Every finding on record at Life Care Center Of Federal Way

Based on observation, interview and record review, the facility failed to ensure accurate and complete pre/post Hemodialysis (HD- mechanical way of eliminating waste from the body when the kidneys no longer functioned) for 4 of 4 residents (Residents 55,11, 62, & 94) reviewed for Dialysis. This failure placed the residents at risk for unintended health consequences and decreased quality of life.Findings included.<Policy>According to a facility policy titled, HD Offsite, dated 09/16/2025, the facility would ensure each resident received care and services for the provision of HD including day of HD assessment of the resident's condition and monitoring for complications before and after dialysis treatment. <Resident 55> According to the 05/08/2026 admission Minimum Data Set (MDS – an assessment tool) Resident 55 admitted to the facility on [DATE]. The MDS showed Resident 55 had a diagnosis of End Stage Renal Disease (ESRD – a disease where the kidneys no longer function to sustain life without treatment) dependent on HD treatment and received HD during the assessment period. Review of Resident 55's health records showed a 05/05/2026 physician order for HD three times a week, every Tuesday, Thursday, and Saturday. Review of Resident 55's pre/post HD assessments showed the 05/07/2026, 05/09/2026, 05/12/2026, 05/14/2026, 05/16/2026, 05/19/2026, 05/21/2026, 05/23/2026, 05/26/2026, and 05/28/2026 assessments were incomplete and/or inaccurate. In an interview on 05/27/2026 at 9:21 AM Resident 55 stated they received HD treatments three times a week at an outside Dialysis Center. Resident 55 stated staff did not perform an assessment of their dialysis site or listen to their lungs before or after HD treatments. <Resident 11> According to the 04/14/2026 Quarterly MDS Resident 11 re-admitted to the facility on [DATE] with diagnoses of ESRD, dependence on HD, and a heart condition. Review of Resident 11's health record showed a 01/02/2026 order for HD three times a week every Monday, Wednesday, and Friday as well as supplemental treatments as needed. Review of Resident 11's pre/post HD assessments showed the 01/05/2026, 01/07/2026, 01/09/2026, 01/12/2026, 01/14/2026, 01/16/2026, 01/21/2026, 01/26/2026, 1/30/2026, 02/02/2026, 02/04/2026, 02/06/2026, 02/09/2026, 02/11/2026, 02/20/2026, 02/23/2026, 02/27/2026, 03/04/2026, 03/06/2026, 03/07/2026, 03/09/2026, 03/13/2026, 04/03/2026, 04/06/2026, 04/08/2026, 04/10/2026, 04/13/2026, 04/17/2026, 04/20/2026, 04/22/2026, 04/27/2026, 04/29/2026, 04/30/2026, 05/01/2026, 05/04/2026, 05/22/2026, 05/25/2026, and 05/27/2026 assessments were incomplete and/or inaccurate. In an interview on 05/28/2026 at 8:57 AM Resident 11 stated staff do not do an assessment before they leave the facility to go to dialysis, they only get vitals before they go and when they get back from the dialysis center. <Resident 62> According to the 05/07/2026 Quarterly MDS Resident 62 admitted to the facility on [DATE] with diagnoses of ESRD, dependence on HD, and muscle weakness. Review of Resident 62's health records showed a 03/25/2026 order for HD three times a week on every Monday, Wednesday, and Friday. Review of Resident 62's pre/post dialysis assessments showed the 04/24/2026, 04/27/2026, 05/01/2026, 05/04/2026, 05/06/2026, 05/08/2026, 05/11/2026, 05/13/2026, 05/15/2026, 05/18/2026, 05/20/2026, 05/22/2026, 05/25/2026, 05/27/2026, and 05/29/2026 were incomplete and/or inaccurate. <Resident 94> According to the 05/25/2026 admission MDS Resident 94 admitted to the facility on [DATE] with diagnoses including ESRD, Dependence on HD, and high blood pressure. Review of Resident 94's health records showed a 05/20/2025 order for HD on every Tuesday, Thursday, and Saturday. Review of Resident 94's pre/post dialysis assessments showed the 05/23/2026, 05/28/2026, and 05/30/2026 assessments were incomplete and/or inaccurate. In an interview on 05/29/2026 at 12:17 PM Staff F (Unit Care Coordinator) stated dialysis pre/post assessments should be completed fully as they can be a life saving process to prevent infections and catch complications related to dialysis. Staff F reviewed dialysis assessments and stated they were not completed and/or were inaccurate. In an interview of 06/03/2025 at 8:45 AM Staff B (Director of Nursing) stated dialysis pre/post assessments should include a general health assessment of the resident as well as a focused dialysis assessment to confirm the HD site does not have abnormal bleeding or signs of infection, as well as to monitor for potential complications such as low blood pressure. Staff B stated the dialysis assessments for Resident 55, Resident 11, Resident 62, and Resident 94 were not completed to expectations. Reference: WAC 388-97-1900(1)(6)(a-c).

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored under sanitary conditions in accordance with professional standards of food safety requirements for 1 of 1 facility kitchens observed. The failure to prepare ready-to-eat foods using sanitary practices and inconsistently monitoring refrigerator and freezer temperatures as required placed residents at risk for ingesting unsafe and/or contaminated food and the development of foodborne illness. Findings included <Facility Policies>The facility policy, Safe Food Handling, revised 05/26/2026, showed all foods prepared and stored were handled using accepted food-handling practices according to federal, state, and local requirements. The policy showed the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The policy showed safe food distribution processes involved refrigeration which was necessary for cold temperature control of potentially hazardous food. The policy showed the facility would ensure food temperatures did not fall in the Danger Zone (temperatures above 41 degrees Fahrenheit [F] and below 135F) for food safety and to limit the growth of pathogens such as bacteria and viral organisms capable of causing foodborne disease. The facility policy, Refrigerator/Freezer Temperature Log, revised 04/29/2025, showed the freezer temperature must remain at zero (0) F or below, and the refrigerator temperature should be maintained at or below 41F. The log showed if the temperatures were not within these ranges, the staff must notify the Director of Food and Nutrition Services or Maintenance immediately. The log showed kitchen staff were instructed to monitor and check the refrigerator and freezer temperatures twice; in the morning (AM) and evening (PM), and to log the result.<Food Preparation - Ready-To-Eat Foods>In an observation on 06/01/2026 at 11:02 AM during lunch service meal preparation, Staff P (Dietary Aide) was observed preparing three plates of garden side salad. Staff P gathered a metal pan of cheese and meats (diced cooked chicken and ham) wrapped in zip lock bags from the refrigerator and set them on top of a plastic tray. Staff P washed their hands, put gloves on, grabbed pre-cut vegetables, cheese, and meats, and placed them on the plates. Staff P moved the metal pan of cheese and meats aside from the plastic tray, touched multiple food preparation surfaces, grabbed some tomatoes, and sliced them on top of plastic tray where the metal pan previously sat on. Staff N (Food Services Director) told Staff P not to use the plastic tray and to cut the tomatoes using a cutting board. Staff P, still with their contaminated gloves on, took a cutting board and continued preparing the garden salad without washing their hands and changing their gloves. In an interview on 06/01/2026 at 11:17 AM, Staff P stated they should have removed their contaminated gloves, washed their hands, and donned new clean gloves before proceeding with the preparation of the green side salad but they did not. In an interview on 06/01/2026 at 11:22 AM, Staff N stated they expected all dietary staff to avoid cross-contamination during food preparation. Staff N stated it was important for the kitchen staff to ensure sanitary practices were observed at all times especially when handling and preparing ready-to-eat foods to prevent foodborne illness. <Refrigerator #1>In an observation and record review on 05/27/2026 at 8:41 AM, the temperature reading for Refrigerator 1 was observed to be 37F. Review of Refrigerator 1's May 2026 temperature log showed the AM refrigerator temperature was 47F on 05/06/2026 and 42F on 05/18/2026; both temperatures fell in the danger zone and were unsafe. The log showed the kitchen staff did not monitor the AM temperature on 05/24/2026 and the PM temperature on 05/25/2026. A pre-filled AM temperature of 40F for the following day (05/28/2026) was observed written on the log and was initialed by a kitchen staff. <Refrigerator #2>Review of Refrigerator 2's May 2026 temperature log showed the kitchen staff did not monitor the PM temperature on 05/25/2026. <Refrigerator #3>Review of Refrigerator 3's May 2026 temperature log showed the kitchen staff did not monitor the PM temperature on 05/25/2026. <Freezer #6>In an observation and record review on 05/27/2026 at 9:19 AM, the temperature reading for Freezer 6 was observed to be -2F. Review of Freezer 6's May 2026 temperature log showed the PM temperature was 1F on 05/18/2026 which was an unsafe temperature. The logs showed the kitchen staff did not monitor the PM temperature on 05/25/2026. Pre-filled AM temperatures of 1F for 05/28/2026 and -2F for 05/29/2026 were observed written on the log and were initialed by a kitchen staff. <Freezer #7>Review of Freezer 7's May 2026 temperature log showed the AM freezer temperature was 2F on 05/18/2026 and 1F on 05/19/2026; both were outside the facility's set parameters as indicated in the log. The log showed the kitchen staff did not monitor the PM temperature on 05/18/2026. In an interview on 05/27/2026 at 9:25 AM, Staff N stated they were not notified regarding the unsafe temperatures recorded in the logs and was not aware of the inconsistent monitoring of the refrigerator and freezer temperatures. Staff N stated the kitchen staff should not pre-fill the refrigerator and freezer temperature reading in the log because it was unsafe. Staff N stated they expected the kitchen staff to consistently monitor the temperature of refrigerators and freezers and to document the actual temperature readings. Staff N stated they expected the kitchen staff to notify them if/when temperatures fell outside of the set parameters so they could act accordingly to ensure food and resident safety. REFERENCE: WAC 388-97-1100 (3), -2980.

Based on interview and record review, the facility failed to ensure grievances and concerns communicated during Resident Council meetings were addressed timely, or to respond and provide a rationale for their response, for 1 of 1 Resident Council groups reviewed. This failure placed residents at risk for unmet needs, frustration, untimely resolution of grievances, and a diminished quality of life.Findings included.<Facility Policy>Review of a Resident Council policy, reviewed 09/26/2025, showed the facility must consider to review concerns in resident groups and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The facility must be able to demonstrate their response and rationale for their response.<Resident Council>In a joint interview on 06/01/2026 at 1:16 PM, Resident 20 and Resident 51 stated the facility did not do anything about many of the complaints and recommendations brought up at Resident Council.<January 2026>Review of Resident Council meeting minutes, dated 01/21/2026, showed multiple grievances and concerns were discussed, including the following:Facility doors were locked and residents were not feeling they could go in/out of building.Residents were having difficulty reaching the Social Services department to address needs.Review of a January 2026 Grievance Log showed no Resident Council concerns were logged.<February 2026>Review of Resident Council meeting minutes, dated 02/26/2026, showed no documentation that follow-up from the January 2026 meeting was communicated to residents. Multiple new grievances and concerns were discussed, including the following:Rooms had chipped paint, scratches, and were depressing.Concerns about cold food.Requests for visitor chairs in resident rooms.A resident's family member expressed concerns about limited rehab preventing the resident from returning home.Limited availability of coffee, and cold coffee.Delayed call light response times, staff using phones, staff sleeping on shift, staff socializing instead of assisting residents.Concerns about a resident who made noise at night.Review of a February 2026 Grievance Log showed no Resident Council concerns were logged.<March 2026>Review of Resident Council meeting minutes, dated 03/18/2026, showed the prior month's meeting minutes and old business were reviewed. No documentation was provided to show how reported concerns were addressed or the facility's response, including rationale. Multiple new grievances and concerns were discussed, including the following:Reports of CNA's sitting at nurse's station, sleeping.A resident yelled all night, staff ignored them and did nothing to help calm them down.A resident reported her clothes were shrinking in the laundry.Review of a March 2026 Grievance Log showed no Resident Council concerns were logged.<April 2026>Review of Resident Council meeting minutes, dated 04/15/2026, showed the prior month's meeting minutes and old business were reviewed. No documentation was provided to show how reported concerns were addressed or the facility's response, including rationale. Multiple new grievances and concerns were discussed, including the following:No improvement with noise at night in hallways.Cold food, due to CNA's not passing trays out when meal carts arrived in hallways.A resident stated there was always something missing from their meal tray.Residents request coffee to be available throughout the day.Review of an April 2026 Grievance Log showed no Resident Council concerns were logged.<May 2026>Review of Resident Council meeting minutes, dated 05/20/2026, showed the prior month's meeting minutes and old business were reviewed. No documentation was provided to show how reported concerns were addressed or the facility's response, including rationale. Multiple new grievances and concerns were discussed, including the following:CNAs yelled down the hallways at each other during the night.CNAs were not offering snacks to residents after dinner, per the facility menu.Complaints that a dog in a resident room barked all night, and a resident in the same room yelled, cursed, and threw things day and night.A resident needed batteries changed for the hand sanitizer dispenser in their room.A resident who returned from the hospital did not receive all their belongings back upon return because of a room move.Review of a May 2026 Grievance Log showed no Resident Council concerns were logged.In an interview on 06/01/2026 at 2:13 PM, Staff V (Activities Director) stated they helped arrange Resident Council meetings and wrote the minutes. Staff V stated when a concern was brought up that warranted a grievance card, the resident would take the initiative to write one. Staff V stated the only time they would write a grievance card was when a resident could not write it themselves. Staff V stated immediately after Resident Council meetings, they went to Staff A's (Administrator) office or the Social Services office and reviewed their notes. Meeting minutes were sent to the various departments, managers, and QAPI (Quality Assurance & Performance Improvement) committee for review and follow-up.In an interview on 06/03/2026 at 8:01 AM, Staff A (Administrator) stated it was their expectation that when concerns were reported at Resident Council, staff would offer the resident a grievance card or offer to complete one for them. Concerns were to be logged into the Grievance Log and follow the grievance process, with documentation to show how the concern was resolved or the facility's response with rationale when it could not be resolved. Staff A stated staff should inform the Resident Council at each meeting of the facility's actions taken to resolve the prior month's concerns. Staff A stated their Resident Council process needed to be better, and they planned to educate staff on the need to document reported concerns and actions taken. REFERENCE: WAC 388-97-0920(5).

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR or PASARR- a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) Level 2 referrals were coordinated timely for 2 of 3 residents (Residents 12 & 56) reviewed for PASRRs and 1 of 5 residents (Resident 38) reviewed for Unnecessary Medications. This failure placed residents at risk of inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included.<Facility Policy>According to the 09/26/2025 Pre-admission Screening and Resident Review (PASARR) policy, the facility would ensure potential admissions were screened for possible serious mental disorders or intellectual disabilities and related conditions. The initial pre-screening (PASRR Level 1) was to be completed prior to admission to the facility. If the PASRR Level 1 screening was positive, an in-depth evaluation of the potential resident (PASRR Level 2) was to be completed by the state-designated authority prior to admission to the facility. Recommendations from the PASRR Level 2 determination and evaluation report were to be incorporated into the residents' Care Plan (CP). <Resident 12> According to the 05/04/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 12 re-admitted to the facility on [DATE], was severely cognitively impaired, had unclear speech, and had diagnoses including depression and stroke with weakness to one side of their body. The MDS showed Resident 12 demonstrated verbal and physical behaviors toward others and received antipsychotic, antianxiety, and antidepressant medications during the assessment period. Observation and interview on 05/27/2026 at 11:01 AM showed Resident 12 was lying in their bed awake and did not respond to any questions. Observation and interview on 05/28/2026 at 9:42 AM showed Resident 12 was sitting up in a wheelchair in the hallway. During interview at this time, Resident 12 smiled and responded with unclear speech, stating they were fine. Review of a 10/20/2025 Level 1 PASRR completed by hospital staff showed no serious mental illness (SMI), and a Level 2 referral was not required. Review of a 12/29/2025 Level 1 PASRR completed by the facility Staff showed Resident 12 had a significant change in condition on 10/29/2025 and Resident 12 had SMI. No box was checked to show which SMI Resident 12 had. Section 4 on the Level 1 PASRR form showed a Level 2 evaluation referral was required for significant change for Resident 12. Review of Resident 12's record on 06/01/2026 showed no evidence that a PASRR Level 2 evaluation was completed. In an interview on 06/01/2026 at 9:15 AM, Staff G (Social Services Director) acknowledged the Level 1 PASRR did not accurately reflect Resident 12's SMI (depression). Staff G stated Resident 12 was admitted to hospice care on 10/29/2025 and the facility updated the PASRR Level 1 on 12/29/2025 with the significant change. Staff G stated they sent a Level 2 referral form to the State authority for evaluation on 12/29/2025 and did not follow up for any recommendations. Staff G stated they should follow up for Level 2 evaluations every month, but they did not. <Resident 56> According to the 04/24/2026 admission MDS, Resident 56 admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder (a mental health condition that causes extreme, cyclical shifts in mood, energy, and activity levels). In an observation and interview on 05/27/2026 at 10:17 AM, Resident 56 became tearful when they discussed wanting to visit their family member. Resident 56 stated they were stressed out and it would be nice to talk to someone. Resident 56 stated they were offered therapy for mental health, but nothing had been done to date. Review of a PASRR Level 1 Pre-admission Screening, dated 04/17/2026, showed a hospital social worker completed the screening and determined Resident 56 showed indicators of serious mental illness and required a Level 2 evaluation referral. Review of an e-mail communication, dated 04/17/2026, showed a state agency received the PASRR Level 2 referral. Review of Resident 56's record on 06/03/2026 showed no documentation of a PASRR Level 2 determination or evaluation report. In an interview on 06/03/2026 at 8:52 AM, Staff G stated a hospital social worker sent Resident 56's PASRR Level 2 referral to a state agency, and Staff G did not know what happened from there. Staff G said the facility was now using a different state agency for their PASRR Level 2 evaluations, and Resident 56's may not have been transferred over to them. Staff G stated they did not follow up on the status of the PASRR Level 2 but should have. <Resident 38> According to the 04/09/2026 Quarterly MDS, Resident 38 admitted to the facility on [DATE] with diagnoses including stroke, anxiety, and bipolar disorder. The MDS showed Resident 38 had hallucinations and physical behaviors directed toward others in the review period. Review of Resident 38's health record showed a hospital-submitted PASSR, dated 01/08/2026, with an exemption not requiring a Level 2 evaluation. Resident 38's health records showed a corrected PASSR was submitted on 01/12/2026 requiring a PASSR Level 2 evaluation. There were no notes indicating follow up with the PASSR evaluator, an evaluation being completed, or a PASSR Level 2 determination on file for Resident 38. In an interview on 06/01/2026 at 12:31 PM, Staff G stated Resident 38's Level 2 referral was sent to the PASSR evaluator in January 2026, though no evaluation had occurred and no Level 2 determination was on file. Staff G stated they had not followed up with the PASSR evaluator but should have. REFERENCE: WAC 388-97-1915(4).

