026, 06/26/2026, 06/30/2026 and 07/07/2026 no additional dressing changes were performed after Resident 3 showers had been completed.Review of Resident 3's June 2026 medication administration record/treatment administration record (MAR/TAR) showed that nursing documentation on the resident's surgical wound was not completed on 06/28/2026 and did not include descriptions of the wound characteristics or the surgical wounds measurements and appearance. The TAR showed that Resident 3's right hip surgical incision dressing change had not been performed on 06/26/2026, 06/29/2026 and 06/30/2026. Additionally, no documentation of the surgical site having required a dressing change from being soiled or displaced.Review of Residents 3's July 2026 MAR/TAR showed that nursing documentation on the resident's surgical wound did not include descriptions of the wound characteristics or the surgical wounds measurements and appearance. The TAR showed that Resident 3's right hip surgical incision dressing change had not been performed on 07/06/2026. Additionally, no documentation of the surgical site having required a dressing change from being soiled or displaced.During an interview on 07/29/2026 at 2:45 PM, Staff Y, Nursing Assistant (NA), stated that when showering if the resident had a wound with a dressing, they would try to cover the wound so that it would not get wet. Staff Y stated they were not able to cover surgical hip incision dressings during showers like with Resident 3 and would let the nursing staff know that a dressing change was needed after the shower, since it would get wet during the shower. Staff Y stated that with each shower they had a long-bordered dressing on their hip which would get wet during showers and the dressing sometimes have a brown stained color to it. Staff Y stated that Resident 3's dressing would come off and/or get soaked from the shower water, so they would notify the nursing staff that after the shower was completed.During an interview on 07/29/2026 at 4:13 PM, Staff E, Resident Care Manager, stated the process for residents with surgical wounds and showering would be to not have the resident complete a shower. Staff E stated they still had some resident with surgical wounds complete showers but they when performing the shower, the NA was to not get the dressing or wound area wet. Staff E stated that when the shower NA staff get resident wound dressing wet, they would notify the nurse, and an assessment/dressing change would need to be completed/documented in the progress notes or assessments tab of the resident medical record.During an interview on 07/30/2026 at 7:25 AM, Staff D, Director of Nursing Services/Infection Preventionist, stated the facility process for residents with surgical wounds was usually for the dressing to remain in place due to the orthopedic provider usually wanting to perform the first dressing change. Staff D stated that surgical dressing was supposed to be in place for 14 days and the dressing would not be changed by the facility staff before that time. After reviewing Resident 3's hospital transfer orders Staff D stated that clarification of the surgical wound care orders should have been completed, and they did not see that it was. Staff D stated they were unable to find an assessment of the Resident 3 surgical site wound other than the wound characteristics form the resident's hospital stay. Staff D stated that nursing staff should have been documenting on the resident's admission assessment, the surgical wounds characteristics, the wounds appearance/measurements and the type of dressing the resident had in place when admitted to the facility but was unable to find it. Staff D stated they were unable to determine if Resident 3 had received dressing changes after their shower was performed and that a progress note should have been completed with a dressing change since the surgical hip dressing was not waterproof and would have been wet after each of the showers. Staff D stated the correct process for Resident 3's surgical wound care treatment and management was not followed.During an interview on 07/30/2026 at 9:38 AM, after reviewing Resident 3's medical record Staff E stated the residents right hip surgical wound care, dressing changes and shower recommendation should have been clarified with the orthopedic provider when the resident was admitted to the facility. Staff E stated they did not see that clarification or communication with the orthopedic provider was completed. Staff E stated they did not see an assessment of the resident surgical wound characteristics, appearance or measurements upon admission or during the resident's stay.During an interview on 07/30/2026 at 12:01 PM, Staff C, Regional Administrator/Registered Nurse, stated they would have expected to see more documentation of Resident 3 surgical wound assessment upon admission and during the weekly assessment. Staff C stated that nursing staff should have been performing dressing changes on a surgical wound after showers. Staff C stated the resident surgical wound care orders should have been clarified regarding the dressing changes due to the dressing being different from the normal post-surgical dressing and communication with the orthopedic provider on specific shower/other restriction for the resident. Staff C stated the correct process for Resident 3's surgical wound care treatment and management was not followed.Reference: WAC 388-97-1060(1)(3)(b)

Based on interview and record review the facility failed to investigate a staff altercation witnessed by 2 of 2 residents (Resident 1 and 2) reviewed for allegation of abuse. This failure placed residents at risk for unidentified emotional/psychological abuse and undermined their right to a safe environment free from the effects of staff misconduct. Finding included.Review of a facility policy titled, Abuse, revised 10/20/2022, showed residents had the right to be free from abuse, neglect, misappropriation or property, and exploitation. Abuse of residents, regardless of mental or physical condition, could cause mental anguish and designated staff would immediately review and investigate all allegations of abuse. Resident 1Review of the medical record showed Resident 1 was admitted with diagnoses including dementia (decline in thinking, memory and the ability to perform daily activities) and muscle weakness. Review of the 03/29/2026 comprehensive assessment showed Resident 1 required one staff member for mobility and had an impaired cognition. Resident 2Review of the medical record showed Resident 2 was admitted with diagnoses including Parkinson's disease (a progressive movement disorder that causes tremors, stiffness and impaired balance) and heart disease. Review of the 03/21/2026 comprehensive assessment showed Resident 2 required one to two staff members for mobility and had impaired cognition. During an interview on 05/06/2026 11:16 AM, Staff C, Licensed Nurse, stated during the night shift on 04/28/2026, the staff scheduled showed Staff D, Nursing Assistant (NA) and Staff E, NA were scheduled to work the night shift. Staff C stated Staff D did not report to work and called another NA to cover the shift. Staff C stated Staff D arrived at work a few hours later and began to yell and curse at them at the nurse's station after they were provided with their staff assignment. Staff C stated there were Resident 1 and Resident 2 were at the nurse's station during the altercation. Staff C stated Resident 1's facial expression became fearful when their eyes widened, and they pointed at Staff D. Staff C stated they told Staff D to stop and directed them to care for residents. Staff C stated the Charge nurse was made aware of the situation by Staff E and was then asked to leave the facility. Staff C stated they informed Staff B, Director of Nursing Services (DNS), of the altercation when their shift ended in the morning. Staff C stated they should have put the residents on alert charting for psychosocial harm monitoring for witnessing the altercation. Staff C stated they did not do this as they had gotten busy. During a follow-up interview on 05/07/2026 at 8:00 AM, Staff C stated they were not provided any follow-up for the reported altercation from administration. During an interview on 05/06/2026 at 12:35 PM, Staff D stated they were not scheduled to work the night shift on 04/28/2026 and there was an error on the schedule. Staff C stated they had received a text message from Staff C telling them they were considered a no call/no show for not coming to work. Staff D stated they then reported to work. Staff D stated when they arrived there were two NA's working. Staff D proceeded to begin cares for residents when they were informed that one NA was sent home and they needed to care for additional residents. Staff D stated Staff C began to yell at them when they questioned their assignment. Staff D stated they did yell at Staff C and Staff E during this altercation. Staff D stated there were residents at the nurse's station during the altercation. Staff D stated they were told by the Charge nurse that they had spoken to Staff B and were instructed to send them home. Staff D stated they had not been provided with any follow-up from administration about the altercation. During an interview on 05/07/2026 at 7:36 AM, Staff E stated they were working the night shift on 04/28/2026 when Staff D had not arrived at work. Staff E stated Staff C had requested another NA to come in and work. Staff E stated when Staff D arrived and was informed, they needed to care for additional residents as the other NA went home. Staff E stated Staff D blew up and began to curse and yell at them. Staff E stated Staff C had told Staff D to stop and they did not. Staff E stated Staff D began to yell and curse into may face and asked them to take it outside. Staff E stated they would not discuss anything further with Staff D without a witness. Staff E stated Resident 1 was sitting at the nurse's station during the altercation and appeared nervous. Staff E stated Resident 1 was pointing at Staff D when they yelled and slammed doors and displayed a worried look on their face. Staff E stated they reassured Resident 1 they were safe and okay. Staff E stated when the Charge nurse told Staff D to leave, Resident 1 appeared relaxed. Staff E stated they believe this altercation was mental abuse towards the residents as they were witnessed to the altercation. Staff E stated they provided a handwritten document of the altercation and provided it to administration and had not heard any follow-up. During an interview on 05/06/2026 at 1:03 PM, Staff B, stated they were aware of the verbal altercation between Staff D and Staff E. Staff B stated they were notified during that night by the Charge nurse of what was occurring and instructed the Charge nurse to send Staff D home for their behavior. Staff B stated they did not perform an investigation into the staff altercation, as it was a staff issue. Staff B stated they did not document any of their conversations with the staff. Staff B stated they were not aware residents had been nearby and heard the altercation. Staff B stated they should have performed an incident report, investigation and placed the residents on alert monitoring. Staff B stated the residents were at risk of psychological harm and could have experienced verbal and mental abuse. During an interview on 05/06/2026 at 3:04 PM, Staff A, Administrator, stated the facility should have handled this incident promptly. Staff A stated the process should have been to complete an investigation and follow up with residents to ensure no lasting fears or concerns about their safety. Staff A stated the process to complete an investigation was not followed and residents should not have been exposed to a staff alteration. Reference WAC: 388-97-0640(1)(3)(a)(6)(a)

Based on observation, interview and record review, the facility failed to ensure call light systems were functioning at all times in 1 of 6 observed resident rooms (room [ROOM NUMBER]) reviewed for call lights. This deficient practice placed residents at risk for avoidable accidents and unmet care needs.Findings included.During an interview, on 01/13/2026 at 1:10 PM, a Resident Representative (RR) stated both call lights in room [ROOM NUMBER] were not working during their visit on 01/11/2025. The RR stated they attempted multiple times to activate the call lights in the room and verified the light above the resident room doorway in the hallway was not illuminated nor the red light at the call light plug in on the wall in the resident room.During a concurrent observation and interview, on 01/13/2026 at 1:45 PM, with Staff D, Nursing Assistant (NA), showed both call lights in room [ROOM NUMBER] were not consistently turned on when the buttons were pressed. Staff D stated the call light for the bed by the door would not turn on at all and needed to be replaced. Observation of Staff D testing the call light for the bed by the window showed the button was pressed more than three times before it turned on. Staff D stated the call light must be sticking and needed to be cleaned or replaced.During an interview, on 01/13/2026 at 2:10 PM, Staff C, Maintenance Director, stated their process for checking call light system operations was to manually test each call light in a particular section of the building once a month. Staff C stated they typically tested on e-half of the building during the first month, tested the second half of the building during the second month, and continued with the rotation with adjustments as needed.Review of the Call Light System Test Log, dated 12/25/2025, showed the call lights in resident rooms 301-315 were tested and passed.During an interview, on 01/13/2026 at 2:40 PM, Staff C stated the process for fixing call lights between test cycles was for care staff to verbally inform maintenance staff of the issue or for staff to input a work order through the TELS platform (an electronic software for managing maintenance tasks and compliance in healthcare facilities). Staff C stated based on the current testing rotation, room [ROOM NUMBER] was scheduled to be tested again in February 2026.During an interview, on 01/13/2026 at 3:15 PM, Staff A, Administrator, stated both call lights in room [ROOM NUMBER] required replacement and all resident call lights should be working at all times. Reference: WAC 388-97-2280 (1)(a)

Based on observation, interview, and record review, the facility failed to provide adequate supervision, assess, monitor, and revise care plan interventions for efficacy, and ensure care planned interventions were consistently followed to prevent avoidable repeated falls for 4 of 5 residents (Residents 21,19, 41, and 29) reviewed for falls. Resident 21 who had 14 falls between 04/13/2025 and 05/23/2025, experienced harm when they had an unwitnessed fall, was found on the floor lying on their left side at the end of their bed, required transfer to the hospital, and was diagnosed with a fracture of the L1 vertebra (the first top bone in the lower back) and required a back brace that supports and stabilizes the spine. Resident 19 fell while unsupervised and experienced harm when they sustained a laceration on their forehead, required transfer to the emergency room (ER) and sutures. Resident 41 fell 17 times in the facility since admission, 12 unwitnessed, from either their wheelchair or bed, and experienced harm when they sustained head trauma, bruising and/or skin tears. Resident 29 experienced harm when they fractured their left fifth toe when they were left unattended in the bathroom, staff were unavailable to provide transfer assistance, they attempted to self-transfer from the toilet and fell. Findings included . Review of the 09/21/2022 Fall Assessment and Management policy showed the facility would identify and document residents' risk factors for falls and establish individualize resident centered fall prevention plans .by identifying underlying medical conditions that may increase injuries from falls .a link between increasing episodes of falls and recent changes in medication regime pharmacy review of medications that could relate to fall risk as well as medication side effects. Care plan individualized interventions will be monitored for effectiveness and modified to increase effectiveness. Review of the Facility's Policy titled, Accident Hazards/Supervision/Device dated 06/2023 showed the facility will provide an environment that is free of accident hazards as is possible and provide supervision and assistant devices, [drop seat wheel chairs(the back seat of the wheelchair tilts back while the front of the wheelchair seat tilts up), Front wheel walkers, manual wheel chairs and nonskid foot wear] to residents to avoid preventable accidents. <Resident 21> Review of the medical record showed the resident admitted to the facility 04/05/2025 with diagnoses including end stage renal disease (when your kidneys have permanently stopped working), muscle weakness and repeated falls with fractures. The 05/16/2025 comprehensive assessment showed Resident 21's cognition was moderately impaired and required assistance of one to two staff members for ADL's. Further review showed Resident 21 had a history of falls prior to admission that resulted in fractures and had two falls resulting in minor injury and no falls with major injury after admission to the facility. Observations on 06/09/2025 at 11:53 AM, 1:40 PM, 2:19 PM, showed Resident 21 lying in bed with his door open and curtain closed. Resident 21 was not visible from the hallway. Review of the care plan dated 04/05/2025 showed that Resident 21 had no care plan in place for being a fall risk and had no interventions to prevent falls. Record review of the fall investigations for Resident 21 showed Resident 21 had a fall on 04/13/2025 with no care plan in place for interventions to prevent falls. Additionally Resident 21 did not have a fall care plan put into place until 04/17/2025 (four days after the first fall). Review of the care plan dated 04/17/2025 showed Resident 21 was at high risk for falls related to deconditioning, gait/balance problems and self-transferring without asking for assistance. Further review showed interventions which included the call light to be within reach and to have appropriate footwear/non skids socks on when transferring. Additionally, there was no intervention for self-transferring in Resident 21's care plan. Review of the facilities reporting log showed Resident 21 had 14 falls between 04/13/2025 and 05/23/2025, nine of which resulted in injuries to Resident 21. Record review of a facility investigation dated 05/04/2025, showed Resident 21 had an unwitnessed fall and was found on the floor lying on their left side at the end of their bed. Resident 21 was able to move all extremities without pain. Resident 21 stated they had pain in their back and neck. When turning Resident 21 to their back to assist them to a sitting position, Resident 21 yelled out in pain and stated their left hip and ankle hurt. Resident 21 agreed to go to the hospital for evaluation. Further review showed the conclusion for Resident 21 was the resident was attempting to self-transfer, care plan reviewed and updated. Review of the care plan showed no updates or interventions were made from the fall on 05/04/2025 that resulted in a major injury. Review of the hospital Discharge summary dated [DATE] showed Resident 21 sustained a fracture of the L1 vertebra (the first top bone in the lower back) and required a TLSO (a back brace that supports and stabilizes the spine) brace with specific instructions to wear when out of bed with instructions on how to apply the brace. Review of the May 2025 orders showed there was no order placed for the nurses to monitor or to place the TSLO brace for Resident 21. During an interview on 06/12/2025 at 1:51 PM Staff P, Registered Nurse, stated they had found Resident 21 on the floor on 05/04/2025 and had sent them to the ER for evaluation. Staff P further stated they should have witness statements written by the staff but were unsure if that happened. Staff P stated they received the TSLO orders from the hospital. Staff P further stated they did not write an order for the brace or collect any witness statements for the fall. During an interview on 06/12/2025 at 11:20 AM, Staff B, Director of Nursing Services (DNS), stated the process for unwitnessed falls with injuries was to call the state hotline and to update the care plan with new interventions. Staff B stated they were aware there were not any witness statements or care plan updates completed for Resident 21's fall on 05/04/2025 and they recognized they have issues with investigations. Staff B stated the process for transcribing orders from the ER was the nurse receiving them were to place them on the Medication Administration Record (MAR) and Treatment Administration Record if necessary. Staff B stated the process was not followed for Resident 21. <Resident 19> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Dementia (decline in mental ability), osteoporosis (brittle bones which increase bone fracture risk), thrombocytopenia (low blood platelets which lead to increase bleeding and bruising), Myeloproliferative disease (blood cancer) and history of falls. The 04/16/2025 quarterly nursing assessment showed Resident 19 was cognitively impaired with ability to respond yes or no to questions and required substantial assistance of one person to stand and transfer to and from their wheelchair. Review of the 01/31/2025 fall incident report showed Resident 19 had an unwitnessed fall at 2:45 PM in their room which showed Resident 19 sitting against the wall on their buttocks. The conclusion was that Resident 19 fell asleep and slid out of their wheelchair and should be laid down after meals or stay at the nurse's station for supervision. Review of the 05/19/2025 fall incident report showed the resident had an unwitnessed fall at 8:40 AM. Resident 19 was on their right side on the floor with their left eye closed shut and bleeding from the back of their head. The paramedics (emergency medical assistance) arrived and placed a cervical collar around Resident 19's neck to keep the neck in one position. Resident 19 sustained a laceration (jagged wound caused by trauma) on their upper forehead by their scalp which required six sutures. There was no additional information about how long the resident was on the floor. Additionally, there was no conclusion or updates to the care plan completed. Review of the June 2025 MAR showed the resident was on an anticoagulant (blood thinner). Review of the 06/23/2021 care plan showed the Resident 19 was at high risk for falls due to deconditioning, gait/balance issues and unawareness of their boundaries. The care plan interventions included laying the resident down after meals, keeping the bed in a low position, reviewing information on past falls, attempting to determine cause of falls, and keep the resident at the nurse's station. During an observation on 06/09/2025 at 8:00 AM, Resident 19 was seated in their wheelchair at a table in the assisted dining room for breakfast and was being fed by a Nursing Assistant (NA). Resident 19 was unable to move their arms up a to hold their utensils . During an observation and concurrent interview on 06/09/2025 at 9:37 AM, after breakfast the resident was seated in their wheelchair alone in their room parked by their bed. The skin on their upper forehead close to their scalp and hair line had a four-inch scar line with scattered small pinpoint black/brown scabbed areas to the scar line. Resident 19 was very soft-spoken when asked questions about their care and could not verbalize events that led up to their last fall on 05/19/2025. Resident 19 had asked to go to bed but was unable to transfer without assistance. The resident's bed was not in a low position. Resident 19 had a bruise on their lower right forearm. During an observation on 06/10/2025 at 8:45 AM, Resident 19 was seated in their wheelchair in front of nurse's station against the front wall. During an observation on 06/10/2025 at 9:10 AM, Resident 19 was still in their wheelchair against the front wall, there were no staff at the nurse's station. Resident 19 stated they were tired and started to tilt, leaning to the right of their wheelchair. During an observation on 06/10/2025 at 10:30 AM, Resident 19 was still seated in their wheelchair against the wall and leaning to their right side. During an observation and a concurrent interview on 06/11/2025 at 10:57 AM, Staff T, Restorative NA, stated Resident 19 gets tired easily and cannot sit up for long. Staff T stated Resident 19's falls were due to sitting in their wheelchair in their room for too long. During an interview on 06/12/2025 at 7:53 AM, Staff B stated Resident 19's incident report was incomplete. Staff B stated staff did not follow the care plan for Resident 19 <Resident 41> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (neurodegenerative disease with brain deterioration that affects body movements by slowing movements and causes tremors and balance issues), reduced mobility, and frequent falls. The 05/10/2025 comprehensive assessment showed the resident was cognitively impaired but able to make their needs known, required substantial assistance with transfers to and from wheelchair and toileting. Resident 41 used a manual wheelchair with a drop seat for mobility. The comprehensive assessment showed Resident 41 wandered around the facility in their wheelchair and had multiple falls. During an observation and concurrent interview on 06/09/2025 at 9:00 AM, Resident 41 was in their room seated in their wheelchair by their bed. The call light cord and button was under the resident's bed where they were unable to reach it. The wheelchair was stuck between their bedside table and the resident was unable to move themselves. During an interview Resident 41's stated that they wanted to go home and felt that staff did not listen to them. Resident 41's right hand had dark purple and green bruises between the thumb and index finger. The resident's right wrist on the top of the forearm to mid upper arm showed bruising brown and light green in color. Resident 41's left hand showed scattered green-yellow bruising from the top of their hand to the elbow. The resident raised their pant leg on the right leg and there was light blue green bruising from the outer lateral side of the mid-calf area to the left knee to mid-thigh. Resident 41's left leg had bruising blue green in color over their knee to mid-thigh area. When asked how they got the bruising Resident 41 stated they had fallen many times. Review of the 01/31/2025 care plan showed Resident 41 was at high risk for falls related to confusion, deconditioning, gait and balance problems, Parkinson's, psychoactive (medications that affect mood and behavior) drug use, and history of falls. Interventions included call light in place within reach, bed in low position, [NAME] wheelchair (tilt in space wheelchair) for positioning and body alignment, do not leave the resident alone in the bathroom, bed against the wall, fall mat by bed and review past falls and review root cause and effectiveness of interventions. The last update on fall interventions was 02/04/2025. During an observation on 06/09/2025 at 10:30 AM, Resident 41 was seated in front of the nurse's station by the right side of the wall. The resident was seated in their low wheelchair with the drop seat and using the woodened hand rail to pull themselves along the wall. from behind the south nurse's station Resident 41 was unable to be visualized due to their low-profile wheelchair. During an observation on 06/10/2025 at 9:45 AM, Resident 41 was in their wheelchair with drop seat leaning forward and using their feet to mobilize the wheelchair. Resident 41 was in and out of other resident's rooms and holding on to the handrail in the hallway standing up. There were no staff observed to be supervising the resident. During an observation on 06/10/2025 at 3:07 PM, Resident 41's wheelchair showed the back side of the wheelchair was loose and uneven. The left armrest was completely down and the armrest and side panel on the right was in the upright position. The resident was leaning forward and started to fall forward but caught themselves in the doorway of the south dining room. There were no staff observed to be supervising the resident. During an interview on 06/10/2025 at 1:49 PM, Staff V, Registered Nurse (RN) stated they were at the nurse's station on 06/03/2025 when Resident 41 was seated in front of the South Nurses station. Resident 41 was seated in their wheelchair for about 20 minutes and slipped out of the wheelchair onto the floor and hit their right elbow and sustained a skin tear. Staff V stated they picked Resident 41 up with assistance and put them back in the wheelchair. Staff V was unaware that Resident 41 was in a drop seat wheelchair or if the resident was positioned correctly. Staff V stated Resident 41 falls frequently and there is nothing else they can do to update the interventions of the care plan. During an observation on 06/11/2025 at 4:10 PM, Resident 41 was yelling from their room help, help in a loud tone and repeatedly asked staff to get them out of bed. Staff observed near Resident 41's room, did not respond to the residents' call for assistance. The surveyor entered Resident 41's room, and observed the resident seated close to the edge of the bed with the bottom part of their body out of the bed. During an interview on 06/11/2025 at 4:30 PM, Staff Z, NA, stated they requested a one on one (one person assigned to supervise a resident) for Resident 41 in the evening related to the resident having increased behaviors with falls and not enough staff to provide supervision. Staff Z stated if Resident 41 was assisted in bed too early they would fall out of bed. During an interview on 06/11/2025 at 4:45 PM, Staff N, RCM, RN, stated Resident 41 becomes restless and wanders around the hallway in the late afternoon. Staff N stated after they leave in the afternoon there were not enough staff to supervise Resident 41. During an interview on 06/13/2025 at 1:00 PM, Resident 41's Resident Representative (RR) stated they were very concerned about the care Resident 41 had received at the facility and the number of falls with bruises and skin tears. The RR stated they had given many interventions that would help Resident 41 such as snacks, quiet areas, conversation, music and phone call to the RR to speak to Resident 41. The RR stated they felt the facility was resistant to any suggestions they offered. Review of Resident 41 fall incident reports from 02/03/2025 through 06/03/2025 showed Resident 41 had sustained 17 falls from either the wheelchair or their bed and had sustained either head trauma, bruising and/or skin tears. Review of the incident reports showed 12 falls were unwitnessed. During an interview on 06/12/2025 at 7:53 AM, Staff B, DNS, stated Resident 19's incident reports were not complete and did not meet the requirements. Staff B stated staff did not follow the care plan for Resident 19 and did not thoroughly investigate to determine if interventions were effective. <Resident 29> Review of Resident 29's medical record showed the resident was admitted to the facility on [DATE] diagnoses to include polyneuropathy (a disease affecting the peripheral nerves in the body, causing weakness, numbness and burning pain), muscle weakness, unsteadiness on feet and repeated falls. The 06/07/2025 comprehensive assessment showed the residents' cognition was intact and required one staff assistance with transfers and toileting and had falls since admission. Review of the care plan dated 06/09/2025 showed Resident 29 was at risk for falls related to weakness and an unsteady balance. Further review showed interventions which included a toileting schedule, evaluate for proper attention to safety, have the call light within reach and reinforce use of the call light. Additionally, to reinforce the use of appropriate footwear for safety with transfers. An observation and concurrent interview on 06/09/2025 at 8:51 AM, Resident 29 was in their night gown, no shoes or socks on sitting in their wheelchair. Resident 29 stated the call lights will stay on forever and they needed help with getting dressed but were told they could do this themselves. The resident stated they could not stand on their own and their hands nor their knees worked. Resident 29 stated I would not be here if I didn't need the help. The resident stated the staff helped them on the toilet and never came back, so they tried to transfer themselves into their wheelchair after waiting a long time and had a fall. They stated the incident happened a month ago in their restroom and they had to yell for help. Additionally, they broke their left fifth toe in the fall. Review of the facilities incident reporting log dated 04/23/2025 showed Resident 29 was found in the bathroom lying on their stomach after a fall in their restroom that resulted in a fracture to their left fifth toe. During an interview on 06/12/2025 at 3:38 PM, Staff Z, NA, stated there were many residents who were a high risk for falls. Staff Z stated they had informed the administration and the nurses about the need for more staff supervision to decrease the falls, but they have not seen any results and the residents continue to fall. Staff Z stated they keep certain residents at the nurse's station to keep a close eye on them but sometimes that doesn't work. During an interview on 06/10/2025 at 2:54 PM, Staff N, RCM, stated when they were coming into work the morning of 04/23/2025 they were walking down the hall and heard someone yell help me. Staff N stated upon entering Resident 29's room, they found the resident lying on their stomach in the residents bathroom. Staff N stated they assisted the resident up, started an incident report, and placed resident on alert charting. Staff N stated there was bruising noted to Resident 29's left lateral ankle and left toes, and the resident had complained of pain to their left fifth toe. Staff N stated an x-ray was taken on 04/28/2025 (five days after the incident) and showed Resident 29 had a latent injury of a fractured left fifth toe. During an interview on 06/12/2025 at 10:35 AM, Staff B stated that their expectation was for staff to follow the care plan and ensure resident safety. Reference: WAC 388-97-1060 (3)(g) Cross reference F725 Sufficient Nurse Staffing; and F610 Investigate Alleged Violations This is a recurring citation from the Statement of Deficiencies dated May 22, 2024

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development of pressure injuries and to implement wound treatment measures consistently to avoid worsening of pressure injuries for 1 of 3 residents, (Resident 46) reviewed for pressure injuries. Resident 46 experienced harm when they developed a pressure related fluid filled blister to the left heel and a pressure injury to their right lateral malleolus (the bony prominence on the outside of the ankle joint) that had both slough and eschar present in the wound. These failures also placed the resident at risk for pain, infection, and other medical complications. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016, defined pressure injury stages as follows: Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin) and may be present as an open ulcer with a red or pink wound bed or as an intact or ruptured blister. Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Review of an undated facility policy titled, Skin Integrity, showed the facility would provide care consistent with professional standards of practice to prevent pressure injuries, promote healing, and prevent infection. <Resident 46> Review of the medical record showed Resident 46 admitted to the facility on [DATE] with diagnoses of a right femur (thigh bone) fracture, severe dementia (an umbrella term for loss of memory and thinking skills that has various causes), severe protein calorie malnutrition ( a condition where there is an insufficient intake of both protein and calories to meet the body's needs), reduced mobility (difficulty or inability to move around freely, easily, and without pain), and heart disease. The comprehensive assessment dated [DATE] showed Resident 46 required maximum assistance of one to two caregivers for bed mobility and transfers and had severe cognitive impairments. An observation of Resident 46 on 06/09/2025 at 8:24 AM, showed a small frail-appearing person lying on their back in their bed with no observable pressure relieving mattress, devices, or footwear to assist with pressure relief in place. Resident 46's eyes were open, though they did not speak or respond when spoken to. Review of Resident 46's facility admission notes dated 05/21/2025 showed the resident had no pressure injuries present on admission to the facility. Review of a nursing note in Resident 46's electronic medical record dated 06/03/2025 at 7:53 AM, showed a licensed nurse (LN) noted a new pressure related blister to Resident 46's left heel. The note further stated the resident was placed on alert charting, to monitor the area, and to float the heels (elevate the heels off the bed surface) when in bed. An additional nursing note dated 06/03/2025 at 7:57 AM stated in part, LN spoke with the resident's representative to notify of the pressure related blister to the left heel, who asked that facility staff monitor Resident 46 closely for any open areas on their lower extremities, as they had issues in the past of not healing well. Review of a nursing note dated 06/05/2025 at 1:18 PM, an LN wrote, while providing wound care LN noted new wound on the right lateral malleolus (ankle), wound care provided, new wound care orders are in place. Review of skin and wound assessment notes showed on 06/03/2025 a blister to the left heel was measured as 5.1 centimeters (cm) (a unit of measure) in length by 4.6 cm in width and described as a fluid filled blister taking up the majority of the left heel. Further review of skin and wound assessment notes showed on 06/05/2025 a right malleolus pressure injury was measured as 1.6 cm in length by 0.7 cm in width and described as having both slough and eschar present in the wound. Review of a Braden Scale assessment (an assessment tool used to assess a patient's risk for developing pressure injuries) completed on the admission date of 05/21/2025 showed a score of 11, indicating Resident 46 was at a high risk for developing pressure injuries. Review of Resident 46's Treatment Administration Records (TARs) for May 2025 and June 2025, showed beginning 05/26/2025 an order was written for LNs to do a complete skin assessment with a narrative (a written assessment of the skin's condition) every day shift on Mondays for skin monitoring. There were no LN initials that showed these assessments were completed on 05/26/2025, 06/02/2025 or 06/09/2025. Further review of Resident 46's TARs showed beginning 06/03/2025, the LN staff were to monitor the pressure related blister to the left heel, to float the heels when in bed, and to apply a heel protector to the left foot when up in their wheelchair every shift. Observations of Resident 46 on 06/10/2025 at 8:16 AM showed them being assisted with breakfast in the dining room. There was no heel protecter in place on the left foot. Observations of Resident 46 sitting at the north nurse's station in a wheelchair on 06/11/2025 at 11:08 AM and 06/12/2025 at 8:47 AM showed there was no heel protector in place on the left foot. Observations of Resident 46 lying on their back in bed on 06/12/2025 at 11:33 AM and 2:05 PM showed the heels were not floated and both heels were pressed into the mattress. Observation of dressing wound changes on 06/12/2025 at 2:26 PM with Staff Q, Registered Nurse (RN), showed the left heel blister was reddish/orange in color, had opened and drained of fluid and measured 5.0 cm by 4.8 cm. The wound to the right ankle showed a pinkish white wound bed with red tissue surrounding the wound and measured at 1.2 cm by 0.7 cm. During an observation and interview with Staff B, the Director of Nursing (DON), on 06/13/2025 at 6:11 AM showed Resident 46 lying on their back in bed with a foam wedge placed under the resident's knees to raise the heels, though both heels were pressed into the mattress. The DON stated the staff did not place the wedge correctly so the heels would float off the mattress and needed more education on how to do so. The DON also pressed on Resident 46's right heel and stated it felt mushy (a feeling of softness or sponginess indicating a potentially early sign of pressure injury development). An observation of Resident 46 on 06/13/2025 at 8:21 AM, showed them sitting in their wheelchair at a dining room table with regular shoes on their feet. Review of Resident 46's care plan on 06/13/2025 showed there was no problem opened for the development of the pressure injuries to the heel and ankle, or that any interventions were put into place to prevent new pressure injuries from occurring or to prevent the current pressure injuries from getting worse. Reference: WAC 388-97-1060(3)(b) This is a repeat citation from Statement of Deficiencies dated 03/12/2024 and 05/22/2024.

