Every finding on record at Life Care Center of Kirkland

Based on interview and record review, the facility failed to complete timely and comprehensive vital-sign assessments (measurements of the body's most basic functions), specifically blood-glucose (sugar) level and temperature, for 2 of 3 residents (Residents 1 & 2) during changes in condition, reviewed for quality of care. This failure placed the residents at risk for unrecognized medical complications, unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Changes in Resident's Condition or Status, reviewed on 08/29/2025, showed that the facility must immediately inform the resident; consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and if there was a decision to transfer or discharge the resident from the facility.Review of the facility's procedure document titled, eINTERACT Change in Condition Process, reviewed 12/01/2025, showed that This process is utilized to identify and assess any resident change of condition. Further review showed a process for nursing staff to complete an eINTERACT Change in Condition Evaluation (SBAR - Situation, Background, Appearance, & Review - a communication form used to inform medical providers) when a change in condition was identified. It further showed that identification of a resident change in condition may be identified by a Report of change of condition from family or visitor and/or Licensed staff observe change in condition.RESIDENT 1Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnosis that included diabetes (a condition where a person's body has trouble handling glucose in the blood) and after care following an orthopedic surgery (type of surgery to repair broken bones). Review of Resident 1's care plan for diabetes, dated 05/29/2026, showed nursing interventions included observation and reporting of signs and symptoms of hypoglycemia (low blood sugar) to include confusion and slurred speech.Review of a nursing progress note dated 06/02/2025 at 3:45 PM, showed [Resident 1's Collateral Contact] arrived and stated that [Resident 1's] orthopedic surgeon requested to send [Resident 1] to ER right now, [Resident 1] is in bed at this time, with no acute distress noted of [Resident 1]. It did not show documentation that Resident 1's vital signs, including blood-sugar level, were assessed to identify a change in condition. It further showed that the progress note was completed by Staff C, Resident Care Manager.Review of a nursing progress note dated 06/02/2026 at 3:59 PM, showed [Resident 1's Collateral Contact] requested that [Resident 1] be sent to [Name of Hospital] d/t [due to] change of condition. Stated that [Resident 1] has stopped talking. [Name of Medical Transport Service] was called to take [Resident 1] to hospital. It did not show documentation that Resident 1's vital signs, including blood-sugar level, were assessed to identify a change in condition.Review of a nursing progress note dated 06/02/2026 at 6:06 PM, showed that medical transport arrived at the facility around 5:30 PM to take [Resident 1] to the ER [Emergency Room] and that Resident 1 left at 5:40 PM.Review of Resident 1's Electronic Health Records (EHR) of the Blood Sugar Summary showed blood-glucose level readings documented at 7:47 AM and at 12:47 PM on 06/02/2026. It showed that Resident 1's blood glucose was recorded as 120.0 mg/dL (milligrams per deciliter - a unit of measurement used to show how much sugar was in a small amount of blood). It did not show additional blood sugar level readings were documented after 12:47 PM on that date.Review of Resident 1's SBAR Communication Form, dated 06/02/2026, showed that the instructions on the form directed staff to check vital signs before calling a healthcare provider. It also showed that vital signs to be checked by staff included finger stick glucose for diabetics. It showed that Resident 1 was marked to have decreased level of consciousness (sleepy, lethargic [drowsy and/or not alert]). Further review showed that Resident 1's recorded blood sugar level was 120.0 (mg/dL).Review of Resident 1's ER records dated 06/02/2026, showed that Resident 1 presented with altered mental status [not alert] and hypoglycemia and that the resident Started to have slurred speech, now they were struggling to communicate and altered. The resident was found to have blood glucose [readings] in the 50's in the field which did not improve with 2 doses of 45 g [grams - unit of measurement] of carbs [carbohydrates - administered for hypoglycemia]. It further showed that on medic evaluation [Medical transport staff that assessed Resident 1 at the facility] the resident apparently had blood glucose in the 50's which was persistent despite sipping juice.Labs (blood tests done at the hospital) were primarily notable for initial blood glucose 50.In an interview and joint record review on 06/16/2026 at 1:28 PM, Staff C stated that nursing assessments used to identify a resident's change in condition include checking vital signs and obtaining blood-glucose levels for residents with diabetes. Staff C stated that nursing staff would complete a SBAR Communication Form when residents were assessed for a change in condition. A joint review of Resident 1's nursing progress notes dated 06/02/2026 showed that Resident 1 was reported to have a change in condition and he stopped talking. When asked when Resident 1's change in condition occurred on 06/02/2026, Staff C stated, Around 3;00 PM through 3:45 PM A joint record review of Resident 1's SBAR Communication Form dated 06/02/2026 and his EHR Blood Sugar Summary showed that his blood-glucose was documented as 120.0 mg/dL on 06/02/2026 at 12:47 PM. Joint record reviews did not show documentation that Resident 1's blood-glucose level was obtained during his change in condition between 3:00 PM and 3:45 PM, prior to medics arriving at the facility. Staff C stated, I would expect that they [nursing staff] check all the vital signs including the fingerstick [blood-glucose level] at the time of the [nursing] assessments.In an interview and joint record review on 06/16/2026 at 3:07 PM, Staff B, Director of Nursing, stated that a resident change in condition was Anything that was different from baseline.A deviation from the patient's [resident] mentation status or an exacerbation of their illness. When asked what nursing assessments were completed to identify a resident's change in condition, Staff B stated, They would assess the patients, their vital signs, their mental status, listen to heart and lungs, that's just standard nursing practice. A joint record review of Resident 1's nursing progress notes dated 06/02/2026 showed that he was reported to have a change in condition. When asked when Resident 1's change in condition occurred on 06/02/2026, Staff B stated, He was sent to the hospital around 5:30 PM, so I would estimate around 4:00 PM. A joint record review of Resident 1's SBAR Communication Form dated 06/02/2026 and his EHR Blood Sugar Summary showed that his blood-glucose was documented as 120.0 mg/dL on 06/02/2026 at 12:47 PM. Staff B stated that they expected Resident 1's blood-glucose level would have been checked at the time of his change of condition and that Yes, I would expect it because he had stopped talking.RESIDENT 2Review of a face sheet showed Resident 2 admitted to the facility on [DATE].Review of Resident 2's care plan for respiratory illness, dated 03/31/2026, showed the resident was assessed as being At risk for respiratory illness/infection due to the resident being immunocompromised (having a weakened immune system that makes it harder to fight off infections), advanced age and a history of pneumonia (lung infection) during their most recent hospitalization. It further showed nursing interventions included Monitor for change in [Resident 2's] condition and notify practitioner of findings, and Perform respiratory assessment on an ongoing basis as directed.Review of a nursing progress note dated 04/14/2026 at 10:32 AM, showed [Resident 2] complained of SOB (Shortness of Breath), assessment revealed wheezing, SOB and O2 (oxygen saturation - measurement of how much oxygen is being carried in the blood compared to how much it could carry, with a normal level between 95-100%) at 86 % with 3L/min (Liters per minute - measurement of how much oxygen is being delivered through a device) on concentrator (medical device). It further showed that a medical provider directed staff to call 911 (Emergency services). Further review did not show documentation that Resident 2's vital signs, including temperature, were assessed to identify a change in condition.Review of a nursing progress note, dated 04/14/2026 at 10:50 AM, showed [Resident 2's Collateral Contact - CC] came to visit and at that moment [Resident 2] developed mild SOB (Shortness of Breath) and signs of congestion [stuffed up and hard to breathe].Wheezing, O2 [saturation] 86%, O2 4LPM [4 Liters per minute] per NC (Nasal canula - small tubes in the nose used to deliver oxygen therapy). Further review did not show documentation that Resident 2's vital signs, including temperature, were assessed to identify a change in condition.Review of Resident 2's EHR of the Temperature Summary showed that Resident 2's last documented temperature reading of 97.5 F (Fahrenheit - unit of measurement) was recorded on 04/14/2026 at 7:43 AM. Further review of Resident 2's EHR of the Blood Pressure (BP) Summary showed that Resident 2's last documented BP reading of 144/78 mmHg (millimeters of mercury - unit used to measure blood pressure) was recorded on 04/14/2026 at 7:43 AM. It did not show additional vital readings of temperature and BP were documented after 7:43 AM on that date.Review of Resident 2's SBAR Communication Form, dated 04/14/2026, showed documented vital signs of BP 144/78 and a temperature of 97.5F. The form also indicated that Resident 2 was noted to have labored or rapid breathing and SOB.Review of hospital records for the hospitalization on 04/14/2026, showed that Resident 2 arrived at the Emergency Department (ED) at 11:11 AM. ED triage documentation noted complaints of congestion and SOB beginning the previous day, an oxygen saturation of 84% on room air that improved with 4 L/min nasal-cannula oxygen, and a fever of 100.4F. Further review of hospital records showed that Resident 2 was admitted on [DATE] for acute hypoxemic respiratory failure [a person's lungs suddenly cannot get enough oxygen into their blood and oxygen level drops dangerously low] presenting with shortness of breath.A joint record review on 06/16/2026 at 1:36 PM with Staff C showed that nursing progress notes dated 04/14/2026 indicated Resident 2 experienced a change in condition. When asked when Resident 2's change in condition occurred, Staff C stated Around 10:30 AM. Further review of Resident 2's EHR showed that the vital signs recorded at 7:43 AM were the same values documented on the SBAR Communication Form for that date. When asked whether Resident 2's vital signs including temperature, were assessed at the time of their change in condition, Staff C stated, No, the only thing that was updated was their oxygen saturation level. Staff C further stated that They should have checked all vital signs.A joint record review and interview on 06/16/2026 at 3:07 PM with Staff B showed that nursing progress notes dated 04/14/2026 indicated Resident 2 experienced a change in condition. Further review of Resident 2's EHR showed that the vital signs recorded at 7:43 AM were the same values documented on the SBAR Communication Form for that date. Staff B stated I would expect that they [staff] would check the vital signs, including to check the temperature. I would expect [Resident 2's] temperature to have been communicated by nursing. Reference: (WAC) 388-97-1060 (1).

Based on interview and record review, the facility failed to ensure an allegation of neglect was reported to the State Agency within the required timeframe for 1 of 4 residents (Resident 1), reviewed for abuse reporting. This failure placed the resident at risk for potential unidentified neglect and lack of protection from neglect.Findings included . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, Neglect means: a) a pattern of conduct or inaction by a person or entity with a duty of care to provide the goods and services that maintain physical or mental health of a vulnerable adult, or that avoids or prevents physical or mental harm or pain to a vulnerable adult; or b) an act or omission that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, welfare, or safety. Review of the facility's policy titled Abuse, Neglect and Exploitation, Chapter 3: Abuse - Reporting and Response -No Crime Suspected, revised on 05/07/2025, showed, The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, and will report the results of all investigations to the proper authorities within prescribed timeframes. The policy further showed, The facility will ensure that all staff are aware of reporting requirements and to support an environment in which staff and others report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Review of the grievance form completed on 02/01/2026 showed that Resident 1 reported that She was in a wet brief from morning till 5:00 PM that day. Review of the February 2026 incident log showed that Resident 1 had a concern documented on 02/01/2026, with the nature of the occurrence recorded as alleged neglect. Review of the incident investigation report dated 02/03/2026 showed, RCM [Residents Care Manager] received a grievance that [Resident 1] reported that on Sunday [02/01/2026] her brief was not changed all day until approximately 1700 [5:00 PM]. Patient [resident] states she was in a wet brief and when activities came to get her, she let them know as well. During that time the CNA [Certified Nursing Assistance] entered the room and when asked why patient hadn't [had not] been changed the aide replied that she was busy and needed to take her break. The report further showed, Investigation initiated, employee suspended pending investigation, [Resident 1] placed on alert for psychosocial/emotional distress, patient interviews in same area initiated, employee interviews initiated. MD [Medical Director], DON [Director of Nursing], family notification completed. In an interview on 03/12/2025 at 10:38 AM, Resident 1 stated, I know that on the weekends there are fewer staff members. I needed to be changed, but she [CNA] did not come the whole day. I asked her a couple of times during that time if she could change me, but she wasn't [was not] able to get to me right away. She should have changed me, and she apologized for that. In an interview on 03/23/2026 at 11:04 AM, Staff C, Assistant DON, stated that they received the grievance form and went to speak with Resident 1. Staff C stated that Resident 1 clarified that their brief was not changed during the evening shift until 5:00 PM. Staff C stated that a round was conducted every day at 2:30 PM and I believe she was seen during that round. However, we do not have documentation for this. Staff C stated they completed an investigation and did not report the allegation to the State Agency because there was inconsistency between what was written on the grievance form and what Resident 1 stated during the follow up interview. Staff C stated that Resident 1 was placed on alert, the staff member involved was suspended, and the investigation was completed. Staff C further stated the incident was entered into the incident log as alleged neglect. In an interview on 03/23/2026 at 12:03 PM, Staff B, DON, stated that they followed the Purple Book guidelines and that allegations of neglect should be reported to the State Agency. Staff B further stated that Resident 1's allegation of neglect should have been reported to the State Agency. In an interview on 03/23/2026 at 12:17 PM, Staff A, Executive Director, stated that Resident 1's allegation of neglect was not reported to the State Agency and that it should have been. Reference: (WAC) 388-97-0640 (5)(a).

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety when expired food items were not discarded for 1 of 1 dry storage room (Kitchen Dry Storage Room), reviewed for food services. In addition, the facility failed to ensure expired paper tests strips (designed to check the level of chlorine [a chemical that kills germs] in the water used to sanitize the dishware during the dishwasher rinsing phase) were discarded. These failures placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages).Findings included .Review of the facility's policy titled, Food Safety, reviewed on 05/01/2025, showed that food was stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Further review of the policy showed that food that was not safe for consumption or the safety of the food was in question would be removed from storage.Review of the facility's policy titled, Ware Washing-Dish Machine/Manual Process, revised on 04/30/2025, showed that food and nutrition services staff were trained in the proper use, cleaning and sanitation of ware washing equipment and sinks. Further review of the policy showed that low temperature dish machines would be used in accordance with the manufacturer specification and that the temperature and parts per million (PPM - unit of measurement for concentration) of the sanitizers (50-100 ppm for chlorine) will be recorded on the Low Temperature Machine Log a minimum of three times per day.EXPIRED FOOD ITEMIn a joint observation and interview on 09/28/2025 at 8:58 AM with Staff I, Cook, showed a bottle of cooking wine with an expiration date of 11/24/2024. Staff I stated that the bottle of cooking wine was expired and that it should have been discarded.In an interview on 11/24/2025 at 11:09 AM, Staff H, Food Services Director, stated that they expected food items to be discarded by their expiration date. Staff H further stated that the expired bottle of cooking wine should have been discarded.EXPIRED TEST STRIPSIn a joint observation and interview on 11/24/2025 at 1:09 PM with Staff H and Staff J, Dietary Aide, showed Staff J was using Precision Chlorine Test Paper to test the low temperature dishwasher machine rinsing phase. Further joint observation showed the chlorine test paper strips container had an expiration date of 05/01/2025. Staff H and Staff J looked for other chlorine test strips and found three more chlorine test strips containers that had an expiration date of 05/01/2025. Staff H stated that all the four chlorine test strips were expired.In a joint record review and interview on 11/24/2025 at 2:53 PM with Staff H, showed the May 2025 to November 2025 low temperature dishwashing machine log were conducted three times a day for breakfast, lunch, and dinner. Staff H stated that staff were using the expired test strips from May 2025 through November 2025 to test the low temperature dishwasher rinsing phase three times daily. Staff H further stated that the facility should not have used expired chlorine test strips.In an interview on 11/26/2025 at 1:00 PM, Staff A, Executive Director, stated that their expectation was for staff to monitor food expiration dates according to facility policies and to discard expired food items. Staff A further stated that expired chlorine test strips should not have been used to check the low temperature machine rinsing phase.Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 4 of 7 days, reviewed for posted nurse staffing information. The failure to post a complete and accurate form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.Findings included .Review of the facility's policy titled, Staff Posting and PBJ [Payroll Based Journal- is the system nursing homes use to electronically report their staff hours to the government] Submission, revised on 09/09/2025, showed that the facility must post the actual hours worked by registered nurses, licensed practical nurses and certified nurse aides on a daily basis at the beginning of each shift. Observations on 11/21/2025 at 9:05 AM and at 2:52 PM, on 11/24/2025 at 11:01 AM and at 3:17 PM, on 11/25/2025 at 9:59 AM and at 3:13 PM, and on 11/26/2025 at 9:43 AM, showed the facility's document titled, Posting of Licensed and Unlicensed Direct Care Staff did not include the actual nursing staff hours worked for the shift. In an interview on 11/26/2025 at 9:58 AM with Staff Q, Staffing Coordinator, stated that their process for filling out the Posting of Licensed and Unlicensed Direct Care Staff posting was to put the actual worked hours on the posting at the end of each shift. In an interview on 11/26/2025 at 10:56 AM, Staff B, Director of Nursing, stated that their process was to update the daily nurse staffing posting at the beginning of each shift. Staff B further stated that the actual hours worked had not been completed at the beginning of each shift and that they should have been.In an interview on 11/26/2025 at 12:46 PM, Staff A, Executive Director, stated that the daily nurse staffing posting must be updated every morning, and the actual hours worked must be completed at the end of each shift. No associated WAC.

Based on observation, interview, and record review, the facility failed to ensure expired medications were discarded for 2 of 3 medication carts (Cascade Medication Cart & Olympic Medication Cart), and for 1 of 2 medication rooms (Central Supply Room), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised and ineffective medications.Findings included .Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, revised on 06/30/2025, showed, Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacture or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.CASCADE MEDICATION CARTDuring a joint observation and an interview on 11/24/2025 at 10:13 AM with Staff M, Registered Nurse (RN), showed the Cascade medication cart had one opened Mupirocin (used to treat skin infection) ointment tube with an expiration date of 10/2025 (October 2025). Staff M stated that the ointment expired last month, and it should have been discarded.OLYMPIC MEDICATION CART A joint observation and interview on 11/24/2025 at 12:47 PM with Staff L, RN, showed the Olympic medication cart had one opened Fiber (a supplement) powder bottle with an expiration date of July 2025. Staff L stated that the fiber powder was expired, and it would be discarded.CENTRAL SUPPLY MEDICATION ROOM A joint observation and interview on 11/24/2025 at 2:09 PM with Staff F, Nurse Unit Manager, showed the following medications stored in the Central Supply Room:- 18 packages of Bisacodyl (medication that helps with bowel movement) 10 milligrams (mg - unit measurement) suppository (a piece of medicine that inserted into a body opening), expired in June 2025.- Four packages of Bisacodyl 10 mg suppository expired in July 2025.Staff F stated that the medications had expired and should have been discarded. In an interview on 11/25/2025 at 12:35 PM, Staff B, Director of Nursing, stated that their expectation was that expired medication should be discarded.Reference: (WAC) 388-97-1300 (2).