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff for daily cares received the assistance they were assessed to require for 5 of 9 sample residents (Residents 5, 10, 12, 21, & 25) reviewed for Activities of Daily Living (ADL). The failure to provide nail care, oral care, bathing, and shaving assistance left residents at risk for embarrassment, poor personal hygiene, and other negative health outcomes. Findings included . <Facility Policy> The facility policy titled, ADLs, revised 09/04/2025, showed the facility must ensure residents received treatment and care in accordance with professional standards of practice, the resident's comprehensive and person-centered Care Plan (CP), and the resident's choices. The policy showed a resident who was unable to carry out ADLs would be provided the necessary assistance to maintain good personal and oral hygiene.<Resident 5> According to the 03/06/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 5 had no memory impairment. The MDS showed Resident 5 required maximum assistance with showers and was dependent on staff for complete transfer to shower assistance. The assessment showed Resident 5 had diagnoses of general muscle weakness and adult failure to thrive. Review of a 01/10/2025 ADL self-care performance deficit CP showed Resident 5's bathing preferences were showers twice weekly and required two staff assist with transfers to shower. Review of Resident 5's May 2026 bathing documentation showed no shower was offered or provided since 05/12/2026. In an interview on 05/28/2026 at 9:26 AM, Resident 5 stated staff did not offer or provide a shower per their preference for three weeks. Resident 5 stated they asked staff when they could get a shower and staff told them Tuesday, but they still had not been offered one. Resident 5 stated they preferred showers at least twice a week and expressed that to several staff members. In an interview on 06/01/2026 at 2:03 PM, Staff B (Director of Nursing) stated they expected staff to offer and provide showers per shower schedule and residents preferences per their CP. Staff B reviewed Resident 5's health records and stated staff did not offer or provide a shower since 05/12/2026 but should have. Staff B stated it was important to offer and provide showers per resident preference for resident rights. In an interview on 06/02/2026 at 8:12 AM, Staff E (Unit Care Coordinator) stated Resident 5 was scheduled to receive a shower every Tuesday and Friday. Staff E reviewed Resident 5's health records and stated staff had not offered or provided a shower since 05/12/2026 but should have per the residents' preferences in their CP. Staff E stated it was important to follow resident preferences for bathing to ensure staff were compliant with resident's rights. <Resident 10> According to the 05/11/2026 admission MDS, Resident 10 had impaired memory and required substantial to maximal assistance with bathing and personal hygiene. The 05/05/2026 ADL self-care performance deficit CP showed Resident 10 required two-person assistance with their personal hygiene. The CP included directions for staff to check Resident 10's nail length, clean and trim them during Resident 10's bath day and as needed. Observation on 05/27/2026 at 3:30 PM showed Resident 10 had long, dirty fingernails. Resident 10's fingernails extended past the tip of their fingers and had black debris under the nail beds. This observation showed Resident 10's toenails were long and chipped. On 05/28/2026 at 10:27 AM, Resident 10 was observed lying in their bed and fingernails remained untrimmed. Review of Resident 10's medical record showed there was no documentation Resident 10 preferred long nails or refused nail care. In an interview on 06/01/2026 at 12:41 PM, Staff E stated they expected staff to provide ADL assistance to all residents including personal hygiene. Staff E stated staff should clip Resident 10's fingernails and toenails on shower days and as needed, but they did not. <Resident 12> According to the 05/04/2026 Quarterly MDS, Resident 12 had a stroke with left-sided weakness and was totally dependent on staff for their personal hygiene. The assessment showed Resident 12 had impaired memory, impaired vision, and had rejection of care during the assessment period. The 02/05/2026 revised ADL self-care performance deficit CP showed Resident 12 was totally dependent on staff for their personal hygiene. The CP interventions included instructions for staff to check Resident 12's nail length, clean and trim them during Resident 12's bath day and as necessary. Observations on 05/26/2026 at 11:21 AM and on 05/28/2026 at 8:21 AM showed Resident 12 was lying in bed in their room and had long and dirty fingernails. On 05/29/2026 at 12:02 PM and on 06/01/2026 at 9:03 AM, Resident 12 was observed sitting up in their wheelchair in the hallway and their fingernails were long and dirty with black dirt under the nail beds. In an interview on 06/01/2026 at 12:20 PM, Staff E stated they expected staff to provide ADLs to all residents during routine morning care including personal hygiene. Staff E stated if residents refuse care, staff should document in resident's record. Staff E confirmed Resident 12 had long dirty fingernails and was unable to provide any refusal of nail care for Resident 12. Staff E stated staff should clip Resident 12's fingernails on bath days, but they did not. In an interview on 06/03/2026 at 9:55 AM, Staff B stated they expected staff to provide ADL assistance to all residents every morning and as needed. Staff B stated nail care should be provided to all residents on their shower/bath day and as needed. <Resident 21> According to the 05/14/2026 Quarterly MDS, Resident 21 was alert, capable of verbalizing their needs, and had medical conditions including a chronic, progressive neurological disorder affecting their movement. The MDS showed Resident 21 had functional limitations in their range of motion in both their upper arms and was assessed to be dependent on staff their personal hygiene/grooming needs. Review of the revised 03/13/2026 ADL CP showed Resident 21 had self-care performance deficit and was dependent on staff for all their ADL cares. A 02/06/2026 CP intervention instructed the staff to check Resident 21's nail length, and to trim and clean them during bath days and as necessary. In an observation and interview on 05/27/2026 at 1:29 PM, Resident 21's fingernails on both hands were observed long, thick, and curling up. Resident 21 stated they would like their nails trimmed to prevent them from digging into their skin. Observation on 05/29/2026 at 10:11 AM showed Resident 21's fingernails remained in the same state as previously observed on 05/27/2026. In an observation and interview on 05/29/2026 at 10:30 AM, Staff F (Unit Care Coordinator) stated they expected the nursing assistants to cut/trim the fingernails of dependent residents. Staff F looked at Resident 21's fingernails and stated the staff should have trimmed and provided nail care to the resident, but they did not. <Resident 25> According to the 03/24/2026 admission MDS, Resident 25 did not have the ability to communicate verbally, did not speak English, and had medical conditions including a brain injury, memory deficits, heart failure, and generalized muscle weakness. The MDS showed Resident 25 was assessed to be dependent on staff for their personal hygiene needs including combing their hair, shaving, and oral hygiene. Review of the revised 03/31/2026 ADL CP showed Resident 25 had self-care performance deficit because of right-sided weakness from their brain injury and was totally dependent on staff for personal hygiene and oral care. Review of Resident 21's physician orders showed a 03/1/2026 order instructing staff to provide the resident oral care twice daily every morning and at bedtime. Observations on 05/27/2026 at 10:40 AM, on 05/28/2026 at 2:14 PM, and on 05/29/2026 at 8:12 AM showed Resident 25 was lying in bed and observed with matted and unruly hair, long facial hair (mustache and beard), and dry, chapped lips. Resident 25's lower lip was peeling off in several areas. In an interview on 05/28/2026 at 10:00 AM, Resident 21's representative stated the resident used to be a Buddhist monk; bald, clean cut, and would prefer to be shaven. In an observation and interview on 05/29/2026 at 8:29 AM, Staff M (Certified Nursing Assistant) went in Resident 21's room and confirmed the resident's needed grooming and oral care. Staff M stated Resident 21 needed their hair combed, facial hair shaved, and mouth/lips cleaned and moisturized. In an interview on 05/29/2026 at 10:30 AM, Staff F stated they expected the staff to provide ADL care because it made residents feel they were cared for, their basic needs met, and for residents to have good quality of life. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review, the facility failed to provide restorative/functional maintenance services for 4 of 7 residents (Residents 56, 41, 21 & 48) reviewed for limited mobility and Restorative Nursing Program (RNP). This failure placed residents at risk for further decline in their Range Of Motion (ROM) and mobility, loss of function, and/or permanent immobility.Findings included.<Facility Policy>According to an Area of Focus: Restorative Nursing policy, reviewed on 12/02/2025, the facility provided a RNP that focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. The RNP included nursing interventions that promoted the resident's ability to adapt and adjust to living as independently and safely as possible, and included walking, range of motion, and splint or brace assistance. The policy showed evidence of periodic evaluation by the licensed nurse must be present in the medical records. <Resident 56> According to a 04/24/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 56 admitted to the facility on [DATE] with multiple diagnoses including wounds to both feet, muscle weakness, and difficulty walking. The MDS showed Resident 56 was able to understand and to be understood. In an interview on 05/27/2026 at 10:17 AM, Resident 56 stated when they first came to the facility, they worked with the therapy department on walking, going upstairs, and balance. Resident 56 stated they had not had any exercises for over three weeks. Resident 56 stated they were told they would have RNP three times weekly, but it did not happen. Review of a Physical Therapy (PT) Discharge Summary, dates of service 04/21/2026 to 05/07/2026, showed PT recommended the RNP for sit-to-stand to walker, and ambulation with walker with stand-by assist and follow with wheelchair for 50 to 75 feet. Review of an Occupational Therapy (OT) Discharge Summary, dates of service 04/21/2026 to 05/07/2026, showed OT recommended the RNP, with plan to follow. Review of a 05/07/2026 Restorative Nursing Communication Tool showed PT and OT requested Resident 56 have RNP three days per week with a goal of maintenance. Exercises included sit-to-stand to walker, ambulation with walker with stand-by assist and follow with wheelchair for 50 to 75 feet, and Omnicycle (a motorized rehab system that uses a smart motor to help residents exercise arms and legs when they have limited strength, endurance or muscle control) for 15 minutes. Review of a Restorative Residents listing provided on 06/02/2026 showed Resident 56 was not included in the RNP case load. Review of Resident 56's Care Plan (CP) on 05/29/2026 showed no evidence of an RNP. Staff were to assist Resident 56 with transfers to a wheelchair. No interventions were included for nursing to ambulate with Resident 56, or to use an Omnicycle. In an interview on 06/02/2026 at 8:18 AM, Staff C (Assistant Director of Nursing) stated typically the therapy department determined appropriate RNP activities and gave the nursing department a referral. Staff C checked Resident 56's records and found no evidence of RNP, no RNP assessments, and no RNP interventions in the CP. Staff C stated it was hard to see if RNP was supposed to be ordered for Resident 56. In an interview on 06/02/2026 at 11:21 AM, Staff T (Director of Rehabilitation) stated PT and OT did refer Resident 56 for the RNP on 05/07/2026 and it should have been started. Staff T stated they gave the referral form to a Resident Care Manager (RCM) that no longer worked at the facility and did not know what happened after that. <Resident 41> According to a 04/02/2026 admission MDS, Resident 41 admitted to the facility on [DATE] with multiple diagnoses including muscle weakness and history of falls. Resident 41 was able to understand and to be understood and was able to walk with supervision or touching assistance. In an interview on 05/27/2026 at 12:31 PM, Resident 41 stated when they first came to the facility, they exercised every day and walked, but not anymore. Resident 41 stated if they were feeling strong, they walked down the hallway by themself, but most of the time they stayed on their bed with no exercise. Resident 41 stated they felt like they walked better when they first came to the facility than they do now. Review of a 04/24/2026 progress note showed Staff G (Social Services Director) responded to Resident 41's request for some sort of exercise or rehab, educated Resident 41 of the potential for the RNP, and stated Resident 41 was excited about starting it. Staff G stated they spoke with an RCM to enroll Resident 41 in the RNP. Review of a Restorative Residents listing provided on 06/02/2026 showed Resident 41 was not included in the RNP case load. Review of Resident 41's CP on 06/02/2026 showed no evidence of an RNP. In an interview on 06/03/2026 at 8:28 AM, Staff C stated Staff G wrote a progress note regarding an RNP for Resident 41, but Staff C wasn't sure what communication happened after that. Staff C stated the previous RCMs no longer worked at the facility, and there should have been documentation to show the decision on whether to implement Resident 41's RNP and what the program would include, but there was not. In an interview on 06/03/2026 at 8:52 AM, Staff G stated they talked to an RCM about starting an RNP for Resident 41, but the RCM no longer worked at the facility. Staff G stated there was no form to fill out, it was a verbal conversation. Staff G stated they did not know what happened with the RNP after that. <Resident 21> According to the 05/14/2026 Quarterly MDS, Resident 21 was alert, capable of verbalizing their needs, and had medical conditions including a chronic, progressive neurological disorder affecting their movement. The MDS showed Resident 21 had functional limitations in ROM in both their upper and lower limbs and was provided two days of active ROM (AROM) during the look back period. Review of the revised 03/13/2026 functional CP showed Resident 21 had limited physical mobility, weakness, and contractures. A 02/26/2026 RNP CP intervention directed staff to provide passive ROM (PROM) to Resident 21's bilateral upper and lower extremities three times a week to prevent further deformities. Review of the 05/29/2026 Kardex (a visual bedside report used by staff in providing daily care) showed the staff were to put splints on Resident 21's bilateral hand/wrist and were kept on for up to six hours as tolerated. In an observation and interview on 05/27/2026 at 8:41 AM, Resident 21 was lying in bed and was observed to have very minimal ability to move independently. A left hand splint was observed applied on Resident 21's hand/wrist and their right hand was stiff, balled up, and contracted. Resident 21 stated they were supposed to have a splint on each hand but only the left splint was being applied routinely. Observations on 05/28/2026 at 8:07 AM and 2:29 PM, and on 05/29/2026 at 9:22 AM and 10:30 AM showed Resident 21 did not have a splint on their right hand. In an observation and interview on 05/29/2026 at 10:31 AM, Staff F (Unit Care Coordinator) confirmed Resident 21 did not have a right hand/wrist splint on. Staff F stated Resident 21's right hand needed to have at least a rolled towel on to prevent moisture build-up or fungal infection from developing. In an observation and interview on 05/29/2026 at 1:19 PM, Resident 21 was observed without a right hand/wrist on. Staff K (Certified Nursing Assistant – CNA) stated they work as a Restorative CNA when coverage was needed. Staff K stated they provided Resident 21 PROM and applied the right hand/wrist splint on around breakfast time. Resident 21 stated a nursing staff took the splint off and did not put it back on after providing morning care. Review of Resident 21's RNP flow sheets showed: On the week of 03/29/2026 – 04/04/2026, staff provided AROM twice on 03/30/2026 and 04/03/2026; on the week of 04/05/2026 – 04/11/2026, no AROM was provided; and on the week of 04/12/2026 – 04/18/2026, no AROM was provided. There was no PROM or splint/brace RNP documented as provided to Resident 21 by the restorative staff from 03/27/2026 through 05/29/2026. In an interview on 06/02/2026 at 10:52 AM, Staff B (Director of Nursing) stated they expected the restorative staff to provide RNP to residents who were assessed to require them in order to prevent mobility and functional decline. In an interview on 06/03/2026 at 9:50 AM, Staff C reviewed Resident 21's RNP documentation and stated the ROM program was set-up wrong in the facility's software system; it was outlined under the AROM category and it should be under PROM which was what Resident 21 was assessed to need. Staff C stated the interventions listed regarding Resident 21's splint/brace RNP was not accurate. Staff C stated they expected the restorative staff to provide RNP's frequency according to the CP. <Resident 48> According to the 04/30/2026 Quarterly MDS, Resident 48 was alert, capable of verbalizing their needs, and had medical conditions including mental health disorders, memory deficits, and a brain injury with resulting left-sided weakness. The MDS showed Resident 48 had functional limitation in ROM in one side of their upper and lower limbs. The MDS showed Resident 48 was not provided any RNP during the look back period. Review of Resident 48's revised 04/28/2025 Activities of Daily Living/mobility CP showed the resident had self-care performance deficit related to their left-sided weakness and contractures. A 12/18/2024 RNP CP intervention instructed the staff to apply a splint/brace on the resident's left hand and to provide AROM or PROM as tolerated. Review of the revised 06/16/2023 functional CP showed Resident 48 had limited physical mobility and contractures because of their brain injury. A 08/18/2025 RNP CP intervention instructed the staff to apply a splint/brace on Resident 48's right ankle and to provide AROM or PROM six times weekly for 15 minutes prevent further deformities. In an observation and interview on 05/27/2026 at 10:11 AM, Resident 48 was observed lying in bed and a left hand splint/brace was on; their fingers were curled up and stiff. Resident 48 was observed capable of minimally lifting their left arm up when prompted. Resident 48 was observed wearing non-skin socks and did not have a right ankle splint/brace in place. Observations on 06/02/2026 at 12:08 AM and 06/03/2026 at 9:16 AM showed Resident 48 did not have a right ankle splint/brace on. Review of Resident 48's RNP flow sheets from 04/01/2026 through 05/31/2026 showed the resident was provided five minutes of splint/brace assistance every time they were seen by the restorative staff instead of 15 minutes as care planned. There was no AROM or PROM documented as provided to Resident 48 by the restorative staff for two months. In an observation and interview on 06/03/2026 at 9:17 AM, Resident 48 was observed without a right ankle splint/brace on. Staff L (CNA) stated they did not see an ankle splint/brace inside Resident 48's room. In an interview on 06/03/2026 at 9:36 AM, Staff I (Restorative CNA) stated Resident 48's RNP involving the application of the R ankle splint/brace was no longer appropriate per the resident's preference, lack of participation, and refusals to have it on. Staff I stated the right ankle splint/brace RNP should be removed from Resident 48's CP. Review of Resident 48's Restorative Program Evaluation log showed the last RNP evaluation done for the resident was completed on 01/31/2025, more than a year ago. In an interview on 06/03/2026 at 9:50 AM, Staff C reviewed Resident 48's RNPs, stated the interventions did not fit the program of the resident as listed in their CP, and the RNPs needed revision. Staff C stated the provision of RNP was important to maintain functional mobility and strength, to prevent decline, and to avoid the development of contractures from immobility. Staff C stated it was important to periodically evaluate the RNPs as required to ensure the residents continue to be benefit from them, and to decrease the restorative staff's workload when RNPs were no longer appropriate. Refer to F641- Accuracy of Assessments. REFERENCE: WAC 388-97-1060(3)(d)(j)(ix).

Based on observation, interview, and record review, the facility failed to ensure the menu set was followed, affecting 1 of 2 sample residents (Resident 21) reviewed for food concerns and 2 supplemental residents (Residents 72 & 54) observed during lunch service. This failure placed residents at risk for lack of food enjoyment, nutritional deficits from poor food intake, and a decreased quality of life. Findings included. <Facility Policy>The facility policy titled, Menus, Substitutions, and Alternatives, revised 05/20/2026, showed menus were planned in advance and were followed as written in order to meet the nutritional needs of residents in accordance with established national guidelines. The policy showed the menus must be followed.<2026 Spring/Summer Menu>Review of the facility's week 1 menu showed the set menu for breakfast on 06/01/2026 was biscuits with sausage gravy, the main dish for lunch was sliced ham with baked sweet potato wedges, and the alternate menu was Salisbury steak and gravy. In an observation and interview on 06/01/2026 at 9:32 AM during lunch preparation, Staff O (Cook) was observed preparing mashed potatoes. Staff O stated they were replacing the sweet potato menu option with the mashed potatoes to serve residents who had orders for a mechanically altered texture diet because they ran out of the sweet potato puree. Staff O stated they did not check the menu to ensure all food items listed were available for meal service. In an interview on 06/01/2026 at 9:41 AM, Staff N (Food Services Director) stated the kitchen staff did not notify them about being out of the sweet potato puree. Staff N stated the residents did not get timely communication regarding the menu change. Staff N stated it was important to stick with the planned menu in respect of residents' food choices and preferences. In an observation and interview on 06/01/2026 at 10:28 AM, Staff O was observed whisking (white) sausage gravy in a deep metal container. Staff O stated it will be served as the gravy together with the Salisbury steak. <Resident 21>In an observation and interview on 06/01/2026 at 12:48 PM, Resident 21 was observed in their bed and was assisted by a family member in eating their lunch. Resident 21's meal tray had ground Salisbury steak topped with sausage gravy; only a small bite was eaten out of it. Resident 21 stated they did not like the food because it did not taste good together. <Resident 72>In an observation and interview on 06/21/2026 at 12:31 PM, Resident 72 was observed eating a slice of ham in the dining room next to Staff S (Restorative Certified Nursing Assistant). Resident 72's meal tray had Salisbury steak with sausage gravy and was observed left untouched. Staff S stated they needed to request a piece of the sliced ham from the kitchen for Resident 72 because the resident did not like the food served. Resident 72 stated the Salisbury steak was their original choice when they placed their meal order last week, but the steak was served with the wrong gravy. <Resident 54>In an observation and interview on 06/01/2026 at 12:35 PM, Resident 54 was observed eating their lunch in the dining room next to Staff S. Resident 54's meal tray had double portions of the Salisbury steak topped with sausage gravy and was observed left untouched. Resident 54 stated they did not like the food served because the combination of the meat and the sauce used tasted bad. In an interview on 06/01/2026 at 1:07 PM, Staff O stated they used the sausage gravy for lunch meal service instead of preparing the (brown) gravy outlined in the menu because they had a lot left over from breakfast. Staff O stated they should have prepared the gravy that went with the Salisbury steak according to the planned menu, but they did not. In an interview on 06/01/2026 at 1:16 PM, Staff N stated the kitchen staff must follow the planned menus as required. REFERENCE: WAC 388-97-1160(1)(a)(b), -1120(3)(c)(4).

Based on observation, interview, and record review the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 3 of 3 residents (Residents 91, 53, & 56) reviewed for Transmission Based Precautions (TBP - used to prevent the spread of transmissible infections), staff used PPE in accordance with Enhanced Barrier Precautions (EBP - infection control measure used to reduce the spread of multidrug-resistant organisms) for 1 of 3 supplemental residents (Residents 84) reviewed for skin conditions, and perform hand hygiene during wound care for 1 of 3 residents (Resident 91) reviewed for wounds. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.<Policy>According to the facility policy titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, dated September 2024, the facility would ensure staff donned gown and gloves with resident's on TBP to prevent the spread of infections to other residents and staff.According to the facility policy titled, Hand Hygiene for Residents, Families, and Visitors, dated 07/08/2025, the facility would ensure staff performed hand hygiene during care provided to residents. <TBP> <Resident 91> According to a 05/30/2026 admission Minimum Data Set (MDS – an assessment tool) Resident 91 admitted to the facility on [DATE]. The MDS showed Resident 91 was on isolation precautions for an active infectious disease. The MDS showed Resident 91 had diagnoses of a multidrug resistant organism, a bone infection, and an amputation of their left great toe. Review of Resident 91's 05/28/2026 infection Care Plan (CP) showed they were on contact precautions for the duration of the infection. Observation on 05/27/2026 at 8:45 AM showed a contact precaution sign posted outside of Resident 91's room instructing staff to put on a gown and gloves before entering Resident 91's room. In an observation and interview on 05/27/2026 at 8:55 AM showed Staff Q (Housekeeping Assistant) enter Resident 91's room without putting on the appropriate PPE. Staff Q exited the room not wearing gloves or performing hand hygiene and carrying a bag filled with rolls of garbage bags. Staff Q stated they should follow contact precautions before entering but did not. In an interview on 06/02/2026 at 10:02 AM Staff E (Unit Care Coordinator) stated they expected staff to follow precaution signs posted outside of resident rooms. Staff E stated it was important to follow TBP to prevent the spread of infection. <Resident 53> According to the 03/09/2026 Quarterly MDS Resident 53 re-admitted to the facility on [DATE] with diagnoses including high blood pressure, a degenerative brain disease affecting memory, and kidney disease. The MDS showed Resident 53 was incontinent of bowels and was dependent on staff for assistance with toileting. Review of Resident 53's health records showed a hospitalization on 05/06/2026 returning to the facility on [DATE] admitting into room [ROOM NUMBER] with Resident 56. Resident 53's hospital discharge records showed a positive result for C-Diff (a highly contagious bowel infection) on 05/09/2026. Review of Resident 53's physician orders showed a 05/12/2026 orders for oral antibiotics to treat C-Diff and contact enteric precautions (precautions used to prevent the spread of infections of the bowels) to reduce the risk of spreading the infection to others. Review of Resident 53's 05/29/2026 loose stool care plan showed an intervention for contact enteric precautions, to place resident in a private room and if a private room was not available to place resident in a room with another resident with the same condition. In an observation on 06/02/2026 at 4:46 AM showed Resident 53 had a contact enteric precaution sign posted outside of room instructed staff to don gloves and gowns before entering room and to wash hands with soap and water before leaving room. In an observation on 06/02/2026 at 4:47 AM showed Staff X (CNA - Certified Nursing Assistant) and Staff Z (CNA) provided peri care to Resident 53 without wearing gowns, wearing gloves only. Staff Z left Resident 53's room and while wearing the same gloves entered a room across the hall to answer a call light. Staff Z then left the room across the hall, removed gloves and used hand sanitizer and returned to Resident 53's room without wearing gown or gloves. In an observation on 06/02/2026 at 4:48 AM showed Staff X left Resident 53's room with a bag of linens and went into a room across the hall with the same bag. In an interview on 06/02/2026 at 4:49 AM Staff Z stated they were supposed to wear gown and gloves every time they entered Resident 53's room and wash hands with soap and water before leaving but did not. In an interview on 06/02/2026 at 5:39 AM Staff X stated they should not have brought a bag of linens from Resident 53's room to another room due to the risk of cross-contamination. <Resident 56> According to the 04/24/2026 admission MDS Resident 56 admitted to the facility on [DATE] with diagnoses of Human Immunodeficiency Virus (HIV – a virus that attacks the immune system making the body vulnerable to infections), chronic wounds to the lower legs, and high blood pressure. Review of Resident 56's 04/29/2026 impaired immunity care plan showed an intervention to keep the environment clean and people with infections away. Review Resident 56's health records showed that they admitted into room [ROOM NUMBER] and received Resident 53 as a roommate on 05/12/2026. Review of a 05/28/2026 Order note showed that Resident 56 began having loose stools and a provider ordered for a stool sample to be collected to test for C-Diff. Review of Resident 56's Physician Orders showed a 05/28/2026 order for contact enteric precautions for loose/watery stools. In an interview on 05/27/2026 sat 3:06 PM Staff D (Infection Preventionist) stated when a resident with C-diff is admitted to the facility they should be admitted to a private room to prevent the spread of infection. Staff D could not say how or why Resident 53 and Resident 56 shared a room. Staff D stated the entire room would be considered contaminated when a resident with c-diff resides there, which is why staff should put on PPE (gowns and gloves) prior to entering the room. Staff D stated it was important for staff to read and follow the precaution signs outside the door of the rooms to ensure they do not potentially spread infections. In an interview on 06/03/2026 at 9:11 AM Staff B (Director of Nursing) stated it was their expectation that staff follow the signs outside the rooms for residents on transmission-based precautions. Staff B stated that the facility had to be careful when placing residents on transmission-based precautions with another resident as they had to be mindful of those who were immunocompromised. Staff B stated that residents with C-Diff should have a room by themselves. <EBP> <Resident 84> According to the 05/04/2026 5 Day Medicare MDS, Resident 84 admitted to the facility on [DATE] and had Medically complex conditions including cancer and seizure disorder. The MDS showed Resident 84 had unstageable pressure ulcer and was dependent on staff to meet their daily needs. Observation on 05/27/2026 at 9:00 AM showed an EBP sign posted outside Resident 84's door. Observation on 05/27/2026 at 10:10 AM showed Staff J (Licensed Practical Nurse) entered Resident 84's room, had medications crushed and mixed with apple sauce in a cup in their hands and was not wearing gloves or gown. Staff J explained and tried to administer medications to Resident 84. Resident 84 spit some of the medications out and Staff J grabbed a tissue and cleaned Resident 84's mouth with no gloves on. Then Staff J tried to administer nasal spray to Resident 84 without gloves but Resident 84 turned their face away. In an interview on 05/27/2026 at 10:26 AM, Staff J stated they did not see the EBP sign posted outside Resident 84's room. Staff J stated they should follow the sign posted outside Resident 84's room. In an interview on 05/29/2026 at 9:00 AM, Staff D stated they expected staff to follow the instructions on EBP sign posted outside resident's room, but they did not. Staff D stated staff should follow EBP precautions to prevent the spread of infection. <Hand Hygiene> <Resident 91> Observation and interview on 06/01/2026 at 3:04 PM Staff R (Licensed Practical Nurse) provided wound care to Resident 91. Prior to wound care, Staff R donned 3 pairs of gloves. Staff R removed the old, soiled dressing from Resident 91's wound, removed the top layer of gloves, and prepared the new gauze to be applied to Resident 91's wounds. Staff R removed another layer of gloves and cleaned the wounds with normal saline and gauze. Staff R removed the third layer of gloves, did not perform hand hygiene and placed another pair of gloves on. Staff R applied gauze and skin prep to wounds, removed their gloves and did not perform hand hygiene. Staff R placed two layers of gloves on and wrapped the wounds with a gauze wrap. Staff R removed the top layer of gloves and secured the dressing with an ace bandage and changed their gloves without performing hand hygiene. Staff R discarded linens and garbage then removed gloves. Staff R stated they were expected to perform hand hygiene before putting gloves on. Staff R stated they layered the gloves, so they didn't have to perform hand hygiene between dirty and clean cares or between glove changes. In an interview on 06/02/2026 at 10:01 AM Staff E (Unit Care Coordinator) stated they expected staff to perform hand hygiene between dirty and clean cares and glove changes. Staff E stated staff were not supposed to layer gloves in place of hand hygiene. Staff E stated proper hand hygiene was important to prevent the spread of infections. Reference: WAC 388-97-1320 (1)(a)(c), (3).