Based on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of competent nursing staff to provide care and services for 16 of 16 residents (Residents 2, 5, 10, 19, 21, 23, 25, 27, 29, 33, 34, 39, 41, 43, 46, and 64)reviewed for Resident Rights, Resident Mobility, Activities of Daily Living (ADLs) for dependent residents, Quality of Care, Pressure Injuries, and Accident Prevention. Additionally, reports in the facility grievance logbook, resident council meeting interviews, and staff interviews provided evidence of insufficient staffing without resolution. This failed practice placed residents at risk of not having their needs met and potential negative outcomes to their physical and mental health. Findings included . <F-550 Resident Rights> The facility failed to provide an environment that enhanced and prompted a dignified lifestyle related to maintaining a prior level of bowel and bladder continence. <Resident 25> During an interview on 06/09/2025 at 2:02 PM, Resident 25 reported that, initially they were continent of bowel and bladder while using the bathroom, they became incontinent due to a lengthy wait for help, which left them feeling embarrassed. <F-688 Prevent/Decrease in Range of Motion (ROM)/Mobility> The facility failed to ensure staff provided care and services to maintain ROM and prevent contractures. <Resident 19> During an interview on 06/11/2025 at 10:57 AM, Staff T, Restorative Aid (RA), reported that Resident 19's Restorative Nursing Programs (RNP) lacked clear goals and guidance. Staff T stated the past two years there had been such a turnover with the Resident Care Managers, and they were no longer involved in the RNP to ensure programs were accurate and followed through. <Resident 27> During an interview on 06/10/2025 at 8:15 AM, Staff CC, Nursing Assistant (NA), stated they had not seen an RA help Resident 27 with eating or perform any ROM. Staff CC stated Resident 27 could only use their right hand but could not use utensils or any weighted items to eat with. Review of the 05/14/2025 through 06/10/2025, showed Resident 27 the RNP dining and range of motion programs were not completed for a period of six days and a total of 12 meals for the dining RNP. During an interview on 06/10/2025 at 11:15 AM, Staff T, RA, stated they had residents that need to be evaluated for a RNP that had not been completed yet. Staff T stated they did not always follow the RNP and would make modifications without the direction of a Licensed Nurse or Therapist. <Resident 10> During an observation on 06/11/2025 at 9:01 AM, showed Resident 10's right hand was noted to have their middle and fourth fingers in a bent position, and they were unable to straighten them. Resident 10 stated their fingers had been like that for a while, then stated that they did not wear a splint or a hand roll. During an interview on 06/11/2025 at 10:09 AM, Staff L, Director of Rehab, stated Resident 10 was no longer in the Occupational Therapy program, the resident was now on an RNP that the nurses were responsible for. <F-677 ADL Care Provided for Dependent Residents> The facility failed to consistently provide assistance with transfers, grooming and nail care for dependent residents. <Resident 2> During an observation on 06/10/2025 at 8:25 AM, Resident 2 had six to ten millimeter (mm) sized strands of facial hair. The resident's fingernails were 1/4 inch long past the tip of their finger and had dark brown debris under the nail tips of both hands. <Resident 25> An observation on 06/09/2025 at 2:90 PM, showed Resident 25's shirt had stains and food particles on the front of it. Resident 25 was unshaven with four to six mm sized facial hairs on the resident's face and neck. The resident's fingernails were ¼ long and past the fingertips with brownish debris underneath the tips on both hands. Resident 25 stated it really drives me crazy that they do not help me enough. <Resident 10> During an observation on 06/11/2025 at 9:01 AM, Resident 10's right hand with contractures of the middle and fourth finger, the resident's nails were long and jagged and had food particles and a dark brown substance underneath them. During an observation and concurrent interview on 06/11/2025 at 1:03 PM, Resident 10 was in bed and answered no when asked if they had got out of bed for the day. <F-684 Quality of Care> The facility failed to ensure care, services and documentation that addressed skin integrity issues were provided in accordance with professional standards of practice. <Resident 33> During an observation on 06/11/2025 at 8:45 AM, Resident 33 had skin tears to the right forearm and left hand with dried blood on them and no dressings in place. During an interview on 06/11/2025 at 2:02 PM, Staff B, Director of Nursing Services, (DNS), stated they did not know Resident 33 had recent skin tears to both their hand and forearm and had not received any incident reports about skin tears. <Resident 27> During an observation on 06/09/2025 at 2:37 PM, Resident 27's right hand had blood on the top of their right hand. Resident 27's top of their right hand had a four by five-mm patch of skin that had been removed or injured and actively bleeding. <F-686 Prevent/Heal Pressure Injuries> The facility failed to ensure pressure injuries did not develop or worsen in the facility. <Resident 46> Review of a nursing note in Resident 46's electronic medical record dated 06/03/2025 at 7:53 AM, showed a new pressure related blister to Resident 46's left heel. An additional nursing note dated 06/03/2025 at 7:57 AM stated in part, LN spoke with the resident's representative to notify of the pressure related blister to the left heel, who asked that facility staff monitor Resident 46 closely for any open areas on their lower extremities, as they had issues in the past of not healing well. Review of Resident 46's Treatment Administration Records (TARs) for May 2025 and June 2025, showed beginning 05/26/2025 an order was written for LNs to do a complete skin assessment with a narrative (a written assessment of the skin's condition) every day shift on Mondays for skin monitoring. There were no LN initials that showed these assessments were completed on 05/26/2025, 06/02/2025 or 06/09/2025. Resident 46 experienced harm related to the lack of monitoring. <F-689 Free of Accidents> The facility failed to provide adequate supervision to prevent accidents for four of four residents in which Residents 21, 19, 41, and 46 experienced harm. Resident 21 had 14 falls between 04/13/2025 and 05/23/2025 (nine resulted in injuries), experienced harm when they had an unwitnessed fall. Resident 19 fell while unsupervised and experienced harm when they sustained a laceration on their forehead, required transfer to the emergency room (ER) and sutures. Resident 41 fell 17 times in the facility since admission, 12 unwitnessed, from either their wheelchair or bed, and experienced harm when they sustained head trauma, bruising and/or skin tears. Resident 29 experienced harm when they fractured their left fifth toe when they were left unattended in the bathroom, staff were unavailable to provide transfer assistance. <Grievance Logbook> Record review of the facility grievance logbook from 02/02/2025 to 06/09/2025 showed grievances filed by residents and families related to care concerns. Additionally, there were five grievances filed by residents and families for not receiving timely assistance (including long call light wait times) to meet their basic care needs. <Staff Interviews> During an interview on 06/10/2025 at 1:23 PM, Staff AA, Staffing Coordinator, stated they completed the facility schedule for nursing staff. Staff AA stated they were unaware of the need to have 16 hours per day of RN coverage. Staff AA stated they had utilized agency nurses due to being short of licensed nurses. During an interview on 06/12/2025 at 10:35 AM Staff B, DNS, stated the facility has had staff turnover and that they have done outreach to obtain new staff, offered bonuses, and started using agency for licensed nurses and care staff coverage. Reference WAC 388-97-1080 (1), -1090 (1) This is a repeat citation from Statement of Deficiencies dated 05/22/2024.

Based on interview and record review, the facility failed to report allegations of potential abuse and/or neglect in a timely manner, for 3 of 5 sample residents (Residents 19, 21, and 29), reviewed for incidents of significant falls with injury. Failure to report an allegation of significant injuries due to unwitnessed falls to the State Survey Agency, as required. This deficient practice placed residents at risk of harm related to potential unrecognized abuse/neglect and disallowed the ability to recognize patterns of repeated incidents and injuries. Findings included . Review of the Washington State Department of Social and Health Services (DSHS) Nursing Home Guidelines 'The Purple Book', dated October 2015, showed Appendix D, titled Reporting Guidelines for Nursing Homes, listing substantial injuries of unknown sources and resident-to-resident altercations with physical abuse, as incidents that required reporting to the DSHS Hotline. An annotation to Appendix D showed that .repeated injuries, even when related to condition, may become abuse or neglect if preventative measures are not taken . Further review of The Purple Book, Appendix K, titled Definitions, defined: Injuries of Unknown Source-any injury sustained by a resident where the source of the injury was not observed directly by a staff person and may be either superficial or substantial in nature. Substantial Injuries-require more than first aid, may require close assessment and monitoring by nursing or medical staff, and include any injury (superficial or substantial) occurring in areas not generally vulnerable to trauma. All injuries occurring in non-vulnerable areas of the body will be considered substantial injuries. Areas Not Generally Vulnerable to Trauma-back, face, head, neck, chest, breasts, groin, inner thigh, buttock, genital or anal areas. Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 09/21/2022, showed if the allegation involves injury of unknown source will be promptly reported to the local, state, and federal agencies and thoroughly investigated by facility management. <Resident 19> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Dementia (decline in mental ability), osteoporosis (brittle bones which increase bone fracture risk), and repeated falls. The 04/16/2025 quarterly nursing assessment showed Resident 19 was cognitively impaired with ability to respond yes or no to questions and required substantial assistance of one person to stand and transfer to and from their wheelchair. Review of the 05/19/2025 Fall incident report showed Resident 19 had an unwitnessed fall in their room and was found on their right side on the floor at 8:40 PM. Resident 19's left eye was swollen shut and they were bleeding from the back of their head. Resident 19 was transported to the emergency room (ER), and it was determined the resident sustained a laceration (a jagged cut caused by trauma to her upper forehead and sutures were applied. Review of the Incident Report log for 05/19/2025 showed Resident 19 had an unwitnessed fall with substantial injuries to areas for the face and head not generally vulnerable to trauma. The incident was not reported to the state agency. <Resident 21> Review of the medical record showed the resident admitted to the facility 04/05/2025 with diagnoses including end stage renal disease (when your kidneys have permanently stopped working), muscle weakness and repeated falls with fractures. The 05/16/2025 comprehensive assessment showed Resident 21's cognition was moderately impaired and required assistance of one to two staff members for ADLs. Review of the 05/04/2025 incident report showed Resident 21 had an unwitnessed fall, was found on the floor lying on their left side at the end of their bed, required transfer to the hospital, and was diagnosed with a fracture of the L1 vertebra (the first top bone in the lower back) and required a back brace that supports and stabilizes the spine. Review of the Incident Report log for 05/04/2025 showed Resident 21 had an unwitnessed fall with injury. The incident was not reported to the state agency. During an interview on 06/12/2025 at 11:20 AM, Staff B, Director of Nursing Services (DNS), stated the process for unwitnessed falls with injuries was to call the state hotline. Staff B stated they recognized they have issues with investigations, and the process was not followed for Resident 21. <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility on [DATE] diagnosis to include polyneuropathy (a disease affecting the peripheral nerves in the body, causing weakness, numbness and burning pain), and repeated falls. Review of the comprehensive care plan dated 04/08/2025 showed Resident 29's cognition was intact. Review of Resident 29's plan of care dated 06/07/2025 showed the resident required contact guard assist (one staff to assist) with transfers and toileting. The resident ' s care plan further showed to ensure Resident 29 had proper footwear in place due to the potential of self-transferring. Review of a facility investigation report, dated 04/23/2025 at 6:10 AM, showed Resident 29 had an unwitnessed fall where they were found on their stomach in their restroom by a nurse coming onto shift the morning of the incident. An additional review showed that the resident had reported to the nurse that they had to use their toes to pull the call light for help. Resident 29 had bruising to their left ankle and left toes. Review of an x-ray done five days after the fall showed the resident had sustained a broken left fifth toe. During an interview on 06/1/2025 at 3:08 PM, Staff B stated the incident involving Resident 29 was not reported to the state agency as they did not see it as a reportable incident. Reference (WAC) 388-97-0640(6)(c)

Based on interview and record review, the facility failed to ensure thorough investigations were completed for 5 of 5 residents (Residents 33, 19, 41, 21, and 29) reviewed for falls, skin impairments, and injuries of unknown source. Failure to initiate incident reports and conduct thorough investigations to identify root cause(s) and all contributing factors placed the residents at risk for unidentified abuse or neglect, unidentified corrective actions, risk for injury, and unmet care needs. Findings included . Review of the Washington State Department of Social and Health Services (DSHS) Nursing Home Guidelines 'The Purple Book', dated October 2015, showed Chapter 2, titled The Investigation Process, listed substantial injuries of unknown source as incidents that must be thoroughly investigated. Chapter 2 highlights that the key elements of any investigation were its prompt initiation and thoroughness. A comprehensive investigation aims to establish whether abuse or neglect occurred and how to prevent further occurrences. Further review of The Purple Book, Appendix K, titled Definitions, defined: Injuries of Unknown Source-any injury sustained by a resident where the source of the injury was not observed directly by a staff person and may be either superficial or substantial in nature. <Resident 33> Review of the medical record showed Resident 33 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD), diabetes, depression ( a mental health condition characterized by persistant sadness, loss of interest in activities, and difficulty functioning in daily life) and heart disease. The comprehensive assessment dated [DATE] showed Resident 33 required moderate assistance of one to two caregivers for activities of daily living (ADLs) and was cognitively intact. During an observation and interview with Resident 33 on 06/10/2025 at 9:10 AM, showed two skin tears, one to the top of the right forearm that was actively bleeding and one to the top back of the right hand that had dried blood present. Resident 33 stated they did not know how they had gotten the skin tears, but the one on the top of the right hand had been there a couple of days and they had just noticed the one on the right forearm the previous evening. During an observation and interview with Resident 33 on 06/11/2025 at 8:45 AM, showed skin tears to the right forearm and left hand with dried blood on them and no dressings in place. Review of Resident 33's Treatment Administration Records (TARs) for the month of June 2025 showed there were no orders to monitor and/or treat the skin tears to right forearm or left hand. During an interview with Staff B, Director of Nursing (DNS) on 06/11/2025 at 2:02 PM, they stated they did not know Resident 33 had recent skin tears to both their hand and forearm and had not received any incident reports about the skin tears. The DNS stated the nursing s should have followed up with an incident report when the injuries were first noted and would ensure incident reports were completed for the skin tears on Resident 33's forearm and hand and investigated to rule out abuse or neglect. <Resident 19> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Dementia (decline in mental ability), osteoporosis (brittle bones which increase bone fracture risk), and repeated falls. The 04/16/2025 quarterly nursing assessment showed Resident 19 was cognitively impaired with the ability to respond yes or no to questions and required substantial assistance of one person to stand and transfer to and from their wheelchair. Review of the 05/19/2025 Fall incident report showed Resident 19 had an unwitnessed fall in their room and was found on their right side on the floor at 8:40 PM. Resident 19's left eye was swollen shut and they were bleeding from the back of their head. Resident 19 was transported to the emergency room (ER), and it was determined the resident sustained a laceration (a jagged cut caused by trauma) to their upper forehead and sutures were applied. There was no other investigative information for the reason the resident was left alone in their room, how long the resident was in their wheelchair in their room unsupervised. There was minimal information as to what Resident 19's activities were before the fall or witness statements. During an interview on 06/11/2025 at 8:00 AM, Staff B, DNS, stated they were aware of the lack of information from the nursing staff to obtain investigation documents to determine if abuse/neglect occurred. <Resident 41> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (neurodegenerative disease with brain deterioration that affects body movements by slowing movements and causes tremors and balance issues), reduced mobility, and frequent falls. The 05/10/2025 comprehensive assessment showed the resident was cognitively impaired but able to make their needs known, required substantial assistance with transfers to and from wheelchair and toileting. Review of Resident 41's fall incident reports from 02/03/2025 through 06/03/2025 showed Resident 41 had sustained 17 falls from either the wheelchair or their bed and had sustained either head trauma, bruising and/or skin tears. Review of the incident reports showed 12 falls were unwitnessed and reoccurrences of falls were not thoroughly investigated as to determine if abuse/neglect were ruled out. During an interview on 06/11/2025 at 7:53 AM, Staff B,DNS, stated there was not sufficient informational evidence to determine if abuse/neglect was ruled out. Staff B stated the nursing staff did not determine the root cause of why the falls occurred nor thoroughly investigated the cause of the falls. <Resident 21> Review of the medical record showed the resident admitted to the facility 04/05/2025 with diagnoses including ESRD (when your kidneys have permanently stopped working), muscle weakness and repeated falls with fractures. The 05/16/2025 comprehensive assessment showed Resident 21's cognition was moderately impaired and required assistance of one to two staff members for ADL's. Review of the 05/04/2025 incident report showed Resident 21 had an unwitnessed fall, was found on the floor lying on their left side at the end of their bed, required transfer to the hospital, and was diagnosed with a fracture of the L1 vertebra (the first top bone in the lower back/lumbar) and required a back brace that supports and stabilizes the spine. Further review showed there was no witness statements obtained, and a thorough investigation was not completed. During an interview on 06/12/2025 at 11:20 AM, Staff B stated they were aware there were not any witness statements completed for Resident 21's fall on 05/04/2025 and they recognized they had issues with investigations, and the correct process was not followed for Resident 21's fall investigation. <Resident 29> Review of the medical records for Resident 29 showed the resident was admitted to the facility on [DATE] with diagnoses including difficulty walking, muscle weakness and repeated falls. The comprehensive assessment dated [DATE] showed the resident's cognition was intact able to make their needs known. Review of Resident 29's fall incident report dated 04/23/2025 showed Resident 29 had a fall with injury in their bathroom, the resident had sustained a broken left fifth toe. Review of the incident reports showed the fall had been unwitnessed and the fall had not been thoroughly investigated as to determine if abuse/neglect were ruled out. During an interview on 06/10/2025 at 1:39 PM, Staff B, DNS, stated there were no witness statements to determine if abuse/neglect was ruled out. Staff B acknowledged that Resident 29's fall had not been thoroughly investigated. Reference: WAC 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to obtain informed consents regarding the potential risks associated with the use of psychotropic medications (medications that alter thought processes) for 2 of 5 residents (Residents 33 and 64) reviewed for unnecessary medication. This failure placed the residents and/or the legal representatives at risk of not being fully informed about the medications prior to administration. Findings included . <Resident 33> Review of the electronic medical record showed Resident 33 was admitted to the facility on [DATE] with diagnoses including depression (a mental health condition where a person experiences persistent sadness, loss of interest in activities, and difficulty functioning in daily life), anxiety ( a feeling of worry, nervousness, or unease, typically about an event or something with an uncertain outcome) and insomnia ( when you have trouble falling asleep, stating asleep, or both, even when you have the chance to get enough rest). The comprehensive assessment dated [DATE] showed Resident 33 required moderate assistance of one to two caregivers for activities of daily living (ADLs) and was cognitively intact. Review of Resident 33's 05/13/2025 physician orders showed they were admitted to the facility on the antipsychotic medication Seroquel. Review of Resident 33's medical record showed there were no records of the resident or of their representative being informed of being placed on the medication or of a consent signed for its use. <Resident 64> Review of the electronic medical record showed Resident 64 was admitted to the facility on [DATE] with a diagnosis of chronic Post Traumatic Stress Disorder (PTSD) (an anxiety disorder that develops in some people who have experienced a shocking, scary, or dangerous event), bipolar disorder (a disorder causing extreme shifts between high and low moods), and depression. The comprehensive assessment dated [DATE] showed Resident 64 required limited assistance of one caregiver for ADLs and was cognitively intact. Review of Resident 64's physician orders showed they were admitted to the facility on two antidepressant medications, sertraline and duloxetine. Review of Resident 64's medical record showed there were no records of the resident or of their representative being informed of being placed on the medications or of consents signed for their use. During an interview on 06/11/2025 at 2:02 PM with Staff B, Director of Nursing Services (DNS), they stated the admission nurses were responsible for getting the consents signed on admission or the floor nurses if a new order came in. The DNS stated she did not know why the consents were not signed for Residents 33 and 64 ' s psychotropic medications when they were admitted to the facility, stating it must have been missed by the admitting nurses. Reference (WAC) 388-97-0260(2)(d)

Based on observation, interview and record review, the facility failed to ensure care and services were provided in a respectful and dignified manner for1of 3 residents (Resident 25) reviewed for dignity. This failure placed residents at risk for being treated with a lack of dignity, respect and embarrassment. Findings included . Review of the 06/2023 Activities of Daily Living (ADLs) policy showed residents will be provided with care, treatment, and services to ensure their ADLs are maintained and do not diminish. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently in accordance with the care plan including appropriate support with assistance with elimination (toileting). <Resident 25> Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain) and right shoulder joint replacement. The 04/10/2025 comprehensive assessment showed Resident 2's cognition was intact and required staff assistance of one person for ADL's including toileting. During an interview on 06/09/2025 at 2:02 PM, Resident 25 stated before they came to the facility, they used the bathroom and were continent of their bowel and bladder. Resident 25 stated they had to wait such a long time for help to use the restroom, they became incontinent in their adult brief even though they were continent and it made them feel embarrassed. Record review of a document titled Admissions Bowel and Bladder Screening, dated 05/27/2025, showed Resident 25 was continent of bowel. Review of Resident 25's care plan, dated 05/27/2025, showed that the resident was continent of bowel and to toilet on awakening and as needed. Review of the June 2025 Nursing Assistant Task report showed Resident 25 was incontinent of their bowels on 06/05/2025 and 06/07/2025. During an interview on 06/13/2025 at 10:17 AM, Staff B, Director of Nursing Services, stated it was their expectation that staff followed the residents' care plan. REFERENCE: WAC 388-97-0180(1-4).

Based on interview and record review, the facility failed to ensure resident funds were transferred to the Resident's Representative (RR) within 30 days of death, for 1 of 2 discharged residents (Resident 120) reviewed for conveyance of funds to the RR after death of Resident. This failure placed the RR at risk for loss of funds. Findings included . <Resident 120> Review of the medical record showed the resident was readmitted to the facility on [DATE] from the hospital on private pay hospice care. The resident passed away on 11/09/2024. The RR was asked to pay a full month of room and board at the facility which was $11,800.00. During an interview on 06/09/2025 at 11:35 AM, Staff GG, Business Office Manager, stated they had a conversation with the RR on 11/08/2024 and stated the money would be refunded the money that was not used for Resident 120's care. Review of the06/10/2025 Transaction Report for November 1, 2024, through June 30, 2025, showed the RR was owed a $11,800.00 refund. During an interview on 06/11/2025 at 4:28 PM, the RR stated they were concerned about their refund and that seven months had passed, and nothing had happened with the facility. Reference WAC 388-97-3040(4)(5)

Based on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review, (PASARR) Level 1 were accurately completed upon or prior to admission and requirements for 1of 5 residents (Resident 41) reviewed for the PASARR process. This failure had the potential to place the resident at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (neurodegenerative disease with brain deterioration that affects body movements by slowing movements and causes tremors and balance issues), depression and anxiety. The 05/10/2025 comprehensive assessment showed the resident was cognitively impaired but able to make their needs known. Review of a PASARR Level 1(Preadmission Screening and Resident Review) dated 01/29/2025 was incorrect in designation of Resident 41 diagnosis of Dementia (symptoms that affect memory, thinking and social abilities). Resident 41 was admitted to the facility on [DATE] and the facility failed to identify the error since the diagnosis of dementia was not designated at that time. During an interview on 06/12/2025 at 4:00 PM, Staff I, Social Services stated they were unaware that the resident did not have a dementia diagnosis and that the PASARR Level 1 indicated mental health issues of anxiety and depression. During an interview on 06/13/2025 at 8:50 AM, Staff I stated Resident 41 did not have a dementia diagnosis and a PASARR Level 1 with a request for a Level 2 evaluation was not requested. Reference WAC 388-97-1915(1),(2)(a-c)

Based on observation, interview, and record review, the facility failed to ensure 3 of 5 residents (Residents 2, 25, and 10), reviewed for activities of daily living (ADLs), received adequate grooming, transferring assistance and nail care according to the residents' care plans. This failure placed the residents at risk for unmet care needs. Findings included . <Resident 2> Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain), muscle weakness and chronic kidney disease (where your kidneys are damaged and they cannot filter blood as well as they should) and diabetes (a disease where your body has trouble regulating blood sugar levels). The 04/10/2025 comprehensive assessment showed Resident 2's cognition was intact and required set- up and supervision with personal hygiene. Review of Resident 2's care plan, dated 02/16/2024, showed that the resident had an ADL self-care performance deficit and required set-up assistance with all personal hygiene. During an observation and concurrent interview on 06/10/2025 at 8:25 AM, Resident 2 had six to ten millimeter (mm) sized strands of hair, Resident 2 stated they wanted their goatee but did not want the strands of hair and would like to be shaved. The resident's fingernails were 1/4 inch long past the tip of their finger and had dark brown debris under the nail tips on both hands. During an observation on 06/12/2025 at 8:57 AM, Resident 2 was sitting up in their wheelchair. The resident continued to be unshaven and fingernails unkept. During an interview on 06/12/2025 at 11:48 AM, Staff EE, Nursing Assistant (NA), stated they offered nail care most of the time if they were doing showers. Staff E stated the shower NAs were supposed to do all nail care on shower days unless the resident was diabetic, then the nurses were responsible. Staff EE stated they would chart any refusals in the resident's nursing assistant task record. Review of the May and June 2025 nursing assistant task record showed no refusals of care for Resident 2. Review of the May and June 2025 Medication Administration Record showed the licensed nurses were doing nail checks every Friday and had no documentation of refusals. <Resident 25> Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain) and right shoulder joint replacement. The 04/10/2025 comprehensive assessment showed Resident 25's cognition was intact and required staff assistance of one person for personal hygiene. An interview and concurrent observation on 06/09/2025 at 2:90 PM, showed Resident 25 lying in their bed, the resident shirt had stains and food particles on the front of it. Resident 25 was unshaven with four to six mm sized facial hairs on the resident's face and neck. The resident's fingernails were ¼ long and past the fingertips with brownish debris under the tips on both hands. Resident 25 stated it really drives me crazy that they do not help me enough. Review of the May and June 2025 task record showed Resident 25 was to have a shower Mondays and Thursdays. Further review showed no documentation on 05/29/2025, 06/02/2025, 06/05/2025 that a shower was given or refused. <Resident 10> Review of Resident 10's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include diabetes (a disease in which the body does not control glucose (a type of sugar) in the blood), dementia (the loss of thinking, remembering, and reasoning- to the extent that in interferes with ADLs), muscle weakness and history of falls. The comprehensive assessment dated [DATE] showed Resident 10's cognition was severely impaired and was dependent on staff for grooming, personal hygiene, bed mobility and transfer assistance. The assessment confirmed that Resident 10 had no prior instances of rejecting care. During an interview on 06/09/2025 at 10:52 AM, Staff DD Nursing Assistant, NA, stated their tasks with showers were to do the weights and skin checks when a resident shower was done. Staff DD stated they were also to do nail care if the resident was not a diabetic. Staff DD stated once done with their tasks they give all information about what they had seen during a resident shower with the Resident Care Manger. Staff DD stated they had given Resident 10 their shower and within the last two months they had been working with the resident that they had not had Resident 10 refuse the care. An observation on 06/09/2025 at 11:01 AM, showed Resident 10 lying in bed, dressed in a purple-colored night gown. The resident's hair uncombed, both hands on their chest and the nails long, jagged with dark substance noted underneath. In an interview on 06/10/2025 at 9:39 AM, Collateral Contact, expressed their disappointment with Resident 10's care, noting that during their visit three weeks ago, the resident appeared in bed with disheveled hair and wearing the same nightgown for days. The Collateral Contact stated that they had called the facility to notify them of their disappointment with care and requested that Resident 10 get up at least three times a day, at least for their meals. The Collateral Contact stated that Resident 10 would be very upset if they were of sound mind as they used to always be up for their day and looked presentable. During an observation on 06/10/2025 at 4:18 PM, Resident 10 was lying in their bed, their hair uncombed, covered with a blanket and sleeping. During an observation on 06/11/2025 at 9:01 AM, Resident 10 was lying in their bed, and they stated they were doing good, while eating a muffin with their right hand. The resident's right hand with contractures of the middle and fourth fingers, the resident's nails were long and jagged and had food particles and a dark brown substance underneath them. During an observation and concurrent interview on 06/11/2025 at 1:03 PM, Resident 10 was in bed with their head of bed elevated, a bedside table over them. The resident was wearing a purple top, and their legs were covered with a blanket. The resident answered no when asked if they had got out of bed for the day. During an interview and concurrent observation on 06/11/2025 at 4:24 PM, showed the resident was lying in their bed covered with a blanket from their chest to their knees while Staff BB, Licensed Practical Nurse, assessed their feet. Staff BB stated the resident's skin was looking better and that nurses were to do the residents' skin and nails if they were diabetic every week depending on the orders. Staff BB stated that Resident 10 tended to refuse care. An observation on 06/12/2025 at 9:05 AM, showed Resident 10 sitting up in their wheelchair fully dressed. The resident's hair was uncombed, their nails long, jagged with a dark substance underneath. Resident 10 had complained that their bottom hurt sitting in the wheelchair. During an interview on 06/12/2025 at 1:22 PM, Staff CC, NA, stated today the nurse on shift explained to the resident that family had called and wanted them out of bed, so we got her up. Staff CC stated the resident did not stay up very long because they had complained about their bottom hurting, During an interview on 06/13/2025 at 10:17 AM, Staff B, Director of Nursing, stated the resident care information would be in PCC (a system in which nursing staff write out information for each resident's daily care). Staff B further stated that the expectation would be that staff followed the care plan and or orders and documented any refusals. Reference: WAC 388-97-1060(2)(c)