Based on observation, interview, and record review, the facility failed to ensure proper transport of clean linens was followed for 1 of 1 staff (Staff U), reviewed for infection control. In addition, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed during medication administration for 2 of 4 staff (Staff O & Staff N). These failures placed the residents, visitors, and staff at risk for infection and related complications.Findings included. Review of the facility's policy titled, Laundry Folding and Distribution, reviewed on 05/27/2025, showed, All linen will be handled, folded, and distributed in a neat and orderly fashion. Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during loading, transport, and unloading. TRANSPORT OF CLEAN LINENSSTAFF U Observation on 11/25/2025 at 8:27 AM, showed Staff U, Laundry Aide, was inside the laundry room putting clean folded towels into a rolling wired laundry basket up to its brim. Staff U then placed an unfolded bath towel over the top of the laundry basket with the sides of the laundry basket not fully covered. Staff U observed pushing the wired laundry basket and stocking up towels in the shower room and the clean utility room both located in the Cascade Hall. In an interview on 11/25/2025 at 8:35 AM, Staff U stated that they placed clean linens in a covered rolling cart and the clean towels in a wired laundry basket covered with a bath towel before transporting it to the unit. When asked if the use of a bath towel to cover the clean towels in a wired laundry basket was their process for transporting clean towels, Staff U stated, yes. In an interview on 11/25/2025 at 8:57 AM, Staff V, Environmental Services Director, stated, Carts should be fully covered, and we used a blanket or a sheet to cover. When we use the basket cart, we use a sheet to fully cover the towels. Staff V further stated that they expected staff to follow the policy and procedure, and they should fully cover the basket cart and not expose cleans towels when transporting them. In an interview on 11/26/2025 at 2:50 PM, Staff B, Director of Nursing, stated, Carts should be clean and fully covered when transporting clean linens [and] towels to the unit. HAND HYGIENE/GLOVE USEReview of the facility's policy titled, Hand Hygiene, revised on 10/28/2025 showed, Associates perform hand hygiene (even if gloves are used) in the following situations:a. Before and after contact with residentb. After contact with blood, body fluids, or visibly contaminated surfacesc. After contact with objects and surfaces in the resident's environment; . STAFF OObservation on 11/24/2025 at 1:03 PM, showed Staff O, Registered Nurse, was preparing to administer medication for Resident 33 via a feeding tube (a flexible tube used to deliver nutrition or medication to the stomach). Staff O put on gloves and gown prior to entering Resident 33's room. Staff O closed Resident 33's room window blinds with their gloved hands. With the same gloved hands, Staff O administered Resident 33's medication via feeding tube. Staff O did not change their gloves after they closed the window blinds and before administering medication to Resident 33. STAFF NObservation on 11/25/2025 at 7:55 AM, showed Staff N, Licensed Practical Nurse, was preparing to administer medication for Resident 24. Staff N entered Resident 24's room, gave Resident 24 their medication, and touched and moved the resident's meal tray sitting on their bedside table. After medication administration, Staff N left Resident 24's room without performing hand hygiene. Further observation showed Staff N continued working on their medication cart without performing hand hygiene. Observation on 11/25/2025 at 8:01 AM, showed Staff N was preparing Resident 23's medication and did not perform hand hygiene prior to preparing Resident 23's medication. Staff N entered Resident 23's room and administered their medication without performing hand hygiene prior to entering the room. In an interview on 11/25/2025 at 8:12 AM, Staff N stated that hand hygiene would be performed between medication administration. Staff N stated that they did not perform hand hygiene after they administered medication for Resident 24 and before they prepared medication for resident 23. In an interview on 11/25/2025 at 12:27 PM, Staff D, Infection Preventionist, stated that they expected staff to perform hand hygiene using hand sanitizer before and after medication administration. Staff D further stated that gloves should be changed after contact with objects and surfaces in the resident's environment. In an interview on 11/25/2025 at 12:41 PM, Staff B stated that they expected staff to use hand sanitizer before and after medication administration. Staff B further stated they expected staff to change gloves between dirty and clean tasks. Reference: (WAC) 388-97-1320 (1)(a)(c)(3) .

Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program (a coordinated effort to optimize the use of antibiotics [medicine that prevents or treats infection] to ensure their appropriate and necessary use) for 1 of 2 residents (Resident 51), reviewed for antibiotic stewardship. The failure to conduct assessment to confirm presence of an infection prior to initiation of antibiotic placed the resident at risk for receiving unnecessary medication and a diminished quality of life.Findings included. Review of the facility's policy titled, Antibiotic Stewardship, revised on 07/22/2025, showed, The antibiotic stewardship program promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. This means that the antibiotic is prescribed for the correct indication, dose, and duration to appropriately treat the resident. It further showed a procedure that included assessment of residents suspected of having an infection.Review of the physician order dated 11/02/2025 showed Resident 51 had an order for Augmentin [an antibiotic] to give one tablet by mouth two times a day for right toe infection for 10 days.Review of the November 2025 Medication Administration Record showed Resident 51 had been administered Augmentin from 11/02/2025 to 11/12/2025.Review of Resident 51's Electronic Health Record (EHR) did not show Resident 51 had been assessed or evaluated for right toe infection prior to initiation of antibiotic.In an interview and joint record review on 11/26/2025 at 1:52 PM, Staff D, Infection Preventionist, stated that they assessed residents for symptoms of infection prior to initiation of antibiotic and that they would inform the physician and document their findings in the residents' progress notes. Staff D further stated that they used order listing report to document and monitor residents' use of antibiotic. A joint record review of a document titled, Order Listing Report, dated 11/03/2025, showed Resident 51 started on Augmentin for right toe infection on 11/02/2025 until 11/12/2025. When asked if Resident 51 had been assessed or evaluated for their right toe infection prior to initiation of the antibiotic, Staff D proceeded to browse over Resident 51's EHR and stated that they did not see documentation related to Resident 51's right toe infection. Staff D further stated that there was no documentation to show that Resident 51 was assessed or evaluated prior to initiation of the antibiotic. In an interview on 11/26/2025 at 2:25 PM, Staff B, Director of Nursing, stated that they expect staff to follow their infection control policies. Staff B further stated that residents should have had an assessment for presence of infection prior to initiation of antibiotic.Reference: (WAC) 388-97-1620(2)(b)(i)(ii) .

Based on interview and record review, the facility failed to ensure a copy of the advance directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Durable Power of Attorney [DPOA- a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) for health care was obtained for 1 of 1 resident (Resident 21), reviewed for advance directive. This failure placed the resident at risk for losing their right to have their preferences honored regarding care. Findings included.Review of the facility's policy titled, Advanced Directives, revised on 11/19/2024, showed staff were required to ask the resident about advance directives and document any wishes the resident may have regarding the care they want or do not want. The policy stated that a written description of the facility's policies regarding advance directives and applicable state law is to be provided to the resident or resident representative. The policy further stated the document should be reviewed during admission, quarterly, and with any change in condition. The Social Services Director (SSD) or designee should document this conversation in the medical record and assist the resident with updating the document if needed.Review of Resident 21's admission packet under the advance directive section showed, Prior to admission, I have executed an Advance Directive and will provide the facility with a copy. A further review of the Electronic Health Record (EHR) miscellaneous tab showed no copy of an advance directive and no documentation that the resident was asked to provide a copy or offered assistance with completing one.In an interview on 09/30/2025 at 12:18 PM, Resident 21 stated that it had been a while and they could not remember if staff asked for a copy of their advance directive. Resident 21 further stated they were given paperwork to fill out upon admission and believed that what they completed was accurate.In a joint record review and interview on 11/24/2025 at 2:06 PM, Staff P, SSD, showed there was no documentation in the EHR showing that an advance directive was requested, offered, or obtained for Resident 21. Staff P stated that a copy of the advance directive should have been requested during admission, and follow-up communication should have been documented in the social work notes. Staff P further stated that if a resident did not have an Advance Directive, they would assist the resident with completing one or provide community resources for support.In an interview and joint record review on 11/25/2025 at 1:17 PM, Staff B, Director of Nursing, stated that it was the responsibility of Social Services to request a copy of the DPOA during admission. Staff B stated that if a resident reported they had an advance directive, a copy should be uploaded to the EHR and the face sheet updated. Staff B further stated that if a resident did not have an advance directive, Social Services would offer guidance to help them formulate one. A joint record review of Resident 21's EHR showed no copy of an advance directive and no documentation that one was requested, offered, or refused. Staff B stated that documentation should have been completed.Reference: WAC 388-97-0280 (1)(3)(a).

Based on interview and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN-a written notice that informs a Medicare [government health insurance program] that a service may not be covered and that resident may be responsible for the cost if they remained in the facility after their Medicare Part A skilled nursing and rehabilitation services ended) for 2 of 3 residents (Residents 104 & 105), reviewed for liability notices. This failure placed the residents and/or their representatives at risk of not having adequate information to make financial decisions related to continued stay in the facility.Findings included .Review of the facility's policy titled, Notice of Charges, revised on 05/06/2025, showed, SNF ABN is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. RESIDENT 104Review of a face sheet printed on 11/26/2025 showed that Resident 104 was admitted to the facility on [DATE].Review of Resident 104's Notice of Medicare Non-Coverage (NOMNC-a written notice that informs a Medicare beneficiary that their covered services are ending and explains their right to request an expedited appeal) document showed that it was issued and signed on 05/02/2025 with the last covered date of 05/05/2025.Review of the Electronic Health Record (EHR- progress note and miscellaneous/documents tab) showed that Resident 104 was discharged on 05/16/2025. Further review of EHR showed no SNF ABN was provided to Resident 104 with information regarding the payment amount for which they were responsible after choosing to continue to stay in the facility. RESIDENT 105Review of a face sheet printed on 11/26/2025 showed that Resident 105 was admitted to the facility on [DATE].Review of Resident 105's NOMNC document showed that it was issued and signed on 07/09/2025 with the last covered date of 07/11/2025. Review of the EHR showed that Resident 105 was discharged on 08/08/2025. Further review of the EHR showed no SNF ABN was provided to Resident 105 with information regarding the payment amount for which they were responsible after choosing to continue to stay in the facility. In an interview and joint record review on 11/25/2025 at 10:15 AM, Staff P, Social Services Director, stated that if the residents were no longer covered by Medicare but wished to remain in the facility, the facility would issue SNF ABN. A joint record review of the EHR did not show that Residents 104 and 105 were provided with SNF ABN after they chose to remain in the facility. Staff P further stated that the SNF ABN should have been issued and placed in the residents' files.In an interview on 11/26/2025 at 12:46 PM, Staff A, Executive Director, stated that they expected staff to issue the SNF ABN forms to Residents 104 and 105.Reference: (WAC) 388-97-0300 (1)(e).

Based on interview and record review, the facility failed to provide bed hold and transfer notices to the residents and/or their representatives in writing for 2 of 2 residents (Residents 69 & 94), reviewed for hospitalization. In addition, the facility failed to ensure a copy of the transfer notice was sent timely to the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) office describing the reason for the transfer and/or the location. These failures placed the residents at risk of not having an opportunity to make an informed decision about their transfers.Findings included. Review of the facility's policy titled, Bed Hold, revised on 04/22/2025, showed that bed hold notice would be provided upon transfer of a resident to the hospital (if in an emergency within 24 hours). The facility would provide written information to the resident or resident representative of the facility's bed hold policy before and upon transfer to a hospital. Review of the facility's policy titled, Notice of Transfer and Discharges, revised on 04/22/2025, showed that the facility would notify the resident and the resident's representative and office of the State Long Term Care Ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. prior to transfer or discharge. [NAME] facilities should use the Nursing Home Transfer or Discharge Notice DSHS 10-237 form. The policy showed that the written notice would include the location of discharge. It further showed that when a resident was temporarily transferred on an emergency basis to an acute care facility, a notice of transfer would be provided to the resident and resident representative as soon as practicable before the transfer. Copies of notices for emergency transfers would be sent to the Ombudsman office when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices. RESIDENT 69Review of a discharge Minimum Data Set (MDS- an assessment tool) dated 07/22/2025 showed Resident 69 had an unplanned discharge to a Short Term General Hospital. Review of a nursing progress note dated 07/22/2025 showed that Resident 69 discharged to the hospital on [DATE] for further evaluation. Further review of the notes did not show a written bed bold and/or transfer notice was provided to Resident 69. Review of the July 2025 discharged residents list showed it was sent to the Ombudsman office on 11/14/2025, 115 days after Resident 69 discharged to the hospital. Further review of the discharge resident list did not show Resident 69's discharge location and/or the reason for discharge. Review of the Electronic Health Records (EHR-under documents tab from July 2025 to November 2025) did not show the Transfer or Discharge Notice (DSHS 10-237) form was completed for Resident 69. On 09/29/2025 at 11:44 AM, Resident 69 stated they did not receive a copy of a bed hold and/or a transfer notice when they discharged to the hospital in July 2025. In an interview and joint record review on 11/25/2025 at 9:18 AM, Staff G, Registered Nurse, stated that bed hold notices would be provided to residents before they were discharged the hospital. A joint record review of the EHR (progress notes and documents tab from July 2025 to November 2025) did not show documentation that a copy of bed hold and/or transfer notice was provided to Resident 69. Staff G stated that they did not see a copy of bed hold and/or transfer notices were provided to Resident 69. In an interview and joint record review on 11/25/2025 at 10:29 AM, Staff P, Social Services Director, stated that transfer and/or discharge notifications were sent to the Ombudsman monthly. A joint record review of the July 2025 discharge list showed Resident 69's discharge notification was sent to the Ombudsman on 11/14/2025, 115 days after their hospital transfer. Staff P stated that Resident 69's discharge notification should have been sent to the Ombudsman the first week of August 2025. In a joint record review and interview on 11/25/2025 at 12:46 PM with Staff P showed the July 2025 discharge list did not include Resident 69's discharge reason or location. Staff P stated Resident 69's discharge reason or location should have been included. Staff P further stated that Resident 69 should have had a transfer notice form completed. In an interview on 11/26/2025 at 12:11 PM, Staff B, Director of Nursing, stated that they expected residents to be provided with a written bed hold and transfer notice before their discharge to the hospital, and in emergency situations within 24 hours. Staff B stated that there was no documentation to show that a copy of bed hold or transfer notice was provided to Resident 69 before their discharge to the hospital on [DATE] and it should have been. In an interview on 11/26/2025 at 12:46 PM, Staff A, Executive Director, stated they expected staff to follow the facility policies for bed hold and transfer or discharge notices. Staff A stated that the transfer discharge notices should have been sent to the Ombudsman office monthly. Staff A further stated that bed hold and transfer notices should have been provided to Resident 69. RESIDENT 94Review of a nursing progress note dated 07/02/2025, showed that Resident 94 transferred to the hospital for further evaluation. Review of a discharge MDS dated [DATE], showed that Resident 94 had an unplanned discharge to a Short-term General Hospital. Review of Resident 94's EHR (progress notes and documents tab from 06/20/2025 to 11/21/2025) showed no documentation that a bed hold notice was provided to Resident 94 and/or their representative. Review of the July 2025 discharged residents list showed it was sent to the Ombudsman office on 11/14/2025, 135 days after Resident 94 transferred to the hospital. Further review of the discharge resident list did not show Resident 94's discharge location and/or the reason for discharge. Review of the EHR (under documents tab from July 2025 to November 2025) did not show the Transfer or Discharge Notice (DSHS 10-237) form was completed for Resident 94. In an interview on 11/24/2025 at 9:16 AM, Staff F, Nurse Unit Manager, stated that to provide and discuss the bed hold notice was the responsibility of the nursing team. Staff F stated that the bed hold notice was not provided to Resident 94 and/or their representative. Staff F further stated that the bed hold notice should have been provided to Resident 94 and/or their representative. In an interview on 11/25/2025 at 12:44 PM, Staff P, stated that social service was responsible for notifying the Ombudsman when there was an unplanned discharge and/or transfer. Staff P stated that they would send the list of residents transferred to the hospital at the beginning of the following month. Staff P stated that the list of residents including Resident 94 who were discharged or transferred was sent to the Ombudsman on 11/14/2025. Staff P further stated that the notice of transfer should have been completed for Resident 94 and sent to the Ombudsman office at the beginning of August 2025. In an interview on 11/26/2025 at 10:56 AM, Staff B stated that Resident 94's bed hold notice had not been provided to them and/or their representative, and it should have been. In an interview on 11/26/2025 at 12:46 PM, Staff A stated that it was their expectation that the facility should complete the notice of discharge, provide education on the bed hold policy, issue the bed hold notice and document it. Staff A stated that the facility should have followed its transfer and discharge policy and provided Resident 94 with a bed hold notice. Staff A further stated that the notice of Resident 94's transfer to the hospital should have been sent to the Ombudsman office timely. Reference: (WAC) 388-97-0120 (2) (a-d) (4) (5)(b) .

Based on interview and record review, the facility failed to accurately assess 1 of 21 residents (Resident 5), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessment was completed accurately on the MDS regarding medications placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included.According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period).Resident 5 was admitted to the facility on [DATE].Review of the admission MDS dated [DATE] showed Resident 5's MDS under Section N0415 (High-Risk Drug Classes: Use of Indication) was marked for anticoagulant (a medication that prevents blood from clotting) use during this assessment period.Review of the August 2025 Medication Administration Record (MAR) showed Resident 5 did not receive an anticoagulant medication during the assessment period.During an interview and joint record review on 11/25/2025 at 9:35 AM, Staff K, MDS Coordinator, stated that the facility follows the RAI manual for completion of MDS assessments and they would review residents' MAR to complete section N (Medications) of the MDS. Joint record review of Resident 5's admission MDS dated [DATE] showed that Section N0415 was marked for anticoagulant use. Joint record review of August 2025 MAR showed Resident 5 did not receive anticoagulant medication. Staff K stated that Resident 5 did not receive anticoagulant medication during the assessment period, and that they would modify the MDS.On 11/25/2025 at 12:48 PM, Staff B, Director of Nursing, stated that the facility follows the RAI manual and they expected MDS assessments to be completed accurately.Reference: (WAC) 388-97-1000 (1)(b).

Based on interview and record review, the facility failed to include the dialysis (a treatment to remove extra fluid and waste when kidneys fail) days, transportation arrangement and contact information of the dialysis center in the comprehensive care plan for 1 of 1 resident (Resident 31), reviewed for dialysis. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Area of Focus: Care Planning-Baseline, Comprehensive, and Routine Updates, reviewed on 11/25/2024, showed that after a completion of Minimum Data Set (MDS-an assessment tool), a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs would be developed and implemented for each resident. Review of a face sheet printed on 11/21/2025 showed Resident 31 was admitted to the facility on [DATE].Review of Resident 31's admission MDS dated [DATE] showed it was completed on 09/22/2025.Review of a physician order summary report dated 11/21/2025, showed Resident 31 had scheduled dialysis services at an offsite dialysis center every Mondays and Thursdays from 8:45 AM to 12:45 PM.Review of Resident 31's hemodialysis (a medical procedure used to treat kidney failure by removing waste products and excess fluids from the blood) comprehensive care plan initiated on 09/13/2025 did not include Resident 31's scheduled dialysis days. Further review of the care plan did not show Resident 31's transportation arrangement and/or contact information of the dialysis center.In an interview and joint record review on 11/24/2025 at 11:58 AM, Staff F, Nurse Unit Manager, stated that Resident 31 went to an offsite dialysis center for their hemodialysis and that it was included in their care plan. Staff F stated that dialysis residents that were admitted to the facility had prior transportation arrangement and that they had a binder that contained the dialysis center contact information. A joint record review of Resident 31's comprehensive care plan did not show the scheduled dialysis days, transportation arrangement and the dialysis center contact information. Staff F stated, No, they are not in [Resident 31's] care plan.In an interview on 11/24/2025 at 2:08 PM, Staff B, Director of Nursing, stated that Resident 31's comprehensive care plan should have had information about their scheduled dialysis days, transportation arrangements and contact information of the dialysis center.Reference: (WAC) 388-97-1020(1)(2)(a).