Based on observation, interview, and record review, the facility failed to ensure the Advance Directives (AD) for 2 of 3 residents (Residents 48 & 9) reviewed were in place in the event residents became incapacitated to make medically related healthcare decisions. The facility failed to follow up on guardianship status (Resident 48) and failed to ensure the AD was accessible to staff as required (Resident 9). These failures placed residents at risk of losing their right to have their stated preferences and decisions honored regarding medical treatment and/or end-of-life care. Findings included . <Facility Policy>The facility policy titled, Area of Focus: AD, reviewed [DATE], showed the facility provided residents and their representatives the policy regarding AD and applicable State law upon admission to the facility, quarterly, and when a change in the resident's condition was noted. The policy showed the Social Services Director (SSD) or designee would assist residents with updating AD documents that needed revision. The policy showed the SSD or designee would ensure resident AD was present and documented in the medical records in accordance with state and federal requirements. <Resident 48>According the [DATE] Quarterly Minimum Data Set (MDS - an assessment tool), Resident 48 had medical conditions including memory deficits, disorganized thinking, mental health problems with behavioral disturbance, and a brain injury with resulting weakness to one side of their body. The MDS showed Resident 48 and their legal guardian participated in the assessment and goal setting process. The [DATE] AD Care Plan (CP) showed Resident 48 elected full code for their life-sustaining treatment. The CP showed Resident 48 was under the care and supervision of a duly appointed guardianship/conservator (a court-appointed individual or organization tasked with managing the financial affairs, daily life, or medical decisions of a person deemed unable to do so themselves). On [DATE] at 10:39 AM, review of Resident 48's medical records showed their legal guardianship letter expired on [DATE]. In a joint interview on [DATE] at 10:15 AM with Staff G (SSD) and Staff H (Social Services Assistant), Staff G stated an AD was important to have because it would help residents and their representatives remember what the resident's wishes and preferences were when needed, .[AD] would validate or speak for them [residents] when they can no longer do so themselves during healthcare decision-making. Staff H stated they ask residents and their representatives regarding their AD status (either with current delegation or the lack thereof) during their initial cognitive evaluation with the resident or during care conferences. Staff G validated Resident 48's guardianship records on file and stated they were expired. <Resident 9>According to the [DATE] Discharge MDS, Resident 9 sustained a fall with major injury while at the facility and was sent to the hospital. A [DATE] Entry MDS tracker showed Resident 9 readmitted back to the facility. The [DATE] Significant Change in Status MDS showed Resident 9 initially admitted to the facility on [DATE], was alert and oriented, had clear speech, and had medical conditions including heart and respiratory failure, unstable blood sugar levels and mental health problems. In an observation and interview on [DATE] at 11:26 AM, Resident 9 was observed lying in bed; they were breathing supplemental oxygen via a cannula to their nose and had a brace on their left leg. Resident 9 stated they had their AD in place and had elected their brother to be their Durable Power of Attorney for Healthcare (DPOA-HC). On [DATE] at 9:31 AM, review of Resident 9's medical records did not show any AD listed for the resident that was accessible to staff as required. In a joint interview on [DATE] at 10:15 AM with Staff G and Staff H, Staff H reviewed Resident 9's medical records and stated the resident's AD was not on file. Staff H stated that in the event Resident 9 could no longer make medical decisions on their own, the facility could not honor the resident's brother as the DPOA-HC during an emergency if the facility did not have the AD paperwork on file. REFERENCE: WAC 388-97-0280 (3)(c)(i-ii).

Based on observation and interview, the facility failed to maintain comfortable sound levels in the environment for 1 of 4 units (100 hall). This failure placed residents at risk for diminished quality of life.Findings included.<Policy>According to the facility's 04/01/2026 Resident Belongings and Home Like Environment policy, the facility would provide a comfortable and homelike environment. The policy provided did not address comfortable sound levels in the facility.<100 Hall>In an interview on 05/27/2026 at 11:09 AM, Resident 27, who resided in room [ROOM NUMBER], stated the television down the hall was too loud at night. Resident 27 stated they had reported it to staff, but it was not resolved.In an observation at the nurse's station on 06/02/2026 at 4:40 AM, loud televisions could be heard from rooms [ROOM NUMBERS] at the end of the hallway. Upon entering the rooms, it was observed that the residents were asleep with the televisions on and the volume turned up.In an interview on 06/02/2026 at 9:09 AM, Staff B (Director of Nursing) stated staff should encourage residents to lower television volume at 10:00 PM to ensure comfortable sound levels for others at night, and to provide headphones for residents that would prefer louder sounds at night to not impede the sleep of others. Staff B stated that this did not occur but should have.REFERENCE:WAC 388-97-0880(4)(b)

Based on observation, interview, and record review, the facility failed to comprehensively assess and monitor the needs of physical restraints for 1 of 3 residents (Resident 12) reviewed for physical restraints. This failure placed residents at risk for harm and diminished quality of life. Findings included.<Facility Policy>According to the facilities policy titled, Physical Restraint Use, dated 09/03/2025, the intent was for each resident to attain and maintain their highest practicable well-being in an environment that prohibited the use of physical restraints for discipline or convenience and prohibited the use of physical restraints to unnecessarily inhibit a resident's freedom of movement. The policy showed when alternatives to restraint use were not effective, the facility should evaluate the least restrictive restraint to promote safety for the residents and should have documentation including physician orders, informed consent, care plans, and reevaluation in resident's records.<Resident 12>Resident 12 readmitted to the facility on [DATE]. According to the 05/04/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 12 was cognitively severely impaired, unclear speech, and had diagnoses of stroke with weakness on one side of their body. The MDS showed Resident 12 was dependent on staff with transfers from bed to wheelchair. The MDS showed Resident 12 was not currently using any form of physical restraints.Observations on 05/27/2026 at 9:33 AM and 05/28/2026 at 8:25 AM showed Resident 12 was lying in their bed. Resident 12's bed was against the wall (right side of the resident), was in lowest position, and floor mat on left side of their bed. Additionally, two folded pillows were tucked under the left side of the mattress causing a large barrier bump. Resident 12 was attempting to move in bed but could not move because of the large bump in the mattress due to pillows underneath the mattress. Observation on 05/29/2026 at 7:30 AM showed Resident 12 was sleeping in their bed. Resident 12's bed was against the wall, in a lowest position with floor mat on left side of the bed, and three folded pillows were tucked under the mattress to restrict the resident from getting out of their bed.In an interview on 05/29/2026 at 7:50 AM, Staff W (Certified Nursing Assistant) Stated they did not work with Resident 12. Staff W stated night shift staff might have tucked the pillows under the mattress to prevent the resident rolling out of bed. Review of Resident 12's record included physician orders, evaluations, and care plans, showed no evidence that the facility had assessed the resident's condition that would warrant use of restraints for the purpose of convenience. In an interview on 05/29/2026 at 8:10 AM, Staff B (Director of Nursing) stated putting pillows under the resident's mattress to prevent resident from moving in bed or from getting out of the bed was not acceptable and could be considered restraints.Reference: WAC 388-97-0620 1(a)(b)2(d).

Based on interview and record review, the facility failed to provide a discharge summary that included a recap of the residents stay and reconciliation of all medications for 1 of 3 residents (Residents 4) reviewed for discharge process and offer a bed hold for 1 of 2 residents (Resident 86) reviewed for hospitalizations. Failure to properly prepare residents for discharge placed residents at risk of rehospitalization, negative health outcomes, and a break in continuity of care. Failure to offer/provide a bed hold to the resident/resident representative placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights.Findings included .<Policy>According to the facility policy titled, Against Medical Advice (AMA) Discharges, dated 08/29/2025, the facility would conduct a safe AMA discharge for residents requesting to discharge earlier than outlined in their Care Plan (CP). The policy showed the facility would complete the required documentation and provide written discharge instructions as with any discharge.According to the facility's undated NW Bed Notification policy the facility would provide the resident or their representative with a copy of the bed hold form upon transfer to the hospital or within 24 hours in the case of an emergency. The policy stated the facility would document multiple attempts to reach resident representatives in cases where they were unsuccessful.<Resident 4> According to the 05/22/2026 Discharge Return Not Anticipated Minimum Data Set (MDS) Resident 4 admitted to the facility on [DATE]. The MDS showed Resident 4 had diagnoses of a bone infection, heart failure, and unstable blood sugar dependent on insulin. Review of Resident 4's health records showed a 05/22/2026 progress note Resident 4 wished to discharge AMA. Resident 4's health records showed no discharge summary or medications were offered or provided to ensure a safe discharge. In an interview on 06/01/2026 at 2:03 PM Staff B (Director of Nursing) stated they expected staff to offer and provide Life-sustaining medications, if they had them available, to residents who discharged AMA. Staff B stated they expected staff to provide a recap of the residents' stay. Staff B stated the facility provider would not write scripts or call in prescriptions for residents discharged AMA to ensure a safe discharge. Staff B reviewed Resident 4's health records and stated staff did not offer/provide a recap of their stay or send them with Life-sustaining medications but should have. <Resident 86> According to the Discharge Return Not Anticipated MDS Resident 86 admitted to the facility on [DATE] with diagnoses of respiratory failure, kidney disease, and low blood pressure. Review of Resident 86's health record showed a 04/13/2026 progress note stated the resident was transferred to the hospital due to a health emergency and the facility was not able to contact their representative. There were no notes regarding offering or attempting to offer a bed hold for Resident 86's unplanned discharge. In an interview on 06/03/2026 at 9:05 AM Staff B stated it was expected of staff to offer a bed hold for Resident 86 at the time of discharge, or to have offered to Resident 86's representative. Staff B reviewed Resident 86's health record and stated that did not happen but should have. Reference: WAC 388-97-0080 (5), -0120(3)(a), (4).

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) of 1 of 20 residents (Resident 21) were completed accurately to reflect the resident's condition and health status. The facility failed to identify Resident 21's appropriate diet and Restorative Nursing Program (RNP) exercises. This failure placed Resident 21 and other residents at risk for unmet care needs and a decreased quality of life. Findings included . <Facility Policy>The facility policy titled, Certification of Accuracy of the MDS, reviewed 08/29/2025, showed the MDS assessment must accurately reflect the resident's status. The policy showed a registered nurse must conduct and coordinate each assessment with the appropriate participation of health professionals. The policy showed appropriate health professionals would correctly identify and document assessed needs necessary for care planning to maintain and/or improve the resident's medical status and functional abilities. <Resident 21>According to the 05/14/2026 Quarterly MDS, Resident 21 was alert, capable of verbalizing their needs, and had medical conditions including heart failure, a chronic, progressive neurological disorder affecting their movement, and was on a mechanically altered and therapeutic diet. The MDS showed Resident 21 had functional limitations in Range of Motion (ROM) in both their upper and lower limbs and was provided active ROM exercises during the look back period.In an observation and interview on 05/27/2026 at 8:41 AM, Resident 21 was lying in bed and was observed to have very minimal ability to move independently. A left-hand splint was observed applied on Resident 21's hand/wrist. At 1:24 PM, Resident 21 stated they did not like eating mashed-up foods and wished the kitchen staff would serve them more regular food items.The revised 05/19/2026 nutrition Care Plan (CP) showed Resident 21 was at risk for malnutrition and listed a 02/12/2026 CP intervention showing the resident's current diet order: Mechanically Altered, thin liquids, diet condiments. The CP did not show Resident 21 was on a therapeutic diet.The revised 03/13/2026 functional CP showed Resident 21 had limited physical mobility, weakness, and contractures. A 02/26/2026 RNP CP intervention showed Resident 21 was on passive ROM exercises to prevent further deformities.Review of Resident 21's 02/12/2026 nutrition assessment showed the resident was on a regular diet. The items Therapeutic or Fortified Foods were not checked off by the Registered Dietician (RD) as applicable to Resident 21 during their evaluation.In a joint interview on 06/02/2026 at 8:54 AM with Staffs AA and BB (Registered Nurse MDS Coordinators), Staff AA stated it was important for the MDS assessment to be accurate because it was the basis of a resident's CP. Staff AA reviewed Resident 21's MDS and stated they coded therapeutic diet because of the diet condiments ordered for the resident. Staff AA reviewed Resident 21's medical records and stated the resident was not capable of actively participating with RNP exercises because of the resident's functional mobility deficits. Staff AA stated Resident 21 was provided with passive ROM exercises (as opposed to active ROM exercises) and that the RNP was inaccurately coded in the MDS.In an interview on 06/02/2026 at 11:37 AM, Staff CC (RD) stated Resident 21 was not on a therapeutic diet.Refer to F688- Increase/Prevent Decrease in Range of Motion/Mobility.REFERENCE: WAC 388-97-1000(1)(a)(b)(4)(a).

Based on interview and record review, the facility failed to conduct care conferences for residents and their representatives and the applicable Interdisciplinary Team (IDT) members for 2 of 3 sample residents (Residents 5 & 41) reviewed for care planning. These failures placed residents at risk for inconsistent and/or inadequate care and treatment, a diminished quality of care, unmet care needs, and other negative health outcomes.Findings included.<Facility Policy>Review of a 08/29/2025 Comprehensive Care Plans and Conferences policy showed the facility would ensure the timeliness of each resident's person-centered, comprehensive CP, ensure the CP was reviewed and revised by an IDT, and that each resident and their representative, if applicable, was involved in developing the care plan and making decisions about their care. Care plans were to be revised based on changing resident needs. The facility had the responsibility to assist residents to engage in the care planning process including care planning conferences, and to encourage their representatives to attend. <Resident 5> According to the 03/06/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 5 admitted to the facility on [DATE]. The MDS showed Resident 5 had no memory impairment. The MDS showed Resident 5 had diagnoses of adult failure to thrive and schizophrenia. The assessment showed Resident 5 did not exhibit any behaviors during the assessment period. Review of Resident 5's health records showed the last care conference offered and provided was 12/01/2025. Resident 5's health records showed no quarterly care conference was offered and provided since 12/01/2025. In an interview on 05/28/2026 at 9:22 AM Resident 5 stated they understood the facility would only offer a care conference annually. Resident 5 stated they would appreciate a care conference every few months to keep them up to date with their care and to be able to ask questions of the appropriate departments regarding their care when needed. In an interview on 06/02/2026 at 10:40 AM Staff G (Social Services Director) stated they expected care conferences to be offered and provided within four days of admission to the facility, quarterly, and as needed. Staff G reviewed Resident 5's records and stated they last had a care conference in December 2025 but had not had one offered since. Staff G stated care conferences were important to give the residents the opportunity to talk with their whole IDT and address specific concerns related to the different departments. Staff G stated they do not provide a copy of the resident care plan to the residents at each care conference but should. <Resident 41> Review of an admission Record, dated 06/02/2026, showed Resident 41 admitted to the facility on [DATE] and was their own Responsible Party. Resident 41 had two family members listed as emergency contacts, and one family member listed as Other. Review of a 04/02/2026 admission MDS showed Resident 41 had medically complex conditions and was able to understand and to be understood. Review of a progress note, dated 04/07/2026, showed Staff H (Social Services Assistant) attempted to contact two of Resident 41's family members to schedule a care conference but was unsuccessful. In an interview on 05/27/2026 at 12:17 PM, Resident 41 stated the facility told them they were going to have a care conference, but they never did. In an interview on 06/03/2026 at 8:52 AM, Staff G stated the facility process was to hold a care conference within 72 hours (three days) after a resident admitted to the facility. Staff G reviewed Resident 41's record and stated they were unsuccessful with attempts to contact family members on 04/07/2026, five days after admission, and no further attempts were documented. Staff G stated Resident 41 did not have a care conference with the IDT but should have. REFERENCE: WAC 388-97-1020 (2)(e)(5)(b).

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed for 1 of 2 residents (Resident 8) reviewed for bowel care and 2 of 5 residents (Residents 83 & 12) reviewed for Unnecessary Medications. The failure to follow orders for oxygen administration, bowel protocols, and parameters for blood pressure (BP) medications placed residents at risk for medication errors, unmet care needs, and other negative health outcomes.Findings included.<Facility Policy>According to a Bowel Protocol policy, reviewed 09/15/2025, the facility would provide effective interventions for signs and symptoms of constipation that were consistent with current standards of practice. Nursing staff would record each time a resident had a bowel movement (BM), and implement physician orders to address the lack of a BM.<Bowel Protocol> <Resident 8> According to the 04/04/2026 admission Minimum Data Set (MDS – An assessment tool) Resident 8 admitted to the facility on [DATE] with diagnoses of high blood pressure, stroke, and muscle weakness. The MDS showed that Resident 8 was incontinent of bowel and dependent on staff for assistance with toileting. Review of Resident 8's physician orders showed the following 02/27/2026 orders: An oral liquid laxative every 24 hours as needed for constipation A laxative suppository every 24 hours as needed for constipation if no results from the liquid laxative A different oral liquid laxative every 12 hours as needed for constipation Review of Resident 8's May 2026 task documentation showed no bowel movements from 05/14/2026 through 05/18/2026 a total of four days. Review of Resident 8's May 2026 Medication Administration Record (MAR) showed no laxatives were given for constipation. In an interview on 06/03/2026 at 8:46 AM Staff B (Director of Nursing) stated Resident 8 was monitored every shift for bowel movements and if they did not have one for three days an as needed laxative should be given. Staff B stated staff should have given a laxative to Resident 8 but did not. <Resident 83> According to the 05/04/2026 admission MDS Resident 83 had medically complex conditions including high blood pressure and constipation, was incontinent of bowel and bladder, and required substantial/maximal assistance with toileting hygiene. Resident 83 had cognitive impairments, was sometimes understood, and sometimes understood others. Review of Resident 83's May 2026 MAR showed the following 04/28/2026 physician order's: Two oral laxative tablets every 12 hours as needed for constipation A liquid oral laxative every 12 hours as needed for constipation A different liquid oral laxative to be given if no BM for 48 hours A laxative suppository (administered rectally) to be given if no BM for three days STEP 1. An enema if no BM after suppository. STEP 3 bowel protocol – if suppository or enema were not effective, nurses were to assess the resident, document in progress notes and notify MD for instructions. Review of Resident 83's task documentation, 04/30/2026 through 06/03/2026, showed the following: No BM for six days, from 04/30/2026 through 05/05/2026, then a BM on 05/06/2026. No BM for four days, from 05/10/2026 through 05/13/2026, then a BM on 05/14/2026. No BM for five days, from 05/22/2026 through 05/26/2026, then a BM on 05/27/2026. No BM for six days, from 05/28/2026 through 06/02/2026, then a BM on 06/03/2026. Review of Resident 83's May 2026 and June MARs showed the following: A laxative suppository was given on 05/05/2026 after no BM for five days. A laxative suppository was given on 05/26/2026 after no BM for four days. An additional laxative suppository was given on 05/27/2026 after no results from the first suppository, instead of an enema per physician orders. A liquid laxative was given on 06/02/2026 after no BM for five days. No other medications to address the lack of a BM were given from 05/01/2026 through 06/02/2026. Review of a 5/30/2026 progress note showed Resident 83 refused a laxative after staff offered three times during that shift. No other documentation was found to show refusals of medications to treat constipation. In an interview on 06/02/2026 at 8:28 AM, Staff C (Assistant Director of Nursing) stated when a resident did not have a BM for three days, a clinical alert was generated that was visible to nurses. Nurses were to offer the laxatives in sequence, according to the resident's physician orders. Staff C stated nurses should check the clinical alerts every shift. Staff C stated they reviewed the BM list (a listing of residents with no BM for three days) every day and informed nurses when they needed to start the bowel protocol. Staff C reviewed Resident 83's BM task documentation and MARs and stated each time Resident 83 did not have a BM for three days, nurses should have started the bowel protocol on day three, but they did not. <BP Medication Parameters> <Resident 83> Review of Resident 83's May 2026 MAR showed a 05/15/2026 physician orders for a BP medication to be given once daily, with instructions to hold (do not give) the medication for a systolic BP (SBP – the top number in a BP reading) less than 110. The medication was given on 05/23/2026 with an SBP of 103, and on 05/27/2026 with an SBP of 101. In an interview on 06/02/2026 at 8:28 AM, Staff C stated that nurses were to check Resident 83's BP results prior to giving the BP medication to ensure it met the ordered parameters. Staff C stated the BP medication should have been held on 05/23/2026 and 05/27/2026, but it was not. <Resident 12> According to the 05/04/2026 Quarterly MDS Resident 12 had diagnoses of stroke with weakness on left side of their body and received hospice care. The assessment showed Resident 12 was dependent on staff for daily activities including personal hygiene and transfers. Review of the May 2026 MAR showed Resident 12 had a 11/03/2025 physician orders to have oxygen at 2 liters per minute continuously per nasal canula. Observations on 05/26/2026 at 10:21 AM, on 05/27/2026 at 8:37 AM and at 12:43 PM showed Resident 12 was lying in their bed in their room and had no oxygen on. Other observations on 06/01/2026 at 9:14 AM and 11:32 AM showed Resident 12 was up in their wheelchair in hallway and had no oxygen on. In an interview on 06/01/2026 at 12:18 PM, Staff E (Unit Care Coordinator) stated their expectation was for staff to follow the physician orders. Staff E reviewed Resident 12's record and stated staff should clarify the order with provider and follow as ordered, but they did not. REFERENCE:WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i).

Based on observation, interview, and record review the facility failed to ensure residents' skin was assessed, documented, monitored, and treated as required for 2 of 5 residents (Residents 5 &11) reviewed for non-pressure skin issues. These failures placed all residents at risk for delay in treatment, worsening of condition, and decreased quality of life. Findings included.<Policy>According to the facility policy titled, Area of Focus: Basic Skin Management, dated 12/03/2024, the facility would ensure all residents had a weekly head to toe skin assessment documenting a thorough description of all skin alterations at the time of the assessment.<Resident 5> According to the 03/06/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 5 had no memory impairment. The MDS showed Resident 5 was at risk for skin injuries and required staff assistance with all Activities of Daily Living (ADL). The assessment showed Resident 5 had diagnoses of general muscle weakness and adult failure to thrive. Review of a 01/10/2025 ADL self-care performance deficit Care Plan (CP) staff would ensure Resident 5 had weekly skin assessments completed every Saturday. The CP showed nurses would assess Resident 5 for any skin alterations. Review of a weekly skin assessment on 05/23/2026 showed no skin alteration to Resident 5's right forearm. Observation and interview on 05/28/2026 at 9:31 AM Resident 5 had a six-centimeter-long x four-centimeter-wide dark purple bruise to their right forearm. Resident 5 stated staff were not monitoring and did not come in to look at it. Review of a weekly skin assessment on 05/30/2026 showed no documentation of Resident 5's skin alteration to their right forearm. In an interview on 06/01/2026 at 2:03 PM Staff B (Director of Nursing) stated they expected staff to do weekly skin assessments documenting a description with measurements, color, breaks in skin, and any swelling. Staff B reviewed Resident 5's weekly skin assessment and stated staff did not assess and document the dark purple bruise to Resident 5's right forearm but should have. Staff B stated it was important to assess and document all skin alterations to be able to monitor for worsening or improvement. In an interview on 06/02/2026 at 8:24 AM Staff E (Unit Care Coordinator) stated staff should have documented Resident 5's dark purple bruise to their right forearm but did not. Staff E stated it was important to assess for worsening and/or improvement. <Resident 11> According to the 04/14/2026 Quarterly MDS Resident 11 re-admitted to the facility on [DATE] with diagnoses of wounds to the lower legs, heart failure, and kidney disease. The MDS showed Resident 11 had non-pressure related wounds to the lower extremities. Review of Resident 11's 06/05/2025 chronic ulcer CP showed interventions to perform weekly skin checks. Review of Resident 11's physician orders showed a 03/27/2026 active wound care order for wounds to right leg and 04/16/2026 active wound care order for wounds to the left leg. Review of Resident 11's health record showed a 05/08/2026 progress note that stated the wounds had resolved. There were no further wound assessments seen and wound care orders were still in place. In an interview on 05/28/2026 at 9:01 AM Resident 11 stated they had chronic wounds to their lower legs. In an observation on 05/29/2026 at 10:19 AM showed Staff U (Licensed Practical Nurse) provided wound care for Resident 11 with wounds to both legs present. In an interview on 05/29/2026 at 10:40 AM Staff U stated Resident 11 had chronic wounds to both legs since admission. In an interview on 06/01/2026 at 1:11 PM Staff F (Unit Care Coordinator) stated wounds should be evaluated weekly for signs of healing and/or infection and to assess if interventions/treatments are effective. Staff F stated they were unaware that Resident 11's wounds had returned and should have been notified. Staff F reviewed Resident 11's health record and stated the wounds should have been seen in the weekly skin assessments but were not. Reference: WAC 388-97-1060(1).