Based on interview and record review the facility failed to ensure staff responsible for providing cardiopulmonary resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) had current CPR certification for 1 of 5 licensed nursing staff (Staff S) reviewed for CPR certification status. This failure had the potential risk of the facility having a lack of staff who were properly trained in CPR readily available to respond in an emergency. Findings included . Record review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) Policy, dated 06/2023, showed personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and or basic life support (BLS), including defibrillation (the use of an electric current to stop any irregular and dangerous activity in the heart muscles), for victims of sudden cardiac arrest (when the heart stops beating suddenly). The facility policy further guided licensed staff to initiate CPR/BLS if an individual was found unresponsive unless the individual had orders that prohibited CPR. <Staff S, Medication Assistant Certified, (MA-C)> Review of Staff S's personnel file showed their CPR certification expired on 02/2025 (four months ago). During an interview on [DATE] at 11:32 AM, Staff G, Staff Development, stated they were unaware of the expired CPR certification for Staff S. Staff G stated they were told that the Nursing Assistants did not require a CPR certification, that the Director of Nursing Services (DNS) keeps track of the certifications. During an interview on [DATE] at 10:35 AM, Staff B, DNS, stated they were aware of the expired CPR certifications for Staff S and would be working on getting staff up to date with their certifications. Reference (WAC) 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure care, services and documentation that addressed skin integrity issues were provided in accordance with professional standards of practice for 2 of 3 residents (Residents 33 and 27), reviewed for quality of care. This failure placed the residents at risk for unmet care needs and negative health outcomes. Findings included . <Resident 33> Review of the electronic medical record showed Resident 33 was admitted to the facility on [DATE] with diagnoses including a fracture to the right wrist, end stage renal disease (ESRD) with dialysis three times a week, diabetes, depression and heart disease. The comprehensive assessment dated [DATE] showed Resident 33 required moderate assistance of one to two caregivers for activities of daily living (ADLs) and was cognitively intact. During an observation and interview with Resident 33 on 06/10/2025 at 9:10 AM, showed them lying on their back in bed. A skin tear was noted on the top of their right forearm measuring approximately six millimeters (mm) (a unit of measure) in length by four mm in width that was open with the skin folded back to the base of the tear and actively bleeding. A second skin tear was noted on the top back of the left hand, measuring approximately two mm by two mm that had dried blood on the top of it. Resident 33 stated they did not know how they got the skin tears, stating their skin would both tear and bleed easily and they had probably bumped their arm and hand on something on their bed, wheelchair, or bedside table. During the same interview Resident 33 stated they had the skin tear on the top of their left hand for several days and it kept opening back up and bleeding daily. They stated they had just noticed the one on their right forearm last evening and showed where their bedsheet had blood on it from bleeding through the night. Resident 33 stated that no one from nursing had come to clean up or put dressings on the skin tears since they had first noticed them, though a nursing assistant had wiped the blood off them last evening with a piece of tissue before bed. During an observation and interview with Resident 33 on 06/11/2025 at 8:45 AM, showed the skin tears to the right forearm and left hand with dried blood on them and no dressings in place. Resident 33 stated no one in the facility had yet come to look at them or dress them. They stated the skin tears were bothersome because they were on a medication that made them bleed easily, and whenever they bumped them or moved the wrong way in bed, they would start bleeding again. Review of Resident 33's Medication Administration Records (MARs) for the months of May 2025 and June 2025 showed an order for the medication Plavix (a medication used to prevent blood clots which increases the risk of serious bleeding because it reduces the blood's ability to clot) to be given every morning beginning 05/15/2025. Review of Resident 33's Treatment Administration Records (TARs) for May 2025 and June 2025, showed beginning 05/13/2025 an order was written for licensed nurses (LNs) to do a complete skin assessment with a narrative (a written assessment of the skin's condition) every day shift on Mondays for skin monitoring. There were no LN initials that showed these assessments were completed on 05/26/2025, 06/02/2025 or 06/09/2025. Further review of Resident 33's TARs for the month of June 2025 showed there were no orders to monitor and/or treat the skin tears to right forearm or left hand. During an interview with Staff B, Director of Nursing Services (DNS) on 06/11/2025 at 2:02 PM, they stated the nursing staff should follow up with an incident report anytime a skin tear was observed and should notify the resident's family and physician of any new skin impairment and obtain orders to monitor and treat the area. Staff B stated they did not know Resident 33 had recent skin tears to both their hand and forearm and had not received any incident reports about the skin tears. Review of nursing progress notes for the month of June 2025 on 06/12/2025 showed no progress notes that either Resident 33's family or physician were notified of the skin tears observed on the right forearm or left hand. Review of Resident 33's care plan showed a problem was opened on 05/21/2025 for potential impairment to skin integrity with interventions that included to follow the facility protocols for the treatment of injury and to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Further review of Resident 33's care plan showed that that a problem was opened on 05/212025 for being on an antiplatelet medication with interventions that included to monitor/document/report to MD as needed for signs/symptoms of complications, blood tinged or frank blood in urine or stool and bruising. <Resident 27> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of contractures (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) of the hands and shoulders, dry skin, fibromyalgia (long-term widespread pain and fatigue), and torticollis (shortening and stiffness of the neck muscles). Review of the 04/27/2025 quarterly assessment showed Resident 27 required substantial assistance with ADL's due to bilateral (affecting both sides) impairment of upper and lower body movement. Resident 27 was able to make their needs known. During an observation and concurrent interview on 06/09/2025 at 2:37 PM, Staff Z, Nursing Assistant (NA), stated the resident could make their needs known. Resident 27 was in bed with the head of the bed at 45 degrees. The resident was positioned leaning to the left side of the bed with their head on their chest. Resident 27's right hand had blood on the top of their right hand. The resident stated they were in pain and uncomfortable. Staff Z stated Resident 27's position was always leaning to the left of the bed and required re-positioning maintained with pillows. Resident 27's top of their right hand had a four by five mm patch of skin that had been removed or injured and actively bleeding. Staff S, Medication Assistant, was notified and stated they would take care of it. During an observation on 06/10/2025 at 10:00 AM, Resident 27 was lying in bed with fresh blood spots on their white top sheet. Resident 27 moved their contracted right hand and hit the top of the right hand under the overbed table. Staff S was notified of the incident. During an observation on 06/11/2025 at 2:00 PM, Resident 27's right top of their hand was reddened with open red spots on the top of their hand. Review of the 02/10/2021 care plan showed Resident 27 was at moderate risk for skin alteration due to resident's diagnoses and dry skin. There were no interventions related to prevent or care of skin impairments. Review of the 02/27/2025 incident report showed Resident 27 was seen by the physician for dermatitis (inflamation of the skin) of the right top of their right hand. The skin incident report showed that the physician requested that nursing staff notified them if the skin to the right hand changed. Review of the June 2025 TAR showed no treatment for Resident 27's right top of their hand. During an interview on 06/12/2025 at 8:20 AM, Staff B stated that nursing staff were to document skin issues and provide some intervention to care for bleeding of the right hand. Reference (WAC) 388-97-1060(1)

Based on observation, interview and record review the facility failed to ensure 3 of 6 sampled residents (Residents 19, 27, and 10) reviewed in a Restorative Nursing Program (RNP) for positioning, range of motion (ROM), and hand splinting, received consistent services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) through use of consistently following documented care plans and providing services to identified residents. This failure of not following the restorative care plans on a consistent basis increased the residents at risk of being unable to maintain their current level of functioning. Findings included . A review of the 11/15/2023 Restorative Nursing Plan policy showed residents will receive restorative nursing care as needed to promote safety and independence. Restorative nursing care consists of nursing interventions .goals and objectives are resident centered and outlined in the resident's care plan. The facility will be responsible for a monthly recap note performed by a licensed nurse. <Resident 19> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including dementia (decline in mental ability), osteoporosis (brittle bones which increase bone fracture risk), thrombocytopenia (low blood platelets which lead to increase bleeding and bruising), and history of falls. The 04/16/2025 quarterly nursing assessment showed Resident 19 was cognitively impaired with ability to respond yes or no to questions and required substantial assistance of one person to eat their meals, brush their teeth, and to stand and transfer to and from their wheelchair. Review of the 08/05/2021 RNP for Resident 19 showed they were to have transfer training from their wheelchair to bed or recliner back to wheelchair six to seven times a week for 15 minutes. Additionally, there was a grooming program for Resident 19 for brushing their teeth seven days a week for 15 minutes. Additionally, there was a nursing program for Resident 19 to ambulate 10 feet after standing in their room, corridor or similar place. During an observation on 06/09/2025 at 11:20 AM, showed the Resident 19 was quickly fed by the NA and wheeled out to a place by the nurse's station. During an observation on 06/10/2025 at 8:20 AM, Resident 19 was wheeled out of the dining room into the area by the nurse's station, at 1:00 PM and 2:00 PM the Resident 19 was lying in bed. During an observation on 06/11/2025 at 7:55 AM, Resident 19 was up in their room and wheeled to the dining room for breakfast. During an interview on 06/11/2025 at 10:57 AM, Staff T, NA Restorative Aide, stated Resident 19's RNP had no real goals or instruction to residents on how to do their programs. Staff T stated they do not do the transfer RNP for Resident 19 from the wheelchair to a recliner or transfers to the bathroom. Staff T stated they brought Resident 19 either to the hallway handrail or bathroom handrail and have them stand up with assistance of the handrail to pull themselves up from the wheelchair and then they can sit down. Staff T stated that was hard to measure if the activity is working or not. Staff T stated they had so much staff turnover at the facility in the last two years with resident care managers who use to do restorative nursing programs. <Resident 27> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of contractures (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) of the hands and shoulders, dry skin, fibromyalgia (long-term widespread pain and fatigue), and torticollis (shortening and stiffness of the neck muscles). Review of the 04/27/2025 quarterly assessment showed Resident 27 required substantial assistance with activities of daily living due to bilateral (both sides) impairment of upper and lower body movement. Resident 27 was able to make their needs known. Review of the RNP dated 05/14/2021 showed a goal of maintain the resident's current ROM of total body, neck, hands and bilateral lower extremities for Passive Range of Motion (PROM) and to maintain bed mobility for pressure relief. Interventions included six times weekly PROM to Resident 27's neck, hands, upper and lower body for 10 repetitions at least for 15 minutes six times a week. A RNP dining plan dated 03/21/2025 for Resident 27 showed they were to participate in set up assistance, simulate a feeding motion while wearing a half pound weigh around their wrist with a two-finger help assist with cueing and assist where needed two repetitions times 10 for 15 minutes six times a week. A 03/21/2025 Therapy restorative nursing referral form showed to optimize Active Range of Motion (AROM) for neck, hands, upper and lower body, (hold for five seconds, 10 times, and repeat) six times a week. During an observation on 06/09/2025 at 8:00 AM, Resident 27 was in bed leaning to the left side of their bed with chin bent to chest. The resident's breakfast food tray was uneaten and located on the countertop by the resident's sink. During an observation on 06/09/2025 at 11:50 AM, Resident 27 was lying in their bed their lunch tray for the resident sat on the resident's bedside table uneaten. During an observation on 06/09/2025 at 2:43 PM, Resident 27 had a small plastic cup with a handle with one third of a cup water in the cup. Resident 27 was unable to lift the plastic cup until Staff Z, poured some of the water out of the cup. Resident 27 could then lift the plastic cup to drink from a straw. There was no assessment as to functional ability for resident to maintain the daily living activities. No summation from the licensed nurse or restorative nurse to determine if the RNP was successful or needed to be revised for Resident 27. During an observation and concurrent interview on 06/10/2025 at 8:15 AM, Resident 27 were lying in their bed, and their breakfast tray was not in their room. During an interview on 06/09/2025 Staff CC, NA, stated Resident 27 rarely ate much and that they had not seen a Restorative Aide (RA) help the resident with eating or ROM. Staff CC stated Resident 27 could only use their right hand but could not use utensils or any weighted items to eat with. Review of the 05/14/2025 through 06/10/2025 showed Resident 27 the RNP dining and range of motion programs were not completed for a period of six days and a total of 12 meals for the dining RNP. During an interview on 06/10/2025 at 11:15 AM, Staff T, Restorative Aide, stated the RNP are not very easy to do, and they had residents that need to be evaluated for a program but there had not been enough licensed nurses or a speech therapist to evaluate residents for dining programs. Staff T stated they did not always follow the RNP and would make modifications without notifying the restorative nurse. There were no identified licensed nursing monthly assessments as to result of improvement functional ability for residents or to maintain their daily living activities. During an interview on 06/12/2025 at 8:57 AM, Staff B Director of Nursing (DNS) stated they were responsible for the RNP and understood that there were concerned about the residents' programs and if they were effective or not. Staff B was unaware that residents' RNP were not being done correctly. <Resident 10> Review of Resident 10's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include dementia (the loss of thinking, remembering, and reasoning- to the extent that in interferes with ADLs), muscle weakness and history of falls. The comprehensive assessment dated [DATE] showed Resident 10's cognition was severely impaired and was dependent on staff for bed mobility and transfers. Review of Resident 10's care plan dated 12/05/2024 showed the resident had started a restorative program due to general weakness and their program scheduled at least 15 minutes six to seven times a week. Additionally, the care plan showed the resident was to have a splint/brace on in AM off in PM related to trigger fingers (a condition in which a finger bends, gets stuck and then snaps straight). During an observation on 06/11/2025 at 9:01 AM, showed Resident 10 lying in their bed, stated they were doing good. The resident's right hand was noted to have their middle and fourth fingers in a bent position, and they were unable to straighten them. The resident stated no they could not straighten their fingers. Resident 10 stated their fingers had been like that for a while, then stated that they did not wear a splint or a hand roll. During an interview on 06/11/2025 at 10:09 AM, Staff L, Director of Rehab, stated Resident 10 had worked with Occupational Therapy (OT) for their trigger fingers. Staff L stated Resident 10 was no longer in the OT program, that the resident was now participating in the restorative program that the nurses were responsible for. During observations on 06/11/2025 at 1:03 PM, and at 4:24 PM, Resident 10 was lying in their bed with their head of bed elevated and their bed side table over their lap. The resident's hands were on top of the table looking at a paper, they had no splint/hand roll to their right hand. During an observation on 06/12/2025 at 9:05 AM, Resident 10 was sitting in their wheelchair and did not have a splint/hand roll to their right hand. During an interview on 06/12/2025 at 1:03 PM, Staff L, stated therapy staff had been doing finger splinting for Resident 10's trigger fingers. Staff FF, Occupational Therapist, stated staff (nurses and nursing assistants) were trained in placement of Resident 10's splint/hand roll. Staff L stated staff should be at least attempting to place the splints for the resident daily. During an interview 06/12/2025 at 1:22 PM, Staff CC, NA, stated they had received teaching on how to place the finger splints and a hand roll for Resident 10. Staff CC stated that the restorative aides were the staff that would take care of the splint. Staff CC stated they were unaware if staff had been placing the finger splint, that they had not worked with Resident 10 in over a week. Review of the June 2025 Treatment Administration Record showed Resident 10's right hand splint/hand roll had not been placed 06/01/2025 through 06/12/2025. During an interview on 06/12/2025 at 1:37 PM, Staff N, Resident Care Manager, stated the placement of the splint/hand roll should be documented whether they placed it on the resident and/or if the resident refused the placement. Staff N stated the last known was small finger splint, and the expectation was that staff at least attempted to place the fingers splint/ hand roll. During an interview on 06/12/2025 at 1:49 PM, Staff B, stated they attended the Medicaid meetings and discussed the facility's Restorative Program. Staff B stated that their expectation for the staff (both nursing staff and restorative staff) was for them to at least attempt to place splint and hand roll after Resident 10's Range of Motion exercises and document the progress and/or any refusals from the resident. WAC: 388-97-1060 (3)(d), (j)(ix)

Based on observation, interview, and record review, the facility failed to ensure that residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice by not assessing or monitoring past experiences of Post Traumatic Stress Disorder [(PTSD) an anxiety disorder (develops in some people who have experienced a shocking, scary, or dangerous event) for 1of 2 residents (Resident 64) reviewed for mood and behavior. This failure placed the resident at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . During an observation and interview with Resident 64 on 06/10/2025 at 9:24 AM, showed them sitting in their wheelchair at the sink in their room combing their hair. A bandage was placed on the stump of Resident 64's lower left leg, which they stated was due for a dressing change that day. Resident 46 stated they were feeling depressed due to their recent amputation and still did not understand what had happened to cause the amputation. They stated the stump wound was not healing well, and they were fearful another amputation was in the future. In addition, Resident 46 stated they had also recently lost their spouse, and it seemed as if their whole world had suddenly changed for the worst possible outcomes. Resident 46 stated they feared being in a care center for the rest of their life and was the only thing the future held for them. During the same interview, Resident 46 stated they had PTSD from being in the Vietnam war, and stated they did and saw things over there that no one should ever experience. They stated they did have flashbacks of the war frequently, had horrible dreams about it and often woke up frightened and could not get back to sleep. Resident 46 stated they had experienced some of those dreams since they had been in the facility but had not shared this or any of their PTSD symptoms with anyone else since they had been in the facility. Resident 46 stated I think someone came to my room and asked me if I had PTSD, but I do not remember who it was, and I did not go into any detail about it. During an interview on 06/11/2025 at 2:10 PM, Staff B, Director of Nursing Services (DNS) stated that Social Services were responsible for doing the PTSD screening and would call in behavioral health if needed for a resident. Staff B stated Social Services were also responsible to assure a care plan with interventions specific to the resident for the diagnosis of PTSD and/or any other mood disorder or behavior problem was completed. During an interview with Staff H, Social Services Director (SSD), on 06/12/2025 at 11:16 AM, they stated they were aware of Resident 46's diagnoses of PTSD, bipolar disorder and depression and did complete a general care plan for their mood disorder. The SSD further stated they did not go into detail about the PTSD or define any triggers Resident 46 may have that the staff should be aware of. The SSD stated they provided weekly visits with Resident 46 to discuss any issues they may have and had called and requested services from the Veteran ' s Administration as they knew Resident 46 was a Vietnam Veteran but had not yet heard back from them. Review of an assessment titled Trauma Screening Questionnaire, completed by the SSD on 05/09/2025 showed, reported PTSD from Vietnam war and a car accident in the 70's. There was no other information concerning possible triggers for the PTSD or interventions to lessen the resident's distress if behaviors were identified. Review of Resident 46's care plan showed a problem was developed on 05/08/2025 showing the resident had a mood problem related to unspecified bi-polar disorder (a brain disorder that causes changes in a person ' s mood, energy, or ability to function). The goal was to maintain an even mood while in the facility and the interventions were to observe for signs and symptoms of mania or hypomania(periods of over-active and high energy behavior that can significantly impact day to day life), racing thoughts or euphoria(a feeling or state of intense excitement and happiness), increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, agitation or hyperactivity, and to encourage the resident to express their feelings in weekly meetings. There was no resident specific care planning addressing Resident 46's PTSD, current depression from the recent loss of their spouse and lower leg, or about their fears of being placed in a long-term care facility. WAC Reference: 388-97-0020

Based on interview and record review, the facility failed to develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) care plan in collaboration with contracted hospice services, that identified the provider responsible for performing each or any specific services/functions for 2 of 3 sampled residents (Residents 21 and 43) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services. Findings included . Review of a policy titled Hospice, dated 03/2024, showed each resident's care plan would include both the most recent hospice car plan and the facility's care plan to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. <Resident 21> Review of the medical record showed the resident admitted to the facility with diagnoses including end stage renal disease (when your kidneys have permanently stopped working). The 05/16/2025 comprehensive assessment showed Resident 21's cognition was moderately impaired and required assistance of one to two staff members for activities of daily living (ADLs). Further review showed Resident 21 was receiving hospice services. Review of Resident 21's care plan dated 05/14/2025, showed the resident was placed on hospice services on 05/14/2025 related to end stage renal disease. Resident 21's care plan was not unique to the needs of the resident's hospice care and lacked documentation of the hospice orders/input. Review of Resident 21's electronic health record (EHR) on 06/10/2025 showed Resident 21 had no hospice care plan. <Resident 43> Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (a loss of blood flow to part of the brain, which damages brain tissue) and dementia (a decline in mental ability, specifically affecting thinking, memory, and reasoning, severe enough to interfere with daily life). The 05/27/2025 comprehensive assessment showed Resident 43's cognition was intact and required assistance of two staff members for ADLs. Further review showed Resident 43 was receiving hospice services. Review of Resident 43's care plan dated 05/20/2025, showed the resident was placed on hospice services 05/20/2025 related to a terminal prognosis (less than six months to live). Resident 43's care plan was not unique to the needs of the resident's hospice care and lacked documentation of the hospice orders/input. During an interview on 06/13/2025 at 10:03 AM, Staff B, Director of Nursing Services, stated the process for hospice services was for the hospice care plan to be integrated into the facility's care plan. Staff B stated the hospice care plan should have been uploaded into Resident 21's EHR and it was probably still waiting to be scanned in. Staff B further stated the process was not followed for Resident 43 and 21. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that documented resident specific goals, physician orders, treatment plans and social services needs for 5 of 5 residents (Residents 1, 2, 3, 4 and 5) reviewed for baseline care plan. This failure place residents at risk of not receiving necessary care and services and continuity of care. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including paralytic syndrome (loss of muscle function/feeling), bleeding around the brain and chronic pain. The 01/15/2025 comprehensive assessment showed Resident 1 required maximal assistance of one to two staff for activities of daily living (ADLs) and was able to make their needs known. Review of Resident 1's admission nursing assessment dated [DATE], showed they had identified a sacral (relating to the sacrum [a triangular shaped bone at the base of the spine, forming the posterior wall of the pelvis]) pressure wound described as a suspected deep tissue injury. Review of Resident 1's baseline care plan dated 01/09/2025, showed no focus areas, initial goals or interventions for Resident 1's specific care needs related to physician orders, treatments, and social services. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including nontraumatic ischemic infarction of right lower leg muscle (decreased blood flow that causes death to a muscle) and nutritional anemia (low oxygenated red bloods caused by lack of nutrients). The 12/30/2024 comprehensive assessment showed Resident 2 was independent/partial assistance with ADLs and had an intact cognition. Review of Resident 2's baseline care plan dated 12/23/2024, showed no focus areas, initial goals or interventions for Resident 2's specific care needs related to physician orders, treatments, and social services. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including heart failure, obstructive sleep apnea (sleep disorder that causes a pause of breathing during sleep), and depression. Resident 3 required assistance of one to two staff for ADLs and mobility and was able to make their needs known. Review of Resident 3's baseline care plan dated 01/22/2025, showed no documentation of initial goals, focus area or interventions for admission orders, therapy and social services. Additionally, there was no pre-admission screening and resident review [(PASARR) - a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care] recommendations, behavioral health goals, or interventions. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes (a group of diseases that result in too much sugar in the blood), dysphagia (difficulty swallowing) and depression. The medical record also showed Resident 4 had a feeding tube (a tube inserted into the stomach to provide nutrition). The 01/09/2025 comprehensive assessment showed Resident 4 required supervision/substantial assistance of one to two staff for ADLs and a moderately impaired cognition. Review of Resident 4's baseline care plan dated 01/02/2025, showed no documentation of initial goals, focus areas or interventions for admission orders, therapy and social services. <Resident 5> Review of the medical record showed Resident 5 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), metabolic encephalopathy (a chemical imbalance in the blood that affects the brain function), and anxiety. The medical record showed Resident 5 required limited assistance of one staff member for ADLs and was able to make their needs known. Review of Resident 5's baseline care plan dated 01/20/2025, showed no documentation of initial goals, focus areas or interventions for admission orders, physician orders or social services. During an interview on 01/29/2025 at 2:53 PM, Staff A, Resident Care Manager, stated they performed nursing admission assessments on new resident admissions. Staff A stated they reviewed the resident's history and prior functional needs with the resident and/or resident representative. Staff A stated they developed a baseline care plan on the resident's admission and the baseline care plan included ADLs, pain and fall risks. During an interview on 01/29/2025 at 3:55 PM, Staff B, Director of Nursing, stated the process of developing a 48-hour baseline care plan should have five areas necessary for resident care needs that included ADL's, pain, fall risks, skin integrity and bowel and bladder continence. Repeat deficiency from Statement of Deficiencies dated 05/22/2024. Reference WAC: 388-97-1020(3)