Based on interview and record review, the facility failed to ensure safety hazards such as a lighter and a box cutter were properly stored for 1 of 2 residents (Resident 13), reviewed for accident hazards. This failure placed the resident at risk for injury, and a diminished quality of life.Findings included.Review of the facility's policy titled, Area of Focus: Incident and Reportable Event Management, reviewed on 11/15/2025, showed, The facility must ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision . to prevent accidents.Review of a face sheet printed on 11/24/2025 showed Resident 13 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set (an assessment tool) dated 07/14/2025 showed Resident 13 had intact cognition.Review of the behavior/mood care plan initiated on 05/29/2025 showed Resident 13 keeps items in room that he is aware is against [facility] policy.An observation on 09/28/2025 at 12:43 PM showed a lighter and an object about four to five inches in length with a visible blade that was later described to be a box cutter (a tool with a blade to open and/or cut boxes) on top of Resident 13's bedside table. Resident 13 was not in their room at that time.An observation and interview on 09/28/2025 at 1:31 PM, showed a lighter and a box cutter next to Resident 13's meal tray on their bedside table. Resident 13 stated that they were a smoker until I came here [in a non-smoking facility] and that they used the lighter for burning strings sometimes. Resident 13 stated that their collateral contact brought them a model kit to work on and used the box cutter as their tool. In an interview and joint observation on 09/28/2025 at 2:18 PM, Staff O, Registered Nurse, stated that residents were not allowed to have lighters or any dangerous items in their room. Staff O stated that if they saw these items, they would keep them and would inform the social worker for proper storage. A joint observation of Resident 13's room with Staff O showed a lighter and a box cutter on top of Resident 13's bedside table. Staff O proceeded to take the lighter and the box cutter and stated that they would talk to the social worker.In an interview on 09/28/2025 at 2:26 PM with Staff P, Social Service Director, stated that Resident 13 cannot have lighters or anything sharp with them and that these items should be locked in a storage. Staff P further stated that they have discussed providing a safety box for Resident 13 during their first care conference.In an interview on 11/24/2025 at 1:31 PM, Staff B, Director of Nursing, stated that residents were not allowed to have a lighter or box cutter in their room as these items were considered safety hazards. Staff B stated that staff were expected to observe items in residents' rooms that may pose a safety hazard and remove them when found. Staff B stated that Resident 13 should not have had a lighter and a box cutter in their room.Reference: (WAC) 388-97-1060(3)(g).

Based on interview and record review, the facility failed to initiate non-pharmacological interventions for pain management prior to administering as needed (PRN) pain medication for 1 of 1 resident (Resident 21), reviewed for pain management. This failure placed the resident at risk for unnecessary medications and incomplete pain control.Findings included.Review of the facility's policy titled, Pain Assessment and Management, revised on 11/11/2025, showed that all residents will be assessed for pain and based on the assessment, the facility in collaboration with the attending physician, other healthcare professionals, and the resident and/or resident representative would develop and implement both pharmacological and non-pharmacological intervention approaches to pain management.Review of the quarterly Minimum Data Set (an assessment tool) dated 09/25/2025 showed Resident 21 was admitted to the facility on [DATE] with diagnosis that included left knee osteoarthritis (a condition in which the protective cushioning at the ends of the bones wears down, causing the bones to rub against each other).Review of Resident 21's physician order dated 07/03/2025, showed an order for Acetaminophen (a medication used to relieve pain) three times a day PRN for pain and/or fever. Further review of the physician order showed instructions for staff to attempt non-pharmacological interventions that included, 1) resting/immobilizing and 2) repositioning prior to administering PRN pain medications.Review of Resident 21's physician order dated 08/25/2025, showed an order for Oxycodone (a narcotic- controlled medication used to relieve pain) every four hours PRN for moderate to severe pain.Review of the September 2025 Medication Administration Record (MAR) showed Resident 21 received PRN Oxycodone without documented evidence that non-pharmacological interventions were attempted on the following dates:09/01/2025, 09/02/2025, 09/03/2025, 09/04/2025, 09/06/2025, 09/07/2025, 09/09/2025, 09/10/2025, 09/11/2025, 09/13/2025, 09/14/2025, 09/15/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/20/2025, 09/21/2025, 09/22/2025, 09/23/2025, 09/24/2025, 09/25/2025, 09/26/2025, 09/27/2025, 09/28/2025, and on 09/29/2025.In a joint interview and record review on 11/25/2025 at 12:05 PM, Staff E, Nurse Unit Manager, stated that staff should follow the physician's orders and that non-pharmacological interventions should be tried before PRN pain medication administration. Further review of Resident 21's September 2025 MAR showed non-pharmacological interventions were not documented for most dates when PRN pain medications were given.In an interview on 11/26/2025 at 2:05 PM, Staff B, Director of Nursing, stated it was their expectation that staff followed physician orders and that non-pharmacological interventions should have been offered to Resident 21 prior to administering their PRN pain medication.Reference: WAC 388-97-1060 (1).

Based on observation, interview, and record review, the facility failed to ensure controlled medications were accurately reconciled for 1 of 3 medication carts (Olympic Medication Cart), reviewed for controlled medication storage/reconciliation. This failure placed the facility at risk for potential loss and/or drug diversion of the controlled medication.Findings included .Review of the facility's policy titled, Management of Controlled Substances, reviewed on 09/16/2025 showed, The facility will maintain a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation, and the facility conduct a periodic reconciliation.The facility will ensure that the incoming qualified individual and outgoing qualified individual count all controlled substances and other medications with a risk of abuse or diversion at the change of each shift. The policy further showed, .using the Shift Change Controlled Substance Inventory Count Sheet [the facility] reconcile the number of doses remaining in the package to the number of remaining doses record on the Shift Change Controlled Substance Inventory Count Sheet.In a joint observation and interview on 11/24/2025 at 12:47 PM with Staff L, Registered Nurse, showed the controlled medications book for Olympic medication cart, page 114 had one remaining tablet of Oxycodone (a strong prescription painkiller classified as opioid [narcotic]). Further observation of the controlled medication box showed there was no oxycodone medication for page 114 remaining in the box. Staff L stated that they had counted the controlled medications in the locked controlled medication box at the beginning of their shift. Staff L stated the oxycodone was administered by the night shift staff but was not signed out on the controlled medication book. Staff L further stated that the oxycodone should have been signed out on the controlled medication book.In an interview on 11/24/2025 at 2:56 PM, Staff B, Director of Nursing, stated that whenever controlled medications were removed for administration, it should be signed out on the controlled medication book. Staff B stated that if there was any discrepancy in the controlled medication count, they should have been notified immediately. Staff B further stated they expected controlled medications counted and reconciled every shift.Reference: (WAC) 388-97-1300(1)(b)(ii).

Based on interview and record review, the facility failed to ensure influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]) were offered for 2 of 5 residents (Residents 6 & 10), reviewed for immunizations. This failure placed the residents at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease.Findings included.Review of the facility's policy titled, Influenza Vaccine Policy for Residents, reviewed on 07/08/2025, showed, Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated, or the resident has already been immunized during this time period. It further showed, The resident's medical record included documentation that indicates.that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.RESIDENT 6Review of a face sheet printed on 11/25/2025 showed Resident 6 was admitted to the facility on [DATE] and discharged on 10/23/2025.Review of Resident 6's immunization record dated 03/19/2024 showed that they received an influenza vaccine on 10/22/2019.Review of Resident 6's Electronic Health Record (EHR) under immunization tab, showed Influenza not eligible. Further review of the EHR showed no documentation that Resident 6 was offered the annual influenza vaccine or was informed about the risks and benefits.RESIDENT 10Review of a face sheet printed on 11/25/2025 showed Resident 10 was admitted to the facility on [DATE] and discharged on 11/24/2025.Review of the EHR under immunization tab showed Resident 10 received the influenza vaccine on 10/15/2018. Further review of the EHR showed no documentation that Resident 10 was offered the annual influenza vaccine or was informed about the risks and benefits.In an interview and joint record review on 11/25/2025 at 9:18 AM, Staff D, Infection Preventionist, stated, Influenza vaccine is offered at the start of [the] flu season, October first. A joint record review of Resident 6 and Resident 10's EHR showed no documentation that the influenza vaccine was offered or refused. Staff D stated that Resident 6 and Resident 10 should have been offered the influenza vaccine around first of October but it did not happen.In an interview and joint record review on 11/26/2025 at 2:43 PM, Staff B, Director of Nursing, stated that they offered the influenza vaccine annually on October first to all residents. Staff B stated that if a resident refused when offered the influenza vaccine, they [staff] should document it and provide education to the resident. Joint record review of the EHR for Resident 6 and Resident 10 showed no documentation that they were offered or refused the influenza vaccine. Staff B stated that they expected everybody in the facility should have been offered the influenza vaccine starting October 1.Reference: (WAC) 388-97-1340 (1)(2).

Based on observation, interview, and record review, the facility failed to accurately assess, provide timely treatment, and implement pressure relieving interventions to prevent worsening of skin condition for 1 of 3 residents (Resident 1), reviewed for pressure injury (localized damage to the skin and/or underlying tissue that occurs due to prolonged pressure on the skin). Resident 1, who was at an increased risk of skin breakdown, experienced harm when a wound on their sacrum (triangular-shaped bone in the lower back located between the hip bones) had not been identified on their admission skin assessment, developed into an avoidable unstageable pressure injury (obscured full-thickness skin and tissue loss) that worsened requiring debridement (surgical removal of dead or infected tissue from a wound to promote healing), was diagnosed as a Stage 3 pressure injury (full thickness loss of skin) requiring application of a Wound Vac [vacuum-machine to assist with wound healing). This failure placed the resident at risk for further skin breakdown, pain, infection, and a diminished quality of life. Findings included .Review of the National Pressure Injury Advisory Panel (NPIAP - leading expert in pressure injuries/wounds), dated February 2025, defined pressure injury stages as follows:-Stage 2 Pressure Injury is a partial thickness skin loss with exposed dermis (the top inner layers of skin) and may be present as an open ulcer with a red or pink wound bed or as an intact or ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation (newly formed) tissue, slough (dead tissue) and eschar (dried blood and tissue) are not present.-Stage 3 Pressure Injury is a full thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissue and epibole (rolled or curled wound edges) are often present. Slough and/or eschar may be visible.-Stage 4 Pressure Injury is a full-thickness loss of skin and tissue with exposed or directly palpable fascia (layer of tissue covering the muscle), muscle, tendon (a cord or band of dense, tough, inelastic, white, fibrous tissue, serving to connect a muscle with a bone or part), ligament (a tough fibrous band of connective tissue that supports internal organs and holds bones together at the joints. It connects bones to other bones and helps hold organs in place), cartilage (a strong, flexible connective tissue that protects the joints and bones acting as a shock absorber throughout the body) or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and/or tunneling often occur. Depth varies by anatomical location.-Unstageable Pressure Injury is an obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.Review of the facility's policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention, last reviewed on 06/11/2025, showed that the facility staff was provided with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP and WONC (Wound, Ostomy [a surgical procedure creating an opening in the body for the discharge of body waste into a collection bag], Continent Nurses Society - the largest and most recognized professional nursing community dedicated to advancing the practice and delivery of expert healthcare to individuals with wound, ostomy, and continence care needs). A comprehensive skin inspection/assessment is completed on admission and readmission to the center.Review of a face sheet showed Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture (break in the bone) to left lower leg, morbid obesity (severe level of obesity that can lead to serious health issues), and moderate protein calorie malnutrition (when not enough protein and calories are consumed and/or metabolized, resulting in muscle loss).Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 08/14/2025 showed Resident 1 had no pressure injury on their sacrum and was cognitively intact. The MDS showed Resident 1 required maximum assistance (helper lifts or holds trunk or limbs) with bed mobility and total assistance (resident does none of the effort to complete the activity) with toileting and transfers. It further showed that Resident 1 was always incontinent of bladder and bowel.Review of Resident 1's BRADEN scale (an assessment tool that measures risk for pressure injury) dated 08/06/2025 showed a score of 15, indicating mild risk for pressure ulcer/injury development. Review of a BRADEN scale dated 08/20/2025 showed Resident 1 scored 12, indicating high risk for pressure ulcer/injury development. Review of the most current BRADEN scale dated 08/27/2025 showed Resident 1 scored 13, indicating moderate risk for pressure ulcer/injury development.Review of Resident 1's Admission/readmission Collection Tool, dated 08/06/2025 showed bruises on their right lower leg and a surgical wound on their left leg related to left ankle fracture surgery. Review of the Weekly Skin Integrity Data Collection, dated 08/13/2025 showed bruises on their right lower leg and a surgical wound on their left leg related to left ankle fracture surgery. There was no documentation that Resident 1 had other skin concern [Moisture-Associated Skin Damage (MASD - inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration and/or wound fluid] or pressure ulcer on their sacrum dated 08/06/2025 and 08/13/2025. Review of the Weekly Skin Integrity Data Collection, dated 08/15/2025 showed Resident 1 had an open wound on their sacrum measuring 5.0 centimeters (cm-unit of measurement) x 8.0 cm with red-pink wound bed and slough on the edges, nine days after admission. The document indicated that the wound was new.Review of the August 2025 Treatment Administration Record (TAR) showed an order dated 08/06/2025 to Assist [Resident 1] with repositioning 3-4 (three to four) times every shift to help prevent skin breakdown. Review of the TAR did not show Resident 1 was repositioned 3-4 times every shift, as it was signed once every shift. The TAR further showed a treatment for coccyx (tail bone)/perianal MASD, to clean it with soap and water, pat dry, and apply moisture barrier cream every shift. The TAR did not show documentation that the coccyx wound treatment was done from 08/06/2025 to 08/17/2025.Review of the facility's incident investigation dated 08/15/2025 showed a hospital note indicating that on 08/02/2025 [while Resident 1 was in the hospital, prior to admission to the facility on [DATE]], Resident 1 had an [unidentified] wound on their sacrum.Review of a progress notes dated 08/15/2025 showed a skin breakdown was found above Resident 1's sacrum/coccyx during incontinent care.Review of a Wound Observation Tool, dated 08/18/2025 showed Resident 1 had an acquired [a new wound was discovered while in the facility] unstageable pressure injury on their sacrum measuring 5.5 cm long, 4.5 cm wide and 0.1 cm deep. It further showed that the pressure injury had slough tissue present. Review of the Physician's Assistant-Certified (PA-C) wound care notes dated 08/19/2025 showed Resident 1 had an unstageable pressure injury on their sacrum measuring 9.5 cm x 6.0 cm x 0.0 cm with 76% to 100% slough before debridement, and 9.5 cm x 6.0 cm x 3.0 cm after this first debridement. The document further showed that due to Resident 1's habitus [body] area is difficult to assess and possibly that wound may have begun while hospitalized .Review of another PA-C wound care notes dated 08/26/2025 showed Resident 1 had an unstageable pressure injury on their sacrum measuring 9.0 cm x 5.0 cm x 3.6 cm with 51% to 75% granulation and 11% to 25% slough and was diagnosed as Stage 3 pressure injury after wound debridement measuring 9.0 cm x 5.0 cm x 3.8 cm with recommendation for wound treatment, and start Negative Pressure Wound Therapy (NPWT or wound vac- treatment that uses suction to promote healing in acute or chronic wounds) on 08/29/2025. Review of the Wound Observation Tool, dated 08/26/2025 showed Resident 1 had a [facility] acquired Stage 3 pressure injury on their sacrum measuring 9.5 cm x 5.0 cm x 3.6 cm. The document further showed that Resident 1 was to transition to Wound Vac on 08/29/2025.In an interview on 08/21/2025 at 9:03 AM, Resident 1 stated they needed staff assistance with repositioning in bed, cleaning, dressing, toileting, bathing, and with transfers in and out of bed using a Hoyer lift (mechanical lifting device). Resident 1 was observed lying in bed with head of bed elevated and had a cast on their left lower leg. Resident 1 stated that they were not aware they had a pressure injury when they were admitted to the facility. Resident 1 further stated that they were made aware they had a pressure injury at the end of last week or the start of this week.In an interview on 08/21/2025 at 9:14 AM, Collateral Contact 1 (CC1), stated that the facility reviewed Resident 1's basic care plan with them on admission. CC1 showed a copy of Resident 1's facility provided baseline care plan dated 08/06/2025, and it did not show a skin concern or pressure injury. CC1 stated that the document noted that Resident 1 was at risk for skin breakdown and that it did not mention a pressure injury. CC1 further stated, no one told me [they] had a wound.A joint observation and interview on 08/21/2025 at 9:47 AM with Staff C, Registered Nurse, and Staff D, Resident Care Manager, showed Resident 1 had a pressure injury on their sacrum. Staff C stated that Resident 1's unstageable sacral pressure wound measured 3.0 inches [7.62 cm] long by 2.5 inches [6.35 cm] wide by 1.0 inch [2.54 cm] deep, and that it was 50% granulation and less than 50% slough. While Staff D was cleaning Resident 1's pressure injury with a gauze, a red colored fluid oozed from the wound and Resident 1 shouted, ouch. Staff D stated, there is a little bit of blood coming out of the wound.In an interview on 08/28/2025 at 12:41 PM, Staff E, Certified Nursing Assistant, stated that they have been working with Resident 1 since they were admitted and that they did not have skin issues. Staff E stated that they found Resident 1 had a wound on their bottom when a piece of skin fell off from the sacral area while they were providing incontinent care on 08/15/2025 and that they reported it to the nurse. Staff E stated that Resident 1 required mostly total care of two staff with toileting, repositioning, and transfers to bed/chair using a Hoyer lift. Staff E further stated that Resident 1 was incontinent with bladder and bowel. A joint record review and interview on 08/28/2025 at 1:24 PM with Staff C, showed Resident 1's weekly skin check dated 08/13/2025 revealed Resident 1 did not have a pressure wound on their sacrum. Staff C stated that they conducted Resident 1's skin check on 08/13/2025 and they did not see a pressure injury at that time. Staff C stated they had worked with Resident 1 since they were admitted and that Resident 1 had developed a Stage 3 pressure wound on their sacrum. A joint record review of the August 2025 TAR showed that Resident 1's coccyx/perianal MASD treatment was not signed (blank - no documentation to show that the wound treatment was provided) from 08/06/2025 through 08/17/2025. Staff C stated, it looks like they [their treatment] were not done until 08/18/2025. A joint record review of the physician's order dated 08/06/2025 revealed Resident 1's coccyx/perianal MASD treatment was created on 08/18/2025. Staff C stated, it looks like the order was not entered until 08/18/2025 but for some reason they entered it as if it was started on 08/06/2025.A joint record review and interview on 08/29/2025 at 10:14 AM with Staff D, showed Resident 1's Admission/readmission Collection Tool dated 08/06/2025 did not indicate Resident 1 had [MASD] or pressure wound on their sacrum. Staff D stated that there was no documentation that Resident 1 had a [MASD or] pressure wound when they were admitted . A joint record review of the wound observation tool dated 08/26/2025 showed Resident 1 had a Stage 3 pressure injury. Staff D stated that Resident 1 was getting wound care for their pressure injury and would start having a wound vac.In an interview and joint record review on 08/29/2025 at 11:14 AM, Staff B, Director of Nursing, stated they expected staff to do a thorough and detailed skin check from head to toe on newly admitted residents, then weekly, and as needed. Staff B stated that the Admission/readmission Collection Tool dated 08/06/2025 had no documentation that Resident 1 had a sacral wound. Staff B stated that Resident 1's pressure injury was discovered on 08/15/2025, and they saw Resident 1's unstageable pressure injury on 08/18/2025, and it was full of slough. Staff B stated that Resident 1's sacral pressure injury was debrided on 08/26/2025 and was staged then as Stage 3 pressure after debridement and that Resident 1 would be getting a wound vac. A joint record review of Resident 1's August 2025 TAR showed the coccyx/perianal MASD treatment were not signed from 08/06/2025 through 08/17/2025. Staff B stated, it looks like it was not done until 08/18/2025. Staff B stated, the order was created on 08/18/2025 with a start date of 08/06/2025 because that was the date [Resident 1] was admitted to the facility. Staff B stated that Resident 1's wound was missed on admission. Staff B stated that if the wound had been identified on admission, wound care and services would have been started at that time. Staff B stated that when they investigated Resident 1's wound incident, they found out that Resident 1's hospital records noted that Resident 1 had wound on their sacral area dated 08/02/2025. When asked if the hospital records mentioned the type of wound and wound size for Resident 1, Staff B stated, no, it did not mention any of that, only that there was a wound on the sacrum. Staff B further stated that Resident 1‘s sacral wound was missed and/or not identified on their admission skin assessment.Reference: (WAC) 388-97-1060(3)(b).

Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 3 residents (Resident 3), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.Findings included.Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, All alleged incidents of abuse, neglect.and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. It further showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences.Review of the facility's policy titled, Abuse-Protection of Residents, reviewed on 05/07/2025, showed, Have evidence that all alleged violations are thoroughly investigated.Review of the quarterly Minimum Data Set (an assessment tool) dated 08/15/2025, showed Resident 3's cognition was moderately impaired.Review of the facility's investigation report dated 07/31/2025 showed Collateral Contact 1 (CC1) reported that the thousand dollars ($1000) they brought in three months ago was missing from Resident 3's wallet. The investigation report showed that CC1 alleged that today [07/31/2025] is the first day that they and Resident 3 had looked in Resident 3's wallet since the money was placed three months ago. Review of the investigation report showed: Immediate Action Taken:-Investigation initiated-Police called-Room was searched for possible misplacement of the money-Belonging list was reviewed with no mention of money-Reported to State Agency.Further review of the investigation report showed that interviews with other residents and staff members were not conducted.In an interview on 08/28/2025 at 12:33 PM, Staff J, Certified Nursing Assistant, stated that they had been assigned to Resident 3 and were not aware of Resident 3's alleged missing money. Staff J stated that they were not interviewed about Resident 3's report of missing money.In an interview on 08/28/2025 at 1:17 PM, Staff K, Registered Nurse (RN), stated that they were assigned to Resident 3 on 07/31/2025 and did not receive a report about Resident 3's alleged missing money. Staff K stated that they were not interviewed about Resident 3's report of missing money.In an interview on 08/28/2025 at 1:22 PM, Staff L, RN, stated that they had been assigned to Resident 3 and did not receive or heard a report about Resident 3's alleged missing money and that they were not interviewed about it.In an interview and joint record review on 08/29/2025 at 10:16 AM, Staff I, Assistant Director of Nursing, stated that they reported and investigated Resident 3's allegation of missing money and that they followed the Purple Book in their investigation process. Staff I stated that they would interview staff members and other residents as part of their investigation process. A joint record review of the investigation report dated 07/31/2025 did not show documentation that other residents and staff were interviewed. Staff I stated that they did not conduct interview of staff and other residents about Resident 3's allegation of missing money.In an interview on 08/29/2025 at 11:01 AM, Staff B, Director of Nursing, stated that they reviewed Resident 3's investigation report and did not see documentation that other residents and staff were interviewed. Staff B stated, I checked [Staff I]'s paper, and I did not see staff interviews or [other] residents' interviews. When asked if the investigation was completed thoroughly Staff B stated, I expected that the investigation should have been thoroughly done and that would include interviews with staff and residents. No, it was not [thoroughly investigated].Reference: (WAC) 388-97-0640 (6)(a).

Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices and/or proper use of personal protective equipment (PPE-glove/gown use) were followed for 2 of 3 residents (Residents 1 & 2), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included .Review of the facility's policy titled, Enhanced Barrier Precautions [EBP-precaution to protect residents from multidrug-resistant organism [MDRO - a germ that is resistant to medications that treat infections]), revised on 08/19/2025, showed that the facility would use EBP for MDRO mitigation as a strategy for residents during high contact care activities that included wounds even if the resident was not known to be infected or colonized with a MDRO. It also showed that EBP would be done for chronic wounds such as pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure), diabetic foot ulcers (skin injury with full thickness skin loss on the foot in patients with diabetes [high levels of sugar in the blood]), unhealed surgical wounds, and venous stasis ulcers (skin injury on lower legs due to poor blood circulation). The policy further showed that EBP required the use of gowns and gloves during high-contact resident care activities.Review of the facility's policy titled, Hand Hygiene, reviewed on 07/07/2025, showed that staff would perform hand hygiene even if gloves were used before and after contact with the resident, after contact with blood, body fluids, or visibly contaminated surfaces.Review of the undated signage/posting titled, Enhanced Barrier Precautions, showed it instructed staff to wear gown and gloves for high-contact resident care activities that included wound care with any skin opening requiring a dressing.GLOVE USE AND HAND HYGIENERESIDENT 1Review of the wound care notes dated 08/19/2025 showed Resident 1 had an unstageable pressure injury (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the pressure injury that cannot be confirmed because it is obscured by slough [soft yellow or white dead tissue] or eschar [hardened, dry, black or brown dead tissue]) on their sacrum (triangular-shaped bone in the lower back located between the hip bones).During an observation and interview on 08/21/2025 at 9:46 AM, Staff C, Registered Nurse, and Staff D, Resident Care Manager (RCM), showed they provided wound care to Resident 1. Staff D had gloves on and touched Resident 1's soiled disposable brief and proceeded to clean Resident 1's sacral (or sacrum) wound with gauze soaked with normal saline (sterile solution composed of water and sodium [salt]). With the same soiled gloves Staff D touched Resident 1's soiled brief, continued to clean Resident 1's pressure injury wound with a gauze, and a red colored fluid oozed from the wound. Staff D stated, there is a little bit of blood coming out of the wound. Staff D was observed holding the resident's hip while Staff C measured Resident 1's sacral pressure injury. Staff D covered Resident 1's pressure injury with a clean silicone dressing to cover the wound. Staff C and Staff D removed Resident 1's soiled brief, replaced it with a clean brief, repositioned Resident 1 in their bed, and covered Resident 1 with their blanket. Staff D touched and moved Resident 1's bedside table closer to them. Staff C touched and handed their bed control and their call light to Resident 1. Staff D removed their soiled gloves and adjusted Resident 1's pillow without doing hand hygiene. When asked about when to change their soiled gloves, Staff C and Staff D stated that they did not touch Resident 1's wound directly when they provided wound care and/or when measuring Resident 1's pressure wound. Staff D further stated they forgot to use the gel [hand sanitizer] after they removed their gloves before adjusting Resident 1's pillow.In an interview on 08/29/2025 at 11:15 AM, Staff B, Director of Nursing, stated they expected staff to follow infection control policies and to do hand hygiene before putting on clean gloves, between glove use, when doing wound care between tasks from dirty to clean. Staff B stated that Staff C and Staff D should have done hand hygiene and changed their gloves between tasks when providing wound care to Resident 1. Staff B further stated that Staff C and Staff D should not have touched Resident 1's environment with their soiled gloves.USE OF GOWNRESIDENT 2Observation on 08/20/2025 at 4:42 PM showed an EBP signage outside Resident 2's room that instructed staff to wear gown and gloves for high-contact resident care activities that included wound care.During an observation and interview on 08/21/2025 at 10:31 AM with Staff G, Licensed Practical Nurse, showed Staff G provided wound care to Resident 2's left lower leg without wearing a gown. A joint record review of the EBP signage outside Resident 2's room showed that staff were required to wear gown and gloves for high-contact care activities that included wound care. Staff G stated, I should have worn a gown prior to the dressing change [wound care].In an interview on 08/29/2025 at 10:09 AM, Staff H, RCM, stated that EBP was done for residents with wounds and that staff were expected to wear gown and gloves. Staff H further stated that Staff G should have worn a gown when they provided wound care to Resident 2.In an interview on 08/29/2025 at 11:21 AM, Staff B stated that staff were expected to wear gown and gloves for residents on EBP. Staff B further stated that Staff G should have worn a gown when they provided wound care to Resident 2.Reference: (WAC) 388-97-1320(1)(a)(c).

Based on interview and record review, the facility failed to provide a written summary of the baseline care plan to the residents and/or their representatives for 4 of 4 residents (Residents 1, 2, 3 & 4), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Baseline Care Plan, reviewed on 09/05/2024, showed staff would 4. Review the baseline care plan and physician orders with the resident and/or representative. 5. Provide the resident[s]and/or representative with copies of the baseline care plan and physician orders. 6. Have all care plan conference attendees sign the last page of the Baseline Care Plan form. RESIDENT 1 In a phone interview on 04/24/2025 at 9:51 AM, Collateral Contact 1 (CC1), stated they did not recall receiving a written summary of Resident 1's baseline care plan. Review of Resident 1's assessment titled, Baseline Care Plan 2, dated 03/10/2025, did not show that Resident 1 or their representative received a written summary of their baseline care plan. Review of Resident 1's nursing progress notes did not show that Resident 1 or their representative received a written summary of their baseline care plan. RESIDENT 2 Resident 2 was admitted to the facility on [DATE]. On 04/24/2025 at 1:48 PM, Resident 2 stated that they did not remember if they received a written summary of their baseline care plan. Review of Resident 2's assessment titled, Baseline Care Plan 2, dated 03/04/2025, did not show that Resident 2 or their representative received a written summary of their baseline care plan. Review of Resident 2's nursing progress notes did not show that Resident 2 or their representative received a written summary of their baseline care plan. RESIDENT 3 Resident 3 admitted to the facility on [DATE]. Review of Resident 3's assessment titled, Baseline Care Plan 2, dated 04/09/2025, did not show that Resident 3 or their representative received a written summary of their baseline care plan. Review of Resident 3's nursing progress notes did not show that Resident 3 or their representative received a written summary of their baseline care plan. RESIDENT 4 Review of Resident 4's assessment titled, Baseline Care Plan 2, dated 03/21/2025, did not show that Resident 4 or their representative received a written summary of their baseline care plan. Review of Resident 4's nursing progress notes did not show that Resident 4 or their representative received a written summary of their baseline care plan. On 05/09/2025 at 12:29 PM, Staff C, Assistant Director of Nursing, stated they would expect a resident and/or their representative to receive a written summary of their baseline care plan. Staff C stated that they could not find documentation that Resident 1, 2, 3, and 4 and/or their representatives had received a written summary of their baseline care plan. Staff C stated that they would have expected the baseline care plan to be signed and uploaded into their Electronic Health Record (EHR) and that there would be a progress note. Staff C further stated the baseline care plan was important because it let the staff know how to take care of the residents and what their needs were and included the resident and/or representative input. On 05/09/2025 at 1:02 PM, Staff B, Director of Nursing, stated that they would expect there to be documentation that a written summary of the baseline care plan was provided to the resident or representative. On 05/09/2025 at 1:42 PM, Staff A, Interim Executive Director, stated that they had Resident 1, 2, 3, and 4's baseline care plan completed and that it was not signed by the resident and/or representative. On 05/09/2025 at 1:48 PM, Staff D, Social Services Director, stated their expectation was to discuss the baseline care plan with the resident and/or representative during the resident's initial care conference and that they would be provided with a written summary of the baseline care plan. Staff D stated that it would be uploaded into the resident's EHR with the resident and/or representative's signature on the signature page and documented in a progress note. Staff D stated that there was no documentation that Resident 1, 2, 3, and 4 had been provided with a written summary of their baseline care plan. Staff D further stated a baseline care plan was important to provide for the residents or representatives because it informed them of the services that would be provided at the facility. Reference: (WAC) 388-97-1020(3)

Based on interview and record review, the facility failed to provide necessary care and services timely to treat and prevent further skin breakdown from a pressure ulcer/pressure injury (PU/PI - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and failed to initiate timely antibiotic medication to treat PU/PI wound infection for 1 of 2 residents (Resident 1), reviewed for PU/PI. Resident 1 experienced harm when they had a rapid deterioration of multiple PU/PIs that became infected and required hospitalization related to bacteremia (presence of bacteria in the blood), and placed other residents at risk for wound infection, delayed wound healing, and a diminished quality of life. Finding included . The [DATE] Resident Assessment Instrument (RAI) User's Manual defines PU/PI as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. The RAI manual defines the Stage 2 PU/PI as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (dead tissue, yellow/white material in the wound bed) or bruising. Granulation (beefy-looking tissue that form on the surfaces of a wound during the healing process), tissue, slough, and eschar (dead tissue) are not present in Stage 2 pressure ulcers. Review of the facility's policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention and Management, reviewed on [DATE], showed that it is the facility's policy to provide associates and licensed nurses with procedures to manage skin integrity, prevent PU/PI, complete wound assessment/documentation, and provide treatment and care of skin and wound utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy [An operation to create an opening from an area inside the body to the outside], Continent Nurse Society). The policy also showed that it is the facility's procedure to complete a risk assessment tool, Braden Scale (an assessment tool used for early identification of patients at risk for forming pressure sores) upon admission, weekly for the first four weeks after admission, then monthly. Resident 1 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS- an assessment tool), dated [DATE], showed Resident 1 required substantial/maximal assistance for bed mobility. The MDS assessment showed Resident 1 did not have a condition or chronic disease that may result in terminal illness or a life expectancy of less than six months. The MDS assessment identified Resident 1 at risk for developing PU/PI and had no PU/PI during the MDS assessment period. Review of Resident 1's care plan initiated on [DATE], showed Resident 1 was at risk for skin breakdown due to weakness/impaired mobility requiring assistance with repositioning, transfers, toileting, bed mobility, bowel/urinary incontinence, and a Braden scale assessment score of 15 (medium risk for PU/PI). Further review of the care plan showed an intervention that Resident 1 would be on pressure redistribution mattress and have a wheelchair cushion in place. Review of the Braden scale assessment dated [DATE], showed Resident 1 scored 11, indicating a high risk for PU. Review of the nursing progress notes from [DATE] to [DATE], showed Resident 1 refused a full body skin check once on [DATE]. There was no other documentation to show Resident 1 refused skin checks. Review of the weekly skin integrity data collection dated on [DATE], showed Resident 1 had intact skin. Review of the physician notes dated [DATE] and created on [DATE], showed Resident 1 had a right gluteal (buttock area) wound consistent with a Kennedy ulcer (an unavoidable skin breakdown, which occurs in some patients [residents] as part of the dying process) with infection. The physician notes showed that the wound infection would be treated with an antibiotic (medication to treat infection caused by bacteria) and the wound would be tested for culture and sensitivity (a laboratory test to find germs that causes infection). Further review of the physician notes and Resident 1's medical record showed no diagnoses or care plan for terminal illness. Review of the [DATE] Medication Administration Record (MAR) showed Resident 1 had an order for clindamycin (an antibiotic) one capsule three times a day for infection for 14 days, started on [DATE] at 6:00 PM [two days after the resident was found with signs and symptoms of wound infection on [DATE]]. Further review of the MAR showed Resident 1's wound culture sample was collected on [DATE], [three days after the resident was found with signs and symptoms of wound infection]. Review of the nursing progress notes dated [DATE], showed Resident 1 was found with open wound on their left ischial area (bony area, also called as sit bones, which the body rests when sitting). Review of a document titled, Nursing Wound Observation Tool, dated [DATE] (signed on [DATE]), showed Resident 1 was found with a Stage 2 PU on their right ischial tuberosity [area] with granulation tissue [granulation tissue does not present in Stage 2 PU/PI]). The assessment showed that the right ischial tuberosity wound had drainage with signs and symptoms of infection. Review of the facility's document titled, Weekly Skin Integrity Data Collection, dated [DATE] (signed on [DATE]), showed Resident 1 had an open area/wound on their right buttock measuring 5.0 centimeters (cm - unit of measurement) x 5.0 cm x 0.1 cm with surrounding redness and moisture associated skin damage (MASD). Review of the facility's document titled, Weekly Skin Integrity Data Collection, dated and signed on [DATE], showed Resident 1 was found with new multiple open wounds on the following areas: 1) Coccyx (tailbone) area measuring 3.0 cm x 3.0 cm. 2) Right trochanter (hip) area 18.0 cm x 8.0 cm and the wound was open and leaking. 3) Right thigh (rear) dry scabbed wound measuring 1.5 cm x 1.0 cm. Review of the nursing progress note dated [DATE], showed Resident 1 was sent to the hospital for evaluation and treatment. Review of the hospital Emergency Department (ED) note dated [DATE], showed Resident 1 was transferred to the ED due to worsening decubitus ulcers [PU/PIs]. The note also showed Resident 1 had some altered mentation at the time of transfer and leukocytosis (high white blood cell count, which indicates infection). Review of the facility's document titled, Incident summary [Skin Related Injury], dated [DATE], showed Resident 1's right ischial tuberosity skin injury was related to the resident's incontinence, abnormal posture, wheelchair dependence, restlessness, and agitation. The investigation showed Resident 1 was refusing wound dressing changes as well as antibiotic medication. Further review of the [DATE] MAR showed no documentation to support Resident 1 refused their antibiotic medication. Review of Resident 1's [DATE] Treatment Administration Record, and progress notes from [DATE] to [DATE], showed no documentation to support wound dressing changes were refused other than refused brief changes. Review of the hospital record dated [DATE], showed Resident 1 had significant right buttock PU wound that had tunneling (or a tunnel from the wound edge or deep within the fat tissue, which happens when the wound remains inflamed or the wound is not healing well) with purulent drainage (liquid discharges coming from wound), cellulitis (bacterial infection of the skin), Methicillin-Susceptible Staphylococcus Aureus (MSSA - an infection caused by a type of bacteria commonly found on the skin) and bacteremia. On [DATE] at 1:30 PM, Resident 1's collateral contact (CC1) stated that they were notified about the resident's buttock wound on [DATE] and that the resident never had a skin issue on their buttocks. CC1 also stated that the facility did not notify them that Resident 1 was refusing skin assessment. Review of a death certificate issued on [DATE], showed Resident 1 died on [DATE] and the cause of death was Methicillin Resistant Staphylococcus Aureus (an infection caused by a type of bacteria commonly found on the skin) bacteremia and infected PI of the deep tissue of right buttocks. In an interview on [DATE] at 10:07 AM, Staff D, Registered Nurse, stated the Resident Care Managers (RCMs) were responsible for doing skin assessments. When asked if Resident 1 has had PU, Staff D stated that the resident had no PU. During an interview and joint record review on [DATE] at 11:10 AM, Staff C, RCM, stated that nurses were responsible for weekly skin assessment. Staff C stated that when they assessed Resident 1's skin on [DATE], they observed that the resident had Stage 2 PU on their left side buttock. The joint record review of Resident 1's medical record with Staff C showed the following: - Scored 11 on Braden scale assessment on [DATE]. - Had intact skin on [DATE]. - With wound infection noted on [DATE] [48 hours after the previous skin assessment]. - Stage 2 pressure ulcer measuring 5.0 cm X 5.0 cm X 0.1 cm with drainage and sign and symptom of infection on [DATE] [24 hours after previous skin assessment]. - An antibiotic treatment started on [DATE] [48 hours after Resident 1 was noted with wound infection]. - Additional multiple wounds noted with a right trochanter wound measuring 18.0 cm X 8.0 cm on [DATE] [48 hours after the previous wound assessment]. Staff C stated that Resident 1's wound worsened within a few days. When asked why Resident 1 was not started on antibiotic treatment for wound infections when it was identified on [DATE], Staff C stated that the physician's note date was incorrect. When asked about Resident 1's high risk for PU, Staff C stated that when a resident was assessed as high risk for PU with Braden assessment, turning/repositioning, frequent brief change, nutritional assessment, and nutritional support would be implemented. Staff C further stated that air mattress would be implemented only for residents with history of pressure ulcer or if they had pressure ulcer. When asked if Resident 1 had a diagnosis and/or care plan for terminal illness, Staff C stated that Resident 1 did not have a diagnosis of terminal illness other than the resident's advance directive was comfort measures only. On [DATE] at 1:05 PM, Staff B, Director of Nursing, stated that they would expect nurses to complete a full body assessment and if a resident identified as a high risk for skin breakdown, the resident would be placed on frequent brief changes, on air mattress and therapy referral would be sent. When asked about air mattress use for Resident 1, Staff B was unable to provide documentation to support an air mattress was provided for Resident 1. Staff B also stated that they believed Resident 1's skin assessment on [DATE] was accurate and that Resident 1 acquired all the wounds within 72 hours period. Staff B further stated that when a resident was assessed with wound infection, antibiotic treatment would start right away. When asked why Resident 1's antibiotic treatment did not start on [DATE], Staff B stated that the date of the physician note was wrong and acknowledged that the antibiotic treatment for wound infection was started on [DATE]. Reference: (WAC) [DATE] (3)(b)