Based on observation, interview, and record review, the facility failed to ensure effective pain management was provided to residents, consistent with professional standards of practice, for 2 of 3 sampled residents (Residents 21 & 38) reviewed for pain management. The failure to offer non-pharmacological interventions to residents experiencing pain, investigate causes of pain, and notify the physician for appropriate pain management placed residents at risk for untreated pain, unnecessary discomfort, and a decreased quality of life.Findings included .<Facility Policy>According to the facility's 12/02/2025 Pain Management policy, the facility would ensure pain management was provided to residents who needed it, consistent with professional standards of practice and the resident's comprehensive assessment and care plan. <Resident 21> According to the 05/14/2026 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 21 was alert, capable of verbalizing their needs, and had medical conditions including muscle pain and spinal cord degeneration with back pain. The MDS showed Resident 21 had severe pain which affected their sleep and day-to-day activities during the assessment period. Review of the revised 03/13/2026 pain Care Plan (CP) showed Resident 21 had pain/discomfort on their back, muscle rigidity, and chronic pain. A 02/09/2026 CP intervention instructed staff to evaluate the effectiveness of Resident 21's pain management. A 03/13/2026 CP intervention directed staff to notify the physicians if interventions were unsuccessful or if Resident 21's current complaint was a significant change from the resident's past experience of pain. In an observation and interview on 05/27/2026 at 1:36 PM, Resident 21 was observed with facial grimacing and their body appeared tense while lying in bed. Resident 21 stated they had a lot of pain issues including muscle spasms and rated their current pain 9/10 (using a pain scale where zero (0) was without pain and 10 as having severe pain). Resident 21 stated their pain was not managed effectively. Review of the May 2026 Medication Administration Record (MAR) showed Resident 21 had PRN (as needed) pain medication for a pain rating of 1-4/10. The MAR did not show Resident 21 had PRN pain medication available to them for a pain rating of 5/10 or higher. On 05/03/2026, Resident 21's pain rating was documented as 7/10 and the nurse administered the PRN medication available which was not intended for the resident's pain rating based on the parameters outlined as ordered. In an interview on 06/02/2026 at 10:54 AM, Staff B (Director of Nursing) stated pain management was important because adequate pain control ensured resident's had quality of life. Staff B stated they expected the nursing staff to follow pain medication parameters and to administer them as ordered. Staff B reviewed Resident 21's May 2026 MAR and stated the nurse should not have administered the PRN pain medication available for a pain rating of 1-4/10 to Resident 21 since the resident reported a higher pain level. Staff B stated the nurse should have notified the physician, informed them of Resident 21's pain rating of 7/10, and obtained an order for what pain medication to administer, but they did not. <Resident 38> According to the 04/09/2026 Quarterly MDS, Resident 38 admitted to the facility on [DATE] with diagnoses of heart failure, hypertension, and stroke. The MDS showed Resident 38 had occasional moderate pain during the assessment period. Review of Resident 38's 01/08/2026 pain CP showed interventions to respond immediately to complaints of pain and to evaluate the effectiveness of pain medications. Review of Resident 38's physician orders showed a 01/19/2026 order for a non-narcotic pain medication to be given three times a day for mild to moderate pain, and a 05/01/2026 order for a muscle relaxer to be given three times a day for neuropathic pain. Review of Resident 38's health records showed pain levels at 10/10 on 05/10/2026 at 2:20 PM and at 8:40 PM. There were no notes in Resident 38's health record to indicate physician notification, pain assessment, or any interventions provided to address the resident's 10/10 pain. Resident 38's health records showed a zero out of 10 pain level at 10:02 PM on 05/10/2026. In an interview on 05/28/2026 at 8:26 AM, Resident 38 stated they did not feel the facility was managing their pain well. In an interview on 06/01/2026 at 1:20 PM, Staff F (Unit Care Coordinator) stated Resident 38's pain on 05/10/2026 should have been assessed and the physician notified, but these did not occur. In an interview on 06/02/2026 at 6:56 AM, Staff D (Infection Preventionist) stated they were the assigned nurse who documented the 10/10 pain for Resident 30 on 05/10/2026. Staff D stated they should have notified the physician as there was no as needed pain medication available to administer, but they did not. REFERENCE: WAC 388-97-1060(i), -1620(2)(b)(i)(ii).

Based on observation, interview, and record review, the facility failed to ensure expired medications were discarded timely for 1 of 2 medication storage rooms (North Medication Room) and to ensure medications were labeled appropriately in 1 of 4 medication carts (200 Hall Medication Cart) reviewed for medication storage. This failure placed residents at risk for receiving incorrect or expired medications, ineffective treatment, and diminished quality of life. <North Medication Room> Observation on 05/29/2026 at 8:00 AM in the North Medication room showed the following: Three inhalers (portable handheld devices that deliver medication via a fine mist, spray, or powder to be inhaled orally) that were opened with no open date. Two boxes containing vials of nebulizer medication (liquid medicine that is converted into a fine, breathable mist by a machine called a nebulizer) with expiration dates of 07/10/2025 and 10/29/2025. Vaccines stored in the refrigerator with expiration dates of 02/12/2025, 05/02/2025, 07/31/2025, and 10/23/2025. Review of a 2024 Medication Storage Guidance provided by Omnicare pharmacy showed the inhalers were to be discarded three months after opening. In an interview on 05/29/2026 at 8:15 AM, Staff D (Infection Preventionist) stated the inhalers should have been dated when opened but they were not. Staff D reviewed the found items and stated the medications were expired and should have been discarded or returned to the pharmacy, but they were not. <200 Hall Medication Cart> Observation and interview on 05/29/2026 at 10:51 AM showed a medicine cup containing five oral medications, including tablets and capsules of varying shapes and colors, was stored in the top drawer of the 200 Hall Medication Cart. The medication cup had no labeling to indicate what the medications were or which resident they were for. Staff U (Licensed Practical Nurse) stated they were not aware the medication cup with medications was in the drawer and did not know which resident they were for. Staff U stated the medications should have been discarded but were not. REFERENCE: WAC 388-97-1300(2).

Based on interview and record review the facility failed to implement an Antibiotic Stewardship Program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 1 of 5 residents (Resident 91) reviewed for unnecessary medications and 1 of 1 supplemental residents (Resident 53). This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.Findings included. <Policy>According to the facility's 06/02/2025 Infection Prevention and Control Program (IPCP) and Plan policy, the facility would conduct antibiotic surveillance to review the appropriateness of antibiotics in the facility to prevent unnecessary antibiotic use.<Resident 91>Review of Resident 91's health records showed they were receiving an intravenous antibiotic starting on 05/27/2026 with no stop date.<Resident 53>Review of Resident 53's health records showed they received an oral antibiotic from 05/12/2026 through 05/19/2026.Review of the facility's May 2026 Line Listing showed Resident 53 and Resident 91 were not listed as having an infection or receiving antibiotics.In an interview on 06/02/2026 at 11:57 AM Staff D (Infection Preventionist) stated they reviewed all antibiotic orders for appropriateness using McGeer's criteria (a tool used to determine antibiotic appropriateness) and included the review on the Line Listing for tracking and trending of infections. Staff D stated that it was important to review antibiotics to prevent unnecessary antibiotics and/or antibiotic resistance. Staff D reviewed the Line Listing and stated neither Resident 91 nor Resident 53 were listed but should have been. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

Based on interview and record review, the facility failed to implement a policy and procedures to assess and manage pain for 1 of 3 Residents (Resident 1) reviewed for pain management. The failure to thoroughly assess resident pain on admission, develop an individualized care plan (CP) in collaboration with the resident, their representative and practitioner, implement the CP, monitor for adverse consequences, notify the resident representative of medication changes, and document resident conditions, placed residents at risk for untreated pain, medication overdose, hospitalization, and diminished quality of life.Findings included.<Facility Policy>Review of the 09/23/2025 revised Pain Assessment and Management Policy showed all residents would be assessed for pain indicators on admission, quarterly, and with any change in condition; an individualized pain management CP would be developed and initiated when pain indicators were identified. The policy showed the facility would collaborate with the prescriber, the resident and/or the resident representative (RR) to develop, implement, monitor, and revise resident-specific interventions to manage pain using medication and non-pharmacological approaches, monitor for effectiveness and side effects. Residents who were prescribed opioid medication would be assessed for the risk of overdose and dependance, when opioids were combined with benzodiazepines the facility would identify and document clinical indications and implement close monitoring for adverse consequences.<Resident 1>Review of the 04/13/2026 admission nursing assessment showed Resident 1 had cognitive impairment, English was not their primary language, was wheelchair bound, required total assistance by staff for mobility and hygiene, had no pain at the time of assessment, and was prescribed an opioid pain medication as needed. The pain assessment did not show a diagnosis for pain, location, effects on quality of life, or non-pharmacological methods of pain relief.Review of the April 2026 care plan for Resident 1 showed no focus area or interventions for Resident 1's pain management.Review of the April 2026 Medication Administration Record (MAR) showed Resident 1 was admitted on [DATE], had diagnoses of pain in one hip, both knees and unspecified bilateral leg pain, and was on pain monitoring every shift. Medications prescribed on admission were routine medication for neurological leg pain, a routine topical pain patch for legs, a mild analgesic as needed and an opioid medication every six hours as needed. The opioid medication was administered three times, twice on 04/14/2026 for pain level 8/10 and 7/10, both doses were documented as effective, one dose on 04/15/2026 for pain level 10/10 and was documented as effective.Review of a 04/15/2026 practitioner initial evaluation note showed a review of past medical history including leg pain. The practitioner assessment note showed Resident 1 was in bed, no acute distress, alert and oriented, able to make needs known, pain level of 2 that morning, with plan of continuing current pain management with opioid and neurological pain medication and noted a medication for anxiety in the medication class of benzodiazepines. The note concluded that nursing had no concerns and directed continued monitoring of Resident 1.Review of a 04/15/2026 medication order change showed the opioid medication as needed was discontinued and changed to a routine opioid dose three times a day.Review of the nursing progress notes from 04/15/2026 to 04/17/2026 showed no documentation of change of condition in Resident 1's pain or reason for change in the pain medication directions.Review of the April 2026 MAR showed the opioid pain medication was changed to three times per day, scheduled at 8:00 AM, 2:00 PM and 8:00 PM. The first routine dose was given on 04/15/2026 at 2:00 PM. Resident 1 had two doses on 04/15/2026, and three doses on each day 04/16/2026 and 04/17/2026.Review of a 04/17/2026 nurse progress note showed Resident 1 was confused, had pain in back and abdomen, and oxygen saturation was low. The note showed the oxygen dose was increased, pain medication was administered, practitioner was informed and directed to send Resident 1 to the hospital, RR arrived, and RR called 911. Medics took over at bedside then transferred Resident 1 to the hospital for advanced medical care.Review of the 04/17/2026 hospital critical care admission note showed Resident 1 arrived at the emergency department due to unresponsiveness, low oxygen level, and low pulse. The note showed Resident 1 required an opioid antagonist medication through an intravenous (IV) tube into their blood stream administered by the medics to reverse the opioid reaction. Resident 1 was diagnosed with unintentional opioid overdose with respiratory failure and was admitted to the intensive care unit.In an interview on 04/30/2026 at 3:42 PM, Resident 1's Representative (RR) stated Resident 1 had chronic pain and took an opioid medication as needed and could take a dose every six hours. The RR stated on 04/17/2026, they called Resident 1who did not answer the phone, so they called the facility and asked staff to assist Resident 1 to answer the phone. When talking with Resident 1 they were not making sense, the phone was on speaker, so they asked the staff in the room what was happening. The RR stated they were told Resident 1 could not hold the phone and kept dropping it. The RR stated they asked staff to get the nurse to see Resident 1 right away. RR stated they drove to the facility while on the phone with Resident 1 trying to keep them awake and engaged in conversation. The RR stated Resident 1 was not making sense, was hallucinating, and very confused. The RR stated when they arrived at the facility Resident 1 was barely awake, was slumped to one side in the bed, their speech did not make sense, Staff E was in the room and would not call 911. RR stated they called 911 and were very scared about Resident 1's condition. RR stated when the medics arrived, they had to administer an opioid antagonist medication and took Resident 1 to the hospital. RR stated Resident was still at the hospital, now 13 days later.In an interview on 05/01/2026 at 12:44 PM, Staff C (Certified Nursing Assistant) stated on 04/17/2026 Resident 1 had been sleepy since the start of their shift at 2:00 PM. Staff C stated Resident 1 did not eat dinner because they were sleepy. Staff C stated when the RR called, Resident 1 could not hold on to the phone, seemed more confused than usual, and was talking in their primary language with RR. Staff C stated the RR asked for the nurse to see Resident 1. Staff C stated they went and got Staff E and brought them to the room. Staff C stated Resident 1's vital signs were checked, and the oxygen level was low in the 50's (normal range 90-100) so Staff E turned their oxygen setting up. Staff C stated the RR arrived in a panic and asked to have 911 called, then called 911 themself. Staff C stated they were not in the room when the medics arrived.In an interview on 05/01/2026 at 1:10 PM, Staff D (Certified Nursing Assistant) stated they worked with Resident 1 on 04/17/2026 on the day and evening shift. Staff D stated Resident 1 was sleepy during the day, was awake and talking when the staff exchanged beds before dinner. Staff D stated they checked on Resident 1 when they were on the phone with RR speaking their primary language. Staff D stated the RR asked Staff D to get the nurse because Resident 1 was hallucinating. Staff D stated they notified Staff E, and Staff E went to Resident 1's room. Staff D stated the RR arrived in Resident 1's room and Staff D left the room.In an interview on 05/01/2026 at 1:22 PM, Staff A (Administrator) stated Staff E no longer worked at the facility for another reason. Staff E could not be interviewed.In an interview on 05/01/2026 at 2:41 PM, Staff B (Director of Nursing) stated Staff E called on 04/17/2026 to notify that Resident 1 was sent to the hospital. Staff E explained to Staff B that RR stated Resident 1 was more confused, Staff E checked on Resident 1 and found them alert and responsive, vital signs were stable, oxygen level was good and there were no abnormal findings on their assessment. Staff E stated the RR arrived and the oxygen saturation was low, so they increased the oxygen setting. Staff E stated they talked with the practitioner and were told to send Resident 1 to the hospital. Staff E stated they were going to call 911 but the RR had already called. Staff E stated Resident 1 was responsive when they left the facility with the medics and the RR.In an interview and record review on 05/01/2026 at 2:47 pm, Staff B reviewed Resident 1's electronic medical records and stated there was not a complete pain assessment on admission, there was not a care plan for pain, Resident 1 was prescribed a benzodiazepine with an opioid which could be contraindicated, the opioid pain medication was as needed on admission on [DATE] and changed on 04/15/2026 to scheduled administration three times a day, there was no pain assessment for a change in pain levels on 04/15/2026, there was no documentation of notification of the practitioner of pain level change on 04/15/2026, there was no documentation for why the opioid order changed on 04/15/2026, there was no documentation of notification of the RR, there was no alert monitoring initiated for the change in opioid pain medication, and the instructions when to administer the as needed opioid antagonist medication were unclear. Staff B stated all these steps should have been, and were not, followed by staff.Reference: WAC 388-97-1060(1)(4), -1620(2)(b)(i)(ii).

Based on interview and record review the facility failed to ensure staff provided care according to the resident's care plan to prevent accidents for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1 experienced harm when facility staff did not use two caregivers as planned when providing incontinence care, they rolled off an air mattress bed and sustained an inoperable leg fracture. Failure to follow resident's care plans placed all residents at risk for injury, falls, and diminished quality of life. Findings included Review of the 11/05/2024 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was on hospice services, was dependent on staff to move in bed, was always incontinent of bowels and bladder, and had functional limitations and poor range of motion in both of their arms. Review of Resident 1's physician and nursing orders showed a 10/29/2024 order for a low-air-loss mattress (a mattress filled with air to reduce pressure on a person's skin) to promote Resident 1's skin integrity. The order directed staff to monitor Resident 1's position in bed and the function and safety of the air mattress. The comprehensive care plan (CP) revised on 11/15/2024 showed Resident 1 required two caregivers to assist with bed mobility. The CP showed Resident 1 wore incontinence briefs and required two caregivers to assist with incontinence care. The care plan did not show Resident 1 used an air mattress until the CP was revised on 12/02/2024. Review of the 11/15/2024 Kardex (care instructions to the caregivers) showed two caregivers were required for Resident 1's bed mobility and incontinence care. The Kardex showed no information that Resident 1 used an air mattress. The Kardex showed no instructions to the staff for Resident 1's safety while moving them on the air mattress. Review of a 11/22/2024 nurse progress note showed Resident 1 fell on the floor during care at 4:30 AM. The note showed Resident 1 was bleeding from the back of their head, had pain, and limited movement in their right knee. The note showed Resident 1 was sent to the emergency room for further assessment of injuries. Review of the 11/22/2024 facility investigation of Resident 1's fall showed the caregiver raised the bed to waist height and started to provide incontinence care to Resident 1. The caregiver did not have a second person to assist with care which was required according to the instructions on Resident 1's CP. The caregiver rolled Resident 1 to their side, out of the bed, and Resident 1 fell on the floor. The facility investigation concluded the fall occurred because the caregiver did not follow Resident 1's CP. The facility investigation did not identify that Resident 1 was lying on an air mattress at the time of the fall. Review of Resident 1's 11/2024 daily documentation by the caregivers on the evening shift showed 11 shifts where staff provided only one caregiver, instead of two caregivers, for bed mobility. The caregiver documentation for the night shift showed 14 shifts provided one caregiver, instead of two caregivers, for bed mobility. In an interview on 12/19/2024 at 6:04 PM, Staff D (Licensed Practical Nurse) stated they were working on the shift when Resident 1 fell . Staff D stated the caregiver was in the room yelling help when Staff D responded. Staff D stated the caregiver was performing incontinence care by themselves and Resident 1 rolled out of the bed, away from the caregiver, and landed on the floor. Staff D stated Resident 1 required two staff for care in bed because Resident 1 could not move by themself. Staff D stated there were enough staff on duty on 11/22/2024 night shift. Staff D stated the caregiver should have asked for help before providing incontinence care. Staff D stated the caregiver did not follow the care plan and Resident 1 fell out of bed, sustained an injury on their head which was bleeding, and had to be transferred to the emergency room where a leg fracture was diagnosed . In an interview on 12/19/2024 at 6:41 PM, Staff B (Float Director of Nursing) stated staff was expected to follow the resident's CP. Staff B was not aware of Resident 1 using an air mattress at the time of the fall. Staff B stated according to the facility investigation on Resident 1's 11/22/2024 fall the staff did not follow Resident 1's CP and Resident 1 fell out of bed. Refer to F684 Quality of Care. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to ensure 2 of 5 residents (Residents 1 & 2) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) were provided the necessary treatment and services consistent with professional standards of practice, to promote healing and prevent the occurrence of a PU/PI. Resident 1 experienced harm when their Moisture Associated Skin Damage (MASD) developed into a Stage 4 PU (a full thickness wound with tissue loss and exposed bone, tendon, or muscle) on their buttock and acquired Osteomyelitis (a bone infection). This failed practice placed other residents at risk for skin breakdown and a diminished quality of life. Findings included . <Facility Policy> Review of the facility policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management, revised 07/09/2024, showed the facility would provide the necessary treatment and services, consistent with professional standards of practice, to a resident with PU/PI to promote healing, prevent infection, and prevent new ulcers from developing. The policy showed preventative measures identified to maintain and improve the resident's skin condition were implemented in the Care Plan (CP) including repositioning at least every 2-4 hours as consistent with the resident's overall goal and medical condition and the use of a pressure redistribution mattress. <Resident 1> According to the 04/16/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 1 admitted to the facility on [DATE] for skilled rehabilitation needs after hospitalization due to an alteration in their mental status. The MDS showed Resident 1 had medical diagnoses including urinary infection, left hip pain, respiratory failure, and generalized muscle weakness. The MDS showed Resident 1 was always incontinent of their bowel and bladder and had MASD. The MDS showed Resident 1 was dependent on staff for their daily cares and was assessed to require total assistance with bed mobility (rolling from left to right when in bed), transfers, and toileting. The MDS showed Resident 1 was not turned/repositioned during the assessment period. Review of the 04/10/2024 Nursing Admission/Readmission Collection Tool showed Resident 1's skin condition upon admission and listed the presence of MASD on their buttocks area. Review of the 04/10/2024 skin CP showed Resident 1 had a break in their skin integrity and an intervention directed the nursing staff to provide treatment as ordered. Resident 1's CP did not show preventative pressure-relieving instructions for staff to perform including turning/repositioning or off-loading (to not bear any weight). The CP did not show the facility addressed Resident 1's refusal with off-loading. Review of Resident 1's physician orders from April 2024 to July 2024 did not show a treatment was put in place to manage the identified MASD on Resident 1's buttocks during admission. On 09/26/2024 at 1:52 PM, Resident 1's representative stated the resident's PU was not adequately cared for while Resident 1 was in the facility, .[Resident 1] was always on their back when we come in to visit .we stay for long periods during the day and visited at least 3-4 times in a week .staff never came to reposition [Resident 1] or at least attempt or mention turning [Resident 1]. Resident 1's representative stated the facility notified them when an open area was first observed on Resident 1's buttocks but were not told the PU was worsening. Resident 1's representative stated a nurse told them Resident 1's PU was so big that they could put their fist in it. Review of the 05/23/2024 incident report investigation showed the facility identified a PU measuring 4 centimeters (cm) long x 3 cm wide, but no depth was listed, to Resident 1's buttocks. The facility attributed the cause of the injury to Resident 1's altered mental status and limited mobility. Review of the 05/28/2024 wound care note showed Resident 1 had an unstageable PU (a full-thickness skin and tissue loss where the extent of the tissue damage could not be seen) on their buttocks measuring 4 cm x 2 cm x 0 cm and an antifungal cream was initiated. Review of the 06/04/2024 wound care note showed Resident 1's unstageable PU measured 2.5 cm x 3 cm x 0 cm and Iodosorb (an antimicrobial gel) was added to the resident's wound treatment. The note showed Resident 1 remained fully dependent on nursing staff for off-loading. Review of the 06/11/2024 wound care note showed Resident 1's unstageable PU developed depth and measured 3cm x 3 cm x 0.2 cm. The note showed the Iodosorb was changed to Santyl (an ointment used to breakdown and remove dead tissue from wounds). Review of the 06/25/2024 wound care note showed the PU was assessed to be a Stage 4 PU after the wound nurse performed surgical debridement (removal of the top layer of skin tissue covering the wound opening) that measured 5 cm x 4.5 cm x 0.6 cm deep; the subcutaneous (layer of the skin made up of fat and connective tissue), tendon (a fibrous connective tissue attaching the muscle to the bone), and ligament (a fibrous connective tissue attaching bone to bone) were exposed. The note showed Resident 1's PU was deteriorating and that healing was compromised by Resident 1's incontinence and poor participation/refusal with off-loading. The note showed a wound culture was taken for suspected wound infection and the treatment was changed back to Iodosorb. Review of the 07/02/2024 wound care note showed Resident 1's Stage 4 PU was bigger and measured 5.5 cm x 3.5 cm x 1.5 cm deep, with newly identified 1 cm undermining (a type of complication where the wound's edges separate from the health tissue around it and create a dead space/pocket beneath); the wound culture showed the presence of multiple bacteria (germs) and indicated Resident 1 was at risk for osteomyelitis. The note showed the wound nurse recommended to discontinue the daily treatment using Iodosorb and changed it back to Santyl ointment and was to be performed every other day. Review of the July 2024 Treatment Administration Record (TAR) showed the staff did not discontinue the Iodosorb and was continuously applied on Resident 1's PU daily from 07/01/2024 until 07/10/2024. The TAR showed a 06/12/2024 order for Santyl ointment that was continuously applied on Resident 1 daily (as opposed to every other day as ordered). The TAR showed that from 07/01/2024 until 07/15/2024, both the Iodosorb gel and the Santyl ointment were simultaneously applied on Resident 1's PU. In a joint interview on 09/26/2024 at 4:54 PM with Staff A (Administrator) and Staff B (Director of Nursing), Staff B reviewed Resident 1's medical records and stated there should be orders and preventative interventions put in place early on when the nursing staff identified Resident 1's MASD during admission, but there were none. Staff B stated that Resident 1's CP did not include information directing staff to provide turning/repositioning. Staff B stated it was important to follow the treatment recommended/ordered by the wound care provider so the resident's PU would receive the proper treatment and heal/resolve and not deteriorate, .[we] should be monitoring the PU to ensure they do not get worse. When asked if they expected nursing staff to carry out and implement the PU treatment as ordered, Staff A stated, Absolutely. <Resident 2> According to the 05/06/2024 Admission MDS, Resident 2 admitted to the facility on [DATE], had clear speech, intact memory, and medical conditions including heart and kidney failure, malnutrition, and cancer. The MDS showed Resident 2 had cancer lesion(s) and MASD during the assessment period. The MDS showed Resident 2 was dependent on staff for their daily cares and was assessed to require substantial/maximum assistance with bed mobility (rolling from left to right when in bed), transfers, and toileting. Review of the 05/28/2024 Discharge Return Anticipated MDS showed Resident 2 had one unstageable PU that was not present on admission. Review of the 04/29/2024 Nursing Admission/Readmission Collection Tool showed Resident 2's skin condition upon admission and listed the presence of three open wounds: Sacrum wound measuring 2.5 cm x 1 cm x 0.1 cm; right buttock wound measuring 3 cm x 0.2 cm; and left buttock wound measuring 3 cm x 0.1 cm. Review of the 04/29/2024 skin CP showed Resident 2 was at risk for skin impairment and CP interventions directed nursing staff to provide treatment as ordered. Review of the 05/07/2024 wound care note showed Resident 2's cancer lesion (from their anal cancer radiation treatment) on their coccyx (tail bone) measured 3.5 cm x 4 cm x 0 cm and the wound base was all covered in slough (dead skin tissues). The wound nurse ordered treatment with Santyl and the use of an air mattress for pressure redistribution. Review of Resident 2's medical records did not show an air mattress was put in place. The facility was not able to provide any documentation to support Resident 2 was provided an air mattress as ordered by the wound nurse. A 05/15/52024 nursing progress note showed staff observed a left hip abrasion on Resident 2 during daily cares measuring 4 cm x 2 cm. The note showed Resident 2 told staff it was probably due to them sitting up for an extended period during transport when they went out for surgery the day prior. Review of the 05/21/2024 wound care note showed Resident 2's left hip abrasion was classified as an unstageable PU and measured 4 cm x 1.5 cm x 0.1 cm. The wound nurse recommended aggressive off-loading and treatment with Santyl ointment daily and as needed. Review of the May 2024 TAR did not show the treatment order for Santyl ointment recommended by the wound care provider on 05/21/2024 to treat Resident 2's left hip PU was implemented by the nursing staff. The facility was not able to provide any documentation to support Resident 2 was provided the treatment they were assessed to require to help heal their left hip PU. In an interview on 09/26/2024 at 4:08 PM, Staff B reviewed Resident 2's medical records and stated the facility did not implement the treatment for the resident's left hip PU as ordered. Staff B stated they do not have any documentation to support an air mattress was put in place for Resident 2 as ordered by the wound nurse. Staff B stated that Resident 2's CP did not include any instructions for staff to provide aggressive off-loading measures. Staff B stated they expected the nursing staff to provide PU treatment and care to residents who were assessed to need them. REFERENCE: WAC 388-97-1060(3)(b).