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer/pressure injury (PU/PI) and to implement wound treatments timely to avoid worsening of a PU/PI for 3 of 3 residents (Residents 20, 41, and 60), who had multiple co-morbidities with an increased risk for PU/PI, reviewed for PU/PI. Resident 20 experienced harm when they developed a Stage II PI (partial thickness skin loss with exposed top inner layers of skin) to their right buttock and an unstageable (a pressure injury that is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) wound to their left buttock, and expressed significant pain and discomfort. These failures placed the residents at risk for development or worsening of PU/PI, pain, infection, and a decreased quality of life. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016, defined pressure injury stages as follows: Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 Pressure Injury is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. Unstageable Pressure Injury is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of an undated facility policy titled, Skin Integrity, showed the facility would provide care consistent with professional standards of practice to prevent pressure injuries, promote healing, and prevent infection. <Resident 20> Review of the medical record showed Resident 20 admitted to the facility on [DATE] with diagnoses including respiratory disease, obesity, diabetes (a long-term condition in which the body has trouble controlling blood sugar level in the body), and hemiplegia (a condition that causes a severe loss of strength or paralysis on one side of the body). The most recent comprehensive assessment, dated 05/01/2024, showed Resident 20 required total assistance of two staff members for bed mobility, transfers, bathing, dressing and toileting, and was cognitively intact. Review of an admission nursing assessment dated [DATE], showed Resident 20 was admitted to the facility with no skin breakdown noted. Review of a nursing progress note dated 05/04/2024, showed a skin assessment was completed on Resident 20 and no skin issues were found. Review of a nursing progress note dated 05/07/2024 showed, shearing (skin abrasions) was noted on both the left and right buttock, each measuring two centimeters (cm, a unit of measure) round. The areas were cleansed and covered with a foam dressing. A new order had been received to change the dressings every other day (QOD) and as needed (PRN). Review of Resident 20's physician orders and Treatment Administration Records (TAR's) for the month of May 2024, showed on 05/09/2024 an order was received to change the dressings to the left and right buttocks pressure wounds QOD and PRN by cleansing the wounds and applying a thin layer of 50/50 Anasept/collagen powder (a specialized absorbent wound filler) to the wounds and then covering with a foam dressing. A concurrent observation and interview on 05/13/2024 at 11:10 AM, showed Resident 20 sitting in a wheelchair in their room. The resident stated their bottom hurt real bad from sores (pressure injuries) on it and asked to be put back to bed for relief from the pain. The resident stated they got the sores after they admitted to the facility and had not had any previous skin breakdown. Observation of the wounds during a dressing change on 05/16/2024 at 10:26 AM by Staff E, Assistant Director of Nursing (ADON), showed two distinct wounds on the right and left buttocks and a darkened area on Resident 20's coccyx (tailbone) area. The removed dressing showed a moderate amount of yellow colored drainage and the wound bed on the right buttock had partial thickness skin loss and was red in color. The wound on the left buttock was larger in size and had whitish colored slough covering the center of the wound with red partial thickness skin loss surrounding the center of the wound. Staff E took photos and measurements of the wounds for weekly wound assessment documentation and stated they would place the document for review in Resident 20's medical record when completed. During the same observation, Resident 20 stated the wounds were always very painful and especially during the dressing changes. The resident made moaning sounds indicating the areas were painful when touched during the dressing change process. During an interview with Staff E on 05/17/2024 at 2:37 PM, while reviewing the wound assessment record and pictures completed on 05/16/2024, showed a wound on the right buttock measured and defined as a 1.0 centimeter (cm, a unit of measure) by 1.0 cm Stage 2 open pressure injury, and a wound on the left buttock measured and defined as a 3.98 cm by 3.1 cm open unstageable area, as a portion of the wound was covered by yellow/whitish slough and the extent of tissue damage could not be observed. A closed deep colored area measuring 2.0 cm by 0.5 cm at the top of the coccyx was also noted on the wound assessment record. Review of Resident 20's care plan showed a problem was opened on 05/08/2024, showing the resident had Stage 2 pressure injuries to both buttocks with the goal to be healed by the next review date. <Resident 41> Review of Resident 41's medical record showed they were readmitted to the facility on [DATE] with diagnoses that included type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and turning it into energy) and a Stage 4 pressure injury on their sacrum (located at the base of the spine) and osteomyelitis (an infection in the bone). Review of the most recent comprehensive assessment dated [DATE] showed Resident 41 was cognitively intact and required no assistance with decision making. During an observation and interview on 05/16/2024 at 9:16 AM, Resident 41 stated their air mattress (a specialized mattress that contains air cells or tubes which alternates to prevent pressure) was malfunctioning for a while and they could not get anyone to fix it. The resident pointed to the right side of the bed where a hard hyper inflated area was observed directly under their sacral wound and caused pain. Resident 41 stated that if the bed was not over inflated to 300 pounds it went flat and they would be sitting on the metal bed frame. It really needs to get fixed because the hardness pushes on my sore. Review of an outside wound care consultant (OWC) assessment note dated 04/25/2024 showed Resident 41's air mattress was malfunctioning and a referral to maintenance had been made to repair or replace the bed. Review of a OWC assessment note dated 05/05/2024 showed the OWC had again requested an air mattress replacement or removal of Resident 41's malfunctioning air mattress. The note stated the air mattress was putting inappropriate firmness under Resident 41's Stage 4 sacral pressure injury. During multiple observations on 05/14/2024 at 10:10 AM, 05/15/2024 at 2:10 PM, 05/16/2024 at 9:10 AM, 05/17/2024 at 3:30 PM, showed Resident 41 was using the same malfunctioning air mattress with the over inflated area putting pressure on their Stage 4 sacral wound set at 300 pounds to prevent it from going flat. An observation and interview on 05/19/2024 at 8:13 AM, showed Resident 41 laying on a non-air mattress (Sedona Medium Risk). The mattress did not include alternating air cells for pressure relief. Resident 41 stated I know it's not an air bed but at least it is not pushing on my sore. During an interview on 05/19/2024 at 9:00 AM, with a staff who requested to remain anonymous stated the malfunctioning air mattress had been reported for weeks, and nothing had been done about it until yesterday (05/18/2024). During an interview on 05/22/2024 at 11:12 AM, Staff B, Director of Nursing, stated they put Resident 41 on a non-air mattress on 05/18/2024. Staff B stated they were aware that the new mattress for Resident 41 was not an alternating air pressure relief mattress and would change the physicians order to discontinue the air mattress. The request for intervention of Resident 41's malfunctioning air mattress replacement took 23 days from the first noted documentation of the mattress malfunction on 04/25/2024. <Resident 60> Review of the medical record showed Resident 60 was admitted to the facility on [DATE] with diagnoses including surgical removal of left leg (below the knee) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The 03/20/2024 comprehensive assessment showed Resident 60 required maximum assistance of one staff member for activities of daily living: set up assistance of one staff member for eating, oral, and personal hygiene. The assessment also showed Resident 60 had an intact cognition. Review of a nursing progress note dated 03/13/2024, showed Resident 60 was admitted with a deep tissue injury (a serious form of pressure injury that rapidly progresses to full thickness skin and soft tissue loss)/pressure injury to their right heel. Review of a progress note dated 04/18/2024 at 5:46 AM, by OWC, showed Resident 60's wound was improving with delayed wound closure. Non peeling eschar (dead tissue that forms over healthy skin, then over time, falls off) present. Keep clean and covered. Review of a progress note on 04/25/2024 at 5:30AM, showed OWC had assessed Resident 60's right heel wound and determined that surgical debridement (removal of damaged tissue from a wound) was necessary and had performed the debridement that day. The wound was then classified as a Stage 4 pressure injury. The OWC documented that the wound had a strong odor with purulent (thick fluid caused by infection) drainage. A wound swab was obtained to guide treatment options including antibiotics. Review of a PN on 05/02/2024 at 5:18 AM, showed the OWC had assessed Resident 60's right heel wound. The assessment showed the wound was deteriorating with severe exacerbation (an increase in the severity of the illness) and recommended labs and imaging to ensure no bone involvement was present. The OWC also documented that they and Resident 60's provider needed results of the wound swab to help guide treatment options including antibiotics. Additionally, the OWC had placed additional lab recommendations due to concerns of osteomyelitis, along with magnetic resonance imaging [(MRI) an imaging technique that is used in radiology to form pictures of the anatomy and physiological process inside the body] or x-ray. Review of the medical record showed the lab results for the wound swab were resulted on 04/26/2024 at 7:49 PM, and a report was generated on 04/27/2024 at 3:18 AM. Review of a nursing PN dated 05/08/2024 at 9:25 AM, showed Resident 60's right heel wound swab results were received and reviewed by the facility provider and antibiotics were prescribed, 11 days after the results were reported. Review of a progress note on 05/16/2024 at 5:18 AM, showed the OWC was unable to locate the wound swab results, inflammation labs, and imaging updates per their last progress note dated 05/02/2024. The OWC documented Please provide update on the following previous recommendations ., referencing the inflammation labs and imaging. During an interview on 05/20/2024 at 1:42 PM, Staff J, Resident Care Manger (RCM), stated they managed Resident 60's care. Staff J stated the results of the wound swab should have been in the record but could not find them. Staff J stated they were not aware of the 05/02/2024 recommendations from the OWC. They stated there was a nurse that had followed the wounds with the OWC during wound rounds, but since they left, they were not sure who followed those residents/wounds. During an interview on 05/20/2024 at 3:12 PM, the facility's Medical Director stated the facility should have followed up on the 05/02/2024 orders by the OWC. They stated they (the orders) were absolutely indicated for this resident. During an interview on 05/21/2024 at 4:29 PM, Staff B, Director of Nursing, stated they were unsure why the antibiotics were not ordered timely. Staff B stated they expected the nursing staff to contact the provider the same day the results were received to get a medication started. Staff B stated when the OWC made recommendations, the facility did not recognize them as orders. Staff B stated the nursing staff should have been reviewing the OWC's recommendations and forwarding them to the facility provider to create the orders. Staff B stated that process was not being followed. During an interview on 05/22/2024 at 11:15 AM, Staff C, [NAME] President of Clinical Operations, stated the OWC recommendations for additional labs and imaging should have been given to the facility provider for follow up. Reference: WAC 388-97-1060(3)(b) This is a repeat citation from Statement of Deficiencies dated 08/28/2023, 11/29/2023, and 03/12/2024. 39652 45117

Based on observation, interview and record review the facility failed to provide the vital services needed for wound healing and treatment of serious infection by consistently providing dressing changes and initiating antibiotics timely for 3 of 3 residents (Resident's 1, 2 and 8) reviewed for pressure injuries (wounds over a bone caused by pressure). Resident 1 experienced harm when the Stage 4 pressure injury (a wound with full tissue loss and exposed bone, tendon and muscle) that was acquired at the facility worsened, they experienced pain and the osteomelitis (a high risk infection in the bone that can lead to full body system wide infection) was not treated timely. The facility's lack of ensuring residents received the treatment needed for healing placed residents at serious risk for worsening of pressure injuries, pain, infection and a significant decline in health status and was determined to be an emergent situation. On 03/07/2024 at 4:20 PM the facility was notified of an Immediate Jeopardy (IJ) at CFR 483.2(b)(1), F686 Treatment/Services to Prevent/Heal Pressure Injuries related to the failure to provide wound care consistent with professional standards of care for pressure injury wounds. This included a pattern of missed dressing changes occurring on the weekends and a failure to timely start an oral antibiotic for a resident with a wound infection. It was determined that the IJ began on 03/01/2024 and the immediacy was removed on 03/08/2024 with an onsite verification from investigators. The facility removed the immediacy by implementing education for licensed nurses to be completed prior to their next scheduled shift. The facility initiated a supervisory plan to ensure weekend dressing changes were completed. The oral antibiotic was started for the resident with the wound infection on 03/07/2024. The measures put in place by the facility ensured that wound care for pressure injuries would be completed according to physician ordered treatments. Findings included . Review of the National Pressure Injury Advisory Panel (leading expert in pressure injuries/wounds), September 2016 defines pressure injury stages as follows; Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passage way under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 Pressure Injury is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. Unstageable Pressure Injury is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of an undated facility policy titled, Skin Integrity showed the facility will provide care consistent with professional standards of practice to prevent pressure ulcers and promote healing and prevent infection. <Resident 1> Review of Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (narrowing of the blood vessels related to a buildup of plaque) and Type 2 Diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident 1's most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact. Review of the care plan dated 02/28/2024 showed the resident required extensive assistance from staff for dressing, bed mobility and used a wheelchair for mobility needs. Record review of Resident 1's February 2024 and March 2024 physician orders showed Resident 1 had a facility acquired Stage 4 pressure injury (not present on admission to the facility) on their sacrum (a bony structure located at the base of the spine) which required wound care twice daily and included application of an antibiotic ointment to the base of the wound to prevent infection. Record review of a recent hospital discharge summary dated 02/27/2024 showed Resident 1 was hospitalized from 02/23/2024 to 02/27/2024 for surgery on their right leg with an above the knee amputation. The record showed while in the hospital Resident 1 had received intravenous (IV, a medication given directly into the blood stream by a tube inserted into a blood vessel) antibiotics for osteomyelitis in their Stage 4 sacral pressure injury. The discharge summary showed Resident 1 continued to require aggressive wound treatment to their sacral wound as their bone was exposed. Additional recommendations included to re-start an oral antibiotic related to the resident's sacral wound infection. During a concurrent observation and interview on 03/06/2024 at 11:26 AM, Staff C, Registered Nurse (RN), completed wound care on Resident 1's Stage 4 sacral pressure injury. The wound was noted to be a deep crater the size of a 50 cent piece coin that was observed to have a larger area of tissue loss under the wound opening which was undermining. The wound had a foul smell with brownish colored drainage on the soiled, removed bandage. Staff C placed a cotton swab into a tunnel in the wound and removed it which showed a three centimeter (cm, a unit of measure) depth to the pressure injuries tunneling. Staff C completed wound care per orders and finished with placing a clean dressing over the wound and securing it. Resident 1 stated the wound was painful and sore. During the same interview, Staff C stated they had concerns about Resident 1's wound care over the past weekend and had notified the provider on 03/05/2024 as the resident had not received their twice daily wound care as ordered. Staff C explained the dressing that had been removed on Monday 03/04/2024, still showed a date of 03/01/2024 written on the dressing which demonstrated the twice daily wound care had not been completed on Saturday 03/02/2024, or Sunday 03/03/2024. Record review of a provider notification document, dated 02/19/2024, showed a pattern of Resident 1's wound care not being completed as ordered on the weekend. The provider had been notified that Resident 1 had not received twice daily wound care to their sacral pressure injury on the weekend. The dressing removed on Monday, 02/19/2024 still showed a date of 02/16/2024 written on the dressing which demonstrated that no wound care had been provided for the resident on Saturday 02/17/2024, or Sunday 02/18/2024 as ordered. During an interview on 03/06/2024 at 11:40 AM, Resident 1 stated the weekend nurse hardly ever changes my dressings. It sure was not done this past weekend. It really only gets done during the week. Review of a wound consultant progress note, dated 02/29/2024, showed Resident 1 had been assessed with a plan to continue providing twice daily wound care. The plan also recommended to re-start a course of oral antibiotics for three weeks. The recommendations were received by the facility on 03/01/2024. Review of Resident 1's March 2024 medication administration record showed the ordered oral antibiotic had not been initiated until 03/07/2024 at 8:00 PM (six days later). During an interview on 03/07/2024 at 11:55 AM, Staff C, stated that the oral antibiotic order for Resident 1 had not been started until 03/07/2024 and should have been started on 03/01/2024. Record review of Resident 1's sacral pressure injury measurement documents showed the worsening of the wound over a two-week period. 02/28/2024 length 2.17 cm and 2 cm in depth. 03/07/2024 length 2.33 cm (which showed an eight percent increase), depth 4.4 cm (which showed a 110% increase). <Resident 2> Review of Resident 2's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular heart rate that often causes poor blood flow) and weakness. Review of Resident 2's most recent comprehensive assessment, dated 02/07/2024, showed the resident was cognitively intact. Review of the resident's care plan, dated 01/15/2024, showed the resident required extensive assistance for dressing, grooming and bed mobility. Review of the Resident 2's March 2024 physician orders showed Resident 2 required daily wound care to an unstageable coccyx (tailbone) pressure injury. During an interview on 03/06/2024 at 1:40 PM, Staff C stated they had notified the provider as Resident 2 had also not received their daily wound care over the weekend. The dressing which had been removed on 03/04/2024 was dated 03/01/2024 which showed that no wound care had been completed on Saturday 03/02/2024, and Sunday 03/03/2024 as ordered. During an interview on 03/11/2024 at 11:20 AM, Resident 2's representative (RR) stated they had been contacted by the facility to inform them that Resident 2 had not received wound care for the entire weekend on 03/02/2024 and 03/03/2024. RR stated they had concerns about Resident 2's wound care because it was not the first [NAME] they received a report that the wound care had not been completed on the weekend. During an interview on 03/11/2024 at 2:10 PM, Resident 2 stated they did not remember if the wound care to their coccyx pressure injury was completed on the weekend. Resident 2 stated they were resting and did not want to have their wound care observed or treated at this time, I'm too tired and want to rest. Record review of the licensed nursing weekend schedule for 02/17/2024, 02/18/2024, 03/02/2024 and 03/03/2024 showed Staff D, Licensed Practical Nurse (LPN), was the nurse who worked on the above weekends. Staff D was the licensed nurse assigned for Residents 1 and 2 on the South Hall and was responsible for their pressure injury dressing changes. During an interview on 03/07/2024 at 2:45 PM, Staff D, stated they worked double weekend shifts at the facility on the South Hall where Resident 1 and 2 resided, which included day and evenings on Saturdays and Sundays. Staff D stated they changed Resident 1's dressing usually daily during their shifts and only twice daily if the dressing was soiled. Staff D further stated that Resident 2 did not have daily wound care orders for dressing changes to their coccyx wound therefore they just checked it and provided pressure injury care only if the dressing was visibly soiled. <Resident 8> Review of Resident 8's medical record showed the resident admitted to the facility on [DATE] with diagnoses including epilepsy (a brain condition that causes repeated seizures) and Type 2 Diabetes. Review of the most recent comprehensive assessment dated [DATE] showed Resident 8 was cognitively impaired. Review of the care plan dated 03/01/2024 showed the resident required extensive assistance for dressing, transfers and mobility. Record review of March 2024 physician orders showed Resident 8 required daily wound care to their Stage 2 left lateral knee pressure injury. Record review of a provider notification document dated 03/05/2024 showed Resident 8 had not received wound care to their left lateral knee pressure injury as ordered on Saturday 03/02/2024, and Sunday 03/03/2024. During an interview on 03/11/2024 at 3:45 PM, Staff B, Director of Nursing stated their expectation for pressure injury wound care was that the provider orders were to be followed and if wound care was ordered daily, that would include the weekend shifts. Reference: WAC 388-97-1060(3)(b) This is a repeat citation from the statement of deficiency dated 11/29/2023 and 08/28/2023

Based on observation, interview, and record review the facility failed to ensure goods and services were provided to avoid a decline in condition for 1 of 1 resident (Resident 1), reviewed for neglect. The facility did not follow through with a physician referral in a timely manner for a diagnostic test magnetic resonance imaging (MRI, an imaging examination to determine an extent of an injury) and a referral to a neurologist (a physician that specializes in the function and treatment of the neurological system). Resident 1 experienced harm when they had a decline in some of their fine motor skills, had increased pain, and anxiety. These failures placed other residents at risk for unmet care services. Findings included . <Resident 1> Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes (a long-term condition in which the body has a hard time controlling blood sugar and using it for energy), osteoarthritis (a type of arthritis that occurs when the tissue on the ends of the bone wears down), and muscle weakness. Record review of Resident 1's most recent comprehensive assessment, dated 12/31/2023, showed the resident was cognitively intact. Review of Resident 1's care plan, dated 02/15/2024, showed the resident was independent with eating. Record review of a cervical spine (neck region) x-ray, completed on 07/14/2023, showed Resident 1 had changes in their cervical spine with moderate to severe degenerative disc disease (a condition of the discs/joints in the spine wearing out). Review of Resident 1's provider progress notes, dated 07/18/2023, showed the physician ordered an MRI of their neck and cervical spine related to the changes shown on the x-ray dated 07/14/2023. The provider documented changes in Resident 1's hands and arms, weakness, and increased pain. The provider notes also showed a referral was made to have a follow up appointment scheduled with a neurologist. Further record review of medical provider progress notes showed the following: 07/20/2023 .Seen for neck pain and dizziness .MRI previously ordered . 09/25/2023 .A recent cervical spine x-ray showed stenosis (a narrowing of the spinal cord with compression) .an MRI has been ordered but has not been done .The patient is having difficulty holding on to the implements (spoons and forks) to feed themselves .At this point it is important that we finish the work-up . 10/03/2023 .The patient complains of cervical neck pain and muscle spasms that radiate into shoulders and arms .An MRI has been ordered which has not been done . 10/19/2023 .The operating diagnosis is that the patient has a cervical spine compression fracture which should show up on an MRI .An MRI of the cervical spine has been ordered again with no results in chart .The patient states they have still not had an MRI and has not been seen by a neurologist. Patient states current anxiety is related to not knowing why they are getting weaker . 01/08/2024 .MRI of cervical spine and neurology referral ordered need to be executed as they were ordered and never done. 02/09/2024 .Patient reports pain everywhere .The MRI was not performed .the patient has not seen a neurologist . During an interview on 02/14/2024 at 11:10 AM, Resident 1 stated they had been having anxiety as the physician had ordered an MRI of their neck related to numbness, pain, and loss of function in their hands. I've been waiting months, and it still has not happened, I feel like I am getting worse each day. I dropped my fork this morning because I could not hold onto it. During an interview on 02/14/2024 at 11:45 AM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM), stated they were recently moved to the South hall where Resident 1 resided to assist with follow up as there was currently no RCM for the unit. During the same interview, Staff C stated they were aware of Resident 1's referral for an MRI and a neurologist consult which had been ordered months ago. Staff C further stated they had obtained a new order as the other order was no longer current and would set up the MRI and consult with a neurologist. Staff C stated they were informed that the MRI was not set up because the resident's insurance had denied it; however, the resident's current insurance did not require a pre-authorization and the MRI had not been denied. During an interview on 02/15/2024 at 11:50 AM, Advanced Registered Nurse Practitioner (ARNP) Consultant, stated they had been asked by Resident 1's Primary Care Provider (PCP) to assess Resident 1's neurological status. They stated they completed a neurological examination earlier in the day of Resident 1 and noted that the resident did have abnormal reflexes and weakness of their cervical area. The ARNP Consultant stated that an MRI and a follow up with a neurologist was definitely needed so that a plan could be developed for the resident's declining condition. In an interview on 02/15/2024 at 12:22 PM, Resident 1's PCP stated they had spoken to the facility nursing management numerous times about scheduling Resident 1 for an MRI and a neurology consult. The PCP stated they had concerns about the resident having permanent damage related to the lack of timely follow up by the facility. During a follow-up interview and concurrent observation on 02/15/2024 at 1:45 PM, Resident 1 stated they had been assessed by the ARNP Consultant earlier in the day and had been informed, It's been too long, and I might have damage to my neck which is probably not reversible. The resident demonstrated that they could not make a fist with their hands. I no longer enjoy playing cards, I can't pick up a penny or write my name. My hands just don't work anymore. During an interview on 02/15/2024 at 2:15 PM, Staff B, Director of Nursing Services, stated they were aware that Resident 1 had a referral for an MRI and neurology consult but they had been struggling with the resident's insurance company denying the test. We have been attempting to get the resident in, but it all has to do with their insurance company. Record review of facility's documented communication efforts provided by Staff B showed a lack of coordination regarding attempts to obtain Resident 1's MRI or neurology consult. Additionally, the documents showed the resident had a new insurance provider as of 11/01/2023. Record review of a progress note, dated 02/15/2024 at 6:40 PM, showed Staff C, RCM, had obtained new orders and had contacted outside centers to schedule Resident 1's MRI and neurology consult. The test imaging center for the MRI indicated they had been contacted once in January by the facility but could not schedule the MRI related to missing information. The imaging test center stated they would call the next day to schedule the MRI as a pre-authorization was not needed from the resident's current insurance company (which had been in effect since 11/2023). A neurology center was contacted and stated they would accommodate the resident in one to two weeks for a consult. Review of a follow up fax received by Staff B, which showed Resident 1 was scheduled for an MRI on 02/22/2024 and had a neurology consult on 02/29/2024. The follow up to the physician's original orders dated 07/18/2023 had taken over seven months to obtain. Reference: WAC 388-97-0640 (2)(a)

Based on interview and record review, the facility failed to ensure a resident was adequately assessed/monitored after an unwitnessed fall which resulted in a lack of timely diagnosis/treatment for a major injury and the resident experiencing unnecessary pain for four days, before they were hospitalized for their right hip pain, for 1 of 3 residents (Resident 2), reviewed for falls. Resident 2 was harmed when they experienced unrelieved pain and distress after the fall on 02/08/2024, required hospitalization on [DATE], and was diagnosed with a right femur (thigh bone) fracture. These failures placed all residents at an increased risk for delay in care, poor health outcomes, and a worsening of their medical condition. Findings included . Review of the facility policy titled, Fall Assessment and Management, dated 09/21/2022, showed that after a resident fall, the assigned nurse would complete an incident assessment/evaluation and place it in the resident medical records. Additionally, the assessment would include the initial bedside intervention implemented at the time of the fall. < Resident 2> Review of the Resident 2's medical records showed they were admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), dysphagia (difficulty swallowing food or liquids) following a stroke, depression, and dementia (an impairment of brain function, which causes memory loss, forgetfulness, and impaired thinking abilities). The comprehensive assessment, dated 12/31/2023 showed the resident had a severely impaired cognition, required supervision with rolling left/right in bed, and sitting/lying when in bed. The comprehensive assessment also showed Resident 2 had no presence of pain. Review of Resident 2's care plan, last updated 01/05/2024, showed the resident had an impaired cognitive thought process related to their dementia and .needs assistance with all decision making. The care plan documented the resident's risk for pain and showed, a goal for the resident to not have an interruption in normal activities due to pain ., with the following interventions; monitoring changes in the resident's usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, withdrawal or resistance to care .report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs/symptoms or complaints of pain or discomfort .monitor/record pain characteristics every shift and PRN [as needed]: Quality (e.g. sharp, burning; Severity (0 to 10 scale) [a verbal way for residents to communicate pain intensity]; Anatomical [specific orientation/part of the human body] location; Onset; Duration (e.g. continuous, intermittent); Aggravating [things that might make the pain worse] factors; Relieving factors . Resident 2 was assessed to require one staff assistance for bed mobility, one staff extensive assistance for upper/lower body dressing, one staff assistance for toilet use, and documented that the resident took a bath/shower two times a week on Mondays and Thursdays. Review of the facility's incident log for February 2024 showed that on Thursday 02/08/2024 at 10:32 PM, Resident 2 had a fall in their room which was logged and reported to the state on Monday 02/12/2024 (four days later). Review of the fall investigation, dated 02/12/2024, completed by Staff B, Director of Nursing Services (DNS), showed that on 02/12/2024 Resident 2 was in bed and has pain in Rt (right) hip with a possible recent fall. Resident foot is rotated out. The resident was noted to be alert but confused with severe cognitive impairment and was sent to the hospital after it was assessed that they had right hip pain and external rotation of their right leg (an assessment of the position of the affected leg, that is observed to be rotated outwards away from the body and can be an indication of a hip fracture). Staff B documented that .a report was made to (state agency) for injury of unknown source as no record of a fall was found in risk management (a comprehensive assessment completed after a fall) or documentation by nurses .on speaking with nurses on unit for Thursday (02/08/2024) it was found that resident had a fall in (Resident 2's) room during hand off of keys from evening shift to night shift with both nursing (Registered Nurses) stating the other (nurse) was to complete the incident report. Additionally, the investigation showed .fall occurred on 02/08/2024 with no reports of pain per staff even with turning and positioning throughout the time from the fall to the report the AM of 02/12/2024 .injury reasonably related to fall . Review of Resident 2's hospital emergency department note, dated 02/12/2024, showed the resident was brought into the hospital after a fall but that it was unclear when the fall happened .no report in the chart a fall but apparently oncoming crew (nursing home staff) was told that (Resident 2) did fall .no clear report regarding the fall. The physical assessment showed a shortened externally rotated right leg (when one leg on the body is observed to be shorter than the other and rotated outwards away from the body which can be an indication of a hip fracture) with pain at the right hip. Additionally, an x-ray of Resident 2's right hip showed a femur fracture. During an interview on 02/15/2024 at 12:27 PM, Staff D, Nursing Assistant (NA), stated they worked the day shift on 02/09/2024 (the day following Resident 2's fall), and was informed by Staff F, NA that Resident 2 was not getting up out of bed because they had a fall. Staff D stated they were helping Staff F, NA, with providing care to Resident 2 and normally the resident was moving around in their wheelchair, talking a lot, and required one staff for mobility in bed, but on the morning of 02/09/2024 the resident was not talking or moving around. Staff D stated, You could tell (Resident 2) was in a lot of pain, when they were assisting with turning/changing the resident while they were in bed, and that it was conveyed to the nurse on shift. Additionally, Staff D stated they also worked the day shift on 02/12/2024 and Resident 2 was the same as on Friday 02/09/2024, in pain, lying in bed and not talking like (Resident 2's) normal self. During an interview on 02/15/2024 at 12:47 PM, Staff E, Registered Nurse (RN), stated they had received report from the night shift nurse on the morning of 02/12/2024 that Resident 2 was acting out of (their) normal and that they must have broken their right hip because the resident was in pain and their right leg was shortened/externally rotated. Staff E stated that there was no report of the resident having a fall or a post fall assessment in the resident records. Staff E stated that Resident 2 was in a lot of pain when they attempted to lift the resident's right heel off the bed, while the resident yelled No, no, no, no. During an interview on 02/15/2024 at 12:55 PM, Staff F, NA, worked the day shift with Staff D on 02/09/2024, stated they were notified in a verbal report that Resident 2 fell and was in pain. Staff F stated that when they went into the resident's room to help with cares, the resident did not want to move at all and refused to get up, go to the bathroom, take a shower or to be changed in bed. Staff F stated that normally they were able to talk with the resident and get them out of bed and go to the bathroom. Staff F stated that at the end of their shift they needed to change the resident's brief and it was the first time that they had to change the resident's brief in bed. During the changing of the resident's brief, the resident was groaning, somewhat loud but did not ask the resident if they were in pain or communicate that with the nurse, because they assumed the fall was already being charted on by the nurse in the resident's medical record. During an interview on 02/15/2024 at 2:47 PM, Resident 2's Representative (RR) stated the facility informed them on 02/12/2024 that at some point (Resident 2) fell and was in a lot of pain. The RR stated the facility staff did not know when the resident fell , but that the resident was in pain and that they might have broken their hip in a fall. RR stated that Resident 2 was hospitalized and was found to have a right femur fracture. During an interview on 02/15/2024 at 2:56 PM, Staff I, RN, worked day shift on 02/08/2024 and 02/09/2024, stated they were completing handoff (a report from the off-going nursing to the on-coming nurse) with Staff G, RN, when Resident 2 had an unwitnessed fall in their room and was found on the floor, on their right side. Staff I stated the process after a resident had an unwitnessed fall was to complete a risk management report, full head to toe assessment of the resident, monitor neurological checks (a series of tests that assesses mental status, reflexes, movement and more, done to identify signs of disorders affecting your brain, spinal cord, and nervous system)/vital signs, notify the primary care provider (PCP)/DNS/RR and place the resident on alert charting (special documentation procedures/precautions that are initiated for a specific time period) for seven days. Staff I stated they did not complete a post fall assessment/risk management report for Resident 2, nor did they notify the PCP /DNS/RR, complete neurological checks, or initiate alert charting on the resident. Staff I stated they were not aware of Resident 2 having any pain on 02/09/2024, but that the resident did stay in bed all day, which was not the resident's normal daily routine. During an interview on 02/15/2024 at 3:16 PM, Staff B, DNS, stated that Resident 2's post fall assessment/risk management report was not documented, it was missed. Staff B stated that both Staff I and Staff G thought the other staff member would have completed the assessment, notify the PCP/DNS/RR, and have placed the resident on alerting/monitoring; so it was not done. Staff B stated they thought that Resident 2's femur fracture was related to their fall on 02/08/2024 or that Resident 2's fracture developed with turning and repositioning the resident in their bed, because not all nursing staff were aware of the resident's recent fall. Additionally, Staff B stated that the resident did not get up out of bed throughout the weekend (02/10/2024 and 02/11/2024) and was not assessed to be in any pain or discomfort until 02/12/2024. During an interview on 02/15/2024 at 6:24 PM, Staff J, NA, worked day shift on 02/11/2024, stated that Resident 2 was out of it and was not their normal self. Staff J stated that the resident would usually get up and out of bed on their own, and if the resident needed to have their brief changed in bed the resident would help and that Staff J was able to change their brief without another staff members help. Staff J stated that on 02/11/2024 they had to ask Staff K, Licensed Practical Nurse (LPN), to help turn and change the resident in bed because I couldn't even roll (Resident 2) by myself because he was in so much pain, and the resident kept saying ouch, ouch. Staff J stated they informed Staff K of Resident 2's pain with turning and changing them. Additionally, Staff J stated the resident was more confused than normal, refused to get up out of bed that day, and did not know that Resident 2 had a fall on 02/08/2024. During an interview on 02/15/2024 at 7:42 PM, Staff K, LPN, stated they did help Staff J with turning Resident 2 on 02/11/2024 but did not remember that the resident was in any pain. Staff K stated they were not aware that Resident 2 had a fall on 02/08/2024. Staff K stated the resident was not on alert charting, neurological checks, or other monitoring, which was what they would see for a resident with a recent fall. Staff K stated that Resident 2's fall was not passed on to them during handoff report nor did the staff see anything in the resident's medical records that indicated they had a fall. During an interview on 02/15/2024 at 8:48 PM, Staff H, NA, stated they worked on 02/08/2024 and assisted Staff L, NA, with turning and changing the resident during the night, because they were refusing to move after they fell . Staff H stated that Resident 2 reported pain in their right hip/leg area when changing the resident with Staff L, which was reported to Staff G, RN. Staff H stated that towards the end of their shift, when they were changing Resident 2's brief, the resident informed the staff member that it hurt when they moved. Staff H stated that Resident 2 usually transferred/moved around themselves and did not require two staff to help change the resident's briefs in bed, out of the ordinary for the resident and something was wrong. Review of Resident 2's February 2024 medication administration record showed the resident was ordered acetaminophen (a type of medication that can be used for mild pain) two tablets by mouth every four hours as needed for mild pain/discomfort. On 02/09/2024 Resident 2 was administered pain medication at 3:14 AM with documentation of a two out of ten on the resident pain scale, no documentation of pain characteristics (quality, location, onset, duration, aggravating or relieving factors) were noted. Review of a progress note, dated 02/09/2024 at 7:09 AM, showed Resident 2 was administered a gout (a type of arthritis that can cause inflammation, pain and swelling at joints on the body) medication, as needed for reported pain in right knee area. During an interview on 02/15/2024 at 11:36 PM, Staff G, stated they arrived early for their night shift on 02/08/2024 and assisted Staff I with responding to Resident 2's unwitnessed fall before their shift had started. Staff G stated, I did my own assessment of the resident (after Resident 2 fell ) .I didn't document the fall assessment because I was not on duty yet and (Staff I) was the nurse that was on duty and suppose to document it. Staff G stated they did not remember Staff H or Staff L informing them that the resident was in pain when changing Resident 2. When Staff G was reminded of pain medication that was administered to the resident the morning of 02/09/2024, Staff G stated the pain medication was administered because the resident reported a headache and they forgot to document it. Staff G stated they did not notify the PCP or the RR of the resident's unwitnessed fall, nor did they monitor neurological checks or initiate alert charting on Resident 2. Additionally, Staff G stated that they observed the resident two times on each shift (02/08/2024 and 02/09/2024) and no others (licensed nurses that had taken care of Resident 2) reported anything to me about the resident having further pain or complications, so they were not concerned with further assessment of the resident. During an interview on 02/16/2024 at 8:09 AM, Staff M, NA, worked the night shift on 02/09/2024, 02/10/2024 and 02/11/2024 with Resident 2, stated that the resident remained in bed during those shifts. Staff M stated that Resident 2 was in so much pain they could not move in bed on their own and that Staff M had to perform all of the resident's cares, it was so painful that (Resident 2) would not move. Staff M stated that normally the resident would be up out of bed or have gotten into their wheelchair or would get up to go to the bathroom. Staff M stated they informed Staff K, who was the nurse on 02/09/2024, that it was out of the ordinary for the resident, to be lying in bed all day, not getting up or talking, and that Resident 2 was in pain when turning them in bed for cares. When performing care Staff M stated Resident 2 would cringe (to draw in or contract one's muscles involuntarily, as from cold or pain) every time when turned. Additionally, Staff M stated that Resident 2 was usually confused at times and not always able to state that they were in pain. During an interview on 02/16/2024 at 9:07 AM, when asked if they were aware of Resident 2's fall, the PCP stated, you mean the resident that had been there all weekend with a hip fracture lying in bed, yes. PCP stated they were made aware by nursing staff of Resident 2's condition on 02/12/2024, but that the original fall/incident had not been communicated on 02/08/2024. PCP stated they were informed by a nursing staff member that was paying attention, to Resident 2 on the morning of 02/12/2024 and assessed the external rotation of the resident's leg. PCP stated the nurse that reported Resident 2's condition did not know what had happened, or that the resident had a fall, whatever happened over the weekend, there was no documentation. Additionally, PCP stated they would have wanted to know the post fall assessment after Resident 2 had fallen so that a determination could have been made on whether the resident needed to go to the hospital right away. Reference: WAC 388-97-1060(1)(3)(g)