Based on record review and interview, the facility failed to ensure professional standards of practice were followed for 2 of 9 residents (Resident 39 & 146) reviewed for removal of Coban dressing (self-adherent elastic wrap, used to secure dressings, compress, or protect wound sites), weekly skin assessment, and conducting neurological/neuro checks (an assessment to monitor level of consciousness, movement of the eye, facial symmetry, motor assessment of the arms/legs) after an unwitnessed fall. These failures caused harm to Resident 39 who was sent to the hospital due to a laceration/skin tear that was profusely bleeding after a staff used sharp scissors to cut the Coban dressing from the resident's left leg resulting in five sutures to close the lacerations, and the failure to complete a thorough/complete skin assessment placed the other resident at risk for delayed identification of skin issues/treatments, harm, and a diminished quality of life. Findings included . RESIDENT 39 Review of Resident 39's face sheet, located in the electronic medical record, showed Resident 39 admitted to the facility on [DATE] with diagnoses that included heart failure, atrial fibrillation (A-fib, irregular heartbeat that increases risk of blood clots), diabetes, and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that is usually drains through the body's lymphatic system). Review of Resident 39's physician's orders showed the following: -Eliquis (an anticoagulant-a blood thinner medicine that reduces blood clotting) 5 milligrams (mg), start date 02/05/2023, two times a day for A-fib. -Coban dressing, start date 12/28/2022, applied to both lower legs for lymphedema. Review of Resident 39's care plan, initiated on 06/01/2021, showed Resident 39 has potential to skin integrity of [lower extremities related to] fragile skin due to lymphedema. Review of Resident 39's progress notes showed the following: -On 03/24/2023 at 11:40 AM, Resident 39 was preparing for a shower when Staff G, Registered Nurse, was asked to remove a Coban dressing from the left inner lower leg. Staff G used sharp scissors to remove the dressing instead of bandage scissors (scissors designed with a blunt tip to protect the skin from injury) and cut Resident 39's leg. After active and profuse bleeding due to the resident taking Eliquis, Resident 39 had to be taken to the hospital where five sutures were used to close the laceration. -On 03/27/2023, the dressing was intact, dry, and resident had no pain. There was increased edema present due to the Coban dressing on hold. An interview with Staff B, the Director of Nursing, on 05/02/2023 at 4:29 PM, showed Staff G used regular scissors, not bandage scissors to remove a Coban dressing. Staff B stated, I do not know how you use sharp scissors to remove a bandage. [Staff G] told me that she was in a hurry accidentally caused a skin tear. A verbal reprimand was given to [Staff G] along with and educational training. In an interview on 05/04/2023 at 12:29 PM, Staff G stated, I was asked to remove [R39's] Coban dressing so the aide could shower the resident. [R39] would not go back to bed, and I had to cut the bandage off while she was in her wheelchair. I used regular scissors that I had in my pocket, and I have used them several times to remove a bandage. The cut was superficial and started to bleed immediately. I bandaged it several times, but it would not stop bleeding. That evening when it continued to bleed, the resident went out to the hospital. When asked why she did not use bandage scissors, she replied, I did not have any with me. I think it was just the position of her leg not being out straight that caused the scissors to tear the skin. [R39's] skin is thin due to the edema. In an Interview on 05/04/2023 at 1:22 PM, Staff A, Administrator stated, Corrective action was taken, education provided, and a skill check was completed for [Staff G]. She knows better. 46829 RESIDENT 146 SKIN ASSESSMENT Review of the facility's policy titled, Documentation & Assessment of Wounds, revised in March 2023, showed the facility must ensure residents received treatment and care in accordance with professional standards of practice. Resident 146 admitted to the facility on [DATE] with a diagnosis that included heart disease. Review of Resident 146's physician's orders showed the following: - Rivaroxaban (an anticoagulant) 15 mg in the evening. Start date 04/07/2023. - Anticoagulant side effects: Monitor for side effects such as, but not limited to, large areas of bruising, prolonged bleeding, even in small cuts; nosebleeds, headache . Start date 04/08/2023. - Multiple dark bruises on arms/hands with largest (about 6-centimeter (cm) x 4 cm) on left forearm - Monitor until resolved. Start date 04/08/2023. Review of Resident 146's skin assessment at the time of admitted d 04/07/2023 showed, Multiple dark bruises on her arms/hands with largest (about 6 cm x 4 cm) on left forearm. Review of Resident 146's shower report form, completed by the shower aide on 04/17/2023, showed the resident had bruises all over the body-tiny spots and greenish bruise marked behind the resident's neck. Review of Resident 146's progress notes, dated 04/17/2023, and the physician's order summary, dated 05/03/2023, showed that nursing had not been notified of the identification of bruises, no monitoring or assessment of the new identified bruise behind the resident's neck and/or bruises all over the resident's body documented by the shower aid on 04/17/2023. Review of Resident 146's weekly skin assessment showed no skin assessment was completed during the week of 04/09/2023 to 04/15/2023. Further review showed that the next weekly skin assessment completed on 04/21/2023, showed, large, scattered bruises to bilateral [both] upper extremities, bilateral lower extremities. Small, scattered bruises to abdomen and back. Further review of Resident 146's progress note, dated 04/21/2023 at 11:34 PM showed, the resident had scattered bruising to bilateral lower extremities, bilateral lower extremities, chest and back. Review of the Reporting Log for April 2023 showed, Resident 146 had two falls on 04/17/2023 with type of injury indicated as none, one fall on 04/21/2023 with type of injury indicated as none, and one allegation of neglect on 4/22/2023. According to the Reporting log Resident 146 had no injury related to skin. On 05/03/2023 at 11:44 AM, Staff E, Unit Care Coordinator (UCC), stated that nursing completed the weekly skin checks and when they identified a new bruise, nursing would measure it, document in the progress notes and the UCC would follow up for treatment and monitoring. When asked about skin assessment, Staff E stated they should have done a skin assessment during Resident 146's second week at the facility and that there was no measurement or description of color for the new identified bruises. On 05/03/2023 at 1:15 PM, Staff B, Director of Nursing, stated that the shower aids gave the shower report form to the administrator and then the administrator notified nursing. Staff B stated that there was no follow up from nursing for Resident 146's newly identified bruises. NEURO CHECKS Review of Resident 146's unwitnessed fall incident report, dated 04/21/2023, showed the aide helped resident to the bathroom and then left to help another resident . resident lying on the floor with her right arm resting on arm of chair. Bathroom call button on. Pain in her right arm and difficulty raising it up. Further review showed that vital signs and the speech assessment, used for neuro checks, were not completed as required for the first 15 minutes, second 15 minutes, third 15 minutes and first 30 minutes. On 05/03/2023 at 12:09 PM, Staff E stated that they expected nursing to fill out all the requirements for the neuro checks such as vital sign and/or the required assessments. Staff E stated that Resident 146's vital signs and speech assessment were not completed for the first 15 minutes, second 15 minutes, third 15 minutes and first 30 minutes. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to prevent physical abuse for 1 of 5 residents (Resident 1) reviewed for abuse and neglect. This failure caused harm to Resident 1 who sustained physical injuries, pain, and psychosocial harm in the form of fear and feeling unsafe at the facility. Findings included . Resident 1 was a long-term care resident at the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had impaired cognition and needed two-person extensive assistance for bed mobility and two-person total staff dependence with transfer. A review of the facility's incident reporting log for the month of May 2022 showed Resident 1 was involved in a resident-to-resident altercation with another resident (Resident 2) on 05/23/2022. The incident report log showed that the incident had resulted to a substantial injury (bruise of deep color/depth) to Resident 1. On 06/09/2022 at 9:30 AM, Resident 1 was observed with multiple, scattered yellowish healing bruise on his left forearm. The biggest bruise was measuring approximately 12 centimeters (cm) long and about 6 cm wide. Resident 1 stated that someone punched and hit him but the resident was not able to recall who and when did the incident happened. Resident 1 also stated he did not feel safe in the facility because of the incident and that the incident keeps him up at night. Resident 1 further stated, he felt helpless because he cannot protect himself if the person returns and decide to assault him again in bed. Resident 1 complained of moderate pain (5/10 scale) to his left forearm during the interview and stated that his pain was getting better but it still hurts sometimes. A review of the facility incident investigation report dated 05/27/2022 showed that the incident between Resident 1 and Resident 2 was witnessed by another resident (Resident 3). The incident report showed that Resident 3 was heard calling for help and saying, there's a fist fight going on here! The incident report showed Staff C, Registered Nurse (RN) was the initial responder and was the one that separated and assessed both residents for any injuries. A review of the written statement provided by Staff C, dated 05/23/2022 showed Resident 1 was yelling for staff to help him empty his urinal and that's when Resident 2 came to his room and asked him do you want me to dump it on your face? The statement showed that this encounter made Resident 1 upset, and this was when the physical altercation started. On 06/09/2022 at 9:45 AM, Resident 2 stated he could not recall any physical altercation between any residents of the facility. However, Resident 2 stated he could recall (no specific details) that there was a loud resident yelling and calling for help across his room that made him upset because he kept yelling all night and that it was very hard for him to sleep. On 06/09/2022 at 10:00 AM, Resident 3 stated she witnessed the incident between Resident 1 and Resident 2 on 05/23/2022. Resident 3 stated that she heard Resident 1 calling for staff to help him empty his urinal for quite a while but there was no staff member around to help and assist him. Resident 3 stated that Resident 1 also upsets her because Resident 1 was very loud and was calling staff for help for a long time but no one responded. According to Resident 3, this was when she saw Resident 2 entered Resident 1's room and asked him what do you need? Resident 3 stated Resident 1 told Resident 2 that he needed help emptying his urinal, but instead of helping Resident 1, Resident 2 responded do you want me to dump it on your face? Resident 3 stated that this response from Resident 2 made Resident 1 upset and told Resident 2 to get out but Resident 2 started punching and swinging towards Resident 1 and that was when they had a fist fight. (See also F689 - Accident Hazards/Supervision/Devices for more information). A review of Resident 3's clinical records and MDS assessment dated [DATE] showed that the resident was alert and oriented to self, place and time and had intact cognition. On 06/09/2022 at 10:30 AM, during a joint interview with both Staff A, Administrator and Staff B, Director of Nursing, they were present when Resident 3 reiterated and stated that Resident 1 and Resident 2 had a fist fight on 05/23/2022. Resident 3 told both Staff A and Staff B that Resident 2 entered Resident 1's room and confronted Resident 1 that resulted in a physical altercation between residents. A review of Resident 1's clinical records and skin assessment dated [DATE] showed Resident 1 sustained multiple clustered dark purplish bruises on his left forearm that measured 14.5 cm in length and 7.0 cm wide. Reference: (WAC) 388-97-0640 (1)

Based on interview and record review, the facility failed to monitor and evaluate the increased risk for skin breakdown, evaluate the effectiveness of current treatment plan, follow written policy and procedures, and implement physician orders/timely interventions necessary to prevent development or worsening of pressure ulcers for 1 of 3 residents (Resident 1) reviewed for pressure ulcers/pressure injury (PU/PI). These failures caused harm to Resident 1 whose identified pressure ulcers had worsened and who had developed additional pressure ulcers while at the facility. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by nutrition, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] (redness) of intact skin ( which means the redness does not go away when press on the area). Intact skin with a localized area of non-blanchable redness, which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] (means the redness goes away and then comes back right away, showing blood flow is not prohibited) or changes in sensation, temperature, or firmness may precede visual changes. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis (middle layer of skin). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar (dead tissue) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia (tissue surrounding muscle), muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Rolled edges, undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. A review of the facility policy titled, Skin Integrity and Pressure Ulcer/Injury Prevention and Management dated [DATE], reviewed and/or revised on [DATE], showed the facility will provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing profession standards of the NPUAP and WOCN (Wound, Ostomy, Continence Nurses Society). The policy directed the facility staff to: A.3. A skin assessment should be performed weekly by a licensed nurse. B. Complete a standardized risk assessment tool to assess a resident's PU/PI risks on admission, weekly for the first four weeks after admission, then monthly or whenever there was a change in the resident's condition. A review of the facility policy titled, Documentation & Assessment of Wounds, dated [DATE], reviewed and/or revised on [DATE], showed the purpose of the policy was to guide the associates and licensed nurse in the assessment of wounds to include pressure ulcer/injuries . The policy directed the facility staff to: A.1. A wound assessment/documentation is required to occur at a minimum of weekly. Nurses performing the treatment would perform a prn (as needed) assessment/documentation if noted changes has occurred i.e. (example) wound has healed/resolved, appears infected, or appears or have declined. B.2. Documentation is located in the HER (electronic health records) - progress notes, Wound Observation Tool (WOT), and/or Skin Integrity Data Collection Tools. Additional documentation from MD (Medical Doctor) office visits or wound clinic notes may be located in the hard copy medical records. Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility with two Unstageable PU/PI on the left buttock and left UPPER buttock areas. A review of the admission assessment and WOT, dated [DATE], documented 2 pressure ulcers: 1. Left buttock pressure ulcer with full thick tissue loss, which measured 3 centimeter (cm) in length, 1.5 cm wide and 0.2 cm in depth. 2. Left Upper buttock pressure ulcer with full thick tissue loss which measured 2 cm in length, 1 cm wide and 0.2 cm in depth. A review of Resident 1's care plan, dated [DATE], showed that Resident 1 admitted with open pressure ulcers to her left buttock area. The care plan directed facility staff to monitor for signs and symptoms of infection and notify the doctor accordingly, and to conduct a weekly skin check. A review of the Resident 1's admission Minimum Data Set (MDS) assessment, dated [DATE], showed the resident had severe cognitive impairment and required two person extensive assistance from staff with bed mobility and transfers. The MDS also indicated the resident had no condition or chronic disease that may result in a life expectancy of less than 6 months. A review of the physician note, dated [DATE] and revised on [DATE], showed the resident had no other skin issues and to refer to the nurses notes for more information. The physician's plan of care documented, This patient is at risk for pressure ulcerations due to weakened condition and injury decreased ability for self-repositioning. A review of a nursing progress note written by Staff A, Licensed Practical Nurse, dated [DATE], showed that on [DATE] at 10:00 PM, Resident 1 started to show a sudden change and decline in condition. The progress note showed that at 10:30 PM, the resident's blood pressure was ,d+[DATE] (normal blood pressure range is ,d+[DATE]), had an irregular pulse of 110, labored respirations of 30 per minute (normal is 12 to 16 breaths per minute), and temperature of 98.0 degrees Fahrenheit (F). Staff A documented that Resident 1 was not responsive with verbal or tactile (touch) stimulation except for low intermittent moaning. The staff notified the physician of Resident 1's condition and received an order to transport the resident to the emergency department for further evaluation and treatment. The resident left the facility at 11:45 PM. A review of the Emergency Department notes, dated [DATE] at 12:08 AM, showed the resident was admitted to the hospital on [DATE] at 11:51 PM. The Admitting/ER physician's physical examination regarding the resident's skin condition showed the resident has 3 decubitus ulcers (pressure ulcers). Wound over her right hip area that is about 2 x 2 centimeter (2 cm length and 3 cm wide) with some purulent discharge and surrounding skin [CONDITION(S)] (redness). She has another ulcer right over her sacral area with some purulent discharge and surrounding [CONDITION(S)] and a smaller one right above there. In addition, patient has lucency (pale area) to her skin on her left hip area. The plan of care showed, patient has multiple pressure ulcers over her sacrum, as well as over her hip areas upon the bony prominences. Unfortunately the area? surrounding the wound looked infected. Likely also playing a part in her [CONDITION(S)] (blood infection) physiology (origin). Wound care to see (wound specialist referral); might need debridement (surgical removal of dead tissue/skin), antibiotics as outlined . Further review of hospital records showed the resident was admitted to the hospital with multiple wounds all POA (present on admission), and all suspected to be pressure injuries. The notes indicated the hospital staff was concerned about neglect. The hospital notes documented the following wounds on admission: A. Coccyx full thickness wound, suspected pressure injury. B. Right Sacrum 2 areas, full thickness wounds suspected pressure injury. C. Right Iliac crest (hip) full thickness wound, suspected pressure injury. D. Left iliac crest (hip) full thickness wound, suspected pressure injury. E. Right Rib Cage - full thickness wound, suspected pressure injury. F. Right Elbow - Pressure Injury stage 1 G. Right Heel - Pressure Injury stage 1 H. Left elbow and left heel - blanchable redness over bony prominences. A review of Resident 1's clinical records from admission [DATE] to [DATE] (2 days after discharge) showed the following: A. The facility did not conduct a weekly skin assessment and weekly wound assessment as directed by facility policy and care plan. The only documented head to skin assessment and wound assessment was completed and dated [DATE]. A head to toe skin assessment and wound observation was due on [DATE], but was not done. There was no documented head to toe skin assessment done prior to the resident's hospital transfer on [DATE]. B. The facility did not implement a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence that the facility had implemented the order, set up an appointment or that the resident was seen by a wound care specialist while at the facility. C. The facility did not implement their written policy related to conducting a standardized assessment tool for predicting pressure sore risk (Braden) weekly after admission. The only documented Braden risk assessment was dated [DATE], which indicated the resident being a high risk for skin breakdown. A Braden risk assessment was due, but not completed on [DATE]. A review of the Medication and Treatment Administration Record for [DATE] (MAR/TAR) showed Resident 1 received wound care and dressing changes to both the left buttock and left upper buttock area every 3 days on [DATE], [DATE] and [DATE] (evening shift). Additional skin interventions were listed on the MAR/TAR, included elevate heels when in bed and to reposition Resident 1 at least 3 - 4 times every shift to help prevent skin breakdown. There was no documented evidence that the facility had thoroughly re-assessed Resident 1's wounds since admission, and evaluated the current treatments/interventions for effectiveness and whether the current treatments/interventions were still appropriate for the resident. On [DATE] at 12:30 PM, Staff G, Registered Nurse stated that she remembered caring for Resident 1 in the past. Staff G stated that she recalled changing Resident 1's wound dressing, even though it was not scheduled on her shift, because it fell off. Staff G also stated that Resident 1 had two wounds on her buttocks, but she really could not recall how the wound(s) looked, how big or how it looked before, and couldn't recall whether Resident #1 had any other wound(s). Staff G said that she did not perform a comprehensive assessment of the 2 wound(s) and she did not perform a head to toe skin assessment on Resident 1. Staff G stated that she did not document anything related to wound care for Resident 1. Staff G said she was not sure when she changed the dressing, Could be on the 6th or 7th, maybe the 8th of April, I wasn't sure. Staff G stated that Resident 1 was on a regular mattress [not an air mattress, low air loss or specialty mattress]. During an interview and record review on [DATE] at 12:35 PM, Staff H, Licensed Practical Nurse/Resident Care Manager stated that he was familiar with Resident 1's care and condition. Staff H stated that he knew Resident 1 had two pressure ulcers on her left buttock area and was not aware of any other wounds. Staff H also stated that the clinical records did not show a completed weekly skin check or wound assessment or a weekly Braden Risk assessment [after the admission assessment], and did not show that a wound consult/wound specialist visit was done for Resident 1. Staff H said that he was not sure why these assessments were not done and why Resident 1 did not see a wound care specialist. Staff H stated that he did not perform any type of skin assessment (including a head to toe and wound care assessments) on Resident 1. On [DATE] at 12:45 PM, Staff F, Staffing Coordinator/Nursing Assistant stated that he had not been assigned to provide care for Resident 1, but he remembered recording vital signs for the resident. Staff F also stated, it was Staff C who had been the aide for Resident 1 and he was not sure about the resident's condition. Staff F further stated that he did not check the resident's skin or provided any direct resident care (personal hygiene/pericare) to Resident 1. In an interview and joint record review on [DATE] at 1:00 PM with both Staff Y, Assistant Administrator and Staff Z, Regional Nurse Consultant, Staff Z stated that there was no weekly skin check or wound assessment completed, no weekly Braden Risk assessment, and no wound consult/wound specialist visit done for Resident 1. Staff Z also stated that there was no documented evidence in the records that the facility had re-assessed Resident 1's wounds since admission to the facility, reassessed current interventions for effectiveness, indicated how the resident was responding to current treatment and interventions or whether the current treatment/interventions were still appropriate for the resident. In a phone interview on [DATE] at 1:30 PM, the resident's family member/POA (power of attorney) stated that she was only aware of the two wounds on Resident 1's left buttock area that developed while at a previous nursing facility. During a phone interview on [DATE] at 3:20 PM, Hospital Nurse #1 (HN1) stated they were concerned about Resident 1's condition when she first came to the emergency room . HN1 stated that Resident 1 admitted with multiple pressure ulcers that were not treated or recorded on the [facility's] medical record. HN1 also stated, the wounds were so bad and was infected at the time of admission. HN1 stated that the wounds that were present on hospital admission included the following: Coccyx full thickness wound, suspected pressure injury; Right Sacrum 2 areas, full thickness wounds suspected pressure injury; Right Iliac crest full thickness wound, suspected pressure injury; Left iliac crest full thickness wound, suspected pressure injury; Right Rib Cage - full thickness wound, suspected pressure injury; Right Elbow - Pressure Injury stage 1, Right Heel - Pressure Injury stage 1, and Left elbow and left heel - blanchable redness over bony prominences. According to HN1, the hospital initially thought Resident #1 was on hospice care/end of life care because of how many wounds and how bad they were when we first saw her. During a phone interview on [DATE] at 5:00 PM, Hospital Nurse #2 (HN2) stated that Resident 1 admitted to the hospital with multiple pressure ulcers. HN2 stated they had filed a report because they were concerned about the lack of care and intervention received by Resident #1 while at the facility. During a phone interview on [DATE] at 2:10 PM, the Physician/Medical Director (MD) stated that he was not notified and was not aware of any changes in condition to Resident 1 until just before Resident 1 was transferred to the hospital on [DATE]. The MD stated he was not notified the resident was refusing to eat or drink at any given time, and he was not aware nor notified of any new wounds or pressure ulcers while the resident was at the facility. According to the MD, the facility should have assessed the resident's skin and wound weekly, and he was not sure why it wasn't done and why the resident did not see a wound specialist. ADDITIONAL STAFF INTERVIEWS AND RECORD REVIEW During a phone interview on [DATE] at 9:12 AM with Staff J, RN stated that she did not do a head to toe skin check and did not complete a comprehensive wound assessment for Resident 1. Staff J could not recall Resident 1 or her skin condition. During a phone interview on [DATE] at 9:25 AM, Staff I, RN stated that he remembered changing the resident's dressings at least once (could not recall when), and said that he did not perform a comprehensive assessment of the wound(s) and a head to toe assessment. Staff I further stated he did not measure the wound(s) and did not document any other information on the clinical records related to the resident's skin condition at the time of the dressing change(s). During a phone interview on [DATE] at [DATE] at 9:31 AM, Staff A Licensed Practical Nurse (LPN) stated he remembered the resident's wound on her left buttock area (two areas) which were present on admit. Staff A also stated that he was the nurse on duty when the resident was transferred to the hospital. Staff A said that he had no idea what the resident's current skin condition was when the resident left the facility and he did not perform any type of skin check at the time of transfer or during his shift. A phone interview was attempted twice for Staff D, Licensed Practical Nurse (LPN) on [DATE] at 9:39 AM and on [DATE] at 2:30 PM with no return call. A written statement from Staff D was provided by Staff X, Director of Nursing on [DATE] at 10:00 AM. The written statement from Staff D, dated [DATE], showed I believe I only worked with her on one occasion, but I didn't remember what I did for her. During a phone interview on [DATE] at 11:50 AM, Staff C, Nursing Assistant Certified stated that she worked with the resident on [DATE] morning shift. Staff C stated that the resident was not looking good during her shift, was not very responsive, and did not eat or drink during breakfast and lunch. Staff C stated that she reported her concerns to the nurse on duty but the nurse was very busy. According to Staff C, she provided a sponge bath to the resident by washing her face and providing peri (personal hygiene) care. Staff C stated she could not recall the resident's skin condition when she provided the care but she did not perform a skin assessment and did not check the wound condition of Resident 1. Staff C stated that Resident 1 was on a regular mattress (not an air mattress, low air loss or specialty mattress). A review of the facility's incident investigation report dated [DATE] showed the facility had interviewed the licensed nurses and nursing assistants that could have possibly cared for Resident 1 from [DATE] to [DATE]. The incident investigation showed no documented evidence that a facility staff monitored and evaluated Resident 1's skin and wound condition since admission to the facility. The investigation also showed that the facility did not follow written policy and procedures related to skin and pressure ulcer management related to the required weekly skin and wound/risk assessment, and did not develop and implement physician orders timely to prevent worsening and the development of pressure ulcers for Resident 1. During a joint interview on [DATE] at 10:00 AM, Staff Y, Assistant Administrator (AA), Staff Z, Regional Nurse Consultant (RNC) and Staff X, Director of Nursing (DNS), Staff X stated, there was no weekly skin check or wound reassessment completed, no weekly Braden Risk reassessment and no wound consult/wound specialist visit was done for Resident 1. Staff X also stated that there was no evidence the facility had reassessed Resident 1's wound since admission to the facility, no documented evidence that the current intervention was reassessed for effectiveness, no documented evidence if the current treatment/intervention were still appropriate for the resident, and no documented evidence on how the resident was responding to current treatment and interventions including any documentation about a sudden change of condition. Resident 1 expired on [DATE]. Reference: (WAC) [DATE] (3)(b)