Based on interview and record review, the facility failed to provide resident focused care through consistent monitoring, assessment, evaluation of the resident's condition, and to implement physician orders timely to identify a change in condition for a suspected urinary tract infection (UTI) for 1 of 5 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harmed when they were hospitalized in the intensive care unit for a bladder and kidney infection which accelerated into a systemic blood infection. This failed practice placed other residents at risk for unmet needs, hospitalization , and diminished quality of life. Findings included . The 06/21/2024 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE] with a spinal fracture. Resident 1 was assessed as always incontinent of urine and required incontinence care from staff. Resident 1 was assessed to have cognitive impairment and refused care one to three days during the assessment period. The 06/27/2024 Care Plan (CP) showed Resident 1 required moderate assistance from staff to use the toilet, had impaired cognitive ability, impaired thought processes, short term memory loss, and communication deficits. The CP showed Resident 1 needed cueing, reorientation and supervision for all personal care. Review of a 07/09/2024 handwritten note from Resident 1's Representative (RR) showed a request to the facility to check Resident 1 for a urinary tract infection (UTI). Attached to the handwritten note was a communication document from nursing to the practitioner, dated 07/09/2024, which showed a request for a lab test to check Resident 1's urine for a UTI related to inappropriate behaviors. A 07/09/2024 11:07 PM nursing progress notes (PN) showed the practitioner ordered the urine lab test. The PN showed staff placed a urine collection device in Resident 1's toilet. (The MDS showed Resident 1 was assessed as always incontinent.) Review of the nursing PN from 07/09/2024 to 07/15/2024 showed Resident 1 had multiple refusals of care, refusals of medications, refusing therapy, grabbing and hitting at staff, using in appropriate sexual language toward staff, hallucinating and having delusional thoughts about going to work, was a high fall risk and was standing without assistance, wandering in the halls, and sleeping in the wheelchair refusing to lie down in bed. The PNs showed Resident 1 required staff to anticipate their needs, one person to assist with personal care, and two staff to assist with transfers in/out of bed and on/off the toilet. The PNs showed Resident 1 was incontinent of bladder and bowels and used an incontinent pad. The practitioner was informed of behaviors but no new interventions were implemented. An attempt of collecting a urine sample was done on 07/11/2024 and was not successful. No other attempts to collect a urine sample were documented. A 07/15/2024 6:55 AM nursing PN showed Resident 1 was incoherent, would not drink fluids, had a change of skin color to slightly blue color, and had a change in level of consciousness. No vital signs were recorded. The staff called 911 for transport to the hospital. After Resident 1 was discharged on [DATE] (Monday) a communication document from nursing to the practitioner was scanned into Resident 1's medical record. The document was completed on 07/12/2024 (Friday) by a nurse, informing the practitioner that staff was unable to collect a urine sample due to Resident 1's refusals and incontinence. The practitioner did not review the document until 07/15/2024 (Monday, six days after the order was given to collect a urine sample and send to the lab) when it was signed, dated and the practitioner wrote Resident 1 was in ED (Emergency Department). The 07/15/2024 hospital history and physical notes showed Resident 1 was admitted to the hospital with a high temperature of 103.1 degrees Fahrenheit (F), low blood pressure 85/63, high heart rate 113, high respirations 26. (Normal range for temperature is 98.6 F, normal blood pressure is 120/70, normal heart rate is 70, normal respirations are 16-18.) Resident 1 was admitted to the intensive care unit (ICU) for severe sepsis (systemic blood infection), cystitis (bladder infection), kidney infection, and acute kidney injury. Resident 1 required intravenous antibiotics, fluids, and was not able to eat or drink given a poor mental state. In an interview on 08/06/2024 at 12:52 PM, Resident 1's RR stated they asked the nurse on 07/09/2024 if a urine test could be completed to see if Resident 1's behaviors were related to a UTI. The RR stated they were informed on 07/10/2024 that an order was received to send a urine sample to the lab. The RR stated they did not hear anything from the nurses until 07/14/2024 when they asked for an update about what the lab test showed. The RR stated the nurse said a urine sample was not collected because Resident 1 could not urinate in the collection device. The RR stated they were going to help get the urine sample, but they were not strong enough to lift Resident 1. The RR stated early the next morning they received a call from the nurse stating Resident 1 had erratic breathing and was being sent to the hospital. The RR stated at the hospital Resident 1 had a very low blood pressure and a kidney infection that turned to sepsis from the UTI. The RR stated the facility never checked the urine for an infection, Resident 1 never got antibiotics or treatment for an infection so Resident 1 ended up in the ICU. An interview on 08/12/2024 at 4:39 PM, Staff B (Director of Nursing) stated staff should monitor a resident for urinary signs and symptoms when a UTI was suspected. Staff B stated when a practitioner orders a urine sample the nurse should collect the urine and send to the lab within two days. Staff B stated when a resident refuses, or the sample was not collected, the nurse should document, report to the practitioner, and obtain further instructions. In an interview on 08/12/2024 at 4:46 PM, Staff A (Administrator) and Staff B reviewed Resident 1's medical record and were not able to locate documentation: that nursing staff monitored Resident 1 for a suspected UTI, attempted to collect any urine samples after 07/11/2024, notified the RR, asked the RR for assistance with sample collection, or notified the practitioner when urine was not collected after two days. Staff B stated there was only one attempt to collect urine on 07/11/2024, no other attempts were made. Staff A stated the order for the urine sample collection dropped out of the electronic medical record on 07/12/2024. Staff A explained when an order drops out of the system the staff is no longer prompted to collect a urine sample. Staff B confirmed Resident 1 went to the hospital for a change in their level of consciousness and decline in medical condition. REFERENCE: WAC 388-97-1060(1).

Based on observation, interviews and record review, the facility failed to protect 1 of 6 (Resident 2) sample residents' right to be free from physical abuse. The facility failed to protect Resident 2 from physical abuse when Resident 1 punched Resident 2 twice on the shoulder. The facility failed to supervise Resident 1, who had a history of verbal and physical aggressive behaviors towards residents, and failed to mitigate known triggers for Resident 1. Resident 2 experienced psychological harm, using the reasonable person concept, as a result of the physical abuse as there is an expectation that the resident would not be punched while in the facility. Theses failures placed all residents at risk for the potential of abuse, psychological harm, and diminished quality of life. Findings included . Review of the 02/02/2024 Quarterly Minimum Data Set (MDS - an assessment tool) for Resident 1 showed the resident had diagnoses to include dementia and psychotic disorder. Resident 1 was assessed as alert and oriented. Review of a 02/12/2022 Behavior Care Plan showed the goal that Resident 1 would not experience behaviors that were harmful to self and others. Interventions included directions to staff to anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately and to intervene as necessary to protect the rights and safety of others. Review of a 03/13/2024 facility Investigative Report showed on 03/08/2024 Staff D (Social Services Director) heard yelling from their office. When Staff D stepped out of the office, they observed Resident 1 hitting Resident 2 on the shoulder. After the resident's were separated, Resident 1 was interviewed and stated they were irritated with Resident 2 because Resident 2 was too noisy and woke them up early in the morning. The 03/13/2024 investigative document showed Resident 2 was known to call out frequently and was often very vocal. Review of the 03/13/2024 facility documented conclusion showed the root cause of the incident was determined to be reasonably related to Resident 2's behaviors and Resident 1 being emotionally affected by those behaviors. Review of a 03/08/2024 4:38 PM Event Note, showed Resident 2 was highly confused, could be disruptive to others, and Resident 2's mood frequently changed. Staff received a report that Resident 2 was hit on the shoulder. During an interview on 04/03/2024 at 12:04 PM, Staff F (Registered Nurse, Resident Care Manager), stated that Resident 2 was confused, repeated things over and over again, and would not recall the incident if asked. During an interview on 04/03/2024 at 12:33 PM, Staff E (Social Services Assistant) stated that Resident 2 repeated the same words, sentences over and over again. Resident 1 did not like hearing the repetitive words and patted Resident 2 on the shoulder. During an interview on 04/03/2024 at 12:39 PM, Staff D (Social Services Director) stated that they saw Resident 2 in the middle of the hallway facing the wall and Resident 1 standing over and behind Resident 2. Resident 1 extended their arm up, fists clenched and punched Resident 2 twice. Staff D stated that Resident 1 did not like noises. Staff D stated at the time of the abuse, Resident 2 looked fearful. Staff D stated that when Resident 2 saw a taller nursing assistant standing over them, Resident 2 asked, Hey, are you the aid that hit me? Resident 1 was observed on 04/03/2024 at 11:22 AM to open their bedroom door, walk out independently with a walker and sit in a chair outside their doorway in the hallway. In an interview at that time, Resident 1 denied any problems with any other residents. Resident 2 was observed on 04/03/2024 at 12:09 PM in the dining room. Resident 2 was talkative and interacted with the investigator but was unable to answer specific questions. Review of the facility investigation showed during Resident interviews conducted by Staff D on 03/08/2024, Residents were asked if they felt safe around Resident 1 and three of four unnamed residents responded no. During an interview on 04/03/2024 at 2:44 PM, Staff D stated two of the resident's interviewed did not feel safe when Resident 1 yelled. When Resident 1 got upset they had a loud deep voice. When asked what the facility was doing to ensure Residents felt safe in the facility, Staff D stated they were working on moving Resident 1 out of the facility. During an interview on 04/03/2024 at 2:27 PM, Staff C (Administrator in Training) stated that Resident 2 could be very talkative, based on what others said, Resident 1 liked things quiet and if there's any disruption Resident 1 got upset. When asked since these were known behaviors, what were the preventative expectations of staff, Staff C stated they were working on a discharge plan for Resident 1. Interviews and record reviews showed no interim plan to protect residents from abuse while working on Resident 1's discharge from the facility. REFER TO WAC 388-97-0640(1)

Based on observation, interview, and record review the facility failed to ensure proper daily oral hygiene and failed to assist residents to obtain prompt dental services for 2 of 3 residents (Resident 34 & 10) reviewed for dental care. Resident 34 experienced harm when they had sharp pain and pressure with eating due to a lack of consistent oral hygiene assistance (severe heavy plaque build up over time, severe gum disease, and bleeding gums) prompt dental care services were not obtained when recommended. This failed practice placed other residents at risk for unmet dental needs and diminished quality of life. Findings included . <Facility Policy> Review of the facility policy, Dental Services, dated 08/23/2023 showed the facility is responsible for assisting the patient in obtaining needed dental services, to include routine dental services. The facility will provide or obtain an outside resource for routine and emergency dental services to meet the needs of each patient. Arrangements will be made promptly (three days) for routine and emergency dental services. <Resident 34> According to the 10/10/2023 Quarterly Minimum Data Set (MDS- an assessment tool) showed Resident 34 was able to make themselves understood and understood others during communication. Resident 34 had medically complex diagnosis which included diabetes (difficulty controlling blood sugar), multiple sclerosis (a progressive neuromuscular disease), and a need for assistance with personal care. Resident 34 had no functional use of their right arm and hand and limited control of the left arm resulting in the use of specialized equipment for eating and drinking. These limited functions resulted in Resident 34 requiring assistance with oral hygiene. Review of the 02/07/2022 oral/dental Care Plan (CP) showed staff were to refer Resident 34 to the dentist if necessary for signs and symptoms of pain or discomfort, abscess, debris in the mouth, teeth decayed, and ulcer or lesions in the mouth. Review of an 11/06/2023 dental care note showed Resident 34 presented with an active gum infection, had observable food debris, a large amount of plaque buildup, and a lot of calculus (a hardened bacteria) resulting in bleeding gums. The provider recommended daily staff assistance with brushing and to see a dentist for an evaluation for suspected oral lesions, exposed root tips, pain, and declining oral tissue health. Review of the Resident 34's medical record showed a referral to see a dentist was not made. An interview and observation on 01/03/2024 at 9:45 AM showed Resident 34 sitting upright in their bed. Resident 34 stated their teeth were decaying in their mouth causing frequent oral pain. An abundant amount of food debris and plaque (a collection of bacteria) buildup coating each observed tooth. Resident 34 stated that they don't receive oral care assistance from staff. Resident 34 stated that they experience sharp pain and pressure with eating their meals. In an interview on 01/10/2024 at 9:30 AM Staff E (Care Manager) stated dental appointments should be made the same day or within a day of discovery of tooth pain and decay. Staff E stated that it was the responsibility of the RCM to ensure progress notes by the dental provider were followed. Staff E stated that an appointment was not made for Resident 34. In an interview on 01/10/2024 at 10:15 AM Staff B (Director of Nursing) stated that they expected dentist appointments to be made promptly to minimize poor resident outcomes. Staff B reviewed the 11/06/2023 dental note and stated it appeared the note was uploaded into the record without being reviewed by nursing staff. They stated that Resident 34's dental needs should have been followed promptly but were not. <Resident 10> According to the 10/23/2023 Quarterly MDS, Resident 10 was assessed to have clear speech and understood others during communication. The MDS showed Resident 10 did not have any oral health issues. The 02/15/2021 Nursing Admission Evaluation form conducted by the admission nurse showed Resident 10 had missing natural teeth. Review of Resident 10's CP showed a nursing problem initiated on 02/16/2021 regarding Resident 10's oral/dental health. The CP showed, Resident 10 is at risk for oral discomfort related to possible broken teeth. A nursing intervention listed on the same date directed staff to coordinate arrangements for Resident 10's dental care. On 01/03/2024 at 10:14 AM, Resident 10 was observed to have broken teeth; an upper tooth was heavily discolored, chipped, and jagged on the edge. Resident 10 stated their gums hurt when they ate because they did not have enough teeth left to chew their food. Resident 10 stated they had not seen a dentist since they admitted to the facility on [DATE]. Review of Resident 10's January 2023 MAR showed a 07/13/2023 physicians order indicating Resident 10 may have dental care as needed. In an interview on 01/08/2024 at 11:36 AM, Staff D (Unit Care Coordinator) stated oral/dental health was important to assess because the presence of cavities, broken teeth, and bleeding or sore gums could bring residents pain and discomfort. Staff D stated if residents could not eat enough because of chewing difficulties, it could lead to nutrition and hydration problems. Staff D stated social services department coordinated the ancillary services needed by residents including dental care. In an interview on 01/08/2024 at 2:58 PM, Staff F (Social Services Assistant) stated they were responsible for coordinating in-house dental appointments for routine services including examination, cleaning, and denture needs. Staff F provided a 07/13/2021 progress note that showed Resident 10 declined dental services. When asked if there were any dental care follow-up made after to address the possible broken teeth identified in Resident 10's CP, Staff F stated, Well, the resident [Resident 10] refused, so of course none. Staff F stated they had no involvement with out-of-facility consults and denied assisting Resident 10 with the dental appointment. Refer to F677 - ADL Care Provided for Dependent Residents. REFERENCE WAC: 388-97-1060(2)(c)(3)(vii). 46471