Based on observation, interview, and record review the facility failed to ensure pain medication was provided in a timely manner to one of three residents (#2) reviewed for pain management when the resident returned from a wound treatment appointment which included debridement (removal of dead, damaged or infected tissue). This failure resulted in actual harm to Resident #2 who experienced uncontrolled pain and psychosocial distress. Findings included . Resident #2. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most comprehensive assessment, dated 01/22/2021, showed the resident required extensive assistance of caregivers for bed mobility, transfers and toileting. The assessment showed the resident experienced moderate pain during the lookback period (7 days previous) and was treated with as needed (PRN) narcotics (class of drugs used to treat severe pain). The assessment showed Resident #2 was cognitively intact. Review of the 01/15/2021 hospital discharge orders showed the resident required treatment to include negative pressure wound therapy or vacuum assisted closure (VAC-a therapeutic technique using a suction placement to remove excess fluid and promotes healing in wounds). The orders included medication for pain management which included: routine [MEDICATION NAME] (a cough suppressant medication indicated for phantom pain - a type of pain from a body part that is no longer there), [MEDICATION NAME] (Tylenol) every six hours as needed, [MEDICATION NAME] (an opiate [MEDICATION NAME]) every 6 hours as needed, [MEDICATION NAME] (an opiate [MEDICATION NAME]) every 6 hours as needed and routine [MEDICATION NAME] (medication indicated for pain). Review of Resident #2's medical record showed the resident admitted to the observation unit (dedicated unit which, housed those residents who were newly admitted or readmitted for 14 days) which was separated from the main wing by a plastic barrier to assist in containment of any potential transmission of COVID-19 infection. Review of the facility's 02/03/2021 staff assignment sheet for the evening shift showed three Nursing Assistants (NA's) were assigned to the observation unit, one who was more senior in experience and two trainees. One Registered (RN) was assigned to the observation unit, but also worked outside of the plastic barrier providing care to the general resident population on the north wing. Additionally, three NAs and two Licensed Nurses (LN) were assigned to care for residents who resided on the South wing of the facility. Staff who worked in the facility carried two-way radios to maintain communication. During an interview on 02/10/2021 at 4:45 PM, Resident #2 was observed in her bed. The resident stated that on 02/03/2021 she returned to the facility around 6:00 PM, following a wound care appointment which, included a treatment of [REDACTED]. Resident #2 stated that upon her return, Resident #2 was in pain and asked the Nursing Assistant (NA) to let the nurse know she needed pain medication. Resident #2 stated that it took several hours and that ultimately the resident was in 10 out of 10 pain (commonly used measurement for pain with zero meaning no pain and ten meaning the worst possible pain). Resident #2 said that she kept asking the NA staff for something to address the pain, but they continually had excuses and told the resident that the nurse was busy on another unit. Resident #2 said that her pain was so great and the resident was so frustrated with the lack of care and pain that the resident called her daughter, crying. As Resident #2 explained to this surveyor what had occurred, the resident began to cry. Review of the February 2021 Medication Administration Record [REDACTED]. The record showed the resident experienced a 6 out of 10 pain relief within 15 minutes of receiving the medication. Review of the facility's 02/03/2021 Incident Report showed that the facility had employed a contracted RN from an agency. The report showed that the NA staff could not locate the contracted RN for several hours. An NA on the shift took the resident's vitals and reported the resident returned from an appointment and she was in pain. The report did not show that the NA reached out via two-way radio or any other means to contact the LNs on the South side of the building to address the resident's pain. On 02/10/2021 at 2:45 PM, Staff B, Director of Nursing Services (DNS), stated that on 02/03/2021 at 7:23 PM, she received a call from the facility and was informed that staff had not been able to find the agency RN assigned to the North wing, for several hours. The RN was eventually located, but was unable to provide care to the residents. The Assistant DNS took over the duties of administration of medications and care for residents on the North wing at approximately 8:15 PM. Staff B stated she did not know why the NA staff did not alert the South wing LNs of the resident's pain. She said it was an emergent situation and that if such an event were to occur in the future, staff had received training to contact other LNs in the facility to address a resident's pain. Reference: WAC 388-97-1060(1)

Past-noncompliance was identified at CFR 483.25 (b)(1) F-686 Skin Integrity/Pressure ulcers, at a scope and severity G and corrected by the facility on 10/25/2020. Based on interview and record review the facility failed to ensure one of three residents (#1) reviewed for pressure ulcers received care to prevent the development of additional pressure ulcers. Failure to reassess Resident #1's risk factors to develop additional pressure ulcers such as nutrition and improved support surfaces may have contributed to the development of an additional pressure ulcer on the residents tailbone 20 days later and caused the resident harm. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) April 2016 defines pressure ulcers stages as: Stage II: Partial thickness Partial thickness loss of dermis (the thick layer of living tissue below the epidermis) presenting as a shallow open ulcer with a red pink wound bed, without slough (A layer of dead tissue separated from surrounding living tissue). May also present as an intact or open/ruptured fluid filled blister Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Unstageable: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (a dry tan, brown or black scab) in the wound bed. Record review of the facility's undated policy titled, Pressure Ulcer/Injury and Skin Monitoring Risk Assessment, showed guidelines for a structured risk assessment to identify all pressure ulcer risk factors to determine which can be modified. The risk factors that increased a resident's susceptibility to develop or not to heal pressure ulcers included: - Undernutrition or malnutrition - Decreased mobility - Impaired diffuse or localized blood flow Once the assessment is conducted and risk factors are identified, a plan can be created to address the modifiable risks for pressure ulcers. Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] from the hospital after a stay for increased weakness and dehydration. The resident was discharged to the hospital on [DATE] for possible internal bleeding and had two unstageable pressure ulcers; one on the right heel and one on the tailbone. Review of the 07/21/2020 admission assessment showed Resident #1 had moderate cognitive impairment, required extensive assistance from staff for bed mobility, transfers and toileting. The resident ate independently with staff set up. The resident had [DIAGNOSES REDACTED].) The skin assessment showed the resident had intact skin and was at risk for pressure ulcers due to the need for extensive assistance to change position in bed. Preventative measures included pressure reducing devices for the bed and wheelchair. Review of Resident #1's Braden Scale Scores (an assessment tool commonly used to quantify a resident's degree of risk for developing a pressure ulcer) showed on 07/14/2020 the resident had a score of 19 equaling no risk and a second score on 09/10/2020 of 16 equaling mild risk. No further structured pressure ulcer risk assessments were found in the resident's medical record after 09/10/2020. Record review showed a progress note on 09/16/2020, the resident was found to have a Stage II pressure ulcer (fluid filled blister) measuring 5.6 centimeters (cm) by 4.2 cm on their right heel. The facility Physician's Assistant- Certified (PA-C) was notified, assessed the wound and treatment was ordered. The investigation showed the cause was related to tight shoes and rubbing heel on the wheel chair foot plate. Interventions put into place included changing foot wear provided by family, removing wheel chair foot plate, added PODUS boots (designed to suspend the heel to prevent skin breakdown from occurring on the bottom of the heel) and floating the feet on a pillow when in bed. There were no changes to the resident's support surfaces on the bed or wheel chair or analysis as to why changes were not made. There were no referrals to the registered dietitian to review the resident's nutrition status (the weight record on 09/12/2020 showed a 10% weight loss since admission). During a phone interview on 11/20/2020 at 2:40 PM, Staff D, Registered Dietitian (RD), stated she was the RD at the facility from June 2020 until the third week of October 2020. She stated she attended a weekly weight and wound meeting, however, many meetings were missed due to the COVID outbreak and administrative staff changes. She stated she did not typically get notified about resident pressure ulcers and there was not a consistent process to notify her of new resident wounds other than the weekly meetings. Record review showed a 09/29/2020 progress note the right heel pressure ulcer was 5.5 cm by 4 cm and Unstageable. Described by the facility PA-C as a circular, open wound over the right heel with central black eschar, and outer border of denuded (loss of the epidermis) skin with some [DIAGNOSES REDACTED] (redness), no active drainage. Record review showed a 10/04/2020 facility PA-C follow up exam on the resident's right heel pressure ulcer. The PA-C documented there were no pulses in the right foot and diagnosed the resident with vascular insufficiency of the extremity. Record review showed progress notes on 10/06/2020 the resident was seen by the facility PA-C for nausea, abdominal pain, black liquid stool and a new open area on the buttocks. The resident was sent to the hospital. A 10/06/2020 wound assessment by Staff C, Licensed Practical Nurse, documented the wound as a new Stage III to Coccyx, 2.4 cm x (less than) .25 cm, full thickness with slough at 12 o' clock. During a phone interview on 11/12/2020 at 4:45 PM, a Collateral Contact, stated that Resident #1's pressure ulcer on the tailbone worsened, became infected and painful. The resident did not return to the facility, was admitted into hospice care and passed away on 10/30/2020. This should not have happened. During an interview on 11/13/2020 at 10:40 AM, Staff B, Director of Nursing (DON), stated she started employment at the facility on 10/19/2020 as the new DON. When asked for a list of residents with pressure ulcers, the DON stated she discovered a problem with the facility skin program on her first day and immediately implemented a Process Improvement Program (PIP). On 11/13/2020 at 11:00 AM, Staff Bs tated, while looking at Resident #1's electronic health record, that she could not find any documentation from the RD after the initial nutritional assessment. She could not find notification to the RD after the resident's pressure ulcer developed on 09/16/2020. She also stated she could not find any changes in the resident's support surfaces such as alternating air mattress or a pressure relieving wheel chair pad. On 11/18/2020 at 3:00 PM the facility Administrator provided the following plan of correction: On October 19, 2020 during daily rounds by the new DON and Administrator a resident alerted the DON to further investigate the current wound systems in place. The new DON requested a copy of the current wound report. After review of the wound report, the Administrator and DON determined that the facility would complete a facility skin sweep. Skin sweep was completed for the north and south units by 10/21/2020. Bradens' and Risk management investigations for any skin issues were completed. Appropriate interventions were identified and implemented. The DON and Administrator reviewed the current system in place which resulted in a PIP. System Correction: - The Policy for pressure ulcer/injury and skin monitoring risk assessment was revised on 10/19/2020 to reflect the plan for the PIP. -The Skin Sweep completed for the north and south units on 10/23/2020 with findings entered in the Wound and Skin Tab in Point Click Care (PCC). -Braden's and Risk Management were completed for any skin issue identified in the skin sweep by 10/25/2020. - The Treatment nurse was re-educated on ensuring proper treatment and preventive measures are identified and implemented on 10/20/2020. - United Wound was contacted for scheduling routine weekly wound rounds with the facility on November 4, 2020. -All treatment orders were removed from the wound tab and moved to the Treatment tab in PCC on 10/25/2020. - The NAC's were in-serviced on turning and repositioning and reporting all skin issues to the team leader/Treatment Nurse on 10/22/2020. - Nurse team leaders were in-serviced on completion of weekly skin assessments, communication with the wound nurse and appropriate intervention implemented on 10/20/2020. - The Treatment/Wound nurse will complete a weekly wound/skin report every Friday that will be distributed to the DON, RCM, MDS, Registered Dietician, Therapy and Administrator begining 10/20/2020. Monitoring: - PCC dashboard will be reviewed Monday through Friday to ensure completion items listed on the TAR. - Weekly room rounds will be completed with the DON, Wound nurse and United Wound. - The treatment nurse will be responsible for completion of the weekly wound report. The wound report will be reviewed by the DON or designee weekly to ensure that wounds are improving and all required documentation components are in place. - The plan includes providing 7 day a week wound care staff. The facility is currently recruiting. Reference: WAC 388-97-1060(3)(b) This is a repeat deficiency from Statement of Deficiency dated 08/26/2020.

Based on interview and record review, the facility failed to ensure one of three residents (#1), reviewed for nutrition status, maintained acceptable parameters of body weight. Failure to identify Resident #1's severe weight loss and implement nutritional interventions may have contributed to the development of pressure ulcers and placed the resident at significant risk for decline in nutritional status and related complications. In addition, the failure to prevent severe weight loss constitued harm to the resident related to a weight loss of greater than eight percent body weight, in a month. Findings included . Record review of the facility's policy titled, Weight Assessment and Intervention, dated September 2008, showed that any weight change of 5 percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will respond within 24 hours of receipt of written notification. Resident #1. Medical record review showed the resident was admitted to the facility on [DATE] from a hospital stay for increased weakness, dehydration, [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching body tissues) and shortness of breath. The resident discharged to the hospital on [DATE] for an acute change of condition and did not return to the facility. Record review showed a 07/14/2020 diet order for no added salt, mechanical soft with thin liquids, there were no supplements ordered and the order remained in effect until the resident discharged to the hospital on [DATE]. Review of the 07/21/2020 comprehensive assessment showed [DIAGNOSES REDACTED]. The resident had moderate cognitive impairment, required extensive assistance from staff for activities of daily living such as bed mobility, transfers and toileting. The resident was able to eat independently with staff set up. The resident's admission weight was 172.2 pounds (lbs.) on 07/14/2020 and the resident's skin was intact. Record review of the 07/23/2020 Registered Dietitian (RD) Assessment showed a goal for the resident to maintain weight between 165 lbs. and 175 lbs. and a goal for the skin to remain intact. Record review showed no further RD documentation after the initial admission assessment. During a phone interview on 11/20/2020 at 2:40 PM, Staff D, RD, stated she was the RD at the facility from June 2020 until the third week of October 2020. She stated she attended the weekly weight and wound meetings, however, many meetings were missed and communication was challenging due to the facility's COVID outbreak and frequent staff changes. She stated she would be alerted to resident weight loss by several sources such as a referral from nursing or the patient care provider. She stated if she were made aware of a resident's weight loss of greater than 5%, that would be severe weight loss and extremely concerning. That would generate a review of the resident's nutritional status to determine what interventions were needed. Review of the September 2020 and October 2020 meal consumption for Resident #1 showed the resident would eat between 50 and 100 percent (%) of the meal, 60 percent of the time. Except for 10/03/2020 to 10/06/2020 where the resident ate less than 25% or refused the meal due to nausea. Review of Resident #1's weight record showed a severe weight loss of 11.4 lbs. between 08/08/2020 with a weight of 168.6 lbs. and 09/08/2020 with a weight of 155 lbs. equaling a loss of 8.18 % of the resident's body weight in 30 days. (F-tag 692 CMS guidelines classifies a weight loss of greater than 5 % in one month as Severe Weight Loss.) Record review showed on 09/16/2020 the resident developed a Stage II pressure ulcer (a partial thickness loss of skin) on their right heel. The right heel pressure ulcer progressed to a Stage III (a full thickness tissue loss and subcutaneous fat may be visible) per record review of a 10/07/2020 wound assessment in the hospital. Record review showed progress notes on 10/06/2020 the resident was seen by the facility Physician's Assistant-Certified (PA-C) for a new onset of nausea, abdominal pain and black liquid stool. The PA-C noted there was a new open area on the buttocks. A 10/06/2020 wound assessment by Staff C, Licensed Practical Nurse, documented the open area as a new Stage III to Coccyx (tail bone), measuring 2.4 centimeters (cm) x 0.25 cm, full thickness with slough (a layer of dead tissue separated from surrounding living tissue) at 12 o' clock. The resident was sent to the hospital and diagnosed with [REDACTED]. Record review of a 10/07/2020 hospital wound assessment confirmed the coccyx wound was a Stage III measuring 3 cm by 1 cm by 0.5 cm with a small amount of drainage. During a phone interview on 11/12/2020 at 4:45 PM, a Collateral Contact, stated that they had noticed during visits that Resident #1 had been losing weight although staff reported she was eating most of her meals. They stated they were very concerned about the pressure ulcers the resident developed during their stay at the facility and wondered if the weight loss was a factor. On 11/13/2020 at 11:00 AM, Staff B, Director of Nursing (DON), stated while looking over Resident #1's electronic health record, that she could not find any documentation from the RD after the initial assessment. She could not find notification to the RD after the resident's pressure ulcer developed on 09/16/2020. On 11/13/2020 at 12:15 PM, Staff C, Lead Nursing Assistant (NA), stated she had provided care for Resident #1 and recalled the resident ate pretty well, would get up daily in the wheelchair and would lay down to rest after meals. On 11/13/2020 at 12:45 PM, Staff A, Administrator, stated the new RD started the 1st week of November. Her first weight meeting was Tuesday, 11/03/2020 with Resident Care Managers, DON and the wound nurse. During a phone interview on 11/18/2020 at 10:15 AM, Staff E, RD, stated she was the new dietitian at the facility. Stated she had been informed of resident weight loss and pressure ulcers by the Resident Care Managers. She also reviewed weekly weights and ran a weight change report to prepare for the weekly weight and wound meeting held on Thursdays. Reference: WAC 388-97-1060(3)(h)