Based on interviews and record reviews the facility failed to take appropriate additional actions related to a respiratory illness outbreak. Moreover the facility failed to take prompt steps in reporting the concern to the Department of Health, State and local authorities. These failed practices may have contributed to multiple residents and staff contracting respiratory like illnesses. The facility was aware of eight residents with symptoms of respiratory illness and/pneumonia by [DATE] but failed to contact the Department of Health to request further guidance and assistance until [DATE]. On [DATE], the facility was asked to provide a census from February 1, 2020. The facility provided a census of 120 residents. As of [DATE], based upon the facility hospitalization tracking form, 54 residents were transferred to the hospital with respiratory like symptoms, 19 residents tested positive for Coronavirus disease (COVID-19) with several pending lab results, and 14 residents expired (#118, #119, #120, #121, #122, #123, #124, #125, #126, #127, #128, #129, #130, #131). The total sample size was 54. In addition several residents expired within the facility and the status of those residents are pending. Additionally the facility failed to operationalize their infection prevention and control program to provide a safe, sanitary and to help prevent the development and transmission of communicable diseases and infections. Refer to example #2 below. Findings include: 1). During a record review on [DATE] of the infection control surveillance program the records reflect that from [DATE] to [DATE] fourteen Facility Acquired Infections of Pneumonia and Lower Respiratory cases occurred at the facility. The Department of Health, State and Local authorities were not notified until [DATE]. In addition the facility hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE]. It reflects that 54 residents had changes in condition (such as changes in vital signs, mental status changes, agitation, respiratory distress) and 54 residents were sent to multiple hospitals, 19 residents were tested positive for COVID-19 and 14 residents died . The hospitalization Tracking Form does not reflect the date or location of COVID-19 testing. On [DATE] at 3:15 PM the Executive Director clarified that the hospitalization Tracking Form was being updated daily by the facility when they recieve the updates from the hospital. Continued Record Review on [DATE] of the hospitalization Tracking Form and Electronic Health Record reveals: 1). Resident #118 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was transferred to the hospital on [DATE] with shortness of breath. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19 and expired on [DATE]. 2) Resident #119 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was transferred to the hospital on [DATE] with weakness and confusion. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive with COVID-19, and expired. The last medical provider evaluation was dated [DATE]. 3) Resident #120 admitted to facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was transferred to the hospital on [DATE] with respiratory distress. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19, and expired. The last medical provider evaluation was dated -[DATE]. 4) Resident # 121 admitted to facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was transferred to the hospital on [DATE] with an elevated temperature. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19 and expired [DATE]. 5). Resident # 122 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was transferred to the hospital on [DATE] with Pleural effusion. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive with COVID-19, and expired on [DATE]. 6). Resident #123 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility infection control report for [DATE] identified that resident acquired a respiratory infection Pneumonia. Resident was transferred to the hospital on [DATE] with increase respiratory rate, clammy. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19, and expired on [DATE]. 7). Resident #124 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was transferred to the hospital on [DATE] with shortness of breath. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19 and expired on [DATE]. 8). Resident #125 admitted to facility on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was transferred to the hospital on [DATE] with respiratory distress. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19 and expired on [DATE]. 9). Resident #126 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was transferred to the hospital on [DATE] increase confusion. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive with COVID-19 and expired on [DATE]. 10). Resident #127 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was transferred to the hospital on [DATE] with respiratory distress. Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive with COVID-19 and expired on [DATE]. 11). Resident #128 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19 and expired on [DATE]. 12). Resident #129 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident tested positive for COVID-19 and expired on [DATE]. 13). Resident #130 admitted to facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated that later the resident test for COVID-19 with pending results and expired on [DATE]. 14). Resident #131 admitted to facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospitalization Tracking Form Transfer since ,d+[DATE] reflects transfers from [DATE] - [DATE] indicated resident expired on [DATE]. The last medical provider evaluation was dated [DATE]. During an interview on [DATE] at 12:35 PM with the IP Nurse she acknowledged having concerns and seeing a cluster with respiratory infections occurring in the facility on approximately [DATE] and had a discussion with MP1. The IP Nurse stated I did not consider calling the Department of Health because it was Flu season and the residents at the facility commonly have Pneumonia. The residents were being treated with antibiotics by the medical providers and being tested for Rapid Flu . Additionally she communicated the respiratory infection concerns with the facility leadership on [DATE]. During further interview, she denied being instructed or directed by anyone to contact the Department of Health prior to [DATE]. She also confirmed having concerns about the respiratory infections, but did not considered reviewing the facility policy in regard to outbreaks. She confirmed that the Director of Nursing (DON) was the person providing oversight for the Infection Control Program (ICP) and served as the back-up person for the IP Nurse. The former DON was not available for an interview. On [DATE] near 3:00 PM during the interview with Medical Provider 1 (MP1) she acknowledged seeing an unusual occurrence of a respiratory illness occurring within the facility starting near [DATE]. On or near that date ([DATE]) three additional facility residents had pneumonia, cough and fever. She further indicated Medical Provider 2 (MP2), the supervisor of MP1, and the Infection Preventionist (IP) Nurse were informed of her suspicions and advised IP Nurse to call the Department of Health. MP1 also communicated with professional colleagues regarding any atypical (not normal) illnesses that they may be seeing or treating in the community; no atypical illnesses had been identified. MP1 explained having another discussion with the IP Nurse in regards to the atypical respiratory illness. By or near [DATE] six more residents were having respiratory illness symptoms. MP1 indicated she had been consulting with MP2 on a case by case basis regarding residents that may be having issues or concerns. During further interview on [DATE] it was revealed that on [DATE] during a collaborative discussion with the MP2, the IP Nurse and Leadership the facility finally decided that the Department of Health needed to be notified. COVID-19 testing was initiated on [DATE] and facility admissions were stopped. On [DATE] near 11:30 PM the facility was informed the test results were positive for COVID-19. On [DATE] at 2:30 PM during an interview with Medical Provider 2 it was validated that he was the primary care provider for greater than nighty percent of the residents at the facility and that he was also the Medical Director. He concurred with all the interview comments shared by MP1. He further validated there was an atypical respiratory illness occurring within the facility, that he was in agreement with the notification to the Department of Health and the last time he was on site was [DATE]. During an interview on [DATE] at 3:15 PM the Executive Director (ED) validated that MP2 was the primary care provider of greater than 90% of the facility residents and that he was also the Medical Director for the facility. The Executive Director confirmed that she was not informed of any respiratory infections concerns within the facility until [DATE]. She further explained that on [DATE] the MP1, MP2 and IP Nurse discussed calling the Department of Health, which was done by the IP Nurse. The ED clarified that the hospitalization Tracking Form was being updated daily by the facility when they recieve the updates from the hospital. Review of facility policy on [DATE] titled Infection Prevention and Control Program (IPCP) and Plan - Outbreak Control and Management last revised on [DATE] and it revealed: Purpose Outbreak surveillance and controls should be considered a high priority of Infection Prevention and Control. (IPC). An outbreak is an occurrence of more cases than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. For example: Policy If an outbreak is identified, the facility must: Take the appropriate steps to diagnose and manage cases, implement appropriate precautions, and prevent further transmission of the disease as well as documentation of follow-up activities in response; and comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. The approach of investigating an outbreak includes but is not limited to: Determining if an outbreak has occurred Developing a case definition Case finding Analyzing the outbreak Formulating a hypothesis regarding the mechanism of transmission Designating control measures Evaluating control measures During a record review on [DATE] of the facility Quality Assurance & Performance Improvement (QAPI) monthly meeting minute it reveals that the facility conducted a meeting on [DATE] and the IP Nurse attended the meeting, but the Medical Director or representative was not in attendance. Additionally no infection control issues or concerns were discussed. On [DATE] another QAPI meeting was conducted the IP nurse nor the Medical Director or was not in attendance. Further review of the QAPI meeting agenda does not include any discussions of the Facility Acquired Infections in relations to the eight Pneumonia and Lower respiratory concerns. 2). On [DATE] near 1:00 PM multiple interviews and observations occurred within the facility. Those being observed or interviewed were direct care facility staff, other assisting staff and ancillary housekeeping/laundry staff. Random separate interviews occurred with 3 facility Certified Nursing Assistants (CNA) and 1 Federal agency staff. a). Facility CNA1 reported he had worked for the facility for approximately [AGE] years. He stated that if he need to clean/sanitize any item that he would use the Sani-Cloth Bleach disinfecting wipes. When questioned if he had received training on the use of the Sani-Cloth Bleach wipes he stated NO. When questioned regarding the amount of time the item being cleaned needed to remain wet for the sanitizing properties to be effective he stated I don 't know. b). Facility CNA2 reported she had worked for the facility for the past 4 years. She stated if she had to clean or disinfect any item she would use the Sani-Cloth Bleach disinfecting wipes. When questioned if she had received training on the use of the Sani-Cloth Bleach wipes she stated NO. When questioned regarding the amount of time the item being cleaned needed to remain wet for the sanitizing properties to be effective she I am not sure. c). Agency staff 2 was interviewed on that same dated regarding the use of the Sani-Cloth Bleach wipes. He stated he I am not sure what the wet contact time is for the disinfecting wipes. He denied receiving training on the use of the product. During an interview on [DATE] at 12:35 PM with Adm Staff 3 she stated the facility was under droplet precautions. In addition acknowledged that the Staff were educated on the use of the Santi wipes during the month of February. The facility expectation is for the staff to use the Santi wipe according to the manufacture recommendations. On [DATE] at 9:00 AM Laundry Staff 1 was observed delivering residents clothing to multiple rooms with a droplet precaution signs at the door. Later that same day, during further investigation she acknowledged that she did not change her gown, mask or gloves as she delivered the clothing from room to room. During a re-interview on [DATE] she stated since she was not a direct care staff, she thought She did not need to change her PPE. During an interview on [DATE] at 4:00 PM with Adm Staff 2 she indicated that the Laundry Staff 1 should have removed her disposable gown, gloves and mask before leaving each room. Review of facility policy on [DATE] titled Infection Prevention and Control Program (IPCP) and Plan revised on [DATE] reveals: Droplet Precautions: Droplet precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets larger than 5 um in size) containing microorganism. Donning and Removal of Personal Protective Equipment: Removal of PPE at doorway before leaving resident room or in anteroom On [DATE] near 3:45 PM, the Executive Director was informed of an immediate jeopardy situation related to failed infection control surveillance with identifying a respiratory infection and PNA outbreak which began on [DATE]. In addition the failure to report the outbreak to the Department of Health timely. The facility needs to ensure once it identifies outbreaks, it will timely notify the Department of Health and get guidance and assistance.