Based on interview and record review, the facility failed to provide adequate and appropriate interventions and supervision to prevent falls for 1 (Resident 1) of 3 residents reviewed for falls. This failure resulted in Resident 1 incurring 4 falls, an acute fracture of the right leg and subsequent hospitalization for a surgical repair of the fracture. Findings included . Review of a 06/04/2020 policy titled Fall Management showed the facility promoted resident safety and reduced falls by proactively identifying, care planning and monitoring the resident's fall indicators through a Fall Risk Assessment. This policy showed that accurate assessment of the resident was fundamental in determining indicators for potential falls. Review of a 2021 Lippincott Procedures associated with the Fall Management Policy and Procedure and titled Fall Prevention, Long Term Care, showed that if a resident was at risk for future falls, the facility would take steps to reduce the danger based on the factors creating the risk. This procedure showed that one of the interventions to prevent falls was to check on the resident every 30 minutes if the resident was at high risk for falls, and to document the times and frequency the resident was checked. This procedure also instructed the facility to consider providing close supervision. Review of a 06/16/2021 Admission Minimum Data Set (an assessment tool) showed Resident 1 admitted to the facility on [DATE] with multiple diagnoses, to include a history of falling, an ankle fracture with surgical repair, and cognitive communication deficit. This assessment showed staff assessed Resident 1 usually made themselves understood and understood others and had intact cognition. Staff assessed Resident 1 required extensive assistance of two people for bed mobility, transfers, and toilet use. This assessment identified Resident 1 was not steady when moving from a seated to a standing position, moving on and off the toilet, or transferring between a bed and a chair or wheelchair. Review of a 06/09/2021 progress note showed Resident 1 had no weight bearing orders to the right leg and was forgetful at times. Review of a 06/09/2021 Fall Risk Evaluation showed staff was instructed to initiate fall prevention interventions with a score of 10 or above. Staff assessed Resident 1's falls risk score at 18 on 06/09/2021, and that Resident 1 required assistance with toileting, needed help to maintain balance, had three or more health conditions or medications that contributed to falls, and had one to two falls in the last 90 days. Review of Resident 1's comprehensive Care Plan (CP) showed the resident was occasionally incontinent of bowel and bladder (06/22/2021), required one person assist for toileting assistance (06/14/2021), was non-weight bearing to the right lower extremity until 08/25/2021, and required 1 person assist for transfers (08/25/2021) and bed mobility (06/10/2021). Review of progress notes between 6/10/2021 and 07/18/2021 showed staff identified the resident required at least 1 person assist with bed mobility, transfers, and toileting needs, was at times incontinent of bowel and bladder, and required assistance for toileting. These progress notes also showed staff described Resident 1 as confused, forgetful, and/or impulsive, had poor compliance with non-weight bearing to the right leg, and short-term memory loss or deficits. Review of a 07/23/2021 Psychiatry Follow-up Note showed, Impression - CVD [Cardiovascular Disease] with possible dementia and [CONDITION(S)]/paranoia. Review of a 07/19/2021 progress note showed staff observed Resident 1 rise and get out of bed unassisted with a poor gait. Review of a 07/20/2021, 07/22/2021, 07/27/2021 and 07/28/2021 progress notes showed staff documented Resident 1 required one person assist for transfers and toileting, and other ADLs. Review of 07/29/2021, 07/30/2021, 07/31/2021, 08/02/2021, and 08/03/2021 progress notes showed the staff documented the resident self-transferred. On 08/01/2021 and 08/05/2021, the staff documented the resident was confused and disoriented, and on 08/05/2021 and 08/06/2021 that the resident went to the bathroom independently and self-transferred. STAFF INTERVIEWS The following are interviews of Licensed Nurses who provided care to Resident 1 from admission through 08/12/2021: On 09/22/2021 at 3:17 PM, Staff C, Registered Nurse (RN), stated that Resident 1 was forgetful and described short term memory loss episodes observed. Staff C stated Resident 1 required one person assist for transfers and bed mobility, and observed Resident 1 self-transfer without assistance from the bed to the wheelchair. Staff C stated that Resident 1 was at high risk for falls. When asked what kind of supervision Resident 1 needed to prevent falls, Staff C stated, Maybe she needs to be near the nursing station and that if the resident turned on the call light, that staff needed to be right there right away because if Resident 1 waited for too long, they would self-transfer. On 09/22/2021 at 3:24 PM, Staff D, Licensed Practical Nurse (LPN), stated that Resident 1 would appear to be alert but was very forgetful and had a confused memory. When asked if Resident 1 used the call light to ask for assistance, Staff D stated that most of the time the resident would get up on their own and would not use the call light, even attempting to self-transfer after a return from the hospital on 09/17/2021. Staff D stated that staff would remind Resident 1 to use the call light when they needed to go to the bathroom, but that the resident would not remember to ask for help. When reviewing Resident 1's falls history, Staff D stated that, If [the resident] was falling that many times, maybe a one on one supervision, would benefit the resident. On 09/21/2021 at 11:17 AM, Staff E (LPN) stated that Resident 1 was alert and sometimes very confused. Staff E stated she and the staff would remind Resident 1 to use the call light when they needed assistance because both Staff E and the staff would find the resident trying to stand up without help. Staff E stated that Resident 1's roommate told her they would see Resident 1 walking around unassisted in their room. When asked if she had reported to anyone of Resident 1's attempts to transfer without assistance, Staff E stated, It was common knowledge. On 09/23/2021 at 9:13 AM, Staff F (LPN) stated that they took care of Resident 1 a month prior to 09/12/2021. Staff F stated that Resident 1, had memory loss problems. The doctor said possible dementia, so [they] did have memory and cognition problems. Staff F stated that Resident 1 would sometimes turn on the call light and ask staff for help and, Many times, we were always continuing to educate and remind [the resident], but [the resident] would get out of the bed. Sometimes would get in her wheelchair, sometimes stand up, without staff assistance. Staff F added that Resident 1, was confused and noncompliant because of memory and cognitive issues. Staff F stated that sometimes Resident 1, would get up and be impulsive about it. You couldn't predict it with [the resident]. You could talk to [the resident] and sometimes [the resident] would understand and be compliant, but it would be occasional compliance. FIRST FALL Review of a 08/11/2021 progress note showed staff heard a crashing sound outside the Resident 1's room and saw the resident on their hands and knees. This progress note showed Resident 1 stated, I was trying to put my shoe on, and I tripped. Review of the 08/11/2021 Fall Risk Evaluation showed an increased falls risk score from 18 to 20, and that staff identified Resident 1 displayed behaviors that contributed to an increased risk for falls, identified the resident was continent and independent with toileting (contrary to the CP), walked with difficulty, and was unable to complete a balance test without physical help. Review of 08/23/2021 Investigative Documents (ID) associated with the 08/11/2021 fall showed Resident 1 fell at 6:00 PM trying to put their shoes on, leaned over and lost their balance, and did not use the call light to ask for help. This ID showed the root cause of the fall was poor safety decisions and muscle weakness. In addition, this ID showed the staff identified the resident was independent with toileting and transfers, contrary to the level of assistance staff assessed Resident 1 required. The ID showed the staff answered, No to the question, Describe the resident's usual routine during your shift and any changes you have observed prior to the fall. This ID showed interventions before the fall included keeping frequently used items and the call light within reach, anticipate needs, and always wear nonskid footwear. This ID showed the Action Plan was to encourage Resident 1 to request assistance from staff to help put shoes on and add a Call Don't Fall sign to remind the resident to ask for assistance. Review of the Kardex [Care Directives] and CP after the fall showed a 08/11/2021 intervention that instructed staff to encourage Resident 1 to ask for assistance from staff to help put their shoes on, and a Call Don't fall sign to remind to ask for help, even though staff knew Resident 1 was forgetful, impulsive, and witnessed the resident transferring themselves without asking for help prior to the fall. Review of the comprehensive CP showed no interventions to compensate for the resident's impulsivity and poor safety awareness or how to anticipate needs. Review of progress notes showed staff continued to identify Resident 1 had short term memory loss and was forgetful on 08/12/2021 and 08/13/2021. SECOND FALL Review of a 08/13/2021 progress note showed Resident 1, slid down on the floor while trying to straighten [their] bed, and staff found the resident sitting down on the floor. A subsequent 08/13/2021 Fall Risk Evaluation showed the fall risk score increased again, from 20 to 24, and that the staff acknowledged the resident's history of falls, required help with toileting, had impaired vision and difficulty walking. Review of a 09/23/2021 ID associated with 08/13/2021 fall showed Resident 1 fell at 11:40 PM while sitting at the edge of the bed, trying to straighten out the bed covers. This ID showed the resident required 1 person assist with ADLs, transfers, and bed mobility, and that the resident can be impulsive and needs frequent reminders to ask/wait for assistance for transferring and bed mobility. This ID showed staff advised Resident 1 to use the call light when needing assistance and not try to do it by themselves. The ID concluded the root cause of the fall was [MEDICATION(S)] [inherent to the individual and not as easily modifiable, like age]. While the facility decided to keep the bed in the lowest position to lower the risk of injury should the resident fall, roll or slide out of bed, the facility did not address the resident's impulsivity, consider the need for increased supervision, or evaluate the effectiveness of staff continuing to remind the resident to ask for assistance. Review of progress notes dated 08/14/2021 and 08/15/2021 showed staff continued to assess the resident as confused and forgetful, and that the staff educated the resident to call and wait for staff for transfers. In an interview on 09/20/2021 at 2:15 PM, Staff G (RN) who documented on 08/14/2021 and 08/15/2021 that Resident 1 was confused and forgetful, stated that if Resident 1 needed something the resident would ask for it, and that sometimes the roommate would ask for it as well. Staff G stated that Resident 1 can be confused, had poor judgment, did not use the call light consistently, and that the resident thought they could do a lot for themselves and not ask for help. Staff G stated that Resident 1 required one person assist for transfers in and out of bed and wheelchair and to get to the bathroom. Staff G stated that falls were prevented by keeping the bed in the lowest position, having the call light within reach, and if staff had the chance, they would check on the resident more frequently. In an interview on 09/20/2021 at 2:25 PM Staff J, Certified Nursing Assistant (CNA), described Resident 1 as forgetful. Staff J stated Resident 1 would transfer without asking for help and was found by staff walking unassisted in their room or in the bathroom. Staff J stated that Resident 1 needed someone to supervise them during transfers and bathroom use. Review of the medical records showed no progress notes on 08/17/2021 and 08/18/2021. THIRD FALL Review of a 08/19/2021 progress note showed Staff G heard a noise in Resident 1's room and found the resident lying on their back on the floor, with the wheelchair located by the resident's head and unlocked. This note showed Resident 1 fell when they reached for a comb from the nightstand. This progress note showed Resident 1 complained of moderate pain to the right leg surgical site. This note showed that despite Staff G's knowledge that Resident 1 was confused and forgetful, they educated the resident to put on the call light and wait for assistance. Needs reinforcement. Review of an undated handwritten statement from Staff I, Social Services Assistant, enclosed with the 08/23/2021 ID associated with the 08/19/2021 fall showed that when they heard a loud thump, they saw Resident 1 on the floor screaming, I fell , I fell , and That [expletive] wheelchair was not locked. Review of 08/23/2021 ID showed Resident 1 fell at 9:30 AM, and that the root cause was identified as [MEDICATION(S)]. This ID showed the resident did not ask for assistance, was impulsive, needed reinforcement to use the call light, slipped on the boot used to support the ankle fracture, and had poor safety awareness. This ID showed the last time a staff saw the Resident 1 was at 9:20 AM, when staff took the resident to the bathroom to brush their teeth. Witness Reports attached to the ID showed two of the three aides were on break at the time of the fall. The Action Taken was to place a sign to remind Resident 1 to lock the wheelchair brakes when not in motion and re-educate the resident, despite previous knowledge that the resident disregarded the signs. This ID showed no documentation the facility addressed the resident's impulsivity, considered the need for increased supervision, evaluated the effectiveness of staff continuing to remind the resident to ask for assistance, or probed why staff placed the burden and expectation on the resident to lock the wheelchair brakes when staff continued to identify the resident had poor safety awareness and was forgetful. Review of a 08/25/2021 ADLS/Mobility CP intervention showed the Resident required 1 person assist for transfers, and that the resident had a history of self transferring, and to remind the resident to call for help before getting up out of bed. In an interview on 09/21/2021 at 9:06 AM, Staff H, CNA assigned to Resident 1 the morning of the fall, stated that she had taken Resident 1 to brush their teeth at 9:20 AM, left the resident in the bathroom unattended, did not remember if she had locked the wheelchair brakes or not before leaving Resident 1 in the bathroom alone, told Staff G and the other aides she was going on a 15 minute break, and that when she returned, she found out Resident 1 had fallen. Staff H described Resident 1 was sometimes confused and inconsistently used the call light. Staff H stated that Resident 1 required a one person assist for transfers and toileting, sometimes would ask for help with ADLs, and sometimes did it themselves but that [the resident] knew [they] weren't supposed to. When asked if the resident had the correct amount of supervision, Staff H stated, It should be more supervision because we knew [the resident] was high risk for falls, but I can't do anything about the staffing. We are so short staffed. FOURTH FALL Review of a 09/13/2021 progress notes showed staff found Resident 1 on the floor on 09/12/2021 at 11:30 PM, with the wheelchair by the side, the resident's head near the restroom door, and that the roommate's call light was on. The progress notes showed an Xray revealed a fractured right leg and Resident 1 was transferred to the hospital. On 09/20/2021 at 2:15 PM, Resident 1 was observed in bed. The resident stated that the day of the fall they were washing their hands in the bathroom, that somebody was trying to get in the bathroom, and that when they went to put their hand on the doorknob they fell . Review of 09/14/2021 ID associated with the 09/12/2021 fall showed that staff found Resident 1 inside the bathroom at the time of the fall and was last seen by staff approximately 45 minutes before the fall. This ID identified the resident did not activate the call light system either in the bedroom or bathroom to summon help to go to the bathroom. This ID showed the resident's roommate stated that the resident was in the bathroom, and it sounded like they were washing their hands, heard a holler and then a booming sound from the bathroom, and turned on the call light for the resident. An additional interview showed that another roommate stated they, heard the staff tell [Resident 1] many times not to get up by [themselves] but [Resident 1] does not listen. The 09/14/2021 ID showed that staff continued to identify the resident required one person assistance for transfers, but that the resident often self transferred and forgot to wait for assistance. The associated ID concluded the root causes of the fall were poor safety decision/impulsiveness to do ADL cares independently and not following safety recommendations; all fall indicators the staff were aware of preceding and in between the falls. This ID showed the facility acknowledged the resident was inconsistent in following safety recommendations but still made no provision to address the failed interventions of reminding a resident with poor safety awareness to call for help. Review of an Admission/Readmission Assessment showed Resident 1 readmitted to the facility on [DATE] with surgical repair of a right hip fracture. This assessment showed Resident 1 had suffered an episode of acute blood loss that required blood transfusion, as well as an episode of [CONDITION(S)] (low oxygen levels in the tissues) and acute [CONDITION(S)] (any brain disease that alters the brain structure or function) during hospitalization . This assessment also showed staff re-educated Resident 1 to using the call light for help before attempting to get up out of bed and waiting for help. Signs are in place for reminders. Review of a 09/17/2021 Hospital Discharge Summary showed Resident 1 was also discharged with a diagnosis of dementia. Review of a 09/24/2021 progress note showed staff assessed Resident 1 had severe cognitive impairment. Review of a 09/17/2021 Falls Risk Evaluation showed Resident 1's fall risk increased to 30, and identified resident behaviors, history of falls, cognition, needing help with toileting, balance and mobility impairments, age, and medications, as contributing factors. Review of 09/18/2021 progress notes written at 10:36 AM and 6:55 PM showed staff observed the resident attempted to get up by themselves but was redirected, assisted, and oriented to the call light and instructed to call for help when needing to go to the bathroom. Review of Resident 1's CP on 09/22/2021 at 5:25 PM showed a new intervention to place the bed against the wall and add a fall mat to the floor (09/17/2021). On 09/20/2021 at 2:25 PM, Staff J stated that before the 09/12/2021 fall, fall prevention measures for Resident 1 included a low bed and telling the resident to put on the call light. Staff J could not identify interventions to prevent falls after the 09/12/2021 fall and stated that since Resident 1's return from the hospital, Resident 1 was bed bound and required two people to assist the resident. In an interview on 09/22/2021 at 1:29 PM, Staff K, Speech Therapist, stated that Resident 1 had mild memory impairment and the original plan was for the resident to go home, but that the discharge was delayed due to difficulty with delayed ankle fracture and incision healing. Staff K stated that Resident 1 did not consistently remember to use the call light and that, how long [they were] willing to wait for staff to answer the call light was kind of up in the air. There was a handful of times [Resident 1] didn't wait because sometimes staff don't always answer the call lights quickly and efficiently enough [for Resident 1]. Staff K stated Resident 1 believed they could do more for themselves than what they were care planned for. Staff K stated that some of the ways to increase safety and memory skills to prevent Resident 1 from falling were staff training and consistency, visual and verbal reminders and, A discussion about supervision, like if they need to be checked on more frequently or a different kind of supervision than other typical residents. Staff K stated that a referral to therapy at an appropriate time was something to consider for recurrent falls or a change in function and added, This is where this went wrong. The team wasn't involved. It needs to be tackled by a team approach and cognitive status needs to be looked at more closely, like a neurologist. The team approach didn't happen and that should have happened and recommend or reassess where they are at, why are the falls happening. When asked if Resident 1 was a resident staff would be able to leave unattended in the restroom, Staff K stated, This is also the problem. [The resident] was there at a certain level of function, then started having falls. I feel staff can get into this routine [thinking] as to what the resident's level is and what their care is. Personally, with [the resident's] history of falls, I wouldn't leave [the resident] in a spot where [they] would transfer on [their] own, especially with the current history. I'd go back to the level of supervision. Somebody should have been there standing and not leaving. Based on this information, her needs for supervision and needs have changed. The above findings were shared with Staff A, Administrator and Staff B, Nurse Consultant, on 09/20/2021 at 3:18 PM. Staff B stated, People are forgetful so they do need reminders. We added the intervention of the 'Call. Don't Fall' sign. [Resident 1's] cognition varies, everything fluctuates for [the resident]. [The staff] just check on [the resident]. A decision was made to lower the bed to decrease the risk for trauma. Based on what her cognition was before, and I have not had many interactions with her before, [the resident] was redirectable and the roommate said the staff would tell [Resident 1] to call all the time for help. [Resident 1] knows how to use the call light and what it is for. Although the facility knew that Resident 1 admitted to the facility with a history of falls, a fractured right ankle, was forgetful, impulsive and did not respond consistently to either visual or verbal reminders to use the call light, the facility continued to remind the resident to call for help. The facility failed to develop and implement interventions that effectively anticipated the resident's needs and addressed the staff's perception that the resident would remember to ask for help, even though they witnessed the resident transferring and walking without staff assistance. This failure resulted in a right hip fracture, placed the resident at risk for additional pain, prolonged convalescing and risks associated with fractures and hospitalization . Reference WAC 388-97-1060 (3)(g).

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 1) reviewed for care and services were provided the mobility device (wheelchair) they were assessed to require to prevent extensive, permanent injury to the hand. The facility failed to supervise Resident 1 who was assessed to be a high risk for falls that resulted in Resident 1 experiencing an unwitnessed fall, resulting in a trans-amputation of the right thumb, continued pain associated with the amputation, and a subsequent diminished quality of life. Findings included . According to 06/02/2021 Admission Minimum Data Set (an assessment tool) Resident 1 was admitted for metabolic [CONDITION(S)] (a chemical imbalance caused by organ disjunction affecting brain function), had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was assessed to require extensive assistance for transfers and limited assistance for walking using a front wheeled walker and a standard wheelchair. Resident 1 was observed on 06/28/2021 at 3:00 PM in her room sitting on the edge of the bed leaning to the left to lie down. Resident 1 sat up, held her thumb, and stated that it (thumb) was hurting. The thumb looked discolored with darkened flesh that was swollen due to underlying healing process. Resident 1 stated it was painful to touch. Review of the 06/02/2021 admission fall risk assessment showed that Resident 1 had a score of 22 indicating Resident 1 was at a very high fall risk with a history of past falls, was confined to a chair, had poor balance, was diagnosed with multiple complicated health conditions and prescribed and being administered three or more medications, all contributing to Resident 1's fall risk. A subsequent fall risk assessment on 06/06/2021 was performed because Resident 1 had an actual fall in the facility. This assessment showed that Resident 1's fall risk score increased to 24, because Resident 1's mobility status changed from walking without problems to walking with problems, increasing Resident 1's risk for falls. Review of care plan created 06/07/2021 showed Resident 1 had a transfer status listed as modified independent, with a stand pivot transfer. No devices were listed to be used for mobility, such as a wheelchair. There was no information on the care plan for Resident 1's mobility status or devices used. Review of the caregiver directives showed no mobility devices listed or directions for device use with ambulation. A Physical Therapy note dated 06/03/2021 showed Resident 1 was assessed for a standard (common) wheelchair with cushion, a front wheeled walker, and maximum assistance of one person for transfers from sitting to standing with a front wheeled walker upon admission. A Physical Therapy note dated 06/07/2021 showed that the therapist obtained a facility loaner high back manual tilt in space wheelchair (a wheelchair that lowers sitting surface to shift body weight into the chair seat and reclines backrest for trunk support) for Resident 1's use temporarily, to increase Resident 1's siting tolerance and upright positioning, in preparation for a swallow assessment with speech therapist. Review of a nursing progress note dated 06/12/2021 showed that Resident 1 had an unwitnessed fall from a specialized wheelchair (tilt in space). Staff F, Certified Nursing Assistant (CNA), responded to the fall and found Resident 1 sitting on the footrests of the tilt in space wheelchair that had fallen on top of the resident. Resident 1 severed their right thumb which was hanging down from the knuckle with massive bleeding. Staff G, CNA placed a towel and applied pressure around the right hand to stop profuse bleeding. The progress note showed the bone of the thumb was not observed due to the amount of blood observed. Staff C, Licensed Practical Nurse (LPN), used a splint to straighten the hanging thumb and bandaged the thumb to secure to other fingers to support the position of the thumb. Review of the undated Investigation Summary showed that Resident 1 was observed at 2:15 PM sitting in a tilt in space wheelchair in the hallway that was tilted back to 45 degrees. At 2:30 PM Resident 1 was sitting on the footrests in front of the wheelchair. The investigation concluded that Resident 1 had leaned forward with their right hand towards the ground, the weight in the chair shifted forward causing Resident 1 to fall to the ground. The tilt in space wheelchair tipped forward on top of the resident who was sitting on the foot rests. Resident 1's right thumb was caught between the right foot rest and the ground resulting in severing and crushing of the thumb. Review of the Hospital Emergency Report dated 06/12/2021 showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The x-rays showed a comminuted fracture (broken in more than two places) with a treatment plan supporting amputation of the thumb. In an interview on 07/01/2021 at 3:30 PM, Staff F stated that at the time of the fall the resident was in the hallway in a tilt in space type wheelchair, tilted back. Staff F was in another room and heard a thud and someone yelling. Staff F responded to find Resident 1 on the floor and the thumb was cut and bleeding. Staff F confirmed that Resident 1 was sitting in a tilt in space wheelchair, and no one saw the resident fall. When asked if there were directions for using a wheelchair, Staff F said no. In an interview on 07/01/2021 at 3:45 PM Staff C, LPN confirmed that at the time of the fall, the resident was in the hallway and was not supervised. When asked if Resident 1 was assessed to use the tilt in space wheelchair, Staff C stated, I do not know. In an interview on 07/02/2021 at 9:30 AM Staff E, Speech Therapist stated that on the day of the swallow evaluation (06/07/2021) Resident 1 needed to be in a sitting position for the evaluation. Staff E asked Staff D, Physical Therapist, and the caregiver to help Resident 1 into the high back tilt type wheelchair for the assessment. Staff E confirmed that a tilt in space chair was not requested for the test. Staff E confirmed that on 06/10/2021 Resident 1 was observed in the tilt in space chair in the hallway during the speech treatment session. From the time of this speech swallow assessment to the time Resident 1 fell severing the right thumb, Resident 1 was using the tilt in space wheelchair for four days, without an assessment supporting the continued use of this device. In an interview on 07/02/2021 at 9:55 AM, Staff D, Licensed Physical Therapist stated that a wheelchair not belonging to the resident was obtained on 06/07/2021 for performance of the swallowing evaluation. Staff D described the wheelchair to have a tilt mechanism. Staff D stated that the tilt in space wheelchair was not removed from Resident 1's room after the swallow evaluation. Staff D confirmed that Resident 1 was not assessed for safety or ongoing use of the tilt in space wheelchair and the care plan was not updated to instruct caregiving staff to use the tilt in space wheelchair. In two interviews on 07/01/2021 at 11:50 AM and 2:55 PM Staff D, Director of Nursing confirmed that there was no an assessment completed for Resident 1 to use the tilt in space wheelchair. When asked about the care plan directions for mobility and equipment used for Resident 1, Staff B confirmed that there was no care plan for safety, mobility or wheelchair. When asked about the supervision provided at the time of the fall, Staff B confirmed that Resident 1 was left in the hallway unattended. Staff B further stated that the facility policy was not followed, for Resident 1, to assess the wheelchair, obtain a device consent for use of the wheelchair, obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to provide the wheelchair that the resident was assessed to require for six days, failure to care plan for residents' mobility needs and failure to provide adequate supervision, resulted in Resident 1 falling forward out of the tilt in space wheelchair, the wheelchair landing on top of Resident 1, pinning the right thumb under the footrest, causing a traumatic crushing fracture to the thumb that ultimately caused Resident 1 to undergo surgery to amputate the right thumb. Resident 1 contused to experience pain related to this trauma. Refer to WAC 388-97-1060(1)(3)(g)

Based on interview and record review, the facility failed to ensure 2 of 2 residents (Residents 1 & 2) reviewed for accidents were adequately re-assessed after accidents and provided supervision to prevent further accidents and associated injuries. For Resident 1, the facility failed to implement supervision to prevent an unwitnessed fall which resulted in a [CONDITION(S)], pain and surgery. For Resident 2, the facility failed to develop and/or implement preventative measures after falls, which resulted in repeated falls with a minor injury. These failures resulted in harm related to serious injuries to the residents. Findings included . Resident 1 According to the 02/15/2021 Quarterly Minimum Data Set (MDS, an assessment tool), Resident 1 was diagnosed with dementia, history of falling and cognitive communication deficit. Resident 1 was assessed to require extensive assistance for transfers and limited assistance for walking. Review of the 05/02/2021 Fall Risk Assessment (FRA) showed a score of 21 indicating a very high fall risk. Review of Resident 1's care plan dated 03/10/2021, showed that the resident was dependent on staff for meeting physical and social needs and had a self-care performance deficit related to activity intolerance and dementia. Interventions included: Toilet use: one person supervision/set up assist with toileting hygiene, toilet schedule upon awakening, before and after meals, at bedtime and as needed; Transfer: 1 person minimum assist; Ambulation: requires one person stand by assist and front wheeled walker, with helmet on to walk; Incorporate wheelchair during self-care routine and provide close supervision at all times. In an interview on 05/21/2021 at 11:46 AM Staff J, Nursing Assistant (NA), stated that on (05/07/2021) Resident 1 was in the hallway after dinner so that staff could monitor her safety because (Resident 1) was a high fall risk. Staff J went on break and Staff E, Licensed Practical Nurse (LPN), and Staff L (NA) were left supervising Resident 1. When Staff J returned from break Resident 1 was on the floor in another resident's bathroom, unsupervised and without the helmet, yelling for help. In an interview on 05/21/2021 at 12:10 PM, Staff E, confirmed that Resident 1 was not being supervised when entered another resident's room to use the bathroom and fell . Review of the fall investigation summary dated 05/07/2021 at 7:30 PM, showed Resident 1 fell in another resident's bathroom and sustained a head and hip injury requiring staff to call 911 then the resident was transported to the emergency room and was subsequently identified with a fracture which required surgery. In a joint interview on 05/21/2021 at 3:00 PM with Staff A, Administrator and Staff B, Director of Nursing, Staff B confirmed that Resident 1 had an unwitnessed fall on 05/07/2021 in another resident's bathroom and sustained a [CONDITION(S)] and head injury. When asked if the staff followed the Resident's care plan for supervision and helmet, Staff B said No. When asked if the record showed the facility identified interventions to prevent falls recurrence and or associated injuries, Staff B, said No Resident 2 According to the 04/07/2021 Admission MDS, Resident 2 admitted to the facility with a diagnosis of dementia, failure to thrive and a history of multiple falls. Review of a 03/31/2021 FRA showed Resident 2 had a score of 20, which indicated a high risk for falls. According to the 03/31/2021 Fall care plan, staff were directed to ensure the resident had a low bed. Review of the incident accident log dated 04/01/2021 through 05/21/2021 showed that Resident 2 had falls on 04/02/2021, 04/30/2021, and 05/03/2021. Review of the 04/30/2021 2:45 PM fall incident showed that Resident 2 had an unwitnessed fall when trying to transfer self out of bed. The resident obtained multiple injuries including a hematoma to the left side of the forehead, measuring 1.5 cm (Length) x 1.0 cm (Width) x 0.5 cm (Height). Resident 2 stated they could not recall how the fall occurred. Record review showed no interventions to prevent further falls. Resident 2 had a subsequent fall on 05/03/2021 that was also unwitnessed. Record review showed no interventions to prevent further falls. On 05/21/2021 at 3:29 PM, Resident 2 was observed lying in bed watching TV with the low bed raised to its highest position. Staff F walked by the room and entered and lowered the bed to transfer height, but not to the lowest bed height. When Staff F was asked what height the bed was supposed to be, Staff F responded, Low Bed. The facility failed to provide supervision for Resident 1 and 2, which left Resident 1 to wander to another resident's bathroom and fall, sustaining a [CONDITION(S)] and a significant head injury, and resulted in repeated falls with sustained injuries for Resident 2. Reference WAC 388-97-1060(3)(g).