Based on interview and record review the facility failed to prevent the development of a pressure ulcer after admission to the facility for one of two residents (#1) reviewed for pressure ulcers. This failure caused harm to the resident resulting in a deep tissue injury to the Right heel that caused pain and eventual loss of the limb after discharge. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, Pressure Ulcer Stages: Suspected Deep Tissue Injury (SDTI) - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar (piece of dead tissue that is cast off from the surface of the skin.) Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Resident #1. Resident record review showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 03/27/2020 admission nursing assessment showed the resident's skin was intact and heels are firm. Review of the 03/27/2020 Braden Pressure Ulcer Risk assessment showed the resident's score was 21. (A score of 15 to 18 is lowest risk on scale.) A score of 21 indicated the resident had no pressure ulcer risk. Review of the 04/03/2020 comprehensive assessment showed Resident #1 was cognitively intact, required extensive physical assistance from two staff for bed mobility and had no pressure ulcers. This assessment determined the resident was at risk for pressure ulcers do to requiring extensive assistance to change position in bed and was frequently incontinent of bowel and bladder. Interventions in place were a pressure reducing mattress on the bed (the standard mattress) and pressure relieving cushion in the wheel chair. Review of the 03/27/2020 Skin at Risk plan of care showed the resident was at risk due to immobility and weakness. The prevention interventions on the plan included to identify potential causative factors and eliminate/resolve when possible. However, the plan did not include assisting the resident to change position on a schedule or to elevate the resident's heels off of the mattress to relieve pressure. Review of the 04/23/2020 progress note showed the resident had a purple area to the lateral aspect of the right heel measuring 3.5 centimeters (cm) long by 5 centimeters wide and appeared to contain a small amount of fluid. Bilateral heel protectors were obtained and placed on the resident. Review of a 04/23/2020 nursing progress note showed Apart from therapy, (the resident) does not move off (their) back much, even with reposition, when (they) allow it. (Physician) updated on skin. Review of the facility 04/23/2020 incident report showed the resident was in the shower and a nursing assistant found a blister and blackened area to the right heel. Predisposing factors included weakness and resident refuses to get out of bed frequently. The incident report did not include an investigation and root cause analysis of what caused the pressure injury to the right heel. Review of the Skin at Risk plan of care showed on 04/24/2020 a SDTI to the right lateral heel was added without any new interventions. Review of the April through June 2020 treatment records showed a 04/24/2020 order to apply [MEDICATION NAME] and let dry to right lateral heel once a day. The treatment was documented as done until discharge on [DATE]. Review of a 05/29/2020 skin assessment showed (Resident #1) continues to have large red area to right heel, area dry, no drainage . (the last documented nursing assessment eight days prior to discharge.) Review of the 06/06/2020 Discharge Minimum Data Set assessment showed the resident left the facility with one unstageable pressure ulcer presenting as deep tissue injury. During a phone interview on 08/05/2020 at 1:50 PM, Staff D, Registered Nurse and Treatment Nurse, stated Resident #1's heel wound started from rubbing their heels on the bed. It started as a blister that popped and the tissue was real dark underneath. The treatment was to paint the heel with [MEDICATION NAME], applied heel protectors and an air overlay mattress. The interventions in place prior to the wound was the pressure reducing mattress and weekly skin checks. During a phone interview on 08/06/2020 at 11:45 PM, Resident #1's Primary Care Provider (PCP), stated their office was not aware of the resident's heel ulcer at discharge on 06/06/2020 and had an appointment scheduled on 06/23/2020. The resident's in home care giver contacted their office on 06/10/2020 requesting more betatine and refill on pain medication. The foot ulcer was observed during a video call and it was decided (Resident #1) required a face to face appointment the next day in the office. At the appointment a wound clinic consultation was scheduled for 07/07/2020 (one month after discharge.) Review of the resident's PCP records showed the following: -A video tele-medical visit was conducted on 06/10/2020 due to the private home provider requesting more wound treatment supplies and pain medication. Resident #1 expressed that the heel wound was painful and ran out of pain medication. A decision was made (by the PCP) to have a face to face acute appointment the following day. - The resident was seen by their PCP on 06/11/2020 in the office. The right heel wound was extremely dry. The wound was a black color in the middle measuring 2.5 cm by 5 cm. A referral was made for wound care at the hospital wound clinic. During a phone interview on 08/21/2020 at 2:25 PM, Resident #1's representative stated they took the resident to the emergency room due to a foul odor coming from the right heel wound. The resident had an amputation of the right lower leg and was currently in the hospital. Review of information received from Resident #1's PCP on 08/27/2020 showed the resident had a right lower extremity amputation from a spreading infection of the pressure ulcer into the bone [MEDICAL CONDITION] (an infection in the blood). Initially there was a [MEDICAL CONDITION], but was determined to need additional infected tissue so ultimately (Resident #1) had an above the knee amputation. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview, and record review the facility failed to implement planned interventions to prevent falls when providing care to one of three residents (#42) reviewed for accidents. Failure to follow the care plan resulted in a fall out of bed causing a [MEDICAL CONDITION] and subsequent hospitilization. Findings included: Resident #42. Per the medical record, the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation and interview with Resident #42 on 01/07/19 showed him lying flat in his bed watching television. He stated that he fell out of bed a month or so ago hitting his head and had been in the hospital after that. He stated he could not remember the details of how the fall happened. Review of Resident #42's most recent comprehensive assessment dated [DATE] showed the resident had moderately impaired cognition and required extensive physical assist of two caregivers for bed mobility, transfers, incontinent care, and dressing. Review of Resident #42's care plan showed he had activity of daily living deficits and a risk for falls related to immobility, weakness, and balance problems due to his bilateral leg amputations and required assistance of two caregivers for turning and changing positions in bed. Review of a nursing progress note, dated 11/26/18 at 4:58 AM, showed Staff H, Licensed Practical Nurse (LPN), charted Resident #42 was being provided care when he rolled off the bed onto the floor. Staff H determined the resident had struck his head on the floor and had a laceration over his right eye. Paramedics were called and Resident #42 was taken by ambulance to the hospital to assess for trauma to the head and brain. Review of the facility incident report, dated 11/26/18, showed Staff G, Nursing Assistant Certified (NA), was providing incontinent care to Resident #42 when he rolled off the bed striking his head on the floor. In an interview with Staff H on 01/14/19 at 10:50 AM, he stated he was working as the charge nurse on the night Resident #42 fell off his bed. He stated after sending the resident to the hospital he began investigating how the fall occurred and found that Staff G had been providing care by herself despite Resident #42 being care planned for two caregivers with all care. Staff H stated he asked Staff G if she was aware Resident #42 required two staff members for care and she stated yes. He stated he then called Staff B, Director of Nursing (DNS), and reported his findings. Staff H stated he suspended Staff G for not following the care plan for two caregivers when providing care to Resident #42, pending the outcome of the incident investigation. In an interview with Staff G on 01/15/19 at 10:20 AM, she stated on the night Resident #42 rolled off his bed, she and another NA had gone to the resident's room to provide incontinent care. She stated shortly after entering the room, another residents call light went off and she told her coworker to go ahead and answer the light and that she could change Resident #42 by herself. Staff G stated she rolled Resident #42 onto his side, then let go of him to reach an item at the foot of the bed and he just rolled off the bed. She stated she immediately went and got the charge nurse to assess him for injuries. Staff G stated she was aware that Resident #42 was supposed to have two caregivers with him during care but she thought she could assist him alone. In an interview with Staff B and Staff E, LPN, Staff Development Director (SDD), on 01/14/19 at 2:20 PM, they both stated they were informed that Staff G provided care alone when Resident #42 fell . They stated that Staff G was counseled for not following the care plan and all NAs were inserviced on the importance of following the care plan for resident safety. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure one of one resident (#1) reviewed was free from neglect when staff failed to provide timely care for Resident #1, who was left on a bedside commode for an excessive period time without the ability to call for assistance. This failure caused actual harm related to the resident experiencing back pain, and numbness to her legs. This failure also resulted in psycho-social harm as evidenced by the resident being distraught and relaying to staff and family members immediately after the event that no-one assisted her off the commode, despite being visualized by a staff member during the time she was left on the commode, which was over an hour. Staff assisted the resident only after the resident began yelling for help. Findings include: Resident #1. Medical record review revealed the resident was admitted to the facility on [DATE] from the hospital after spinal surgery. Review of the 09/11/18 spinal surgeon report revealed Resident #1 had spinal surgery on 09/06/18. The resident required fall and spinal precautions and a maximum assist with two persons (log roll) to turn in bed. The hospital transfer form dated 09/13/18 indicated the resident had a midline upper back surgical incision with staples, experienced pain to the upper back at 5 of 10 (on a scale with 10 as the highest pain), and received a narcotic pain medication three times a day for the pain. The information also indicated the resident's last bowel movement was on 09/12/18. A 09/13/18 Landmark Care Report Sheet included notes from a phone report by the sending hospital that showed the resident had additional [DIAGNOSES REDACTED]. The resident required a Hoyer (mechanical lift) for transfers, had numbness to lower extremities and was forgetful. A 09/13/18 Physical Therapy evaluation noted the resident was illiterate and doesn't tell time. Extreme LE (lower extremity) weakness and decreased sensation in the LE's. The resident was oriented to person, place, situation, caregivers . She states she doesn't remain oriented to (date) month and year. Review of the resident's 09/13/18 baseline care plan revealed the resident requires total assist with transfers via Hoyer and used a commode for toileting. Review of a 09/15/18 facility grievance/concern report completed by Resident #1's family member read as follows: Patient was given breakfast and after was taken to bathroom after was left in lift chair for couple hours. Was not moved until lunchtime. (Resident #1) was yelling calling for help and nurse came told her to stop screaming and making noise because they had other patients to help and shut the door on her didn't leave her a call light, and did not check on her. Review of the 09/15/18 facility Incident Report completed by Staff A, Director of Nurses (DON), revealed the following statements: - Description of Allegation: Resident reported being left on commode without call light in reach and that LN (licensed nurse) opened door to talk to her but did not assist. - What happened? Resident was assisted onto the commode using a Hoyer for her transfer. Resident was left on the commode without her call light within reach. Nurse heard resident yelling for help and opened her door to tell resident that the staff was in another room. Resident states that the nurse asked her to stop yelling. LN went to go get the charge nurse who called for staff on the radio. Resident was transferred to her bed. - Actions to prevent. Staff inserviced (sic) on need to place call light within resident's reach. Staff also inserviced on need to check on resident and not to leave resident unattended when using Hoyer. - Were injuries sustained? Yes. - Describe injury. Resident is complaining about numbness in left leg. - Describe treatment required: Resident transferred to ER for assessment. On 09/20/18 at 4:00 PM Staff A stated she investigated the concerns about the resident being left on the commode and being told by a nurse to stop yelling. On 09/15/18, the breakfast floats (Staff B and Staff C) put the resident on the commode and failed to put the call light in reach. Then about 30 to 60 minutes later, Staff B heard the resident yelling from her room and she was transferred back to her bed with the Hoyer. In addition, the resident stated a nurse (Staff D) was telling her not to yell and said your call light's on, you don't need to yell. Staff A stated Resident #1 had not had a bowel movement since admission and was taking medications to help her go; she was experiencing pain in her abdomen. Saturday (09/15/18) at about 6:30 PM, after no results from a suppository and an enema, we sent her to the hospital. The hospital diagnosed her with ileus (intestinal paralysis). Review of a 09/15/18 hospital record revealed Resident #1 was admitted to the hospital with [REDACTED]. On 09/21/18 at 10:50 AM Staff E, Nursing Assistant (NA), stated she provided care for Resident #1 on 09/14/18 day shift and stated the resident used her call light appropriately to get help. She stated the resident had back precautions and required two staff to log roll her from side to side. She stated they used a cross leg sling with the Hoyer (mechanical lift) to transfer the resident to and from the commode several times on Friday (09/14/18) because she was having trouble going. She explained that the sling remained behind the resident when on the commode after the sling was unhooked from the lift. Then the lift was moved out of the way in the room. In an interview on 09/26/18 at 8:25 AM Staff F, NA and shower aide, stated the resident talked with her during her shower on 09/15/18 at approximately 10:35 AM. The resident told her two people left her on the commode around breakfast time. The resident was mad at a nurse and said, She was yelling for help, he told her to stop yelling, your light was on, the staff were busy and will get to you. The resident added, He shut the door when he left. Upon returning to her room after her shower, the resident pointed to Staff D, Licensed Practical Nurse (LPN), who was standing at a medication cart near her room, and told Staff F, That was the nurse. The approximate timeline for the morning of 09/15/18 through interviews and record reviews revealed Resident #1 was spoken to by Staff D at least twice and she was on the commode from sometime between 8:30 AM/8:45 AM until 10:10 AM/10:30 AM (between 85 and 120 minutes): - 8:00 AM Resident #1 received her breakfast tray while in bed (Staff G, Environmental Aide, per interview 09/24/18 at 12:00 PM.) - 8:30 AM Staff D, LPN, approached resident's door when he heard her yelling and noted her call light was on. The resident was seated either in a chair or her bed and stated, I need to poo. Staff D indicated he told the resident, Your light is on, we know you need help, you don't (need) to yell, I'll go get you help. (Per Staff D 09/15/18 written statement and interview on 09/26/18 at 9:05 AM.) - 8:40 AM Staff B and Staff C, both NAs, answered the resident's call light: On 09/24/18 at 2:10 PM Staff B stated regarding morning of 09/15/18, she was floating during breakfast and answering lights. She and Staff C put Resident #1 on the bedside commode using the Hoyer lift. The commode was near the end of bed on the left side. After unhooking the sling and moving the lift out of the way, Staff B stated, I asked the resident if she needed anything else and she stated no. I observed (Staff C) place the call light at the corner of the bed next to the resident. I did not see if the light was pinned down. After leaving the resident's room, Staff B stated she saw Staff E (a NA working on the resident's hall) and I let her know we just assisted (Resident #1) onto the commode and she stated she still had a couple minutes left in the independent dining room. On 09/26/18 at 10:20 AM Staff C stated he was floating during breakfast on 09/15/18 and just after 8:00 AM Staff B asked for help transferring Resident #1. After the resident was on the commode and the sling unhooked, I told Staff B to put the call light in reach. He stated he did not remember where the call light was while he was in the room and did not put it next to the resident. He left the room before Staff B. - 9:50 AM Staff D, LPN, brought the resident's medication to her room. On 09/26/18 at 9:05 AM Staff D stated he took a cup of the resident's medications to her room on 09/15/18 at about 9:45 AM. I knocked on the door, opened it and saw the resident was on the commode and I stated I'll be back. She looked at me but did not say anything and she did not look in distress. I locked up the medications in my cart and eventually gave them to her around 10:15 AM when she was back in bed. Review of the resident's electronic Medication Administration Record [REDACTED]. - 10:10 AM Staff B stated she heard Resident #1 yelling from behind her closed door and told Staff H, NA, that the resident was yelling out. On 09/24/18 at 12:10 PM Staff E stated on 09/15/18, after signing back in from her first break at 10:05 AM, Staff H asked for help with Resident #1 because Staff B heard the resident yelling from her room. She recounted, When I entered the room I saw the resident on the commode and the call light was pinned to the top half of the bed, not in her reach. (Resident #1) stated she was in pain and had been yelling out for help. She could not reach the call light. The resident said the med nurse opened the door and told her not to yell. The resident was very upset and stated she was there since breakfast time. At this time, I remembered Staff B mentioned this resident was on the commode as we passed in the hallway when I was heading back to the independent dining room. This was sometime between 8:30 AM to 8:45 AM. On 09/24/18 at 1:10 PM Staff H recounted the morning of 09/15/18. S/he stated she was assigned to Resident #1 and first saw her around 7:00 AM for morning cares. The resident wanted to eat breakfast in bed. Staff H stated, The next time I saw her was after my break at about 10:10 AM when Staff B told me my lady in room [ROOM NUMBER] is screaming. When I entered the room, I saw the resident on the commode, holding the arms of the commode and leaning back. She looked uncomfortable and stated she had been there since after breakfast. She also stated the medication nurse told her to stop yelling and shut her door. I saw her call light clipped near the head of the bed on the left side, too far for her to reach. She also stated she could not feel her legs, her back hurt and she felt like she was going to pass out. She did not pass out while we were with her calming her down. We were in her room until 10:30 AM to about 10:45 AM and reported to the Charge Nurse. On 09/24/18 at 2:10 PM Staff B stated she heard Resident #1 yelling from her room as she was leaving for her break the morning of 09/15/18 and alerted Staff H. She stated she believed it was before her first break at 9:30 AM. Review a form dated 09/13/18 to 09/15/18 revealed Staff B signed out for her first break at 9:30 AM and signed out for her lunch break on 10:26 AM. She stated after alerting Staff H, she followed Staff H and E into the resident's room. She stated the resident was on the commode, leaning back and looked frantic. The call light was on the floor. She stated she then went on for her break. She stated she saw Resident #1 again at 11:00 AM and around 1:45 PM. One of these times the resident told her, she was upset because while on the commode, someone stuck their head in and just left. - 10:15 AM Staff D, LPN, stated he gave Resident #1 the medications he prepared prior and locked up in the medication cart. On 09/26/18 at 9:05 AM, Staff D stated after he locked up the resident's medication after he saw she was on the commode and stated, I'll be back, and he gave other residents their medications from his cart parked across the hall near Resident #1's room. He stated when he returned with her medication sometime between 10:00 AM and 10:15 AM, he knocked on the resident's open door, entered and handed her the cup of medications. He stated the resident was in bed at this time. When asked if he realized Resident #1 had been on the commode for approximately 60 minutes when he opened her door around 9:50 AM; he stated, he did not know when she got on the commode and did not consider the length of time. He stated he did not speak to her other than he would be back, he did not ask her if she needed help or check to see if she had the call light in reach. He stated he did not hear the resident yelling from her room while she was on the commode. - 10:35 AM Staff F took Resident #1 for a shower. Review of a late entry progress note for 09/15/18 at 11:32 AM by Staff J, LPN, revealed the following , .met with resident's family to discuss concerns, family requesting that a new nurse care for their mother . Family also expressed concern about the call light not being available information discussed with Social Services and DNS (Staff A). On 09/15/18 at 5:49 PM in a progress note Staff B, DON, wrote: Spoke with the resident, sister, daughter and care giver. Resident is complaining about increased numbness in her left leg after using the commode .Resident has not had a bowel movement since she was admitted to the facility. Resident has had a suppository and an enema with little results Call placed to (on call health care provider). Received new orders to send to (hospital) for evaluation. Daughter and resident in agreement with orders to transport. Resident #1 experienced physical discomfort and emotional distress by being left on the commode for between 85 and 120 minutes, nine days after spinal surgery. She was not able to summon assistance while on the commode without having the call light in reach. The resident was reported as upset and mad about the nurse who opened her door after she had been on the commode for approximately 60 minutes and did not offer assistance. Reference: WAC 388-97-0640(1)

Based on record review and interview, the facility failed to ensure one of five sampled residents (#1) received treatment and care in accordance with professional standards of practice and the resident's comprehensive care plan. Deficient practice was identified for Resident #1 who experienced serious, evolving medical complications [REDACTED]. The resident experienced harm due to the facility's failure to recognize the advancing symptoms as medical complications [REDACTED]. Findings included: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] following back surgery (on 11/01/17). Hospital transfer orders noted the resident was to maintain lumbar (lower back) spine precautions for patients with a spinal fusion. The resident was able to walk with assistance and a gait belt (a belt placed around the resident's waist area for staff to grasp) and a walker. The resident also had a back brace. The resident was noted to be continent of bladder and bowel. The transfer sheet also provided orders for physical therapy (PT) and occupational therapy (OT) services. An 11/07/17 nursing entry noted the cognitively alert resident was admitted to the facility for skilled therapy services to help improve her ADL (activities of daily living) function and mobility so she could return to her prior level of function and prevent any potential for decline. admission orders [REDACTED]. According to the resident's 11/07/17 care plan, she was able to perform full weight bearing and transferred/ambulated with the assistance of two persons. The resident was to wear a back brace at all times and log roll in bed during care. The resident's discharge plan was for her to return home with her spouse. The 11/08/17 nursing entry noted the resident was to have a daily weight but she refused stating she was unable to stand and get out of bed. An 11/08/17 PT treatment note documented the resident had been refusing standing activities due to pain with upright activity. The following day, on 11/09/17, the resident was assisted by the PT Assistant with standing and limited walking at the parallel bars. Her pain level did not limit her activities. On 11/10/17 the resident's Primary Care Physician (PCP) evaluated the resident. The resident complained that the [MEDICATION NAME] was effective but it did not last six hours. She complained of pain in her low back, bilateral lower extremities, at the incision site, and at her right buttock. The resident was not experiencing numbness or loss of bowel or bladder function. New PCP orders included changing the frequency of the [MEDICATION NAME] to every four hours as needed and changing the [MEDICATION NAME] to 650 mg orally three times per day with a daily maximum dose of 3250 mg per day from all sources. According to an 11/12/17 PT treatment note, the resident had her back brace off due to a rash. The brace was replaced and the resident participated in a log roll, a transfer, and short period of standing at the parallel bars. An 11/14/17 PT treatment note documented the resident's pain was a 10 on a scale of zero to 10, with 10 being severe pain. She had pain medicine earlier and wasn't able to have additional meds (medications). The PT documented the resident needed to have her pain management addressed. Also refer to F760 for details pertaining to the medication errors during this timeframe and elevated INR values (increased bleeding risk). Per a nursing entry, during the afternoon on 11/14/17 the resident complained of increased pain to her lumbar area radiating across her lower back from hip to hip. The PCP ordered an extra dose of [MEDICATION NAME] 5 mg and the resident was to be reassessed in one hour. A call was also placed to the Surgeon's office. Later in the day, the Surgeon provided clarification that the resident was to wear the back brace 23 hours a day, removing it for a shower. The resident was to sleep in the brace as well. On 11/16/17, a PT treatment note documented the resident stated her feet feel like they are in cement and are not easily moved. The resident stated she had significant pain a couple days earlier and since that time she had a problem with her legs. She was going to see the Surgeon the next day. Review of the 11/17/17 the Surgeon's post-op visit documentation showed the resident's Status is: worsening. Pain level is: 10/10. The resident indicated she was pretty much bed-bound because of pain and bilateral lower extremity weakness since going to the nursing facility. She reported back pain and bilateral lower extremity pain. The resident denied any fevers or loss of bowel or bladder control. The Surgeon recommended stronger pain medications. Additionally, the Surgeon recommended x-ray(s) and a MRI (a specialized imaging procedure) for a further evaluation. If the imaging studies did not show any notable findings, then the plan would be to continue PT and rehabilitation. A follow-up visit was also planned. The resident received instructions/counseling on post-operative care and precautions. On 11/17/17 the resident's PCP changed the resident's pain medication to [MEDICATION NAME] (a stronger narcotic pain medication) 2 mg orally every four hours as needed. After returning from the Surgeon's appointment on 11/17/17, the PT Assistant documented the resident was in bed screaming in pain that her left lower extremity had pain of 12+ out of 10. The PT Assistant spoke with a named nurse about the resident's pain medication. The resident had pain medication two hours earlier and the nurse planned to provide the resident a muscle relaxant. The resident refused the remainder of the therapy due to pain. On 11/18/17 a nursing entry documented the resident stated the pain medication was managing her pain. The 11/18/17 PT treatment note stated the resident was at the parallel bars assisted by two persons but she was only able to stand half way up as she was unable to bring her hips underneath her. A 11/20/17 nursing entry revealed there had been a report that the resident was non-complainant with the back brace over the weekend. The resident had stated she did not have to wear the brace while in bed. A call was placed to the Surgeon's office. The individual at the Surgeon's office reported the resident had stated that PT had not worked with her and she could not move her legs. The facility nurse spoke in length with the individual at (the Surgeon's) office about resident care, individual stated that d/t (due to) conflicting stories that resident(')s original report in (sic) now under question, this nurse proceeded to the resident(')s room to speak with the resident(.) The resident was working with PT at the time. Resident #1 was lifted by two PT workers into a sitting position on the bed. Later on 11/20/17, a nursing entry documented the resident was incontinent of bowel and bladder .will continue to monitor. According to the facility's 11/2017 Change of Condition policy, nursing assistants were to report any changes including a change of bowel or bladder function to the licensed nurse. The licensed nurse was to assess the resident. The resident would be placed on alert charting for a minimum of 72 hours. The resident, resident representative, and physician would be notified of the change. The care plan would also be updated with any change of condition. A late entry for 11/20/17 documented an on-call physician was notified about an elevated INR value (a critical lab result signaling increased bleeding risk). There was no documention of a report to the physician of the change in the resident's bowel and bladder function despite a recent back surgery. The 11/21/17 PT treatment note documented, Pt (patient) is unable to move her L (left) LE (lower extremity). During the session, the PT Assistant and OT were attempting to assist the resident to stand but the resident's knee buckled requiring four persons with maximum assistance to return her to the wheelchair. The resident was experiencing decreased strength and increased pain. An 11/21/17 nursing entry also documented the resident was incontinent of bowel and bladder. There was no mention in the nursing entries on 11/21/17 about the resident's inability to move her left leg or of increased weakness. The medical record documented a scheduled MRI on 11/27/17 at the hospital (based on the Surgeon's previous directive for imaging). On 11/22/17 another nursing entry showed the resident was incontinent of bowel and bladder. The resident received as needed pain medication. Review of the 11/2017 E-MAR (Electronic Medication Administration Record) revealed the resident had an increase in the as needed [MEDICATION NAME] with five doses a day between 11/20/17-11/22/17 and a daily dose of the muscle relaxant medication during that timeframe. According to the 11/23/17 PT discharge summary, the resident required increased assistance with her lower extremities. The resident was unable to move L LE own leg; pt presented with increased pain 10/10 requiring Max x 2 (maximum asstance from two individuals) with all Bed (sic) mobility. Additionally, the resident was unable to walk due to unable to stand. The resident was educated on the importance of wearing her back brace in order to provide pressure to keep her spine in place. Pt felt it was uncomfortable (sic) and would remove the back brace. An 11/24/17 10:14 AM nursing entry documented the resident's family member had come to the nurses' station and stated he wanted the resident to be sent to the hospital. It has been 20 days after surgery and she isn't getting any better. When the resident was approached, she stated, I need more pain meds (medications) and they are telling me I have to wait four hours. The resident had received a muscle relaxant at 8:45 AM and [MEDICATION NAME] at approximately 7:00 AM. The PCP was notified of the resident requesting to go to hospital after above statements. The ambulance was called thereafter. Review of an 11/24/17 nursing entry, revealed the resident was admitted to the hospital. The resident had a hematoma (a collection of blood) on her spine and we will be sending her (to hospital across the state) for emergency surgery(.) On 05/07/17 an interview was conducted with Staff C, PT, at approximately 12:15 PM. The PT had provided some of the PT services for Resident #1. Staff C reviewed the documentation related to PT services provided for the resident during her 11/2017 stay. Staff C stated on 11/14/17 the resident experienced a major increase in pain that was documented during the session. On 11/16/17 the documentation reflected the start of a change when the resident reported her feet felt like they were in cement. By 11/21/17 the resident was unable to move her left leg. The resident had decreased strength and increased pain. The resident was having a complete change. An interview was conducted on 05/07/17 at approximately 2:00 PM with the resident's PCP. The PCP reviewed the hospital transfer orders for management of the resident's anti-coagulant medications, INR lab monitoring, and other aspects of the resident's care. The facility had a [MEDICATION NAME] Flow Sheet and the goal for the INR range had been changed from the hospital order. Additional information was added to the top of the [MEDICATION NAME] Flow Sheet but not dated. The PCP stated she had not been provided the hospital transfer sheet with orders for her review. The INRs were not completed as directed by the hospital but were ordered at longer intervals without the hospital orders to review. Additionally, the PCP recalled the resident's back brace had caused her discomfort and she was self-limiting with the brace. The PCP stated she was aware of the resident's increased pain. Review of the Surgeon's 11/17/17 note with the PCP revealed the Surgeon documented the resident's condition was worsening and he had ordered further imaging. However, following the Surgeon's visit the resident developed bowel and bladder incontinence and increased weakness with pain. The facility staff had not notified the PCP of the change in the resident's condition related to the pattern of incontinence of her bladder and bowels and/or of the resident's increased weakness. The PCP stated she wished she had been given the opportunity to examine the resident. Reference (WAC) 388-97-1060(1)(2) This is a repeat deficiency from Statement of Deficiencies dated 04/11/18, 03/07/18, 11/09/17, and 05/23/17.