Based on observation, interview, and record review, the facility failed to comprehensively assess a resident's increased risk for skin breakdown and failed to implement timely interventions necessary to prevent the development of a facility-acquired pressure ulcer for one of two residents (46), reviewed for pressure ulcers. These failures caused harm to Resident 46 who developed an avoidable pressure ulcer with full thickness skin loss and pain. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages included: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable redness. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible undermining and tunneling may occur. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. The facility policy, dated 07/05/18, entitled Pressure Ulcer/Injury Prevention and Management indicated all resident were assessed for existing skin issues at the time of admission and readmission. It indicated a common risk assessment, the Braden Scale was used to determine a resident's risk for developing a pressure ulcer and noted that weekly skin assessments were completed by the Licensed Nurses. It also listed measures that could be implemented to maintain and improve tissue tolerance, and protect the patient against external mechanical forces, described as pressure, friction, and shear, were implemented in the plan of care. The policy noted that when skin breakdown occurred, it required attention and a change in the care plan to appropriately treat the patient. RESIDENT 46 Resident 46 was admitted to the facility in 2011. The last annual Minimum Data Set (MDS) assessment, dated 05/26/18, showed the resident had memory problems, sometimes understood others, and spoke a language other then English. The resident needed extensive assistance from one staff member to complete most activities of daily living (ADL's) such as bed mobility and transfers. The MDS also showed Resident 46 was at risk for pressure ulcers, but had no pressure ulcers. The quarterly MDS assessment, dated 11/13/18, showed the resident needed the extensive assistance of two staff members for bed mobility and transfers, and did not have any pressure ulcers. The next quarterly MDS assessment, dated 02/06/19, indicated the resident had developed a Stage III pressure ulcer (on the right heel). During observations on 03/27/19 and 03/28/19, Resident 46 was observed seated in her wheelchair in her room throughout the day, and sleeping intermittently. A blue padded boot covered the right foot and a slip-on shoe was on the left foot. Both feet rested on the floor. There was no black bolster cushion observed on the bed. Observation by a nurse surveyor on 04/10/19 at 1:45 PM of Staff C, a Registered Nurse, who completed wound care to Resident 46's right heel. The wound was observed to display a full thickness skin loss, approximately 3 centimeters(cm) Length x 3 cm Width x 0.3 cm Depth. The wound bed was 80% dark red and 20% covered with slough(dead tissue), had a foul odor, and yellowish discharge. The wound edge was tender and the surrounding skin was macerated (skin change related to prolonged exposure to moisture). The resident was observed groaning and was guarding the area during the wound care treatment. (See citation under F 679 for concerns about lack of implementing adequate pain management plan) On 04/10/19 at 2:00 PM, the family member who also observed the wound treatment stated that she was surprised to see the condition of the wound and was concerned about infection because of the odor and yellowish discharge. The family member stated that she believed the wound developed due to the resident remaining seated in her wheelchair too long, causing pressure to the heel. The Braden Scale assessments (to identify the risk for skin breakdown) were documented at least monthly between 11/27/18 and 04/01/19 and showed that the resident had a mild risk of skin breakdown. The Care Plan (CP) dated 11/22/18 was updated on 12/27/18 to identify an open ulcer on the right heel. The only intervention was for staff to provide wound care treatment per order(s). A separate section on the CP, initiated 11/22/18, showed that the resident was at risk for skin breakdown. The goal, initiated 11/22/18, was to maintain intact skin through 05/14/19. The interventions included: minimize pressure over boney prominence's and off-load pressure throughout day as appropriate. The CP did not specify how staff were to off-load pressure or identify other specific interventions to ensure pressure relief for the resident's heels. Review of the record showed a weekly skin check dated 11/24/18 that documented no open areas were found. A progress note, dated 11/28/18, also showed the resident was on alert charting for a toe abrasion and that the resident was encouraged to float her heels with pillows. A second progress note on 11/28/18, noted the resident's heels slightly red, but blanch slowly. An order to treat the heels with [MEDICATION NAME]-iodine swabs was obtained. It also noted a wedge cushion was refused and padded boots were not appropriate due to self-transfers and risk of falls. A wound observation tool, dated 12/11/18, documented the resident had a Stage 1 pressure ulcer was on the left heel and noted the Stage 1 ulcer on the left heel was first observed on 11/28/18. The progress notes between 11/28/18 and 12/24/18 showed no further mention of redness on the resident's heels. On 12/24/18, a progress note showed the resident had a non-blanchable area measuring 3 cm x 3.5 cm on right outer foot near the heel and, Right heel covered with Alevyn heel cup. It showed that Tylenol was helpful with pain and the Heel was floated with black bolster cushion. The entry noted the physician was notified of the pressure ulcer. A 12/26/18 progress note showed there was a cream-colored hard skin area on the right outer foot near the heel that is intact except for a small 0.2 area. Then on 12/27/18, an order for [REDACTED]. The progress notes after 12/24/18 showed intermittent use of positioning devices, referred to as a black bolster pillow or heel protectors. There was no evidence the resident refused the positioning devices. The wound consultant's initial visit occurred on 01/08/19. The consultant report indicated the resident had a Stage 3 pressure ulcer on the right heel. The recommendation was for frequent repositioning while in the wheelchair, every 2-3 hours, to ensure the heels remained free from pressure. However the Care Plan, dated 11/22/18, was not revised to reflect this recommendation, there were no specific directives provide position changes while in the wheelchair, or pressure relieving devices. The care guide directives for the Nursing Assistants, found no directives to indicate position changes should occur while in the wheelchair, nor did it identify the pressure relieving devices that were implemented. The (MONTH) 2019 Treatment Administration Record (TAR) showed a directive to float the heels when in bed that was initiated on 12/27/18. According to the TAR, an order to reduce pressure to the heels while seated in the wheelchair was not implemented until 03/08/19, more than 60 days after the right heel ulcer was first observed. On 04/11/19 at 09:10 AM, Staff A, the Resident Care Manager, a Registered Nurse, was interviewed. When asked about the right heel pressure ulcer and how it developed, she stated the resident refused a wedge cushion on her bed and that padded boots would have increased the resident's risk for falls. When asked if the resident was still able to transfer, Staff A stated the resident had declined in the ability to use the transfer pole. The facility failed to accurately assess the risk of pressure ulcers and implement timely interventions to off load heel pressure which resulted in the development a Stage 3 pressure ulcer on the right heel. Reference WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to comprehensively assess, initiate appropriate and timely fall interventions, provide adequate supervision, or follow the plan of care for 3 of 5 residents (95, 56 and 17) reviewed for accidents, hazards, and falls. The facility's failure to provide adequate supervision, failure to initiate timely and appropriate fall interventions and the failure to follow written policy and plan of care caused harm to Resident 95 who suffered multiple falls with injuries and contributed to the development of a substantial injury (fracture) of the clavicle (collar bone), and placed the other residents at risk for fall recurrence and injury. Findings included Clavicle fracture (broken collarbone) is a partial or complete break in the collar bone due to external force . and Are usually a result of injury or trauma. Sub-Acute Fracture; the term sub-acute refers to the pain following the fracture of a bone rather than the actual fracture itself. It is the pain that occurs in the first few weeks as the bone and soft tissue begin to heal . A review of the facility policy titled, Fall Management, dated 12/13/18, defined avoidable accidents means that an accident occurred because the facility failed to: a. Identify environmental hazards and/or assess individual resident risk of an accident, including need for supervision and/or assistive devices. b. Evaluate/analyze the hazards and risks and eliminate them, if possible, or if not possible, identify and implement measures to reduce the hazard/risks as much as possible. c. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident. d. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. The policy directed the facility staff as follows: 1. Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall event utilizing Fall Risk Evaluation form. 2. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS (Minimum Data Set assessment), upon a fall event and as needed thereafter. 3. Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls . Patient conditions may vary throughout the day, week, month or other time period and the identification of patient fall indicators is an ongoing, interdisciplinary assessment process. RESIDENT 95 Resident 95 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment, dated 03/13/19, showed the resident had severe cognitive impairment and needed one person assistance with bed mobility, transfers, and toileting needs. Review of the resident's care plan, dated 09/16/18, showed the resident was at risk for falls related to dementia (memory problem), impaired mobility and history of falls. The care plan included the following intervntions: A. Call light within reach. Created and initiated on 09/16/18. B. Frequent checks. Created and initiated on 09/25/18. C. Frequent repositioning when in bed. Created and initiated on 09/25/18. The care plan also showed the following documented falls for Resident 95: 1. 09/24/18 at 7:30 PM. Rolled out of bed. 2. 10/02/18 at 5:15 PM. Found on floor next to w/c (wheelchair). 3. 10/06/18 at 3:50 PM. Fall with (R) (right) hand swelling and bruise. 4. 10/10/18 at 3:10 AM. Per roommate she rolled out of bed. 5. 10/15/18 at 4:50 PM. Tipped wheelchair backwards resulting in hematoma (collection of blood caused by an injury/trauma to the wall of a blood vessel) to back of head. 6. 10/19/18 at 11:00 AM. Found sitting on the floor in doorway of another resident's room. 7. 10/29/18 at 10:00 AM. Found on the floor next to bed. 8. 11/06/18 at 2:35 PM. Found on the floor next to bed. 9. 11/13/18 at 11:15 PM. Found near bathroom door on the floor. 10. 11/18/18 at 8:20 AM. Found sitting on comforter on the floor next to bed. 11. 11/26/18 at 10:30 AM. Found sitting on the floor next to bed. 12. 12/05/18 at 11:00 AM. Found on the floor next to bed. 13. 01/31/19 at 9:25 PM. Found on the floor next to her bed. 14. 03/07/19 at 11:30 AM. Found next to bed, sustained abrasion to inner upper lip and redness to tip of nose. 15. 03/13/19 at 9:15 PM. Resident 95 was found on the floor next to her bed . The care plan showed it did not contain specific interventions related to the circumstances of the falls, and was not consistently reviewed and/or revised after each fall occurrence and as directed by the facility policy. The care plan was not person-centered with individualized interventions related to the resident's poor cognition, and physical and mental limitations. Review of the nursing progress notes from admission to 03/29/19 showed the resident also had a fall on 12/11/18 at 8:00 PM. During several observations on 03/27/19 at 10:15 AM and 03/27/19 at 11:48 AM, the resident was alone in her room, lying in bed. During a joint interview and observations on 03/28/19 at 8:31 AM with Staff D, Nursing Assistant (NA) and Staff C, Registered Nurse, (RN), the resident was observed in the same position as above. Both the staff members stated that they tucked pillows under the right side of the mattress because the resident constantly tried to get up and get out of bed. Both Staff D and Staff C stated that the resident was a frequent faller and the pillows helped to prevent her from getting up and it made it harder for her (Resident 95) to get up. (Refer to F604 - Right to Be Free from Physical Restraints for more information.) The incident investigations showed the following information about supervision of the resident: 11/26/18-The fall investigation showed the resident was found sitting on the floor at 10:30 AM. The resident was last seen and cared for by staff at 10:10 AM. Interventions included: Cont. (continue) freq. (frequent) monitoring, toilet her when she is restless, when resident or roommate calls out, go to room immediately. 12/05/18-The fall investigation showed the resident was found on the floor by her bed at 11:05 AM. The resident was last seen and cared for by staff at 10:30 AM. Interventions included: Has had constant monitoring. She does call for help . continue to monitor and follow care directives . Continue to monitor frequently . 12/11/18- The fall investigation showed the resident was last seen and cared for by staff at 7:00 PM. and was found on the floor at 8:00 PM. Interventions included: Continue frequent visual check for safety to prevent fall. 01/31/19- The fall investigation showed the resident was last seen and cared for by staff at 9:15 PM. The resident was lying on the floor at 9:25 PM. Interventions included: Frequent visual checks when in bed . 03/07/19- The fall investigation showed the resident was last seen and care for by staff at 11:30 AM. The resident was found on the floor, at 11:25 AM. Incident description: get out of bed on her own, attempted to walk, fell on the floor. Interventions included: continue with frequent checks, if restless get up and place at nurse's station or hallway in room. 03/13/19- The fall investigation showed the resident was last seen and cared for at 8:30 PM. The resident was found on the floor at 9:15 PM. Interventions included: Continue frequent visual checks for safety. All the above incident investigations reviewed above were missing specific and objective, measurable interventions in order for the facility staff to implement, analyze and evaluate the effectiveness of each specific intervention attempted (frequent checks and supervision needed by Resident 95). There was no evidence or documentation that showed the facility followed and completed post-fall evaluations for each occurrences, as directed by the facility policy and fall incident report procedures. During a joint interview on 03/28/19 at 8:31 AM with Staff D, NA and Staff C, RN, the staff members stated that frequent checks could be different depending upon the situation. The staff stated that frequent checks could be every two hour checks, every hour or every thirty minutes. Both indicated that in general for residents identified as being at risk for falls, frequent checks could mean that staff will look in the resident's room every time they walk past or perhaps every fifteen minutes. Both staff members stated that a frequent checks intervention should be specific. The staff stated they were not sure on how frequently they should check Resident 95. During an interviews on 03/28/19 at 9:02 AM with Staff A, RN/Resident Care Manager, Staff A stated that frequently checking of a resident who at risk of fall could be every 15 to 30 minutes. On 03/28/19 at 9:25 AM with Staff I, Licensed Practical Nurse, (LPN), Staff I stated that frequent checks of a resident at risk for falls could perhaps be every 1-2 hours and as needed. Review of the resident's clinical records showed the resident was hosptalized on [DATE] for several [DIAGNOSES REDACTED]. The hospital notes noted the resident had a fall out of bed several weeks ago and indicated this was a new fracture During a joint record review and interview on 04/08/19 at 2:43 PM, the Director of Nursing (DNS) reviewed the resident's clinical records and fall investigations with the surveyor. The DNS stated that the intervention listed as frequent checks should have been more specific for staff to effectively implement and evaluate the effectiveness of the intervention. The DNS also stated that the resident's orthostatic blood pressure (a vital sign gathered from a patient who has potential blood pressure problems when transitioning positions, going from lying down to sitting up, sitting to standing, etc.) was not obtained and evaluated from each incident of falls for Resident 95. The DNS further stated that Resident 95's care plan should have been reviewed and revised for every fall incident to minimize the risk of re-occurrence of fall incidents. RESIDENT 56 Resident 56 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment, dated 02/13/19, showed the resident had impaired cognition and needed one person assistance with bed mobility and transfers. During several observations on 03/27/19 at 9:46 AM and 03/28/19 at 8:23 AM, the resident was alone in the room, lying in bed. Review of the resident's clinical records, showed the resident had 3 documented falls on 12/28/18, 12/12/18, and 01/03/19. Review of the resident's care plan dated 11/30/18, showed the resident was at high risk for falls related to current use of psychoactive medications (medications that can alter brain functions) and was unaware of her safety needs. The care plan was not revised at the time of each incident and as directed by the facility policy. Review of the fall incident investigations dated 12/28/18, 12/12/18, and 01/03/19 were missing specific and objective, measurable interventions in order for the facility staff to implement, analyze and evaluate the effectiveness of each specific intervention attempted (frequent checks and supervision needed by Resident 56). There was no evidence or documentation that showed the facility followed and completed post-fall evaluations for each occurrences, as directed by the facility policy and fall incident report procedures. RESIDENT 17 Resident 17 was admitted on [DATE] with a terminal [DIAGNOSES REDACTED]. The initial MDS assessment, dated 10/17/18, indicated the resident could ambulate independently, did not identify any behavioral issues and received no [MEDICAL CONDITION] medications, or Anti-Anxiety (AA) medication was administered. The last quarterly MDS, dated [DATE], showed the resident was administered an AA medication ([MEDICATION NAME]) every day during the assessment period. It also documented Resident 17, had three falls since the previous quarterly assessment, dated 01/10/19, was completed. The care plan, initiated 10/10/18, identified the risk of falls. The interventions included: assist with Activities of Daily Living as needed, keep the call light in reach, complete fall risk assessment and orient the resident to the room and encourage non-skid socks when not wearing shoes. The interventions were all initiated on 10/10/18. The accident incident log documented Resident 17 experienced three falls, which occurred on 02/13/19 at 10:00 PM, 02/25/19 at 2230 (10:30 PM), and 03/17/19 at 0015 (12:15 am). The investigations completed by the facility, found a fall risk assessment was completed after each fall. It was also noted the resident was administered the anti-anxiety medication prior to each of the fall incidents. The Medication and Treatment Administration record for (MONTH) 2019 directed staff to monitor the resident for adverse side effects related to the administration of the AA medication. The MAR/TAR noted the staff were monitoring the resident for Ataxia (drunk walk), dizziness, confusion The care plan for the use of the AA medication included additional side effects, including loss of balance, cognitive impairment that looks like dementia and an increase risk of falls, broken hips and legs. It also listed clumsiness, slow reflexes, . disorientation, . memory loss and forgetfulness The adverse side effects related to the use of the AA medication, clearly identified increased risk of falls. However, there was no evidence the facility considered the falls could be a adverse side effect of the AA medication and effectively addressed this issue. On 04/11/19 at 11:20 AM, the Director of Nursing Services was interviewed about the AA medication administered to Resident 17. The DNS explained the medication order was implemented by hospice, and was in place as a PRN (or as needed) at the time of admission. She stated she did not know if the staff had considered the medication as a possible factor contributing to the falls during the facility investigations of the incidents. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to comprehensively assess residents' nutrition and hydration status, failed to implement written policies and procedures related to weight loss, and failed to initiate timely interventions as needed to prevent significant weight loss and dehydration for 4 of 5 residents (95, 21, 52 and 56) reviewed for nutrition and hydration status and weight loss. These failures caused harm to Resident 95, Resident 21 and Resident 52 who developed severe and unplanned weight loss, and placed Resident 56 at risk for further weight loss and decline in nutritional status. Findings included . The Minimum Data Set (MDS) assessment defined a clinically significant weight loss episode for nursing home residents as a loss equal to or greater than 5% within a 30-day period or 10% within a 180-day period. Review of the facility's policy titled, Weight monitoring, dated 03/01/13, identified a process to obtain, record, and track resident's weights and ensure accuracy. The policy directed facility staff to: 1. For the development of a successful height and weight program/process, the facility involves Nursing, Food and Nutrition Services, Rehab and Maintenance. 2. The criteria for reweighs are as follows: A. A reweigh is obtained when a resident's weight varies by 5 pounds (lbs.) in a month or 3 lbs. in a weekly or bimonthly weight. Reweighs should occur in the same shift but no more than 24 hours after the first weighing. B. Weekly weights would be obtained for New admissions weekly for 4 weeks and Any resident receiving an enteral(gastric) feeding. C. For any resident who experiences an unplanned weight loss, significant weight change, or undesirable weight change, notification will be made to the physician and responsible party. D. Planned/expected weight loss is weight loss that is intended or expected, documented, and included in the resident's care plan before it occurs. E. Each identified resident with a weight change has a current nutrition assessment/progress note. F. The Interdisciplinary Care Plan team addresses the issue of the weight loss/poor intake or weight gain, assesses dining needs if indicated, provides realistic and measurable goals, indicates specific and individualized interventions, and more as needed. The resident's interdisciplinary care plan reflects the current interventions, evaluations, and revisions. The nutrition progress notes describe the changes, plan of action, and progress or lack of progress. G. Interventions for weight loss/declining intake may include but not limited to: Food is tried first, snacks/supplements are intended to in increase the number of calories consumed daily. H. Once it is determined that a resident has unplanned weight loss and/or declining intake, the interdisciplinary team does the following: a. Interview the resident, CNA's (Certified Nursing Assistants), family and/or responsible party for any new or alternative food preferences, b. After reviewing nutritional intake a determination is made if large/double portions can be provided, c. Try whole milk at meals if the resident consumes milk, d. Try other fortified foods if the resident will consume them, e. If increase food at meals is not an option due to intake, try a high calorie snack between meals such as half sandwich with milk, pudding, milk and cookies . I. If the above interventions have been implemented and the goal is not met, the RD (Registered Dietitian) assesses for more aggressive interventions, such as a fortified supplement . J. If weight monitoring is not indicated, such as for a terminally ill resident, obtain a physician's orders [REDACTED]. RESIDENT 95 Resident 95 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment, dated 03/13/19, showed the resident had severe cognitive impairment and needed one person assistance with eating. The MDS also showed the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months and was not Hospice care (end of life care). The resident had lost more than 10% of her weight in the last 6 months and was not on a physician-prescribed weight loss regimen. Review of the resident's nutrition care plan, created and initiated on 09/21/18, showed the resident has nutritional problem r/t (related to) medical dx (diagnosis): Alzheimer's dementia, depression, [MEDICAL CONDITION]. Weight loss since admission. Intake <50% (less than 50 percent). The care plan directed the facility staff to: A. Observe and report resident's refusals to eat. B. Observe and report to the Medical Doctor, as needed, signs and symptoms of malnutrition and significant weight loss. (3 lbs. in one week, greater than 5% in 1 month, greater than 7.5% in 3 months and greater than 10% in 6 months.) C. Monitor intake and record every meal. A review of the resident's Weight Summary showed the following weights: 09/16/18 = 134.2 lbs. (admission) 10/15/18 = 125.6 lbs. 11/15/18 = 125.8 lbs. 12/03/18 = 123.8 lbs. 01/31/19 = 99.0 lbs. 02/13/19 = 105.4 lbs. 02/20/19 = 102.0 lbs. 02/27/19 = 100.0 lbs. 03/06/19 = 97.4 lbs. The resident's weight on admission was 134.2 lbs. The resident's weight on 10/15/18 was 125.6 lbs. which was a loss of 8.6 lbs. in 30 days, and a 6.41% loss of body weight. Resident 95's weight continued to decline. Her weight on 03/06/19 was 97.4 lbs. which totaled a significant weight loss of 36.8 lbs. and a 27.42% loss of body weight in approximately 6 months. A review of the resident's meal intakes from 02/27/19 to 03/27/19 showed the resident was consuming less than 50% of her meals. The meal intakes also showed the resident was only offered snacks six times during that time frame, and consumed 50 percent or less on average. The resident's meal intakes did not consistently document information related to the amount of fluid the resident was consuming during each meal, and whether staff had offered any other source of food or fluid to the resident related to the resident's poor oral intake. Review of the quarterly MDS note, dated 03/19/19, showed the resident eats 25% to 50% of her meals, her daughter brings food from home and she has a [DIAGNOSES REDACTED]. Proceed with care plan. Review of the quarterly Nutrition Assessment, dated 03/21/19, completed by Staff B, Registered Dietitian (RD), showed the resident's intake was variable (and stable) per usual with averaged 36% (ranging 24-48%). The assessment also showed the resident had a significant weight loss and the plan was to continue with current nutritional plans, honor food and fluid wishes, monitor monthly weights. Review of the previous Nutrition Assessment and weight change notes, dated 02/04/19 and 01/02/19, showed the resident's average intake was 33% to 39% per day. However, the facility did not comprehensively assess the resident's hydration status and fluid intake to determine if this low intake could be a contributing factor for the resident's continued weight loss. The resident's clinical records, Nutrition care plan, quarterly MDS notes, quarterly Nutrition Assessments/weigh change notes, Physician's notes, and nursing progress notes, showed no evidence the facility had comprehensively assessed the resident's hydration status/fluid intake. The assessments were missing key information, such as the resident's target weight range, required calorie,nutrient, and fluid intake needs, and whether the resident's documented intake was adequate to meet those needs. Additionally, the resident's nutrition care plan interventions were never updated or revised as needed related to the resident's poor intake and continued weight loss. All of Resident 95's care plan interventions were created and initiated upon admitted d 09/21/18. During an observation on 03/27/19 at 10:15 AM, the resident was observed in bed asleep. The resident's breakfast tray was at the bedside and appeared untouched. The resident was observed with dry skin on her face, arms and legs with dry, cracked lips. During a joint observation and interview on 03/28/19 at 8:31 AM with Staff D, Nursing Assistant (NA) and Staff C, Registered Nurse, (RN) Resident 95 was observed in bed with dry skin and cracked lips. Staff D stated that the resident had poor intake and does not eat or drink much almost every meal. According to Staff D, the resident's daughter comes daily, at least twice a day, and helps feed the resident. Staff D further stated, She (Resident 95) will not eat or drink with us, only with her daughter and stated the resident was not on any supplement or snacks for meals which the resident refuses all the time. In an interview on 03/29/19 at 8:07 AM with Staff E, NA, Staff E stated that the resident had poor intake and did not eat or drink much at most meals. During a record review and interview on 03/29/19 at 2:34 PM with Staff A, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 95 was not on input and output monitoring. Staff A stated that no fluid intake was being documented and monitored for the resident during meals and/or every other time. Staff A reviewed both the resident's electronic medical records and hard copy charts and stated that there was no evidence of any fluid monitoring and/or hydration evaluation for the resident. Staff A also stated that the resident was recently started on Intravenous (IV) fluid therapy due to severe dehydration, and stated that the resident's weight should have been monitored weekly(more frequently) due to her increase risk of dehydration, poor intake, and continued weight loss. In an interview on 03/29/19 at 2:51 PM with Staff C, RN, stated the resident only takes fluids from her daughter and not with staff which could have contributed to the resident's dehydration. According to Staff C, there was a discussion about hospice and palliative care in the past for Resident 95, but the resident and her daughter were not ready yet so the resident was never put on hospice and/or palliative care. Staff C further stated that the resident was not on any fluid monitoring and there were no other supplements such as health shakes or med pass currently being offered or provided to the resident. Staff C also stated that she was not sure why the resident was not on weekly weights because the resident was losing a lot of weight and had a very poor intake. During an interview and record review on 03/29/19 at 3:10 PM with Staff B, RD, stated the expectation and the facility policy was to weigh the residents with documented weight loss weekly until their weight stabilized. Staff B stated that she was not sure why Resident 95's weight was not being monitored weekly due her increased risk for dehydration and weight loss. Staff B stated that she had no valuable information to evaluate the resident's hydration status because there was no documentation of fluid intake for the resident. Staff B further stated that the resident was not on any high calorie/high protein drinks to address the resident's weight loss. Staff B stated that she was not sure whether she had offered these interventions to the resident's representative/daughter recently because there was no documentation that showed such a conversation. Staff B stated that the resident's recommended fluid intake was 1500 milliliters (mL), but she had no information if the resident was consuming any fluids. Staff B also stated that the resident's meal intake documentation of less than 50% per day should also include the amount of fluid intake the resident had consumed, and stated that she had no supporting documents to show the facility staff were monitoring the resident's fluid intake and hydration. Review of the resident's blood chemistry report dated 03/28/19 showed the resident's blood sodium level of 164 (normal value = 135 to 145), a blood urea nitrogen of 55 (normal value = 8 to 25) and a creatinine level of 1.2 (normal value = 0.5 to 1.0). These results were indicators of fluid deficit and dehydration. During an interview and record review on 04/08/19 at 1:16 PM, the Director of Nursing (DNS) stated that the facility monitored and evaluated the resident's nutrition and hydration status through the meal monitor and meal consumption documentations in Point Click Care (PCC is an electronic medical record). According to the DNS, the meal percentage documentation included any water or fluid consumed by the resident during meals. However, when asked whether the resident was receiving adequate hydration and adequate nutrition, when the documented intake was only 50% or less on the daily meal monitors, the DNS was not able to provide an answer. The DNS reviewed Resident 95's clinical records and stated that the resident had significant weight loss, and there was no documentation to identify how much fluid was being offered and/or consumed by the resident. During a phone interview on 04/11/19 at 9:21 AM with the resident's attending physician and Medical Director (MD), stated he was notified of the resident's weight loss recently on/or before 03/27/19. The MD was not aware that the facility was not monitoring the resident's fluid intake. The MD stated that the resident's fluid intake should have been monitored closely, and the resident's weight should have been monitored weekly, as required and directed by the facility policy. Further review of the resident's clinical records showed the resident was hosptalized on [DATE] with the [DIAGNOSES REDACTED]. RESIDENT 21 Resident 21 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment, dated 01/13/19, showed the resident had intact cognition and needed one person assistance with eating. The MDS also showed the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months and was not Hospice care. Review of the resident's nutrition care plan dated 10/23/18, showed the resident had a nutritional problem or potential nutritional problem related to [MEDICAL CONDITION], difficulty swallowing, and history of [MEDICAL CONDITION]. The care plan directed the facility staff to: A. Observe and report resident's refusals to eat. B. Observe and report to the Medical Doctor as needed signs and symptoms of malnutrition and significant weight loss. (3 lbs. in one week, greater than 5% in 1 month, greater than 7.5% in 3 months and greater than 10% in 6 months.) C. Provide and serve supplement as ordered: shakes three times a day with meals and fortified cereal at breakfast. D. Provide adaptive equipment for feeding as needed: sippy cups or straws. A review of the resident's Weight Summary showed the following weights: 09/03/18 = 101.0 lbs. 10/01/18 = 95.3 lbs. 10/30/18 = 92.1 lbs. 11/30/18 = 93.2 lbs. 12/13/18 = 97.0 lbs. 01/09/19 = 89.6 lbs. 02/13/19 = 88.0 lbs. 02/19/19 = 91.0 lbs. 02/26/19 = 90.0 lbs. 03/04/19 = 88.4 lbs. 03/25/19 = 86.2 lbs. The resident's weight on 09/03/18 was 101.0 lbs. The resident's weight on 03/04/19 was 88.4 lbs. which was a loss of 12.6 lbs. in 6 months and a 12.48 % loss of body weight. The resident's weight continued to decline. The resident's weight on 03/25/19 was 86.2 lbs. which totaled to a significant weight loss of 14.8 lbs. and a 14.65% loss of body weight in approximately 6 months. A review of the resident's meal intakes from 02/27/19 to 03/27/19 showed the resident was consuming less than or equal to 50% of her meals per day. The meal intakes also showed the resident was offered a snack only 3 times in that timeframe, and consumed 50 percent or less on average . The resident's meal intake documentation did not contain information related to the amount of fluid the resident was consuming during each meal, or whether staff had offered any other source of food or fluid to the resident related to the resident's poor oral intake. During an observation and interview on 03/27/19 at 2:04 PM, the resident was observed eating alone in her room. The resident was struggling to put food in her mouth using a fork and had difficulty drinking from a regular cup. The resident's tray did not have sippy cups or straws as directed by the resident's plan of care. The resident was observed with dry skin on her face, arms and legs and had cracked lips. The resident stated that sometimes she needed help with eating, and she does not get snacks or fluids in between meals. The resident also stated that she was thirsty and hungry. During a joint observation and interview on 03/28/19 at 2:03 PM with Staff C, RN and Staff F, NA, Resident 21 was observed in her room eating lunch. The resident appeared to be struggling to eat her food and drink from a regular cup. The resident attempted to scoop her food and take bites, but the food kept dropping off the utensil onto her chest area. Staff F stated that the resident needed a sippy cup, but it was not on the resident's tray. According to Staff F, the resident also needed cueing and limited hands on assistance with meals, and stated, she was not sure why there was no staff to feed her. Staff F further stated that the resident's tray showed the resident only consumed 15% of her meal and mostly were dropped on the floor. During a record review and interview on 03/29/19 at 2:34 PM with Staff A, RN/RCM, stated that Resident 21 was not on input and output monitoring. Staff A stated that fluid intake was not being monitored and documented during meals or any other time. Staff A reviewed the electronic medical record and hard copy chart and stated that there was no evidence of any fluid monitoring and/or fluid evaluation for the resident. Staff A also stated that there was no evidence that staff had provided supplements or shakes to the resident as directed by the resident's plan of care. Staff A further stated that the resident's weight had not been obtained weekly for the month of (MONTH) 2019, and stated that the resident should have been monitored weekly due to her significant weight loss. During an interview and record review on 03/29/19 at 3:10 PM with Staff B, RD, Staff B stated that the expectation and facility policy was to weigh the residents who had documented weight loss weekly until their weight stabilized. Staff B stated that she was not sure why Resident 21's weight was not being monitored weekly, despite her increased risk for dehydration and weight loss. Staff B stated that she had no valuable information with which to evaluate the resident's hydration status because there was no documentation of fluid intake for the resident. According to Staff B, she was not aware of Resident 21's significant weight loss and stated that, I haven't reviewed her yet. Staff B stated that Resident 21's recommended fluid intake should be 1200 mL per day. Staff B stated that she was not able to show any documentation that the resident's hydration was comprehensively assessed and monitored by the facility. Staff B further stated that Resident 21 was not on hospice or palliative care, and not on a planned physician weight loss program. Review of the resident's clinical records from 09/01/18 to 03/28/19, showed no evidence that the facility staff had comprehensively assessed the resident's hydration status and fluid intake. The documentation showed that facility staff did not consistently implement written policies and procedures related to weight loss. The assessments did not contain key information, such as the resident's required calorie,nutrient, and fluid intake needs and whether the resident's documented intake was adequate to meet those needs. Additionally, the resident's nutrition care plan, created on 10/23/18, showed that interventions were never updated and/or revised as needed related to the resident's poor intake and continued weight loss prior to 03/28/19. During an interview and record review on 04/08/19 at 1:16 PM, the DNS confirmed and stated that Resident 21 had a significant weight loss and she was not sure why the resident was not reviewed by the interdisciplinary team. The DNS reviewed Resident 21's records and stated that the facility had no documentation to support how much fluids were being offered and consumed by the resident. Tha DNS also stated that there was no documentation as to whether the resident's physician was aware of her continued weight loss (prior to 03/28/19). During a phone interview on 04/11/19 at 9:21 AM, the resident's attending physician (who was also the facility Medical Director (MD) stated he could not recall when and if he was notified of Resident 21's weight loss prior to the survey inspection on 03/27/19. RESIDENT 52 Resident 52 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The last annual MDS assessment, dated 02/13/19, documented the resident needed extensive assistance from one staff to complete the Activities of Daily Living such as mobility, dressing, grooming, toileting, and hygiene, and needed supervision and cueing from one staff with eating. The assessment showed the resident experienced weight loss and that the resident was on a therapeutic diet. The care plan directive concerning dining assistance, dated 11/30/18, stated Resident 52 is able to eat on her own with set up. Occasionally requires physical assistance with eating. The section addressing nutritional problems included the following directives: -Monitor and report significant weight loss including weight loss of greater than 5 % in 1 month. -Glucerna (a drinkable nutriton supplement) daily. -The resident needs a calm, quiet setting during meal times with adequate eating time. Observations on 03/29/19 during breakfast and lunch showed Resident 52 received a tray for each meal while in her room. Staff placed the tray on the overbed table and then left the room. The resident only ate a couple of bites of food at each meal. Observations on 04/09/19 during breakfast and lunch showed Resident 52 was seated in the dining room. The resident did not eat. Although staff were present in the dining room during both meals, staff did not provide Resident 52 with any cueing or encouragement. During the breakfast meal, an activities staff stop by the table momentarily, and offered to hold the resident's baby doll which the resident agreed to. The staff took the item from the resident but did not provide any verbal cueing or encouragement. The only verbal cueing was observed during the noon meal when a staff person approached Resident 52 and offered a cup of cocoa. (See F 676 for more detailed information about lack of providing assistance with dining for Resident 52) Resident 52's weight record documented a 5.8 % weight loss between (MONTH) and (MONTH) 2019. On 02/19/19, the resident's weight was 154 lbs. Then on 03/20/19, the resident's weight had dropped to 145 lbs. The resident had lost 9 pounds in 30 days which according to the guidelines established by Centers for Medicare Services (CMS) is characterized as severe weight loss. Review of nutritional assessments, dated 12/14/18 and 02/15/19, were completed by the Registered Dietitian. Both showed the resident was on a therapeutic diet and received a regular texture diet with no added salt. The RD assessments also indicated the diet was tolerated well, even though the resident had no bottom denture and had missing teeth. On 03/30/19, a nutrition/dietary progress note by Staff A, RCM/RN showed the resident was offered assist at meals but (the resident) frequently stated, that is enough, no more. The note also showed Unavoidable weight loss form in process. The entry also showed that the drinkable nutritional supplement Glucerna was increased to twice a day. Staff A documented the family was informed of the resident's weight loss and that the family did not want lab tests done and to just keep the resident comfortable. Record review showed a document Unavoidable Weight loss that was initated by Staff A on 03/21/19, and signed by the Physician on 03/21/19. The form noted weight loss prevention measures were in place and listed the following interventions: supplements, offering meal replacements, providing one to one feeding assistance, and ensure the resident received the appropriate diet texture. Further review of the record showed the resident's care plan did not include those interventions. During the meal observations on 03/29/19 and on 04/09/19, Resident 52 was not staff did not ask or offer a meal substitution, any supplements and Resident 52 with one to one feeding assistance. The observations were noted as follows: On 03/29/19 08:18 AM, Resident 52 was observed sleeping in bed, a breakfast tray on the over bed table, the tray meal included pancakes, a round sausage patty and scrambled eggs. The resident was easily aroused by verbal stimulation. When asked if staff ever help her with the meals, she stated no, and said they just bring it in and leave it here. On 03/29/19 at 08:58 AM, during another observation, although the food had been cut into pieces the food and fluids remained untouched. On 03/29/19 at 12:30 PM Resident 52 was observed seated in the wheelchair in the hallway, outside her room. An unnamed staff member was observed to assist the resident to her room and set up the resident with a lunch tray. At 12:49 PM, Staff W, a NA who was observed passing trays in the hallway where Resident 52 resided. Stated only one Resident in the hallway needed assistance with dining and identified then by name, it was not Resident 52. At 1:16 PM, Resident 52 was seated in the wheelchair, with a tray on the over bed table before her. The plate of food appeared untouched. At 1:38 PM the resident was observed sleeping, with the tray before her. A different NA, Staff D entered the room, but did not provide any cueing or encouragement for Resident 52. At 1:43 PM, Staff W, entered the room and removed Resident 52's tray. A visual check, of the tray, when the staff exited the room, found only taken a couple of bites of the food served on the plate and part of the desert item were consumed. Staff W, commented Resident 52 said she was full. On 04/08/19 at 8:45 AM, Resident 52, was heard calling out softly help, help. After entering the room, it was discovered the meal had been spilled, the food was scatted in her lap and in the bed sheets. The resident's call light was turned on, Staff W, responded to the call light and entered the room to assist. Within, approximately 15 minutes Staff W, exited the room. With the soiled linens, and when asked about the meal she reported, the Resident 52 said she was finished. On 04/09/19, at 8:45 AM, Resident 52, was seated in the Baker Dining Room, with a plate of food at the place setting before her, but it remained untouched. Resident 52, was observed holding a baby doll, and would occasionally sip on a cup of coco before her, the plate of food remained untouched. At 8:50 AM, Staff X, a Restorative Nursing Assistant, approached Resident 52 who removed the lid from the bowl and verbally cued Resident 52 to eat, Resident 52 responded we will wait a bit, and continued to sit at the table with the food items untouched. At 8:49 AM, an unnamed activities staff, approached the table, she offered I can hold the baby while you drink your Coco. The resident agreed, however the food remained untouched. At 8:50 AM, the resident plate was removed from the table. Although Resident received cueing once and had another verbal exchange, no one asked her why she was not eating or offered a substitute replacement. On 04/09/19, at 12:35 PM, during observation in the Baker dining room, Resident 52 had a full plate of food, a piece of chocolate cake, and glass of water. The resident was readily engaged in eating the dessert and had not touched the plate of food. At 12:55 pm, an Unnamed Activities Staff approached Resident 52, and asked if she wanted a cup of hot chocolate, the resident responded yes. The staff member returned to the table with in a few minutes and provided the item. At 12:58 PM, the plate of food that remained untouched at her place setting. When asked about the meal, the resident stated she could not eat it, and stated it was dry. The resident then self-propelled the wheelchair out of the dining room. The facility failed to failed to ensure the nutrition services provided were consistent with the facility policy. In addition, there was no evidence the interventions listed on the form Unavoidable Weight Loss had been implemented or attempted. These failures contributed to the resident experiencing a pattern of weight loss. RESIDENT 56 Resident 56 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment, dated 02/13/19, showed the resident had impaired cognition and needed one person assistance with eating. Review of the resident's care plan, dated 12/03/18, showed the resident had a nutritional problem or potential nutritional problem related to intake appears less then optimal on average, however progressive weight gains. The care plan directed facility staff to: A. Observe and report resident's refusals to eat. B. Observe and report to the Medical Doctor as needed signs and symptoms of malnutrition and significant weight loss (3 lbs. in one week, greater than 5% in 1 month, greater than 7.5% in 3 months and greater than 10% in 6 months.) C. Monitor intake and record every meal. A review of the resident's Weight Summary showed the following weights: 09/04/18 = 164.0 lbs. 11/26/18 = 166.0 lbs. 04/02/18 = 156.0 lbs. No other weight were documented between 09/04/18 through . During an observation on 03/28/19 at 8:23 AM, the resident was observed in bed. Her meal appeared untouched. The resident was not able to reach her food because of the bed's position. There was no water pitcher or any fluids at bedside. The resident's skin appeared dry (face, arms and legs) and she had dry, cracked lips. Review of the resident's meal intake documentation from 03/11/19 to 04/08/19 showed the resident was consuming less than 50% of meals per day. The documentation showed the resident had consumed 25% or less of her meals on the following dates: 03/18/19, 03/22/19, 03/23/19, 03/24/19, 03/25/19, 03/26/19, 03/27/19, 03/30/19, 03/31/19, 04/01/19, 04/02/19, 04/03/19, 04/05/19, 04/06/19, 04/07/19 and 04/08/19. The resident's meal intake documentation was missing information related to the amount of fluid the resident was consuming during each meal, and whether the facility staff had offered any other source of food or fluid to the resident related to the resident's poor oral intake. During an observation on 04/09/19 at 1:51 PM, the resident's weight was obtained by the facility staff and documented a weight of 156.6 lbs. This was a weight loss of 9.4 lbs., a 5.66% loss of body weight from 11/26/18 through 04/09/19. During a meeting on 04/09/19 at 2:08 PM with the DNS, Administrator, and Regional Nurse Consultant 1, they stated that the resident's weight should have been taken and monitored at least monthly and/or weekly as needed related to the resident's increased risk for weight loss and poor intake. The resident's clinical records, (Nutrition care plan, quarterly MDS notes, Physician's notes, and nursing progress notes) showed no evidence the