Based on observation, interview and record review, the facility failed to provide adequate supervision of staff, and care and services for residents, that was necessary to avoid accidents for three (#s 2, 6 & 4) of six residents reviewed for accidents. The facility failed to provide 1:1 supervision to two (#s 6 & 2) of two residents reviewed that were assessed to require it. Failure of the facility resulted in a fall with injury to Resident #6, which constituted harm, and fall with injury by Resident #2, which constituted harm, and ingestion of a non-edible substance by Resident #2. The facility failed to provide care and services according to care planned intervention for two person assistance and care in pairs for two (#s 4 & 5) of two Residents reviewed. Failure to provide supervision as required contributed to Resident #4's fall out of bed and subsequent fracture and pain, which constituted harm. Refer to CFR 483.50(b)(2), F-777, Radiology Findings included . Record review of the facility's Fall Management Procedure dated 06/04/2020, showed that Facilities are obligated to provide adequate supervision to prevent accidents. Determination of adequate supervision is based on the individual resident's assessed needs and identified hazards in the resident environment. ONE-ON-ONE CARE RESIDENT #2 According to the 08/24/2020 Admission Minimum Data Set (MDS - an assessment tool), Resident #2 had a [DIAGNOSES REDACTED]. Review of progress notes dated 08/24/2020 showed staff documented wanders at night, and walks from room to room .Resident ambulates with only one shoe on this evening - Very High risk for falls. Sleeps for 3-4 hours, gets up, ambulates, then sleeps again. Review of progress notes dated 08/24/2020, 08/31/2020 showed Resident #2 wanders at night, and walks from room to room. Review of progress notes dated 09/04/2020 and 09/05/2020 showed Resident one to one for wandering. During an interview on 10/22/2020 at 1:38 PM, Resident #2's representative stated that the resident was an elopement risk, wanders into people's rooms and was on 1:1 care 24/7 (twenty-four hours a day, seven days a week). During an interview on 10/30/2020 at 3:13 PM, Staff B, Director of Nursing stated that Resident #2 was on 1:1, or close to, at admission secondary to being an elopement risk and wandering into other people's rooms and frightening other people. Review of progress notes dated 09/20/2020 at 8:32 PM, showed Walking past resident's room when I heard a knock on the bathroom door. Opened door and found resident sitting on bathroom floor with one shoe off with gripper socks on. Resident stated I got up from the toilet and my leg slipped out from under me and I fell on the floor. Resident states she hit her head and her arm. Resident assessed for injuries with 2 cm (centimeter) x 5 cm irregular shaped bruise to left forearm and two small superficial abrasions to left knee. Review of progress notes dated 09/30/2020 showed Resident has resolving bruise to left forearm r/t (related to) recent fall. Resident continues to impulsively get up from bed and ambulate out into hallway without assist. Monitored frequently throughout all shifts. Will discontinue alert charting at this time During an interview on 10/22/2020 at 1:38 PM, Resident #2's representative stated that the facility called to say they found Resident #2 on the floor as she was knocking on the bathroom door. There was no 1:1 at the time so no one saw it. Resident #2's representative stated that Resident #2 fell a week later, hit her head and was bleeding. They're not providing 1:1 care 24/7 or she would not have fallen twice. Review of the 09/20/2020 Fall Scene Investigation Report showed that Yes the incident was preventable, and there was No 1 to 1 on 2:00 PM to 10:00 PM shift for Sunday 09/20/2020. The nurse identified the root cause of the fall as, Resident 1 to 1 and known fall risk due to gait imbalance. No 1 to 1 at this time. Review of the 09/24/2020 Facility Investigation showed, the facility concluded Resident #2 required 1:1 supervision, on the day of the incident there was no 1:1 assigned, and the plan was to continue to provide 1:1 as able. Review of the 09/24/2020 Fall Risk Care Plan (CP) listed the intervention 1:1 care as able. During an interview on 10/30/2020 at 3:13 PM, Staff A, Administrator stated that they try to provide 1:1 24 hours/day, meaning not always successful. Review of progress note dated 10/02/2020 at 4:26 PM showed, Heard noise in hallway and entered resident's room to find resident on floor bleeding from head. Resident with 1 to 1 staff in room. Assessed resident for any other injuries to head and c-spine with none found, applied pressure to stop bleeding and dressed 2 cm lac(eration) to left eyebrow. Asked resident and staff what happened. Resident stated, I turned around, tripped and fell hitting my head. 1 to 1 staff stated resident examining her walker when she turned and caught foot against walker, lost balance and fell on to left side striking head against foot board of bed and against floor. Resident found on left side with walker laying by her feet. Review of progress notes dated 10/02/2020 at 7:19 PM Resident #2 was assessed with [REDACTED]. Review of the facility 10/05/2020 investigation showed the 1:1 staff was across the room at the time of the fall. The facility concluded the resident was ambulating around her bed with her FWW (walker) as she should be. The preventative measure implemented was that the facility moved the bed up against the wall in order to increase personal space and not impede with transfers. During an interview on 10/30/2020 at 3:13 PM, Staff B stated that the 1:1 couldn't get to her fast enough. Staff B stated that the 1:1 is to prevent wandering and elopement, not to prevent falls, we don't want to invade her space, and stated the 1:1 was outside of the room, by the door. Further review of progress notes showed the resident continued to get up and wander in the room with no 1:1 provided on 10/02/2020, 10/03/2020, 10/04/2020, 10/08/2020 10/09/2020, 10/10/2020, 10/11/2020, 10/15/2020, 10/17/2020, 10/18/2020, and 10/21/2020. During an interview on 10/30/2020 at 3:13 PM, Staff A stated that they did try to cut back on providing 1:1 a little bit. Staff B added, We cut back on noc shift, but she started wandering into other people's rooms. On 10/22/2020 the CP was revised to provide, 1:1 staff monitor q (every) shift. Review of progress notes dated 10/22/2020 at 5:22 PM showed the nurse was Notified by CNA (Certified Nursing Assistant) who was performing 1 to 1 with resident that resident placed bottle of personal cleaner to mouth, bottle immediately taken away from resident's mouth by CNA and got resident to spit out what was in her mouth. Review of the facility investigation report dated 10/22/2020 identified the root cause as Resident confused. During an interview on 10/30/2020 at 3:13 PM Staff B, stated Resident #2, thought peri-cleanser was mouthwash and she rinsed her mouth and spit out. Review of the facility incident investigation dated 10/27/2020 showed the CNA was sitting in a chair approximately two resident beds away from resident, looked up and witnessed resident actions and immediately ran to resident and told resident to spit contents in mouth. It is unknown how much personal cleanser was in bottle prior to opening and ingesting and how much she had actually swallowed prior to spitting out. One of the interventions the facility implemented to prevent reoccurrence was to place a chair for the assigned 1:1 CNA in the resident's room to be kept up against the wall in the center of the room so close supervision could be kept on resident. During an interview on 10/30/2020 at 3:13 PM, Staff A stated that Resident #2 was now on 1:1, 24 hours a day. Observations on 11/06/2020 from 10:45 AM to 11:25 AM, showed Residents # 2, #6 and #7 were in the same bedroom, under observation of one facility staff member. During an interview on 11/06/202 at 11:05 AM, with the staff member assigned to observe the residents, Staff E, Dietary Aid, stated that she tried to ensure safety for the three residents. Review of the 1:1 log book in the room, showed documentation for all three residents, in separate columns on each page. During an interview on 11/06/2020 at 11:26 AM was asked if the facility was providing 1 staff to 3 residents for observation, Staff A, replied, Yes. When asked how long they had been providing 1:3 rather than the 1:1 the residents were assessed to require, Staff A stated, It was awhile ago. RESIDENT #6 Review of the 09/11/2020 Quarterly MDS showed Resident #6 was assessed with [REDACTED]. Review of the prior MDS dated [DATE] showed the resident had no falls since the prior Quarterly MDS dated [DATE]. Review of the 11/04/2019 Fall Risk CP showed Resident # 6 had a history of [REDACTED]. In addition, Resident #6 had had multiple falls without injury on 01/05/2020, 01/23/2020, 02/29/2020, 04/19/2020, 05/19/2020, 06/27/2020. Review of the 11/04/2019 Fall Risk CP and Kardex showed the intervention, dated 06/27/2020 , 1:1 (One on One) care for safety management. Review of 09/24/2020 10:59 AM progress notes showed the Licensed Nurse (LN) was notified by the 1:1 who just arrived at 6:00 AM that resident was found on the floor sitting next to her bed. Resident stated she hit her head, but there was no visible sign or skin impairment. Neurological checks were initiated per protocol. Review of 09/24/2020 7:39 PM progress notes showed Resident #6 was noted with latent injuries of bruising to right forehead and bruising around right eye socket. Review of the facility incident investigation dated 09/24/2020 showed the resident required 1:1 care due to frequent falls from self-transfers and ambulation. Resident #6 did not have a 1:1 staff assigned at the time of the fall as it was change of shift. The assigned CNA had left for the day prior to the 1:1 CNA arriving for start of shift. TWO-PERSON ASSIST/CARE IN PAIRS RESIDENT #4 & #5 Review of the 09/11/2020 Quarterly MDS showed Resident #4 was alert and oriented, required extensive two person assistance with bed mobility, was on a scheduled pain medication regimen, received no as needed (PRN) pain medication, experienced occasional pain, at a level of five out of ten, had experienced no falls since the previous MDS. Review of the 08/20/2020 Mobility CP showed Resident #4 required two person extensive assist for bed mobility. On 08/28/2020 the intervention was added to Care in Pairs. The 02/20/2020 Falls CP listed the intervention of two person assist with bed mobility. The Pain CP listed an intervention dated 05/12/2020 of an acceptable pain level of five out of ten. Review of a facility fall investigation, showed Resident #4 fell out of bed on 10/27/2020 at 6:40 PM. A 10/28/2020 statement of an interview with Resident #4 showed Resident #4 requested help to get cleaned up, Staff D, CNA was in the room at the foot of the bed when the resident grabbed the headboard with her left arm and pulled herself off the right side of the bed. A 10/28/2020 statement of an interview with Staff D showed that the call light was on, and both Resident #4 and Resident #5 needed cleaning. Staff D grabbed supplies and placed them at the end of the bed, told Resident #4 she was going to help her roommate (Resident #5) first. During care with the roommate, Staff D heard a thud and help. During an interview on 11/03/2020 at 2:12 PM Resident #4's representative stated that Resident #4 was supposed to have two nursing assistants with her, and there was only one in the room at the time. Resident #4's representative stated that Resident #4 told her the nursing assistant was alone in the room, changing her at the time of the fall. Review of the undated facility investigative summary showed both Resident #4 and Staff D agreed there was no additional staff in the room at the time of the incident. According to Staff D, she was behind the privacy curtain, providing care to the roommate (Resident #5) at the time of the incident. Review of the POC (Point Of Care) documentation by nursing assistants retrieved 11/03/2020 showed in the last 30 days, twelve nursing assistants, including Staff D failed to provide Resident #4, two person physical assist with bed mobility 57 times. On 11/06/2020 at 11:20 AM Resident #4 was observed in bed, with a splint on the right leg. During an interview at that time, when asked if staff were providing two person assist with bed mobility, Resident #4 stated, They are now. They weren't before. Review of Resident # 5's 06/19/2019 ADL CP showed Resident #5 required two person assist with bed mobility since 05/06/2019 and care in pairs since 06/19/2019. Review of the POC documentation by nursing assistants retrieved 11/03/2020 showed in the last 30 days, including on 10/27/2020 staff failed to provide two person physical assist with bed mobility 38 times. During an interview on 11/06/2020 at 11:15 AM, when asked if staff consistently provided two person assist, Resident #5 stated, No. According to the undated facility investigative summary of Resident #4's fall, The incident occurred because the resident attempted bed mobility without assistance. The incident would have been avoidable if the resident had waited for appropriate help. The plan of prevention included, Care plan was reviewed after incident. Care plan was correct and consistent with (Resident #4's) needs. The facility failed to identify that Staff D failed to provide the supervision and assistance the residents were assessed to require. During an interview on 11/06/2020 at 11:26 AM, Staff B stated that the facility had since conducted training with all care staff regarding providing two person assistance. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview and record review, the facility failed for one (Resident #3) of four residents, reviewed for falls, injury and investigation, to thoroughly investigate the incidents that resulted in a fracture to the left ankle, and report this injury of unknown origin. This failure placed Resident #3 and all other residents at risk of being abused and/or injured. Findings included: The facility's 09/15/17 Abuse/Neglect training policy included a Stop and Watch protocol that informed staff, A critical part of the care we provide our residents is being proactive in acknowledging changes in their condition and acting on them. Every associate has the ability to identify a difference in a resident's behavior, condition and/or demeanor. When we identify these changes, which may be minuscule, complete a Stop and Watch form. The protocol further instructed staff, .Floor nurse will provide an immediate intervention, document steps on form (Stop and Watch form) .give to (Residential Care Manager). The protocol informed staff to bring this information to the general staff meeting the morning following the discovery of a change in a resident's condition. Chapter II of the facility's undated Abuse policy included, .A through investigation is a systematic collection and review of evidence/information that describes and explains an event or series of events. It seeks to determine if abuse, neglect .occurred, and how to prevent further occurrences. Critical components of any investigation include .The timeliness of the initiation of the investigation; and the thoroughness of the investigation .Staff must protect residents from harm, immediately report incidents .and begin investigation as soon as possible .protect resident(s) from possible reoccurrence .The investigation should end with the identification .what, when, where, why and how the incident happened including the probable or reasonable cause . Resident #3, a long-term care resident, was assessed on 06/06/17 with a significant change in condition, according to the Minimum Data Set of that date. Staff assessed Resident #3 to be unable to understand when spoken to, never/rarely made decisions requiring a surrogate decision-maker, had difficulty focusing attention, required extensive assistance of two staff for activities of daily living including transfers, and with a [DIAGNOSES REDACTED]. Resident #3 was observed on 08/09/17 at 1:30 p.m. in a low bed with a contoured mattress to prevent falls, the right side of the bed was against the wall and a mat was on the floor on the left side of the bed. Resident #3 did not participate in the interview. On 08/14/17 Resident #3 was observed up in the tilt-n-space wheelchair waiting to be fed his lunch. Resident #3 responded to questions about his care. Asked if he was comfortable he said, Yes. When asked , How's your foot? Resident #3 responded, Alright. Interview with the family on 08/10/17 at 3:15 p.m. revealed, the injury was identified as early as 07/16/17, at the same time the left foot rest of the wheelchair was observed to be damaged. Review of the facility's 07/18/17 evidence of investigation revealed, a family member identified Resident #3 was in pain and observed swelling in the left foot, and dated the incident occurrence, as 07/16/17. The facility provided no documentation to support staff identified the injury, assessed the resident for injury, initiated an investigation, notified the physician at the time of the discovery, or implemented comfort measures beyond first aid until 07/19/17, when a physician's orders [REDACTED]. And it was not until 07/22/17, that the facility obtained physician orders [REDACTED]. (temperature). The facility's 07/18/17 investigation indicated Resident #3 suffered a fractured toe on the left foot. However, review of the initial 07/18/17 x-ray and repeat x-ray of 07/28/17 revealed, Resident #3 suffered from, Acute mildly displaced fracture, distal fibula metadiaphysis . (a [MEDICAL CONDITION] of the two long bones in the lower leg near the ankle). The 07/28/17 x-ray report indicated, Questionable mild cortical disruption of proximal phalanx of 5th digit . ([MEDICAL CONDITION]). The radiologist added a [DIAGNOSES REDACTED]. Staff documented on the investigation report the injury most likely occurred during a stand-pivot transfer on or around 07/15/17, and updated the resident's care plan to reflect Resident #3 would be transferred with a mechanical device from this point forward. Staff N, a Physical Therapist, interviewed on 08/09/17 at 1:45 p.m., said Staff O modified Resident #3's wheelchair in July 2017 to accommodate the swelling with an elevated foot rest, and was unable to explain the repairs to Resident #3's wheelchair prior to the application of the footrest. Subsequent to the State's investigation supporting this citation, the facility reinvestigated the incident and include a statement from the now identified maintenance Staff M who, was asked to repair the left side footrest. The foot plate was angled in the downward angle. I had to forcibly pull the footrest back even with the right side and retighten. Interviewed on 08/14/17 at 12:00 p.m. Staff M said, No (staff) wrote a work order to have the wheelchair's (left footrest) repaired. The normal wheelchair repair guy wasn't here so they caught me in the hall and so I just took care of it. The (footrest) was bent down . Staff M could not recall the date of this repair but indicated it was at least a couple of weeks ago. Staff did not elaborate on the 07/18/17 investigation, how a resident who required extensive assistance of up to two staff for mobility, transfers or locomotion could have fractured his tibia without staff involvement. No staff admitted to knowing anything about the dramatic circumstances that would have been required to precipitate an injury of this nature. According to Staff B, the Director of Nursing, interviewed on 08/14/17 at 12:00 p.m., the family reported Resident #3 suffered an injury to the left lower extremity. The facility did not identify the injury, assess Resident #3 after the facility was informed of the injury, implement the Stop Watch protocol, call the State with the potential abuse/neglect, and did not investigate what happened, when the injury occurred, where the injury may have taken place, or how the injury was caused until the incident was reinvestigated after the State inspection. The facility failed to thoroughly investigate the circumstances that would have caused the wheelchair footrest to be forceably bent causing Resident #3's fractured leg, implemented interventions that would not have prevented a recurrence in light of the revised investigation which included a more reasonable scenario, thus failed to ensure safety for Resident #3 and all other residents. Refer to WAC 388-97-0640(2)(a)(b) Abuse Polices and Procedures

Based on observation, interview and record review the facility failed for one of three sampled residents (Resident #1) reviewed for provision of medically related social services to aggressively identify Resident #1's reasons for refusing care and services on a more than daily basis and provide necessary care and services to prevent skin issues. The failure to identify causes of Resident #1's care refusals placed Resident #1 in a continuous position to receive less than required care and for deterioration in overall health and wellness, osteomylitis (bone infection) and sepsis. Findings included: Resident #1, a long-term resident of the facility, had a [DIAGNOSES REDACTED]. Review of Resident #1's MDS data from April of 2016 through July of 2017 revealed the last time Resident #1 was assessed with [REDACTED]. Review of six Braden Scale for Predicting Pressure Sore Risk assessments from March 2017 through August 2017 revealed staff assessed Resident #1 to be at moderate risk for pressure ulcers despite the development and continued presence of pressure ulcers. Care planned interventions to prevent pressure ulcers were listed on the 07/07/17 Impaired Skin Integrity Care Plan as; Braden Scale quarterly, Weekly skin check, Reposition every 2 hours (resident) refuses, pressure relieving mattress, RoHo cushion, (Risks and Benefits of) not wearing sunscreen wear hat, incontinence care (as needed), Lantiseptic cream application, refuses blue boots float heels on pillows as resident allows, .Treatment per MD (physician) order. According to other care planned interventions Resident #1 refused multiple interventions such as dental care. Resident #1 was observed lying on his back on a alternating pressure mattress on 08/15/17 at 3:50 p.m., eating peanut M&M's, watching television and shaving. Wounds were observed to be dressed according to physician orders. Interviewed at the same time Resident #1 did not indicate any problems with care or staff but seemed distracted and did not remember meeting the investigator despite frequent contact in the past. Interview with Staff B, the Director of Nursing, on 08/15/17 at 3:50 p.m. revealed Resident #1 refused care frequently and had quite a few wounds some of which were related to Pemphgoids. Pemphgoids are non-pressure related blisters that occur when a person's immune system attacks the person's skin. The cause of Pemphgoids is unknown. Documentation to substantiate Resident #1's refusals for turning and personal care and other pressure relieving interventions and the Nurse Practitioners, Staff C, [DIAGNOSES REDACTED]. No data to support Resident #1 refused care to prevent pressure ulcers was provided. Nurse Practitioner notes supporting the non-pressure ulcer skin issues was provided. Staff J the Social Service staff interviewed on 08/15/17 at 5:00 p.m. said the facility had provided risks and benefits of refusing care to Resident #1. Documentation was requested. Staff J provided Social Service notes from March 2017, July 2017 and August of 2017 that did not mention Resident #1's alleged copious refusals, reasons behind Resident #1's refusals or alternative approaches which might otherwise meet Resident #1's skin needs and to prevent pressure ulcers. Review of Social Service notes from 2016 revealed no data to support the facility was comprehensively assessing or planning for Resident #1's many refusals. At 7:15 a.m. on 08/16/17 Staff K, the Physical Therapy Director, said, (Resident #1) didn't want to get up (in the manual wheelchair) because the facility removed Resident #1's use of the electric wheelchair because (the Resident) was running into people. Staff K said Resident #1 repeatedly refused to see the staff from the company assigned to provide a new wheelchair according to Resident #1's needs. Staff K said this information was not documented because as a new employee there was some confusion over where to document data. Staff L, a Certified Nursing Assistant (CNA) said in an interview on 08/16/17 at 9:25 a.m., that (Resident #1) refused care (turning, brief change, eating .) almost every day, most every day. When asked for documentation to support Resident #1 refused care Staff L said We don't have any way to document. The nurse documents (the refusals after we tell the nurse the resident refused care). Staff L said Resident #1 refused all types of care from eating to turning. Of turning Staff L said, (Resident #1) doesn't like it at all. (Resident #1) will pull the pillow out every day. Staff L and Staff B, the Director of Nursing were asked what other interventions could be implemented to facilitate pressure relief in light of the resident's refusal on 08/16/17 at 9:25 a.m. No answer was given. Staff G, the Registered Nurse, said in an interview on 08/16/17 at 9:55 a.m., (staff) would explain the need for care or the risks and benefits of refusing .Every day! When asked where this information was documented Staff G said the information was not documented because eventually Resident #1 would accept care. When asked if Social Services or the Director of Nursing was informed of or had knowledge of Resident #1's constant refusals Staff G replied, Yes. The facility had knowledge of Resident #1's copious refusals in every area of care including interventions to prevent pressure ulcers, turning, brief changes, removal of the heel manager . but failed to identify the reasons behind the refusals or identify alternative approaches that would afford Resident #1 a greater chance of pressure ulcer prevention. Refer to WAC 388-97-0960(1) Social Services

Based on observation, interview and record review, the facility failed to ensure one of four residents (#3) reviewed for pain relief was relieved of pain. This failure resulted in harm when the resident was in pain following a fractured tibia, for as long as six days without benefit of added medications, or additional significant non-medicinal interventions. Findings included: Refer to CFR 483.13(c)(1)(iii)&(2)&(3)&(4) Abuse Polices and Procedures, Identification, Investigation, Protection, Reporting/Response Resident #3, a long-term care resident, was assessed on 06/06/17 with a significant change in condition according to the Minimum Data Set of that date. Staff assessed Resident #3 to be unable to understand when spoken to, never/rarely made decisions requiring a surrogate decision-maker, had difficulty focusing attention, required extensive assistance of two staff for activities of daily living including transfers, and with a [DIAGNOSES REDACTED]. Resident #3 was observed on 08/09/17 at 1:30 p.m. in a low bed with a contoured mattress to prevent falls, the right side of the bed was against the wall and a mat was on the floor on the left side of the bed. Resident #3 did not participate in the interview. On 08/14/17 at 12:10 p.m., Resident #3 was observed up in the tilt-n-space wheelchair waiting to be fed his lunch. Resident #3 responded to questions about his care. Asked if he was comfortable he said, Yes. When asked, How's your foot? Resident #3 responded, Alright. With each question and answer Resident #3 responded with a sad, anguished facial expression and crying. Interview with the family on 08/10/17 at 3:15 p.m. revealed, the injury was identified as early as 07/16/17 at the same time the left foot rest of the wheelchair was observed to be damaged. The family indicated Resident #3 said his foot hurt repeatedly. Review of the facility's 07/18/17 evidence of investigation revealed, the injury occurred on 07/16/17 and was identified by the family not staff. This information was confirmed in an interview with the Director of Nursing, Staff B on 08/14/17 at 12:00 p.m. A Nursing Order was written on 02/18/17, Pain assessment bid (twice daily) Document pain scale 0-10, assess effectiveness of hernia belt placement. Review of the July 2017 and August 2017 Medication Administration Records (MAR) revealed, staff documented Resident #3 experienced no pain on 07/16-22/17 despite the significant injury, fractured tibia, identified by family on 07/16/17, and recorded in the facility's 07/18/17 investigation which was supported by the 07/18/17 and 07/28/17 x-ray reports. Staff documented on 07/23-27/17, Resident #3 experienced varying levels of pain from 6-8. According to Staff B interviewed on 08/14/17 at 12:00 p.m., the facility used the facial recognition scale to determine Resident #3's level of pain. Review of the July and August 2017 physician's orders [REDACTED]. The physician also wrote an order on, 10/22/15 for Tylenol 650 mg at HS (bedtime), for pain. Review of the MARs for July and August 2017 revealed, Resident #3 received the bedtime dose of Tylenol 650 mg consistently. The July 2017 MARs indicated staff only administered this as needed two tablets of 325 mgs of Tylenol once on 07/16/17 and once on 07/19/17 despite the severity of Resident #3's injury to the left lower tibia, a fracture. The only additional physician's orders [REDACTED].#3's ankle was swollen on the 07/19/17 nursing progress notes. This suggests staff did not elevate or ice and clearly did not document Resident #3's left leg was iced or elevated from 07/16-19/17, three days. It was not until 07/22/17, that the facility obtained physician orders [REDACTED]. Staff documented on the July 2017 MAR, [MEDICATION NAME] was administered initially on 07/22/17 and discontinued on 07/27/17, according to the physician's orders [REDACTED].#3's expressed level of pain as interpreted by staff and was not administered after this date. The August 2017 MARs indicated the ice to the left ankle was Already Completed and the [MEDICATION NAME] and as needed Tylenol were not administered. However, staff obtained another order for [MEDICATION NAME] 500 mg bid on 08/02/17 without a stop date. Staff documented this medication was administered twice daily. Staff also recorded Resident #3 did not present with pain on the facial recognition charting scale Following a significant injury, Resident #3 was not afforded pain relief for three days and limited non-medicinal relief for three to four days. Questionable pain relief was obtained after the 07/22-23/17 physician order [REDACTED].#3 said he was alright, however, his facial expression suggested sadness, anguish, and the resident was crying. Refer to WAC 388-97-1060(1) Care and Services/Highest Practicable