Based on record review and interview, the facility failed to ensure one of four sampled residents (#1) who received anti-coagulant medication(s) (blood thinning medications) was free of significant medication errors. Administering additional anti-coagulant medication doses, beyond the duration of physician's written orders, was a contributing factor to the resident's deteriorating physical condition. Resident #1 developed an accumulation of blood in her spinal region, in the area of her recent surgical procedure. Findings included: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] following back surgery. According to the 10/30/17 hospital history and physical, the resident had been on [MEDICATION NAME], an oral anti-coagulant medication, prior to back surgery. The resident also had an artificial heart valve. Hospital transfer orders, dated 11/07/17, documented orders for administration of [MEDICATION NAME] 100 milligrams (mg), an injectable anti-coagulant medication, every 12 hours until the INR (a lab test showing a ratio, a measure to help prevent/protect the resident from blood clot formation) was in therapeutic range. The hospital physician had identified the therapeutic INR range as 2.5-3.5. INR lab tests were to be conducted every Monday, Wednesday, and Friday to aid in identifying when the therapeutic range was reached. The resident was admitted with a prescribed dose of [MEDICATION NAME]. In addition, the resident was to receive a daily dose of Aspirin 81 mg, another medication that could increase the resident's bleeding risk An INR was checked on Wednesday, 11/08/17. The value was 1.8, below the desired level. Instead of obtaining an INR on Friday, 11/10/17, as ordered, the next INR was obtained on 11/13/17 (three days later). On 11/13/17 the INR was 4.8, too high, and the physician ordered the [MEDICATION NAME] be held for two days, on 11/13/17 and 11/14/17. Review of the 11/2017 E-MAR (Electronic Medication Administration Record) revealed the [MEDICATION NAME] was administered twice daily through 11/16/17, despite a directive to discontinue the medication once the therapeutic INR was reached. Six doses were administered following the 11/13/17 INR showing the resident was above therapeutic level and necessitating the [MEDICATION NAME] to be held (due to an increased bleeding risk). (A seventh dose, on 11/15/17 in the morning, was not administered. The corresponding nursing entry on 11/15/17 in the morning documented the facility was awaiting a pharmacy delivery). According to a 11/17/17 physician's orders [REDACTED]. The 11/2017 E-MAR showed the [MEDICATION NAME] was stopped thereafter. The 11/20/17 INR was 8.6, a critically high value. The [MEDICATION NAME] was to be held and the next INR was to be checked on 11/23/17. A 11/20/17 nursing entry documented the Physician directed the facility to monitor the resident for signs and symptoms of bleeding. The resident was placed on alert charting for increased monitoring. On 11/22/17 an INR was obtained and and the value remained high at 3.7. The [MEDICATION NAME] was to be held on 11/22/17 and the resident was to receive 5 mg of [MEDICATION NAME] on 11/23/17. A repeat INR was ordered for 11/24/17. An 11/24/17 10:14 AM nursing entry documented the resident's family member had come to the nurses' station and stated he wanted the resident to be sent to the hospital. It has been 20 days after surgery and she isn't getting any better. When the resident was approached, she stated, I need more pain meds (medications) and they are telling me I have to wait four hours. The resident had received a muscle relaxant at 8:45 AM and [MEDICATION NAME] at approximately 7:00 AM. The PCP was notified of the resident requesting to go to hospital after above statements. The ambulance was called thereafter. Review of an 11/24/17 nursing entry, revealed the resident was admitted to the hospital. The resident had a hematoma (a collection of blood) on her spine and we will be sending her (to a hospital across the state) for emergency surgery(.) On 05/07/18 at approximately 2:35 PM, an interview was conducted with Staff A, Licensed Practical Nurse/Resident Care Manager (RCM). The RCM stated they did not typically fax the hospital transfer orders to the Physician. They obtained an INR the day after admission and let the Physician write the orders thereafter per her understanding to their policy. Resident #1 had a bridging [MEDICATION NAME] order, to be administered until the therapeutic INR level was reached. Adding the directive on the E-MAR should signal the nursing staff when to discontinue the [MEDICATION NAME]. Staff B, Director of Nursing Services (DNS), was interviewed on 05/08/18 at approximately 9:45 AM. The DNS stated she was previously unaware of the medication errors involving additional [MEDICATION NAME] doses, when it was administered beyond reaching therapeutic level (and with a high INR level necessitating holding the [MEDICATION NAME]). Reference (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to complete assessments for one of one resident (#56) reviewed for severe and worsening left shoulder pain and an acute respiratory illness. Although narcotic medication was administered for left shoulder pain, the pain increased over a four-day period until the resident was unable to be repositioned without crying and moaning. Failure to thoroughly assess the resident's pain disallowed the development and implementation of interventions, besides medication, to manage the resident's shoulder pain and resulted in resident harm from the deteriorating quality of life and health complications. In addition, failure to identify and assess the resident's coughing and signs of respiratory distress placed the resident at risk of increased health decline. Findings included: Resident #56. Review of the medical record noted she resided in the facility for several years. Her [DIAGNOSES REDACTED]. PAIN ISSUE On 10/30/17 at approximately 2:40 PM, the resident sat in a wheelchair in the hallway. She cried out that her left shoulder hurt; she repeated it more than once. Staff AA, Registered Nurse (RN), went to the resident and told her she would get her pain medication. On 10/31/17 at approximately 1:15 PM, the resident was seated in the wheelchair in her room. She pointed to her left shoulder and stated she had left shoulder pain. Looking at the left shoulder from the side, it appeared to be slightly out of alignment when compared with the right shoulder. She stated she received pain medication but it doesn't help. She said she could not move her shoulder without unbearable pain; I can't stand it. When asked the cause of the shoulder pain, she stated she just woke up one morning and it was hurting. Her facial expressions exhibited grimaces when she rubbed, touched, or moved her left shoulder; the resident lightly rubbed the shoulder throughout the interview. Observations noted the resident's left shoulder and neck area did not move as easily as did her right side when she moved in her wheelchair and the wheelchair had no supportive devices to relieve downward pressure on her left shoulder. On 10/31/17 at approximately 1:30 PM, Staff AA stated she gave the resident her narcotic pain medication at noon and reported, It is a new order. Staff AA stated the resident had received it on night shift, but night staff documented the narcotic wasn't working. Staff AA said she tried using Biofreeze with Capsazin (topical pain relief product) along with Tylenol earlier that morning. She stated that treatment seemed to help the resident more than the narcotic medication. On 11/02/17 at 10:40 AM, the resident sat in the dining room in front of the television. An activity assistant and two other residents were actively watching the show and talking. The resident's head leaned to one side and her wheelchair had no headrest. Her closed eyes gave the appearance of being asleep. On 11/02/17 at 2:15 PM, the resident was in her wheelchair attending a church service. Observation showed the resident's head tilted to one side without support. On 11/02/17 at 2:45 PM, the resident cried loudly from her room; the crying was heard down the hallway. Observed in her room, Staff AD and Staff AE, Nursing Assistants (NAs), were attempting to transfer the resident from her wheelchair to her bed. Staff AB, RN, also present, stated the activity assistant said the resident needed to be put to bed so Staff AB requested the NAs do that. The NAs placed a transfer belt around the resident's waist; she cried about her shoulder pain. Her eyes were closed and she leaned to her right side as observed earlier in the dining room. The resident protested being touched. She was unable to follow directions to lean forward or to scoot forward to assist with standing and pivoting into her bed. The NAs both said the resident was not able to stand. As the resident continued to cry loudly in pain, Staff AB stated she would call Staff H, RN/Restorative Nurse, to come help with the transfer. Staff AB also stated the resident had received narcotic medication for pain at 12:20 PM and she would give her more when it was time. Within approximately five to ten minutes, Staff H and Staff AJ, LPN, arrived with Staff AB. Staff H attempted to talk with the resident about her pain; however, the resident continued to cry out with her eyes closed and did not answer questions. Staff H supported the resident's left forearm and stated to the LPN and NAs this was how to take pressure off the shoulder joint. Staff H pointed out this should be done whenever moving the resident. At this point, Staff H and the two NAs used another type of transfer to move the resident to the bed. The resident resisted, cried, and screamed loudly in pain during the transfer. Once in bed, Staff H raised the head of the bed slightly and positioned a pillow under the resident's left arm and shoulder. The resident stopped crying. Reviewing the wheelchair, Staff H noted it was a wheelchair without a headrest and special armrests to take pressure off of the resident's shoulder. The wheelchair would tilt back, but without a headrest, it did not allow for head and neck support. Staff H also stated there were adaptive wheelchair devices to support the arm, such as an arm trough, to prevent pressure on the shoulder joint and help with pain management. Staff H stated when a resident had injury to joints, bones, and/or muscles, nursing staff was to conduct an investigation as to when, why, and how the pain had started/occurred. Following the investigations and assessments, interventions to help decrease the pain level would be developed, implemented, and documented in the care plan. Staff H stated there had not been any notification to the Restorative Unit about staff concerns and the resident's expressions of pain until the resident was in crisis and needed assistance to transfer into bed. On 11/02/17 at 4:00 PM, Staff AF, Activity Assistant, stated she had been with the resident during activities in the dining room. She stated the resident moaned in her sleep during activities. Staff AF stated she believed the resident's left shoulder hurts her. On 11/03/17 at 8:00 AM, the resident agreed to let Staff S, Rehabilitation Aide (RA), and Staff AI, NA, get her up and ready for breakfast. The NAs helped the resident sit at the side of the bed. The resident said she was not in pain but her left shoulder was sore. Staff S put a transfer belt around the resident's waist, despite the resident protesting its application, and then told the resident the NAs would help her stand up. Staff S was on the resident's left side and Staff AI on the right. Staff S took the belt in one hand and placed her other arm under the resident's upper left arm/shoulder joint. As Staff S put pressure on the joint, the resident immediately became agitated and said, Don't do that; it hurts my shoulder! Staff S readjusted her grip and the two NAs helped the resident into the wheelchair. Both NAs voiced they did not know the resident had any problems/pain from her left shoulder/arm. On 11/06/17 at approximately 9:00 AM, the resident was seated in the assisted dining room. A left arm sling was in place and when Staff H approached, the resident smiled. Staff H asked how the arm felt; the resident said it hurt at times if I move it. Staff H quickly evaluated the sling position on the resident's arm and adjusted the straps for better support. On 11/06/17 at 9:00 AM when asked about an acute care plan system or way to make care plan changes if an acute issue arose for a resident, Staff I, LPN/Charge Nurse, stated there was no acute care plan system in place except for residents with Medicare benefits. A 24-hour report binder allowed nurses to document the need for alert charting when an issue arose for a resident but just the problem that needed monitoring was all that was written; no interventions were developed and documented on the alert charting sheet. Staff I said one of the Resident Care Managers updated residents' care plans quarterly or if brought to her attention. Review of progress notes in the resident's record dated 10/30/17 at 8:46 PM included the resident's physician had ordered an x-ray of the left shoulder. The findings included a note that the resident's shoulder displayed a boney projection that can be associated with rotator cuff impingement (pinching (impingement) of the rotator cuff in the resident's left shoulder would cause pain and limit the resident's ability to move the shoulder/arm). Review of the resident's record showed a lack of thorough assessments related to the left shoulder pain, including characteristics of the pain. Entries documented between 09/25/17 and 10/30/17 showed licensed nurses documented how the resident felt her pain was on a one to ten pain scale. No assessments by multi-disciplinary professionals appeared in the resident's record until 11/03/17 after the resident was in crisis and unable to transfer due to her severe pain despite receipt of narcotic pain medication or Tylenol and the pain cream. RESPIRATORY ISSUE: On 10/30/17 at 2:40 PM, the resident sat in her wheelchair in the hallway, crying out in pain and coughing. On 10/31/17 at approximately 1:15 PM, the resident sat in the wheelchair in her room. The resident coughed throughout the interview with the surveyor. The resident stated the coughing made her left shoulder hurt. On 11/03/17 at approximately 7:30 AM, during the resident's morning care with Staff S and Staff AI, NAs, observations showed the resident coughed frequently and spit out green mucous. The surveyor reported the observation to Staff H, RN, who called for an emergent physician visit for the resident. Progress note entries after 8:00 AM on 11/03/17 documented assessments of the resident's respiratory symptoms. The assessments revealed the resident had a temperature, low oximetry levels (low oxygen levels in the blood) and was placed on isolation for her cough (resident to stay in her room, staff to take specific preventive measures to prevent exposure of illness to other residents). The physician ordered tests to determine what made the resident sick and if she needed to remain in isolation. Not until the surveyor reported the resident's respiratory symptoms to Staff H did subsequent documentation by licensed nurses show lung assessments completed each shift. The assessments included lung sounds, oximetry readings (checking for oxygen level in the blood), vital signs, and observations of coughing. Reference: (WAC) 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to provide necessary care and services that included timely identification, consistent monitoring, and appropriate treatment of [REDACTED].#s 156, 26, 53, and 39) reviewed for pressure ulcers. This failure caused harm to Resident #156 who developed an unstageable pressure ulcer on the left heel which was not correctly identified and treated by the facility and a Stage II pressure ulcer to the left buttocks approximately three months after admission to the facility. This failure also caused harm to Resident #26, who was admitted with a Stage II pressure ulcer, which advanced to a Stage III without appropriate treatment. Findings include but were not limited to: The definitions for Stages of pressure ulcers from The National Pressure Ulcer Advisory Panel (NPUAP) are as follows: Stage I pressure ulcer: An observable, pressure-related alteration of intact skin, defined as an area of persistent redness or blue, purple hues. Stage II pressure ulcer: Partial thickness loss of dermis (inner layer of two main layers of skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough. This ulcer may also present as an intact or open/ruptured serum-filled blister. Stage III pressure ulcer: Full thickness skin loss involving damage / death of subcutaneous tissue that may extend down to, but not through, underlying connective tissue. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV pressure ulcer: Full thickness skin loss with extensive destruction, tissue death, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and tunneling also may be associated with Stage IV pressure ulcers. Unstageable: Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present. The anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed and should be classified as unstageable. Resident #156. Record review revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] documented the resident had short term memory problems and required extensive assistance for bed mobility, transfers, toilet use, and supervision for eating. No skin issues were identified. On 01/23/17 at 9:00 a.m., Staff Member C, a Licensed Nurse (LN), stated the nursing staff had identified a blister on the resident's left heel on 01/11/17. As a result of the blister, the resident was no longer wearing shoes and her heels were being floated. Review of Resident #156's medical record revealed a skin assessment dated [DATE] which documented the resident was at low risk for developing pressure ulcers. The 01/11/17 nursing progress note documented a NA had notified the nursing staff of a bruise to the outside of the resident's foot toward the heel/outer aspect of heel . Staff Member D proceeded to document directives to remove the resident's shoes, for the resident to wear non-skid socks, and to float the resident's heels. Additionally, the directives included removing the chair peddle (sic) from the resident's wheelchair as it had a small metal peg that might have caused the skin injury. The January 2017 treatment sheet included the resident's need for assistance to turn/change position every 60-120 minutes and floating her heels when in bed or wheelchair. An additional directive with a start date of 01/10/17 documented to monitor the resident's heel every shift and to ensure the heels were floated three times a day for mushy heels and redness. Ensure NAs are floating resident heels at all times til (sic) redness is resolved. On 01/17/17 and 01/19/17 Staff Member D, the treatment LN, documented the left heel was 1 cm by 1 cm and the skin continued to be intact. On 01/24/17 at 9:25 a.m., Staff Member D stated she was the treatment nurse and had been monitoring Resident #156's left heel. She added when I first saw the injury to her left heel, I assessed it to be a bruise. It is on the outer aspect of her heel. She was wearing a pair of shoes that I felt the top edges of her shoes were hard and they were rubbing or putting pressure on the outer aspect of her heel. The LN stated the skin injury could also have been caused by the metal peg on the foot pedal. The LN added, I spoke with the doctor yesterday and she told me that I needed to have notified her of the resident's skin changes. I just did not know I had to notify the doctor about this skin injury. I also feel she sits in her wheelchair too long; she is up most of the morning. On 01/24/17 at 9:35 a.m., Staff Member D was observed to assess the bottom of the resident's left heel using a mirror. The left leg appeared reddened and swollen, the skin was dry and flaky. The pressure ulcer was circular in appearance, approximately the size of a dime with the top edge yellow in appearance and the bottom half of the pressure ulcer was dark. On 01/24/17 at 10:00 a.m., Staff Member A, the Director of Nursing Services (DNS), stated Staff Member D had not been formally trained to assess pressure ulcers. She acknowledged Staff Member D had not assessed Resident #156's skin injury correctly and had not followed the facility policy to complete an incident report and call the resident's doctor when the pressure ulcer had been identified. The DNS stated she would assess the resident's pressure ulcer today. On 01/24/17 at 1:55 p.m., the DNS and Staff Member D were observed to measure the left heel pressure ulcer. The DNS stated the resident does have an unstageable pressure ulcer which is measuring 1 cm by 1 cm. The DNS added the current foot rest and foot cushion was not the correct device for the resident's heel as her heels were not being off-loaded. On the mornings of 01/23/17 and 01/24/17 the Resident #156 was observed sitting in her wheelchair with her feet resting on the foot pedal for approximately 3 hours despite the treatment nurse's directives to the NAs to reposition the resident every 2 hours and float her heels when she was up in her wheelchair. On 01/25/17 Staff Member R, a LN, documented she had re-assessed the resident's skin and found a 0.5 cm by 0.5 cm Stage II pressure ulcer on her left buttock (this pressure ulcer had not been previously identified) and an unstageable 2 cm by 1.5 cm pressure ulcer on her left heel (larger than previously documented). Resident #26. Per record review, the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/24/17 at 1:30 p.m., the resident agreed to allow Staff Member J, a LN, to inspect the resident's bottom for any open areas/wounds. After removing the resident's pants, observations included an open area, triangular in shape, just to the left of the resident's coccyx on the top of the left buttock. The open area was approximately 1.2 cm by 0.8 cm; two of the wound edges were red-rimmed. The wound base could not be visualized and appeared to be light brown in color. Beneath the open area was a spot about 2 cm in length which appeared to be rolled skin. The wound had no dressing/covering in place on it. On 01/24/17 at approximately 2:00 p.m., Staff Member C, a LN, was heard to described the resident's ulcer as, It's like a horn. She has them all over. On 01/24/17 at 2:12 p.m., Staff Member D, the facility's designated treatment LN, said she had just placed a [MEDICATION NAME] dressing over the resident's wound. When asked, the LN was unable to describe the wound's appearance or describe the classification/staging of the wound. The LN said the treatment regimen consisted of placing a [MEDICATION NAME] dressing over the wound every three days or sooner if the dressing came off. On 01/24/17 at 2:40 p.m., the wound was viewed again with Staff Member A, the DNS. When the DNS saw the wound on the top of the left buttock next to the resident's coccyx, she stated the wound bed could not be seen because something covered the wound bed. Documentation in the resident's record revealed a nursing skin assessment dated [DATE] which included information the resident had reddened areas that remained 30 minutes after pressure reduction (indicated a Stage I pressure ulcer) but no open ulcers. Later in the same note, the LN wrote a dressing was in place over the resident's coccyx but the LN did not remove the dressing to visualize the area directly, although reddened skin could be visualized around the duoderm (a [MEDICATION NAME] dressing). Two days later when the dressing was changed, a LN documented a pressure sore approximately 2 cm by 1 cm which appears to be drying. Documentation in the resident's 5-day comprehensive assessment dated [DATE] listed the resident admitted with a Stage II pressure ulcer to her coccyx. Review of the resident's December 2016 Wound sheet revealed the pressure ulcer was to be covered with duoderm, monitored daily, and the dressing changed as-needed. Documentation on the form indicated this order was discontinued on 12/22/16. On the January 2017 Wound sheet, documentation revealed an order on 01/16/17 to apply house barrier cream to buttocks every shift to OPEN AREA L (left) CHEEK three times a day. On 01/18/17 nursing began to monitor placement of a [MEDICATION NAME] dressing to the resident's left buttock area and change every three days. On 01/25/17 at approximately 1:30 p.m., Staff Members G and H, both LNs, were interviewed about the resident's wound. Staff Member G stated the resident had been re-assessed for pressure ulcers. The LN reported there was a pressure ulcer on the upper left buttock. The LN explained, while cleansing the wound, a hard piece of yellow material was on the edge of the bottom of the wound. Staff Member H said she removed the yellow material and found it was a piece of a [MEDICATION NAME] dressing that was previously left on the wound. Staff Member H then reported she believed the piece of wound dressing had been left on the wound bed for a week or more but she was not sure. Staff Member H said after the wound was cleansed, it was measured and had increased in depth to a Stage III pressure ulcer. Both LNs reported there were now new and appropriate treatment orders for the care of the resident's pressure ulcer. Staff Member G stated the facility had not accurately assessed the resident's pressure ulcer or used appropriate interventions for treatment. Documentation dated 01/25/17 by Staff Members G and H about the area on the resident's bottom revealed a 3 x 3 cm Stage III (pressure ulcer). Hardness noted at 6 o'clock. Stage III, cleanse with wound cleanser, apply hydrogel with collagen, cover with 2 x 2 silicone dressing. Check every day, change every 3 days and PRN (as needed). Resident #53. Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to her current plan of care, the resident required staff assistance for bed mobility, transfers, and toileting. The resident was generally continent but had incontinent episodes. Resident #53 typically used a wheelchair for mobility. The resident was noted to have impaired cognition and short term memory loss. Additionally, the care plan identified the resident had a history of [REDACTED]. The resident refused to lay down between meals and preferred to be up in her wheelchair during the daytime. Review of January 2017 Treatment Administration Record revealed the resident was to receive a weekly skin check. She had been receiving Triple Compound 1:1:1 containing [MEDICATION NAME] (an anti-fungal) Cream, [MEDICATION NAME] (a steroid to reduce inflammation) Cream, and Zinc Cream (a moisture barrier) twice daily for a buttocks rash since 10/20/16. A 10/20/16 nursing entry documented the resident had two open wounds on her bottom. The specific location of the open areas was not identified. The resident stated she scratched herself. The follow-up weekly skin assessment noted on 10/22/16 that the resident was complaining of itching and was scratching herself intensely. She was given a wash cloth to scratch her body. On 10/26/16 the skin assessment documented a small open area to the right buttock measuring 0.5 cm by 0.5 cm and continued itching and scratching by the resident. An 11/02/16 assessment note documented the chronic non-blanchable [DIAGNOSES REDACTED] (redness) continued on the buttocks. A nursing entry on 11/03/16 noted the resident scratched her buttocks and opened a wound on the right buttock. The 11/09/16 skin assessment documented a slight rash to buttocks (without mention of an open area) and a history of a fungal rash. According to the 11/15/16 Nurse Practitioner documentation, the resident had a slight rash to her buttocks and there were no acute changes. The current treatment was to continue. Weekly skin assessments continued with variable assessments related to the condition of the buttocks and site(s) of skin breakdown. On 11/17/16 the weekly skin assessment noted a history of fungi [MEDICAL CONDITION] to the buttocks and continued discoloration with a chronic open area on the right buttock. The 11/23/16 assessment noted a small chronic open spot on left buttock. The resident refused off loading/laying down. Additionally, the 11/30/16 assessment noted chronic discolored buttocks with pin point open area. The resident scratched her buttocks and lower back when toileting. The 12/14/16 note documented the resident's buttocks remained discolored. There were multiple raised skin areas (without mention of an open area). The resident refused to lay down. A 12/16/16 nursing entry stated there was a chronic open area 0.5 cm by 0.5 cm on right buttock and an open area on the left buttock. The 12/28/16 entry documented only discoloration to buttocks without mention of any open areas. On 01/03/17 the nursing entry referenced monitoring for a chronic open area 0.5 cm by 0.5 cm on the right buttock and a chronic open area on left buttock (size not specified). The 01/06/17 nursing entry also referenced two open areas on buttocks. The 01/11/17 skin assessment noted only a chronic open area on right buttock without measurement. There was no mention of the left buttock status. The resident's Primary Care Physician (PCP) evaluated the resident on 01/16/17. Documentation noted the resident's feet were without sores. There was no documentation pertaining to the condition of the resident's buttocks. On 01/23/17 at approximately 4:45 p.m., the PCP was interviewed and stated she relied on the nursing staff to notify her of current changes and operated off the principle of no news was good news. The PCP did not observe the resident's buttocks on 01/16/17. Observations on 01/24/17 at approximately 11:30 a.m. revealed the resident's buttocks had a notable reddish/purple discoloration present on the lower half of her skin surface on both buttocks. Additionally, her left buttock had an open area and a small abraded area above the open area. The right buttock had a 0.3 cm by 0.3 cm open area as measured by the DNS, who was present. Review of a 01/24/17 evening shift skin assessment by Staff Member G, a LN, revealed documentation that the skin had two Stage II pressure ulcers involving both buttocks and both measuring 1.0 cm by 0.5 cm (larger than previously assessed). New treatment orders were initiated. On 01/27/17 at approximately 1:13 p.m., a telephone interview was conducted with the resident's family member/Power of Attorney (POA). The POA stated she was unaware of any open areas on the resident's buttocks and had not received any recent update on the resident's skin status or changes in her treatment. Resident #39. A review of the 01/13/17 resident assessment revealed that the resident was able to speak but was confused and unable to make her needs known. She did require extensive assistance from staff for transfers, toileting, eating, bathing and personal hygiene. The resident had a history of [REDACTED]. The resident's 10/19/16 care plan documented the resident had potential/actual alteration in skin integrity related to fragile skin, immobility and chronic recurrent pressure ulcers. The interventions in place were to apply barrier cream every shift to the resident's bottom and weekly skin checks. A review of the nursing progress note dated 12/16/16 revealed the resident was identified with an open scarred area that was very fragile. On 12/17/16 a nurse's note documented that the resident had two small open areas. On 12/31/16 two small areas on buttocks remain. On 01/07/17 two small red areas to buttocks remain, dressing applied to right buttock. There were no thorough assessments completed related to the pressure ulcers to the resident's buttocks and no description of whether the pressure ulcers had increased or decreased in size. A 01/18/17 skin assessment narrative did not identify any open ulcers or persistent reddened areas [MEDICATION NAME] over 30 minutes, no abrasions or bruises. On 01/23/17 at approximately 9:45 a.m., Staff Member DD and Staff Member O, both NAs, assisted the resident to bed and changed her clothing. The resident had two large purple/red skin areas on the mid-left and mid-right buttocks with white scarring to the middle areas of the mid-left and right buttocks. The NAs stated they had notified the nurses of the resident's skin condition about a week ago. Additionally, Staff Member O stated there was supposed to be a dressing to each purple/red skin area for protection but they were not on the resident's skin. According to Staff Member O the resident had been up from early that morning, approximately 6:00 a.m. until 9:45 a.m., when the NAs put her to bed. On 01/23/17 at 10:00 a.m., Staff Member C, a LN, stated the resident's skin issues come and go because she sits so long. I have told the NAs to lie her down after meals. According to Staff Member C, the resident should have had the ordered dressings on her left and right buttocks for protection. The physician's orders [REDACTED]. Additionally, the LNs were to assess the resident's skin every Saturday and chart the results. The last skin check was documented on 01/21/17 and was charted as pink, clean, warm and dry with good turgor. On 01/24/17 at 10:00 a.m., Staff Member A, the DNS, stated that when the new skin issues occurred, the LNs were to fill out an incident report so they could track and follow-up with the physician. The DNS stated both the treatment LN or other LNs had not completed a thorough skin assessment for this resident. The DNS stated there was really no continuity of care.

Based on observation, interview and record review, the facility failed to ensure nutritional assessments were done and also failed provide necessary interventions for 2 of 4 residents (#s 57 and 102) reviewed for nutrition. This failure caused reduced food intake, weight loss, and decreased nutrition status, resulting in harm for Resident #57. Findings include: Resident #57. Re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] documented the resident as cognitively intact and required supervision and setup with meals. Morning observations on 02/18, 02/19, and 02/22/16 revealed the resident in her room with her breakfast meal tray setup in front of her on the bedside table, untouched. Each time, the resident was observed sleeping or awake and stated she was too tired to eat. On 02/22/16 at 9:36 a.m., Staff Member DD, a Nursing Assistant (NA), stated it seemed as the resident had been losing more weight since she returned from the hospital on [DATE]. The NA stated the resident had not been eating as much and was either in pain or nauseated during meal time. On 02/22/16 at 9:43 a.m., Staff Member AA, a Licensed Nurse (LN), stated Resident #57 had been offered protein shakes since she returned from the hospital, but continued to refuse them. He stated the protein shakes were offered since she was not eating well. He further explained the resident would average approximately 50% intake of her meals prior to her surgery for [REDACTED]. Review of the meal consumption documentation revealed the resident averaged 0-25% consumption of all meals since readmission on 02/08/16. Review of the comprehensive care plan documented the resident was grieving related to the loss of a body part and physical abilities. The most recent nutritional assessment was dated 01/18/16 (prior to the resident's surgery for [REDACTED].#57) is at severe nutritional risk (related to) very low BMI (Body Mass Index) (14), recent surgery, poor appetite and intake, advanced age . The nutrition assessment documented an ideal body weight (IBW) of 115 lbs. (pounds), plus or minus 10 percent. Note: A BMI of 14 is considered severely underweight. There was no documentation of a nutritional assessment since the readmission of the resident and the significant change related to the amputation of a limb (15 days prior). Reviews of the resident's weights revealed the following: 01/27/16 88.9 lbs. (77% of her IBW) 02/03/16 75.5 lbs. (a 13.4 lbs. loss from 01/27/16) 02/17/16 68.2 lbs. (after [MEDICAL CONDITION]) 02/21/16 66.8 lbs. (after [MEDICAL CONDITION]) Note: If the 02/17/16 and 02/21/16 weights were adjusted to estimate the resident's weight as though she still had the now missing limb, using a formula published by the Academy of Nutrition and Dietetics, the estimated weights would have been 75.77 lbs. on 02/17/16 and 74.2 lbs. on 02/21/16. The estimated weights revealed a continuing downward trend. On 02/22/16 at approximately 2:00 p.m., Staff Member Q, a LN, stated she contacted the facility Registered Dietician (RD) on 02/12/16 (left a voicemail) to notify her of the resident's poor food intake and concern for the surgical incision healing. .I was at a loss as what to do because she (Resident #57) is so picky (food choices). On 02/22/16 at approximately 2:10 p.m., Staff Member G, a LN/Resident Care Manager, stated the resident was discussed several times, before the recent hospitalization , at skin and nutritional meetings with key staff, including the RD. The LN stated the concern for the resident was related to weight loss and poor intake. Her weights are so critical .even half-a-pound. (Resident #57) is a huge concern. The resident, already severely underweight, lost 13 lbs. prior to her amputation surgery. Upon return to the facility on [DATE], the resident continued with poor appetite and weight loss, eating less than 25% of her meals. She also had the additional nutritional burden of healing from a major surgery. The facility failed to ensure a nutritional assessment was completed for the resident after her readmission to the facility following the surgery, even though she had been identified to be at severe nutritional risk. This denied the resident access to nutrition interventions to try to reverse her weight loss and improve her intake, and allowed her to nutrition status to continue to deteriorate. Resident #102. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. A review of the resident's 01/22/16 admission record revealed that the resident acquired pressure ulcers, Stage 1, (redness non-blanchable area of skin), to areas on the spine and sacrum. Additionally, the resident received 2 units of blood while in the hospital due to [MEDICAL CONDITION]. According to the 01/28/16 comprehensive assessment the resident was alert and oriented and made her own decisions. The resident's chronic pain had also interfered with her daily living activities. At her admission on 01/22/16, the resident was on a no added salt diet with regular texture. Review of the resident's weight record revealed on 01/22/16, the resident weighed 124 lbs. and on 02/16/16 the resident's weight had dropped to 113 lbs. in 25 days, (a 7.5% weight loss) due to poor intake and appetite. The meal monitor documentation from 01/25/16 through 02/19/16 revealed that the resident ate 0-25% of most meals. On 02/19/16 at 10:15 a.m., Staff Member D, a LN, stated the resident did not want to get out of bed and the resident was always in pain. Staff Member D stated she was unaware of the resident's weight loss and saw that there was no nutritional assessment or recommendations for assessment by the dietician. After continuing the conversation with Staff Member D on 02/19/16 at 10:20 a.m., the LN was heard to be calling the RD to come in and assess the resident. When she finished the phone call with the RD, she stated the RD told her she did not do the nutrition assessment and that she owned it. On 02/19/16 at 10:28 a.m., Staff Member Q, a LN, stated the resident had pain when she moved and had been taking less pain medications than before, but noted the resident says she doesn't want to get up when we encourage her. Review of the resident's Medication Administration Record [REDACTED]. Additionally, the level of pain the resident had experienced on a 1 (least pain) to 10 (extreme pain) was between 6 and 10. An interview 02/19/16 at 11:00 a.m., Resident #102 stated she did not have an appetite and had no desire for food. She stated that her pain was an issue as far she was concerned that would have an effect on her appetite. On 02/19/16 at 2:00 p.m. Staff Member W, a NA, stated the resident did not like getting out of bed but had been wanting to get out of bed more lately. But when she got up, she had pain and wanted to go back to bed. She noted the resident did not like to eat too much. On 02/19/16 at 10:30 a.m. Staff Member B, the Director of Nursing (DON), stated she was aware that there was lack of follow through with nutrition assessments. The DON stated that new admissions were to be assessed by the registered dietitian within two weeks of admission, unless the resident was in need of an immediate assessment due to disease and condition. The DON stated that there was only one registered dietician for three local facilities. In an telephone interview on 02/29/16 at 10:20 a.m., Staff Member KK, the Registered Dietitian (RD), stated she was notified of new admissions by accessing the electronic record system remotely. She could also electronically review weights and prioritize who needed to be assessed first through data in the electronic record. She noted she was in the building at least once a week, on Wednesdays. She stated her goal was to complete a full nutrition assessment on each new admission or re-admission within two weeks. She explained she was caught up with her work until around 01/19/16, when there was an increase in the number of admissions in the three facilities she was responsible for. Currently, she is behind schedule in completing assessments on time. The facility failed to provide nutrition assessment and support for both residents when they experienced significant weight loss and had significant medical events that increased their nutrition risk. The continued weight loss and poor intake was not addressed, causing harm for Resident #57 and potential decline in nutrition status for Resident #102.

Based on record review and interview, the facility failed to ensure that 1 of 2 sampled residents (#1) received sufficient fluid intake to maintain proper hydration. Resident #1 experienced a significant decline in her health with resulting diminished fluid intake requiring hospitalization . Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. Assessments on 11/20/12, the day of admission, documented the resident had some bilateral lower extremity [MEDICAL CONDITION] which was reportedly her baseline. The 11/20/12 hydration assessment noted the resident ingested less than 1,500 cubic centimeters (6 1/4 cups per day) of fluid per day. The resident's plan of care did not identify a plan with specific interventions to address/maintain the resident's hydration. On 12/03/12 the Registered Dietitian met with the resident and assessed her fluid needs as 2200 cubic centimeters daily (approximately 9 cups). A 12/12/13 nursing entry identified the resident was totally soaked with urine and she had stated, 'I can't even tell when I am going." The Registered Dietitian met with the resident on 12/12/12 to discuss her dietary preferences. The resident requested ice to chill her vanilla Ensure (liquid nutritional supplement) that she liked to drink for breakfast. The 12/13/12 nursing entry at 6:13 a.m. reported the resident was weaker that morning requiring two persons to assist with transfers and toileting and she was unable to stand by herself. Later that evening the nursing entry documented the resident had a decrease in mentation that day and the day before. A urinalysis had been sent to the lab stat (urgent request). On 12/14/12 the resident's physician was contacted for an order change for one of her medications as she was having trouble swallowing the larger tablet. On 12/15/13 the resident had a low grade temperature of 99.6 degrees Fahrenheit per the nursing entry. The 12/16/12 nursing entry noted the urine culture results were obtained and revealed >100,000 of an organism present. The resident had a UTI (urinary tract infection). Instead of treating the UTI on 12/16/12, the resident's physician ordered a blood test for a complete blood count on 12/17/12 and a head CT scan (when it could be scheduled). Although some licensed nurses documented that fluids were encouraged thereafter, the facility failed to document a plan to increase attempts to hydrate the resident which was even more important since the resident was not being treated with an antibiotic for the UTI and had exhibited an increased temperature, a UTI, weakness, and changes in mentation. When interviewed on 4/11/13 at approximately 11:18 a.m. Staff Member D, a licensed nurse, recalled she had noticed quite a change in the resident's condition when she returned to work on 12/17/12. The resident was not eating or drinking well, was in bed, and was not talking much. Staff Member D stated she had correlated the changes with the UTI. She stated there was no intake or output monitoring data or specific hydration assessment. The Staff Member stated she offered a health shake on 12/17/12 to try to offer fluids because "if you are not eating or drinking you can dehydrate quickly." Staff Member D had spoken with the alternate physician about her observations of the resident's condition. Review of the alternate physician's 12/18/12 documentation revealed she recorded the resident had increased confusion and was alert but fatigued, conversant. A UTI was assessed and an antibiotic was ordered earlier that afternoon. The December 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No plan to increase the resident's fluid intake along with administering the antibiotic was implemented. The 12/19/12 9:07 a.m. nursing entry by the wound care nurse documented the resident was very fatigued, refused her breakfast foods, and drank only some fluids but was experiencing difficulty sucking. The resident was also having numerous loose stools. The 12/19/12 9:30 a.m. nursing entry recorded that the family member wanted the resident sent to the hospital because she "has gotten so bad." The resident's physician was notified and he provided orders to transfer the resident to the hospital. Further investigative review identified that despite references to intake and output contained in the nursing charting template, no intake and output data was located. No hydration assessment was found (since admission) despite the resident's weight loss, UTI, diarrhea, and progressive difficulties with swallowing. When interviewed on 4/03/13 at approximately 9:35 a.m., Staff Member C, a licensed nurse care manager, stated that the only hydration assessment was the one completed on admission and she was unaware of any intake and output monitoring completed. Staff Member C provided a computerized summary of fluid fluid intake totals associated with the resident's meals between 12/11/12 and 12/17/12. Totals ranged between 420 cubic centimeters (less than two cups) to 660 cubic centimeters (2 3/4 cups). The data was obtained in conjunction with preparation for the comprehensive assessment (not current but reviewed later, likely after discharge). The totals did not track fresh water, water with medications, or fluids from the nutrition station. The resident continued to receive a daily diuretic during the course of her stay (promoting excretion of urine). Facility administrative staff obtained/provided other fluid intake reports from their computer in response to questions pertaining to intake. The new data reportedly included the other fluid sources. Daily fluid intake totals between 12/12/12-12/18/12 ranged from 1,200 cubic centimeters (12/12/12) to 540 cubic centimeters daily (on 12/14/12, 12/15/12, and 12/18/12. In addition, the resident's intake had been below her estimated fluid needs since admission. (Despite her diuretic, diarrhea, urinary tract infection, and swallowing difficulties.) An investigative interview was held with the resident's legal representative/family member. The family member reported the resident had admitted to the facility for short term rehabilitation. She was initially making great gains. A conference was held on 12/03/12 and there was a plan discussed for approximately two more weeks of therapy prior to discharge. According to the hospital records, the 12/19/12 physician's history and physical, the resident was admitted due [MEDICAL CONDITION] (a systemic infection) secondary to a urinary tract infection and acute renal (kidney) failure. The emergency room record documented the resident's mucous membranes were dry (indicating poor hydration). Intravenous fluids were administered initially at a rate of 1000 cubic centimeters an hour (a fast rate) for hydration. The physician's 12/20/12 entry documented the use of antibiotics but identified an AKI (acute kidney injury), likely from volume depletion (low body fluids). Despite staff knowledge of the resident's ongoing diuretic use, a UTI diagnosed on [DATE], her decreased functionality and fluid intake, a temperature elevation, diarrhea, swallowing difficulties, and the onset of antibiotic treatment on 12/18/12, there was no specific assessment of the resident's hydration status or a plan to implement specific interventions to address her hydration needs. The resident's condition continued to decline until she was hospitalized at the request of the family. Refer to F309 related to the failure to advocate for timely treatment of [REDACTED].