Based on observation, interview and record review the facility failed to ensure for two of two residents reviewed for pressure ulcers, accurate assessment and timeliness of interventions. These failure resulted in the development osteomylitis [MEDICAL CONDITION] for Resident #1 [MEDICAL CONDITION] and potential amputation of the lower leg for Resident #2 that was determined by a local hospital to be pressure related. Findings included: Refer to CFR 483.15(g)(1) Social Services RESIDENT #2 Resident #2 experienced a major change in condition in June of 2017 after suffering a stroke with subsequent weakness and [MEDICAL CONDITION] according to the 07/12/17 Minimum Data Set (MDS) a comprehensive assessment. Staff assessed Resident #2 to require two-person extensive assistance with activities of daily living including bed mobility. A subsequent MDS dated [DATE] reflected the recent stroke with one side weakness, [MEDICAL CONDITION] and a [DIAGNOSES REDACTED].#2 had any wounds. Resident #2 was reviewed as a closed record and was not available for interview. Staff documented on a 07/21/17 Braden Scale for Predicting Pressure Sore Risk Resident #2 was at high risk of developing pressure ulcers. A subsequent 07/27/17 assessment garnered the same results. The Resident at risk for break in skin integrity care plan instructed staff to perform the Braden scale quarterly, perform weekly skin checks, involve the dietitian, reposition or encourage the resident to reposition every two hours, apply pressure reducing mattress and wheelchair cushion, pad oxygen tubing .open area on abdomen-treat per physician's orders [REDACTED]. The facility's Weekly Skin Integrity Data Collection Sheet indicated staff identified old possible pressure related skin issues on Resident #2's coccyx as early as 05/25/17 but no issues on the right leg. Staff documented on the Non-Pressure Ulcer Condition Record, Resident #2 presented with a 6.5 x 1.5 cm (centimeters) wound with a depth of 0.5 cm with no granulation and no necrotic (dead/black) tissue. There was no mention of the wound appearance or odor. Staff R, the night Registered Nurse, documented in the nursing 07/28/17 progress note at 11:30 p.m., when skin assess found open area to resident's right lower outer leg. Staff R also documented on the 07/29/17 nursing notes as a late entry for 07/28/17, The open area to the right lower outer leg is intact, no noted drainage and no s/s (signs or symptoms) of infection. There was no entry indicating the facility notified the physician/nurse practitioner. But there was a physician's orders [REDACTED]. There was no care plan update for this identified skin issue. There was no note to indicate the facility notified the family of this finding. There was no indication staff knew the etiology/cause of the wound. Staff R documented on 07/30/17 at 12:11 a.m., the right leg wound had, a small amount of clear brown drainage and a small amount of blood was noted after cleaning (resident's) leg. But Staff I, the day shift RN, documented at 6:19 p.m. on 07/30/17 there was no drainage. Staff I documented on the 08/10/17 nursing notes at 4:07 p.m., (Resident) on alert for (wound) to right lower leg. The last note in the clinical record is by Staff R who documented on 08/11/17 at 12:56 a.m., The dressing to the right outer lower leg is changed during the day. Staff I, who was interview on 08/16/17 at 9:45 a.m. said, .The evening shift does the dressing change. I looked at it a couple of times when it was bleeding and needed changing. The last time was on the 08/08/17 or 08/09/17 when it had a little bit of drainage. When asked if it was black Staff I replied, No. Despite staff daily dressing changes and observation of the wound there was no further documented assessment of wound changes including, size, depth, drainage, odor, condition of the wound bed, color and etc. The August 2017 Treatment Administration Records (TAR) indicated staff implemented treatment to the right outer lower leg as ordered during the first of two facility shifts on 08/11/17. There was no description of the wound on the TAR or progress notes. According to progress notes of that same date Resident #2 presented with a change in condition related to bleeding from the recently placed gastrostomy/feeding tube. Staff notified the physician who sent Resident #2 to the hospital. Hospital records dated 08/11/17 upon admission to the emergency department as well as photographs of Resident #2's right leg wound indicated Resident #2 was observed to have a right lower extremity necrotic (wound) measuring 12 x 6 cm (centimeters), twice the size of the facility's original measurement. emergency room staff identified a tendon was visible, meaning the wound was very deep and, darkening, and [MEDICAL CONDITION] in the surrounding tissue (around the wound) and extending to the foot. There was no facility documentation to support these changes in wound condition were transmitted to the facility physician/nurse practitioner. After several days of testing the final [DIAGNOSES REDACTED]. On 08/15/17 the hospitalist wrote, .Likely pressure necrosis with possible PAD ([MEDICAL CONDITION]) .Would proceed with amputation. This means the wound was so significant and so damaged the tissue could not be saved. The facility failed to accurately and timely assess Resident #2 for a change in wound condition contributing to Resident #2's dire condition presently. RESIDENT #1 Resident #1, a long-term resident of the facility, had a [DIAGNOSES REDACTED]. Review of Resident #1's MDS data from April of 2016 through July of 2017 revealed the last time Resident #1 was assessed with [REDACTED]. According to Staff B, the Director of Nursing, interviewed on 08/15/17 at 3:50 p.m. Resident #1 was seen at wound clinic on 07/31/17 and sent directly to the hospital where hospital records indicated Resident #1 [MEDICAL CONDITION] (systemic infection) and osteomylitis (bone infection related to the gluteal fold wound). Review of six Braden Scale for Predicting Pressure Sore Risk assessments from March 2017 through August 2017 revealed staff assessed Resident #1 to be at moderate risk for pressure ulcers despite the development and continued presence of pressure ulcers. Care planned interventions to prevent pressure ulcers were listed on the 07/07/17 updated Impaired Skin Integrity Care Plan as; Braden Scale quarterly, Weekly skin check, Reposition every 2 hours (resident) refuses, pressure relieving mattress, RoHo cushion, (Risks and Benefits of) not wearing sunscreen wear hat, incontinence care (as needed), [MEDICATION NAME] cream application, refuses blue boots float heels on pillows as resident allows, .Treatment per MD (physician) order. According to other care planned interventions Resident #1 refused multiple interventions such as, personal care, turning, getting up in the wheelchair, dental care and etc. Pressure Ulcer Status Records from June 2017 through August 2017, progress notes, physician/nurse practitioner visit notes and interview with Staff D, the Residential Care Manager, on 08/16/17 at 9:55 a.m. revealed Resident #1 had at least five pressure ulcers; right and left buttocks, right gluteal fold and upper and lower left leg. During the interview Staff D indicated and provided documentation to support Resident #1 had at least two non-pressure related skin issues. According to these documents and Staff D, the gluteal fold (ischeal) wound was identified by the facility on 06/16/17 and was observed by and treated by the physician and/or nurse practitioner with progressive interventions including application of Lantseptic ointment (a barrier product), Calcium Alginate (useful for moderate to heavy wounds with fluid), Santyl (enzymes that remove dead tissue). Calcium Alginate was lastly prescribed on 07/18/17 covered with a dry dressing. Ten days after this wound was initially identified, according to the 06/27/17 entry on the Skin Condition Record the gluteal fold/ischeal wound presented with necrotic (dead) tissue. One week after this assessment, on 07/07/17 the wound presented with 40% necrotic tissue. On 07/17/17 the wound was completely necrotic according to this document. The nursing progress notes dated 07/14/17 indicate the gluteal fold, wound black in discoloration, indicating dead tissue was present. Additional 07/14/17 notes indicated the facility spoke with the physician and implemented physician direction to make an appointment with the wound clinic. On 07/14/17 the physician documented (Left) Ischeal (wound) deep necrotic tissue .refer to wound team. On 07/19/17 the nurse practitioner wrote, .consult wound team if needed . The recommended wound clinic appointment did not occur until 07/31/17 when Resident #1 was sent to the hospital due to the severity of multiple wounds. A 07/16/17 nursing progress note indicated the gluteal fold wound was foul smelling. And a 07/18/17 progress note includes the presence of a urinary tract infection and the wound was observed with, black discharge. These descriptions support Resident #1 had developed a deep tissue injury (DTI) that was no longer stageable with dead/necrotic tissue that according to 07/31/17 hospital record affected the bone causing a bone infection,osteomylitis and [MEDICAL CONDITION] complicated by a urinary tract infection. According to the facility's undated Pressure Ulcer Prevention policy, .When skin breakdown occurs, it (the wound) requires attention and a change in the plan of care to appropriately treat the patient .Response to treatment based on the goal for the patient's wound is note .when a wound is not responding to treatment . The facility's delayed response to Resident #1's deteriorating gluteal pressure ulcer placed Resident at risk for more serious illness and even death. Refer to WAC 388-97-1060(3)(b) Pressure Sore Development

Based on observation, interview and record review the facility failed to implement care interventions for one (Resident #1) of six residents assessed to be at risk for falls. The failure of staff to use two care givers for bed mobility as assessed and care planned, contributed to Resident #1's fall, causing the resident's cervical vertebrae to be fractured. In addition the facility failed to develop a system by which all assistive devices implemented for resident use, including low air loss mattresses, were assessed for safe use by Residents (#1, #2, #3 and #4), and also the facility also failed to ensure a care plan for one of six residents (#4), assessed to be at risk for falls, was developed. These failures prevented staff from implementing interventions to prevent accidents and falls, placing the residents at risk for injury. Findings included: RESIDENT #1 Resident #1 had a history of [REDACTED]. This assessment indicated the resident required two person assistance with activities of daily living including bed mobility. The resident was wearing a cervical collar and lying in bed on 1/8/13 at 1:20 p.m., and did not engage in conversation. According to the Fall Risk Evaluation form, staff assessed the resident to be at risk for falls each quarter from 9/17/11 to the most recent assessment on 10/31/12. The facility developed a care plan, last updated on 11/10/12, that instructed staff to implement measures to prevent falls including two person assistance for bed mobility, a low air loss mattress (for safe positioning) and mechanical transfer. The 12/4/12 Care Directive instructed direct-care staff to implement two person assistance for bed mobility, a air loss mattress (for safe positioning) and mechanical transfer as interventions to ensure the resident was safe. There was no indication the facility assessed the air loss mattress for safety before implementation. Review of the facility's 1/2/13 evidence of investigation revealed a single direct-care staff provided assistance with bed mobility that resulted in the resident's fall and subsequent identification of fractured cervical vertebrae by a local hospital on [DATE]. The direct-care staff was not available but the Director of Nursing (DNS), when asked what prompted the staff to attempt care alone, said, in an interview on 1/8/13 at 3:00 p.m., "The aide told me that she didn't need two people to dress and turn the resident." The Director of Nursing was asked if the facility had a process for assessing devices before they were implemented. According to the DNS, interviewed on 1/8/13 at 3:00 p.m., "I don't think we have." The DNS indicated none of the residents, including (#2, #3, and #4), for whom air loss mattresses were implemented and observed, were assessed for safe use of the devices. When asked when the Resident #1's low air loss mattress was implemented, the DNS reported, "At least a year." RESIDENT #4 Resident #4, was admitted to the facility on [DATE]. Observed on 1/8/13 at 3:40 p.m. with a low air loss mattress and two side rails, the resident said, the mattress was "having a little trouble." Review of the clinical record revealed staff assessed the resident to be at risk for falls on 12/16/12 but did not develop a care plan to instruct staff on measures to prevent falls and did not assess the air loss mattress for safety in the presence of the side rails. According to the DNS interviewed on 1/8/13 at 4:00 p.m. the facility had 21 days to develop a care plan. The interview took place on the resident's twenty third day. The failure of staff to follow Resident #1's care plan directly impacted the resident's safety causing harm. Failure to develop a process that ensured comprehensive safety assessment of resident's assuasive devices and care plan development placed all residents at risk for injury.

Based on interview and record review the facility failed to recognize, assess and treat a resident (#36) who experienced pain. Failure to identify causes and characteristics of pain and consider administration of pain medication prior to care and services that reasonably could be anticipated to cause pain caused Resident #36 to experience untreated pain and for a reasonable person would result in fear and emotional distress. Findings include: Resident #36 admitted to the facility with a goal of returning home. She received therapy, but was transitioned to Comfort Care when her condition declined, and her goal, according to Therapy staff, changed to discharging home with hospice. Despite the resident's deterioration, the facility continued to provide therapy, during which the resident frequently complained of pain. Her routine pain medication was discontinued and she did not consistently receive adequate treatment for [REDACTED]. Record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility pain assessment (Abbey pain scale, for measurement of pain in people with dementia who cannot verbalize), dated [DATE], indicated the resident demonstrated no indicators of pain and had a score of 0, despite the [DIAGNOSES REDACTED]. Staff documented in the [DATE] progress notes, the resident "shouting out 'no, no' when trying to stand her up...discomfort with turning...". Night shift notes, dated [DATE], indicated "very restless... (medication given) for restlessness and c/o (complaints of) pain to her (lower) back. Very little relief noted." Record review revealed all regularly scheduled oral medications, including the [MEDICATION NAME], were discontinued on [DATE] when the Physician documented "still confused and appears in pain"..."terminal care"... "will start [MEDICATION NAME] (a narcotic pain medication.)." A PO dated [DATE], directed staff to administer 10 milligrams (mgs) of [MEDICATION NAME] as needed for pain assessed as "moderate, ,[DATE] (on a pain scale of ,[DATE])" and 20 mgs as needed every two hours for "severe, pain ,[DATE]". There was no evidence facility staff considered a physician request to initiate a regularly scheduled pain medication for either arthritis or [MEDICAL CONDITION] since the previously scheduled medication had been discontinued. According to Comfort Care Measures dated [DATE], the listed goal was "to provide a comfortable and dignified death for the resident and to support the family." Interventions included: "pain medication as needed and discontinue therapy unless otherwise ordered for comfort." When asked in an interview on [DATE] why the resident continued to receive aggressive therapy in direct conflict with the resident's Comfort Care Measures, Staff F (Director of Therapy) indicated the plan was for the resident to return home with hospice. The facility pain assessment, dated [DATE], reflected the resident now experienced acute pain, demonstrated multiple indicators of pain and had a pain score of 7 (,[DATE] indicated mild pain). A Pain flow sheet entry dated [DATE] at 7:45 a.m. indicated the resident had severe pain (,[DATE]) in her right arm that was precipitated by movement. Staff administered Tylenol, despite physician instructions to administer 20 mg of Roxinal for "severe, ,[DATE]" pain. When asked in an interview on [DATE] at 11:25 a.m. why staff did not administer [MEDICATION NAME] as directed, Staff B indicated it was a nursing judgement. Progress notes, dated [DATE] at 3:00 p.m., indicated "screams when transferred...". This note indicated the resident "spit out" the liquid Tylenol that was offered. There was no evidence the physician was notified or an alternate route for administering the pain medication was considered. A later, untimed, [DATE] entry indicated, "complaint of pain when asked. Tylenol given". There was no indication in the record the resident was assessed for severity or location of pain nor was there documentation to support what time the Tylenol was given or it's effectiveness. The [DATE] Minimum Data Set assessment (MDS) reflected the resident was no longer on a scheduled pain medication regimen but still required the use of as needed pain medications. According to this MDS, the resident demonstrated increased indicators of pain including: Non-verbal sounds (crying, whining, gasping, moaning or groaning; vocal complaints of pain (that hurts, ouch, stop) and facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) during three to four of five days reviewed. There was no evidence facility staff acted on the resident's increased frequency of pain indicators or considered the lack of regularly scheduled pain medications as a contributing factor. A weekly pain meeting note, dated [DATE], indicated the resident experienced pain she rated from six to eight related to back pain, right arm pain and [MEDICAL CONDITION]. At that time the physician documented, "Be more aggressive in giving [MEDICATION NAME] (more often) for pain/discomfort. If has difficulty (oral) [MEDICATION NAME] should be started for comfort care." Record review revealed the resident received no [MEDICATION NAME] from [DATE] to [DATE]. Care plan documents, dated [DATE], indicated a problem of "alteration in comfort r/t (related to) resident c/o back pain and r(ight) shoulder pain. Resident has dx (diagnosis) of [MEDICAL CONDITION]. Resident on comfort measures only." The listed goal was "Resident will have pain less than 3 on a pain scare ,[DATE]." Interventions included "notify LN (Licensed Nurse) if resident has any (signs/symptoms) of pain", "respond immediately to c/o pain", and "monitor and assess pain status and medication effectiveness." Staff administered medication on the following days and determined upon reassessment the resident continued to experience pain: ,[DATE], 26, 28, ,[DATE] (two shifts), ,[DATE] (two shifts), and ,[DATE]. Facility staff failed to consider administration of pain medication or other interventions when the resident was assessed to experience pain which exceeded care planned pain goals. In an interview on [DATE] Staff B indicated staff assessed the resident's pain level and documented it every shift on the Medication Administration Record (MAR). Staff documented on the MAR the resident had a pain level of "0" on the following days (for one or more shifts) when therapy notes and/or nursing entries indicated the resident experienced pain: [DATE], 14, 15, 16, 18, 19, 22, 23 and 28 and [DATE]nd, 2011. Failure to identify the pain assessment system did not reflect the resident's actual pain placed staff in a position to be unable to accurately assess the frequency and severity of the resident's pain. THERAPY NOTES An Occupational Therapy (OT) note dated [DATE] at 1:23 p.m. indicated, "When I ranged her arms, she expressed some pain with movement of her right wrist...she expressed some pain in her shoulders too...". There was no evidence therapy staff conveyed this information to nursing or that nursing provided treatment for [REDACTED]. A Physical Therapy (PT) note dated [DATE] at 3:59 p.m. indicated, "Pt (patient) was moaning and crying during the dressing and hygiene." An OT note dated [DATE] reflected "pt screams out at times when hands and arms touched...some swelling noted in left hand...pt unable to state if anything hurts." The resident did not receive [MEDICATION NAME] on [DATE] or on [DATE] despite a documented "8" on the pain scale, which was considered by the physician to constitute "severe" pain. A PT note dated [DATE] at 4:40 p.m. indicated "3 attempts for gait training... we still can't get her up for walking. Pt screamed, 'No' for gait." There was no evidence staff ruled out pain as a contributing factor for these refusals. In a note dated [DATE] at 10:31 a.m., PT documented, "Patient was not wanting to participate but did not verbalize this. Patient requires setup time due to yelling 'ouch' with all movements... patient started yelling and refused. The therapist then tried to persuade the patient to do the gait and she stated no." Nursing notes dated [DATE] at 11:00 a.m. were not reflective of the resident's pain, "no c/o or s/s (signs/symptoms) of pain/discomfort." There was no evidence of a system of communication between therapy and nursing as evidenced by the pain flow sheet which reflected the resident did not receive pain medication before, during or immediately following therapy. Nursing notes dated [DATE] at 8:00 p.m. indicated the resident, "reported neck pain (,[DATE]) at 6 pm, relieved by prn (as needed) Tylenol." There was no documentation to support why the resident received Tylenol rather than the prescribed [MEDICATION NAME]. PT notes dated [DATE] at 3:25 p.m. indicated, "Pt was resisting initially... Pt c/o right wrist pain and mouth soreness. Nurse was notified." There was no documentation to support the resident received pain medication as it related to this complaint. According to pain flow sheet documents the resident received Tylenol on [DATE] at 8:00 p.m. for back pain rated ,[DATE], almost five hours after PT staff documented the resident experienced pain. In an interview on [DATE] Staff B was unable to explain why nursing staff administered Tylenol when the POs clearly directed staff to administer [MEDICATION NAME] for pain rated more severe than four. A PT Progress report dated [DATE] indicated historically, "the patient reports a pain scale rating of ,[DATE]...for low back with supine (to) sitting (positions)." There was no evidence staff considered pre-medicating the resident prior to therapy given the identified ,[DATE] pain level for low back pain. In an interview on [DATE] at 12:00 p.m. Staff F, the Therapy director, stated it was her expectation that staff look for pain symptoms including, "squirming in chair, grimacing... obviously crying." Staff F indicated the ,[DATE] pain reported by the resident was "transient" with "position changes" and staff would request medication if "repeatedly doing that movement." A PT note dated [DATE] at 4:13 p.m. indicated, "attempted to do gait training but patient started yelling, screaming, and refused... Pt resisted and screamed initially from sit to stand, then she started to walk." There was no documentation to support the resident was assessed for or received pain medication as it related to position changes. A PT note dated [DATE] at 4:58 p.m. indicated, "patient continues to have limited participation in PT, does not want to ambulate. Discussed need to ambulate in order to return home, states that she would rather not return home then. Care Conference indicated, will discuss with SW (Social Worker)." There was no evidence of a Care Conference, SW intervention or consideration that refusals were related to pain. According to the ,[DATE] pain flow sheet the resident received as needed Tylenol on ,[DATE], ,[DATE], ,[DATE] and ,[DATE] for pain that was assessed as ranging from ,[DATE] when [MEDICATION NAME] was indicated, according to physician orders. For each occasion which staff documented the resident received as needed pain medication, staff assessed the precipitating/aggravating factors as movement. At no time did staff consider a regularly scheduled pain medication or premedication prior to therapy. Additionally, staff documented on the front of the Medication Administration Records (MAR) that the resident received as needed Tylenol for pain on ,[DATE], ,[DATE], ,[DATE], and [DATE] without assessment of location or severity and without documentation to support effectiveness of the medication. In an interview on [DATE] Staff B indicated it was her expectation staff evidence this process either on the back of the MAR or on the pain flow sheet. A PT note dated [DATE] at 12:55 p.m. indicated, "attempted to do gait training with the patient, but not successful... she resisted our help physically and said, 'no'." A Physician's note dated [DATE] indicated, "pt not alert... condition worsening, supportive care only." Despite the physician's concern the resident should receive supportive care only, the resident continued to receive therapy on [DATE] when OT staff documented, "...pain in her r wrist...she expressed pain with any movement of her UE (upper extremities)...pt participated in group session of nail care and hygiene..was unable to hold the toothbrush or brush...". Staff F, in an interview on [DATE], was unable to answer why the resident continued to receive therapy for nail and hygiene when the Physician clearly documented "supportive care only." The resident died in the early morning of [DATE]. In an interview on [DATE] at 11:25 a.m. facility administrative staff stated the resident's behaviors (refusals, crying out) were related to dementia and not pain. The facility failed to consistently administer [MEDICATION NAME] for moderate and severe pain when it was assessed to be required, did not consistently provide pain medication of any kind when the resident expressed pain, and did not consider premedication in instances (therapy) when pain with movement could be reasonably anticipated, which contributed to the resident's continued experience of pain. .