Based on record review and interview, the facility failed to provide necessary care and services for 1 of 3 residents (#1) reviewed with changes of condition. Resident #1 developed a urinary tract infection [MEDICAL CONDITION] in conjunction with multiple areas of physical decline. The facility failed to analyze and address the significant factors and advocate for the resident to secure timely treatment. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. Assessments on 11/20/12, the day of admission, documented the resident had no ulcers. Her admission weight was 161 pounds. The resident had admission orders [REDACTED]. A cognitive assessment on 11/21/12 noted the resident scored 14:15, revealing she scored as cognitively intact. The 11/23/12 nursing entry documented the resident had received her last dose of antibiotics for treatment of [REDACTED]. The 12/03/12 weekly Medicare Review documentation recorded that the resident required only stand by assistance with her walker, had walked a distance of 375 feet, was independent with bed mobility, and demonstrated good safety awareness. Review of the weight record noted the resident had lost 8 pounds between 12/03/12 and 12/10/12. There was no facility assessment of the weight loss. A 12/12/12 nursing entry identified that the resident was totally soaked with urine and she had stated, "I can't even tell when I am going." In addition, on 12/12/12 the skin assessment revealed the resident had developed two pressure sores on her bottom. Nursing entries on 12/13/12 recorded the resident was weaker, required two persons to assist her for transferring as she could not hold her balance. In addition, it was documented the resident had a decline in her mentation yesterday (on 12/12/12). A urine dip was positive so a urine sample was sent to the lab on 12/13/12. A cognitive assessment, dated 12/13/12, revealed the resident was scoring 7:15, a drop of 7 points since admission, placing her in the severe impairment range. Additionally, the 12/14/12 physical therapy note also recorded the resident was now unable to stand. The resident's change was reported to nursing. On 12/15/12 the resident had a low grade temperature of 99.6 degrees Fahrenheit. The 12/16/12 nursing entry recorded that the urine culture results were received from the hospital and showed greater than 100,000 organisms (a large number). The results were reviewed by the physician. Instead of deciding to treat the urinary infection at that time, the physician ordered a blood test, a complete blood count, for the next day and a head CT (when it could be scheduled). During an interview with the Staff Member A, the Director of Nursing, on 4/03/13 at approximately 2:30 p.m., she stated the first urinalysis was contaminated so they had to obtain another sample. When the results returned (on 12/16/12) the physician didn't chose to treat the UTI but ordered other tests. The 12/17/12 social service entry stated the resident was feeling hopeless and would like to go home. The resident does have a UTI and is awaiting treatment orders from the physician. A 12/17/12 nursing entry documented the resident 's urine was "foul smelling." The resident's weight record revealed an 11 pound weight loss, a loss of 5%, in approximately 30 days (mainly in December 2012). Additionally, the resident's hydration issues were not adequately assessed and addressed to meet her increasing need for fluids. Refer to F327 for further details. Although there was data available to potentially access, related to changes in the resident's condition, there was no assessment analyzing the scope of the resident's decline indicating the global impact of the infection on the resident. Consequently, facility staff did not advocate timely to secure timely treatment of [REDACTED]. On 12/18/12 during the day shift (5 days after the documented onset of urinary symptoms) a nursing entry by Staff Member B recorded that the resident's family member was in with complaints that "staff doesn't seem to be as concerned about (Resident #1's) recent decline and that she really wants more aggressive treatment done to get her back to her previous functionality." Staff Member B explained that staff were concerned but the physician did not want to treat the UTI at that level of bacteria and the white blood count was only marginally elevated. Staff Member B documented he would arrange for an alternate physician (the primary physician's associate who also saw residents at the facility) to come to the facility later that evening and examine the resident. The medical record revealed that the primary physician provided an order for [REDACTED]. When interviewed on 4/11/13 at approximately 11:18 a.m., Staff Member D, a licensed nurse on-duty on 12/18/12 recalled she had noticed quite a change in the resident's condition when she returned to work on 12/17/12. The resident was not eating or drinking well, was in bed, and was not talking much. Staff Member D stated she had correlated the changes with the UTI. On 12/19/12 in the morning there were multiple entries from the social worker documenting the resident was having "trouble swallowing" and the resident and her daughter were concerned about the resident's care. The 12/19/12 entry by the wound care nurse documented the resident was very fatigued, refused her breakfast foods, drank only some fluids, was experiencing difficulty sucking, and was having numerous stools. The 12/19/12 9:30 a.m. nursing entry recorded that the family member sent a nursing assistant down to get the charge nurse. The family member stated she wanted the resident sent to the hospital because she "has gotten so bad." The resident's physician was contacted and provided an order to transfer the resident to the hospital. According to the hospital records, the 12/19/12 physician's history and physical, the resident was admitted due [MEDICAL CONDITION] (a systemic infection) secondary to a urinary tract infection and acute renal (kidney) failure. The family member reported the resident had admitted to the facility for short term rehabilitation. The resident was initially making great gains. Starting on 12/10/12 the resident was reporting she was feeling poorly and her urine smelled like ammonia. The family member reported to the staff and requested a urinalysis. Reportedly, there was a problem with the first sample. Between 12/13/12 to 12/17/12 the resident went from walking independently to the bathroom to requiring total care from two caregivers. The resident was "declining every day." On 12/18/12 the family member reported to nursing staff that the resident had declined further. On the morning of 12/19/12 a staff member placed the medication in the resident's mouth with water and she choked and vomited up the medication (the antibiotic for the UTI). The family member requested a transfer to the hospital and staff facilitated the transfer at her request after contacting the physician. According to the hospital records, the 12/19/12 physician's history and physical, the resident was admitted due [MEDICAL CONDITION] (a systemic infection) secondary to a urinary tract infection and acute renal (kidney) failure. The resident was not treated timely for a urinary tract infection. Although this did affect the resident's overall well-being, the facility failed to look at all the significant factors effecting the resident's health status and address all the contributing factors in the resident's change of condition. Facility staff failed to advocate for the resident in an effective and timely manner to facilitate necessary treatment.

Based on observation, record review, and interview, the facility failed to prevent accidents by ensuring that staff provided immediate supervision when it was needed for 2 of 3 residents reviewed with accidents (#1 & #2). Resident #2 experienced actual harm when he fell forward out of a shower chair onto the floor sustaining blunt head trauma with neck fractures and bleeding in his brain. Cognitively impaired Resident #1 possibly ingested nail polish remover at the nurses station. Findings include but were not limited to: Resident #2: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's plan of care noted he had generalized weakness and impaired mobility. Resident #2 required the use of a mechanical lift and two assistants to transfer him. He was documented as at moderate risk for falls related to his lack of awareness of his safety needs, confusion, and deconditioning. Additionally, the resident's plan of care noted, "Do not leave (the resident's name) unattended while toileting" because he required assistance for the physical process of toileting related to: "fatigue/lethargy, Imp. (impaired) mobility, Decreased strength/balance." Additionally, the resident's cognition was impaired with noted short term and long term memory losses. A 12/28/12 7:10 a.m. nursing entry documented the resident was found lying face down on the floor with a puddle of blood surrounding his head. Emergency services were obtained for the resident and he was transported to the hospital for further evaluation and care. According to the 12/28/12 physician consultation at the hospital, the 12/28/12 CT scan of the resident's head and neck revealed two fractures in his neck, a subtle fracture of C6 (cervical vertebrae) and a fracture of C7. Additionally, the resident had two subdural hematomas (collection sites of blood) on the brain, one on each side of the brain, and bleeding in another space as well. The resident remained in the hospital for monitoring and non-surgical interventions. Review of the 12/28/12 facility fall investigation revealed Staff Members A and B, two nursing assistants (NAs), transferred Resident #2 with a mechanical lift to a shower chair in preparation for his shower. One of the NAs was putting away the lift while the other (Staff Member A) remained with the resident. Staff Member A gave the resident verbal and tactile cues to sit back in the shower chair by looking at him and placing her hand on his shoulder. Then, Staff Member A left the resident's side and went to the doorway to see if the "bath girl" was coming to take him to his bath. When she turned back around, the resident had leaned forward (again) and was falling but she was unable to reach him in time. On 1/18/13 at approximately 1:45 p.m., Staff Member A stated she was familiar with the resident's care needs as she frequently cared for him. Staff Member A stated that while seated in his wheelchair, the resident occasionally leaned forward and staff tilted his wheelchair back for safety. On 12/28/12 the caregivers had transferred the resident to his (upright) shower chair. Staff Member A remained with the resident. He had been "sitting fine" in the shower chair but then he leaned forward and she reminded him to sit back and he did. Staff Member A walked to the door of the room leaving the resident by his bed in the shower chair. The caregiver saw the resident falling forward out of the corner of her eye (but was unable to reach him). Staff Member A further stated the resident "forgets and thinks he can walk." He puts his hands on the arm rests and pushes off with his good hand. When interviewed on 1/18/13 at approximately 2:00 p.m., Staff Member B, the second NA who assisted with the dependent resident transfer into shower chair on 12/28/12 identified the shower chair used that day. The shower chair was an upright model and did not recline. Staff Member B stated on occasion the resident would lean forward in the shower chair. On 1/18/13 at approximately 2:05 p.m., Staff Member C, the Licensed Nurse (LN) on-duty on 12/28/12 recalled responding to the resident's room. Resident #2 had fallen face down onto the floor. Staff Member C maintained the resident's airway and called for assistance. Staff Member C stated the resident was usually in a tilting wheelchair, tilted a little bit as the resident forgets he can't get up. The LN identified the location of where the resident was found, on the floor near the foot of his bed, approximately 5-6 feet from the door into the hallway. When interviewed on 1/28/13 at approximately 11:48 a.m., Staff Member F, Resident Care Manager, stated the resident's care plan directive stating he was not to be left in the bathroom unattended pertained to his poor sitting balance. On 1/28/13 at approximately 11:50 a.m., Resident #2 was observed up in his wheelchair tilted back at approximately 45 degrees. The resident was wearing a soft cervical collar. Despite knowledge of the cognitively impaired resident's behaviors of leaning forward, (even directly before the 12/28/12 fall) and attempting to rise, and care plan directives about not leaving him in the bathroom unattended due to balance problems, Staff Member A left the resident in the shower chair to check on the whereabouts of another staff member. The resident fell forward sustaining a facial laceration requiring sutures, two cervical fractures, and bleeding in his brain, two sub-dural hematomas and a sub-arachnoid bleed in another area. Resident #1: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to the resident's plan of care, the resident had impaired cognition related to his head injury, wandered aimlessly in his wheelchair, and had impaired safety awareness. The resident "enjoys sitting at the nurses station. This helps with monitoring his whereabouts also." Additionally, the resident had confusion with disorientation and problematic behaviors including verbal and physical aggression. Review of the 12/16/12 nursing entry revealed the resident was placed on every 15 minutes safety checks following an incident when the resident exited the facility without direct staff supervision. A 12/27/12 8:29 a.m. nursing entry recorded that Resident #1 was found "with an open bottle of nail polish remover in hand." He stated "this tastes pretty good." Poison Control was called and the contact directed that fluids be pushed. Fluids were encouraged and the resident was monitored. No negative resident outcome was identified at that time. Review of the 12/27/12 Fifteen Minute Checks Page #2 failed to identify safety checks that occurred prior to 1415 (2:15 p.m.) on 12/27/12. Safety check documents were provided and reviewed with the Staff Development Director on 1/18/13. According to the 12/27/12 facility investigation, updated on 12/31/12, nail polish was out on the counter at the nurses station on 12/27/12 as staff had been assisting a patient with her nails. On 1/18/13 at approximately 1:10 p.m. Staff Member E, the investigative LN, stated on 12/27/12 someone, thought to be Staff Member D, found the resident behind the desk in the nurses station with a bottle of nail polish remover "mostly gone" with approximately 1/4 of the fluid in the pink bottle left. The resident had made the statement that "it tastes good." The bottle had been discarded after discovery . Staff Member D, a LN, was interviewed on 1/18/13 at approximately 4:45 p.m. and recalled she was administering medications on 12/27/12 during day shift. She had last seen the resident in his room before breakfast and had directed staff to get him up. Some time later, Staff Member D found the resident unattended in the nurses station. The gate to the nurses station was open and he had a cup of coffee in one hand and a bottle of nail polish remover in the other hand. The Charge Nurse was away from the nurses station attending the morning stand-up meeting at that time. Staff Member D reported the incident to the Resident Care Manager for follow-up. Staff Member D stated a caregiver had used polish and the polish remover the evening before and it was left at the nurses station until it could be returned to the activity department. When interviewed on 1/18/13 at approximately 5:25 p.m., the Activity Director identified the brand of nail polish remover used by the facility. The eight ounce pink bottle was strawberry scented. The warning label included cautions such as: "Keep away from children...Do not breathe the vapors...Harmful if taken internally. If ingested seek medical attention immediately and contact the local poison control center. In case of eye contact, flush with water and seek medical attention..." Staff Member G, a NA, was interviewed on 1/21/13 at approximately 9:25 p.m. and recalled obtaining nail care supplies, polish and remover, from the activity department (on 12/26/12) and she had painted a resident's nails. The NA placed the polish and remover at the nurses station with a plan to have it returned to the activity department the next day. Staff members were aware of the nail care products at the nurses station. On evening shift the gate was reportedly usually closed. Resident #1 was often kept in the area of the nurses station, in front of the desk and occasionally behind it. The cognitively impaired resident was frequently brought behind the nurses station for staff supervision, an intervention described in his plan of care. On 12/27/12 the resident was found unattended at the nurses station. Facility staff failed to ensure the resident was adequately supervised in order to prevent access to potentially harmful products/chemicals.

Based on record review and interviews the facility failed to : A) provide services to restore as much normal bladder function as possible for 1 of 1 sampled resident (#159) with an avoidable decline in urinary function and B) provide appropriate, timely catheter care for 1 of 2 sampled residents (Resident #167) with [MEDICAL CONDITION] catheters in accordance with physician's orders [REDACTED]. Findings include: Resident # 159: Review of the medical record revealed the resident was admitted to the facility on [DATE] following an acute infection that impacted her nerves and muscle function leaving her paralyzed and totally dependent for all her care. She was admitted to the facility for rehabilitation. A nursing progress note on 6/23/11 documented a report from the sending hospital on the resident's condition. The reporter stated the resident was alert and oriented, cooperative with care but was very weak and unable to bear weight. From the neck down she was flaccid and had no strength in her extremities. "She uses a bed pan..." According to the 6/23/11 facility admission assessment the resident was continent of bladder and used a bedpan. Her care plan identified she was continent and was to be on a toileting program with assistance to void upon awakening, before meals, before activities, and as needed. The resident's 6/29/11 comprehensive assessment documented the resident used a bedpan and was scored as a "1", only occasionally incontinent of bladder. Further review of the nursing documentation revealed the resident was continent on 6/24/11. The 6/2011 Bladder Continence Report with data from the nursing assistants performing care documented bladder incontinence beginning on 6/28/11. A 7/12/11 nursing assessment documented the resident was continent but she was on a check and change program (check for incontinence and change the disposable brief as needed). The 7/2011 Bladder Continence Report revealed the resident started the month typically continent with occasion continence but after 7/06/11 the report showed persistent incontinence. There was no assessment related to the change in the resident's continence. The resident's plan of care continued without change documenting the resident was continent and on a toileting program as initially identified. At the time of the 9/17/11 quarterly assessment, nearly three months after admission, the resident was scored as a "3" always incontinent of bladder and there was no toileting program in place. Despite documentation of the change in the resident's continence, there was no reassessment in the medical record identifying why the resident had declined in her urinary continence despite advances in other areas of her rehabilitation. On 10/27/11 at approximately 3:35 pm the resident stated she wore incontinent briefs and staff were good about changing and cleaning her. She had attempted to use a bedpan in the past but had some urgency and was unable to wait until help arrived at times. Staff told her it was easier this way (wearing briefs) and they didn't mind cleaning her up. The resident further stated she had made alot of progress in her therapy and she demonstrated how she was able to move her arms. On 10/28/11 at approximately 8:45 a.m., NA #D stated the resident was aware when she needed to be changed (when she urinated). The NA was not using the bedpan for the resident. The Rehab Director was interviewed on 10/28/11 at approximately 9:00 a.m. and discussed the resident's therapy plan. She stated therapy was not involved in a toileting program. When interviewed on 10/28/11 at approximately 10:10 a.m. and 10:28 a.m., LN # E stated there was no reassessment of the resident following the identified change/decline in her bladder function noted in the 9/17/11 assessment. LN #E also stated the care plan was inaccurate, the resident was not continent or on a toileting program. The LN further stated the resident would "probably benefit from a toileting program and an evaluation (medical)". The facility failed to identify the cause of the change in the resident's demonstrated continence shortly after admission and failed to ensure the appropriate plan of care was implemented. Direct caregivers offered brief changes in lieu of bedpan use and the resident was conditioned to accept the care resulting in decreased continence. The resident signaled staff after she had voided to receive a brief change. Despite a change in urinary incontinence also documented approximately three months later during the quarterly assessment, the facility failed to recognize the change and reassess the resident for physical, mental, or psychosocial factors that might have contributed to her decline in continence. Resident #167: admitted to the facility from the hospital on [DATE] with a [MEDICAL CONDITION] catheter. Review of a physician's orders [REDACTED]. Review of Treatment Records between July-October 2011 revealed no documentation staff had changed the retention catheter as ordered. An interview on 10/26/11 at 11:55 a.m. with the resident's spouse revealed the resident had not had his catheter changed since date of admit. She stated she would definitely know if that had occurred as she was there most of the day. An interview with Licensed Nurse # B on 10/26/11 at 12:00 noon revealed the retention catheter was to be changed monthly per physician's orders [REDACTED].

Based on interview and record review the facility failed to ensure that 1 of 4 sampled residents (#1) received care and services that maintained optimal health, prevented the deterioration of their health and/or received timely emergency services. The facility failed to recognize Resident #1's decline in health as an emergent concern. This failure resulted in harm to Resident #1. The situation was determined to be an Immediate Jeopardy. The Immediate Jeopardy was determined to be abated on 03/15/11 after an onsite partial extended visit to the facility. Findings included: Resident #1. The [AGE] year old female had a documented history of asthma, hypertension, diabetes type 2, sleep apnea and a right shoulder joint replacement. She was independent with walking and required a front wheeled walker for long distances. She had previously not required supplemental oxygen. The resident had been injured in the right shoulder on the job and the subsequent surgery had been planned as a same day surgery. However, the resident had planned to stay for 2 days at the nursing facility due to living alone and needing some help initially after the surgery. On 02/02/11 at approximately 5:00 p.m. the resident was admitted to the facility after having a surgical fixation of her right shoulder earlier that day. She was noted to be "alert and oriented x 3 (alert to person, place and time)," and "able to answer questions appropriately." Additionally, her room air (RA) oxygen saturation (02 sat) was 90 %. (Normal oxygen saturation is 90% and above. Below normal levels may cause respiratory distress, confusion and restlessness. ) She was given 2 liters of concentrated oxygen. However, the physician protocol/standing orders for use of oxygen stated "may initiate 02 to keep sats (greater than) 88%." The resident did not fit the physician protocol to start oxygen treatment. On 02/03/11 at approximately 9:00 a.m. the progress notes documented the resident was unable to participate in activities of daily living due to shortness of breath (SOB) and anxiousness. She had made multiple requests for breathing treatments (and gotten them) and her 02 sats were at 80 to 88%. She was unsteady with walking and required limited assistance to walk and extensive assistance to transfer. On 02/04/11 at approximately 10:20 a.m. Licensed Nurse (LN) #1 documented in the progress notes the resident had , "pallor poor "(pale skin), 02 sat 80 to 88%, was unable to answer questions appropriately, was unsteady and needing extensive assistance to bed and with bed mobility. At that time she was on 5 liters of oxygen, the limit of what the nursing could give to her per the oxygen concentrator setting, and her 02 sat was 90%. On 03/10/11 at approximately 8:45 a.m. LN #1, (the LN on duty on 02/03/11) stated she didn't feel the doctor needed to be called for the 02/03/11 concerns as the resident appeared clearer, less confused, after spending more time with her. However, when the resident's presentation worsened on 02/04/11 she did call the surgeon and the pulmonologist (lung specialist) to let them know of her changes. She did not get an order at that time, but instead got a cell phone number from the doctor's nurse (the pulmonologist) to call if the resident's condition worsened. On 02/04/11 at 3:08 p.m., 5 hours later, a progress note documented a returned call from the pulmonologist stating if the resident became SOB and had further lowering of her oxygen levels to send her to the emergency room (ER) for evaluation and treatment. On 03/10/11 at approximately 8:00 a.m. the Director of Nursing stated at each change of shift the nurses report changes in the residents' conditions to the on-coming shift. "Any thing going on with her (Resident #1) would have been reported to the next shift on." "We don't keep the reports." On 02/04/11 at 5:22 p.m. the progress note documented the resident continuously took off her oxygen nasal cannula and her 02 sats fell into the 62% to 72% range "very quickly." A call was being placed to her sister who was told of the problem of "non-compliance" (not cooperating with following the nurses directions) and the sister was coming in to sit with the resident "to help her be compliant." The physician was not notified at that time despite the resident having had a significant change in her room air oxygen saturation from her admission status of nearly 30%. On 03/08/11 at approximately 12:30 p.m. the family member of the resident stated she had been called by LN #2 and asked to come into the facility on [DATE] at approximately 5:00 p.m. She stated the nurse had said, "she (the resident) is restless and confused and we are low on staff and we can't take care of her." "Can you come and sit with her?" The family member arrived to the facility shortly after. The family member further stated the resident had not been confused in the past and when she arrived at the nursing home that night and the resident was really confused and exhausted. "I went to the nurse 4 or 5 times with different symptoms....she was really red and hot all over, she felt like she was short of breath even with her oxygen on." When the family member went to LN #2 to share the concerns of shortness of breath the nurse stated, " I have already called the lung doctor and they said we could send her to the ER (emergency room ) but they would probably send her back." "When I went back to tell my sister they were nto going to send her to the ER she looked depressed....(resident's name) was having trouble moving around and looked like she might fall out of bed and having trouble moving when she was in bed so, I went to the nurse and asked for a bedrail and she just flat out said NO!...A little later the nurse came in the room and knelt in front of her and stated, "you are just fine, we have old people that are really ill and other sick people and we have 2 ambulances going out to the hospital right now, so can I get you to cooperate?" "My sister hung her head and asked the nurse, am I going to die?" The nurse replied, "no you are not, you are going to be just fine." The family member stated the nurse left and another nurse came in with two pills. The resident took them and didn't say much else and went to sleep. On 03/08/11 at approximately 7:40 p.m. LN # 2 stated she remembered the family member of the resident coming and talking to her on the night of 02/04/11. "It was a needy family." The LN stated she had a concern with non-compliance because the resident was taking her oxygen off. Additionally, she stated that after the resident had her window opened for her and fan put in her room she had settled down. She further stated there had been , "real distressed residents that night (and named them) who had to be sent to the ER by ambulance." She further stated she had recalled the family member had asked for a bedrail on the bed because of the way the resident was sitting on the bed and having trouble moving herself around. LN #2 stated she had put in a request to the rehabilitation department to evaluate the resident for falls. The LN failed to recognize the family members multiple visits to the nurses' station with concerns for her sister were possibly not "needy" but instead real attempts to get medical attention focused on the resident who she had not seen in that condition prior to that night. Additionally, the LN failed to consider the resident's continuing change of condition shared during change of shift report, the resident's present condition (oxygen saturation dropping quickly when oxygen off) on her shift and the family members concerns as an emergent situation. On 02/04/11 at 11:19 p.m. the resident had a blood pressure reading of 146/121 (normal is approximately 120/80.) No re-check of the blood pressure was done. On 02/04/11 the progress notes documented at 2:05 a.m., the resident had fallen out of bed and landed face down on the floor, she was cyanotic (blue around her lips/facial area from lack of oxygen) and would not respond to verbal stimuli. Her pulse was 40 (normal = 60 to 90 average) and respirations were 10-12 per minute and shallow (normal average = 12 to 16.) The nursing staff was unable to obtain an oxygen level or blood pressure. The Emergency Response Team (911) was called. On 02/05/11 at 2:06 the City Fire Department (CFD) arrived at the scene. The incident report from the CFD documented the resident was "blue in color and did not have a pulse." The resident was propped up against her wheelchair and unresponsive upon arrival and the E-93 (fire department response team member) "slid patient so her back was flat on the floor, began chest compressions and placed the AED (electrically charged pads that send electricity to the heart in an attempt to restart it) pads on her." "Staff advised she was just admitted three days ago post shoulder surgery." On 03/08/11 at approximately 10:30 p.m. LN #4 stated the resident had a bump and bruise on her forehead after the fall. He had noted it after he turned her head to put her oxygen back on at 2 liters. A written statement, dated 03/10/11, from LN #3 documented the resident had been sitting propped up against a chair when she entered the room. The resident's "head was dropped down - resident was not responsive." The facility failed to recognize the resident's serious change of condition since admission. When the resident's concentrated oxygen came off her oxygen saturation rapidly decreased by almost 30% down to 62% - 72 % from her baseline of 90% on room air. She was confused, restless and had a significant increase in her blood pressure and it was not rechecked. Finally, after falling off of her bed and possibly landing on her forehead (hence the bruise that had been noted by LN #4) the nursing staff rolled her over and instead of leaving her lying on the floor they sat her up and propped her against a wheelchair letting her head fall to her chest. Her head falling to her chest placed the resident at risk for advancing a possible neck injury from the fall and/or that same position further decreased the effectiveness of her oxygen intake, shallow as it had already been noted.

Based on interview and record review the facility failed to ensure 1 of 2 residents (#1) in the sample of 13 were supervised to prevent a fall despite having had knowledge of the resident being at risk for falls due to multiple concerns such as difficulty breathing, difficulty moving and positioning, confusion and restlessness. The lack of prevention and supervision resulted in harm to the resident on [DATE] when she fell from her bed. The resident sustained [REDACTED]. Additionally, after the fall the nursing home staff placed the resident in a seated position that may have further compromised her situation and did not follow the basic CPR (Cardio Pulmonary Resuscitation) guidelines. Findings included: Resident #1. On [DATE] at approximately 5:00 p.m. the resident admitted to the facility after having undergone a right shoulder repair surgery. She had arranged to stay at the facility for approximately two days for the extra assistance as she lived at home independently and felt she would need the help. She had multiple health [DIAGNOSES REDACTED]. A progress note, dated [DATE] at 5:09 p.m., documented the resident was "oriented x 3" (oriented to person, place and time) and while she appeared anxious she was able to answer all questions appropriately and "is a good historian." Her oxygen saturation on room air (without the use of oxygen supplementation) was at 90 percent (%) when she entered the facility. During her approximate 2 ,[DATE] day stay at the facility she began taking off her oxygen nasal cannula and her oxygen level had been noted to drop to the low 80's when she was not wearing the nasal cannula. On [DATE] at approximately 3:10 a.m. Nursing Assistant (NA) #1 stated "I took care of her a lot, she was confused a lot, she would call out a lot and say she was too hot." "She was confused and always sat on the edge of her bed at night and didn't sleep well." "She had a habit of sitting on the side of her bed and leaning over on her bed side table." The NA demonstrated the resident's posture to the surveyor - arms spread out and forward while leaning forward from her chair with her elbows on the table. On [DATE] a written statement from LN #4 noted the resident's "baseline mental status was confused." That was not congruent with the admit assesment describing the resident as alert and oriented and a good historian. The resident had a same day shoulder surgery on [DATE] and within a day began exhibiting confusion, restless and shortness of breath. That was a significant change from her admit assessment. Her family member had told the staff of her concerns regarding the residents confusion, restlessness and shortness of breath. Additionally, the family member had alerted LN #2 regarding her own concern for the possibility of the resident falling from her bed due to the confusion, restlessness as well as the way she had been sitting on her bed and having difficulty moving in her bed. Despite the noted changes from staff and the family member drawing further attention to the resident's significant changes from her normal baseline, the facility failed to send the resident for further medical evaluation. Further, the staff noted the resident's risk for falls and the family member's stated concern regarding the resident's risk for a fall and they failed to further evaluate and provide a preventative safety plan to protect the resident. Cross reference F309 the facility failed to ensure care and services were provided.