Based on interview and record review, the facility failed to provide adequate pain treatment and management for two of two residents (46 and 51) reviewed for pain management. Failure to accurately assess and identify sources and expression of pain caused harm to Resident 51 and Resident 46 who experienced uncontrolled pain, severe discomfort, and diminished quality of life. Findings included . Review of the facility policy titled Pain Management, dated 06/2016 and 11/2016, showed the facility would ensure that pain management was provided to residents who required such services, consistent with standards of practice. The policy showed that staff should recognize when a patient was experiencing pain, identify circumstances when pain can be anticipated, and evaluate the pain, existing causes, and manage pain or prevent pain. The policy showed all residents will be assessed for pain indicators at the time of admission, readmission, and quarterly, and with any event. It showed that an individualized pain management care plan would be developed and initiated when pain indicators were identified. In addition, it showed the interdisciplinary team would review and revise(the plan of care) if indicated. RESIDENT 46 Resident 46 was admitted to the facility in 2011. The last annual Minimum Data Set assessment(MDS), dated [DATE], showed the resident needed extensive assistance of one staff member to complete most activities of daily living, such as bed mobility, transfers, dressing, toileting and hygiene. The MDS also showed the resident had declined having an interpreter to communicate with medical staff and care providers. Observation on 04/10/19 at 10:25 AM, showed Staff C, a Registered Nurse (RN), attempting to remove a dressing from a right heel wound. During the observation, the resident was screaming, and repetitively verbalizing unknown words, grimacing, sweating, and was tearful. Staff C stated the resident makes this noise all the time and may just be upset, and continued with unwrapping the resident's heel dressing. The resident continued to scream and show non-verbal signs of distress. When Staff C was asked what Resident 46 was trying to communicate, she responded that she wasn't sure and said she would have to call the resident's family member on the phone to interpret for her. The family member then listened on the phone to the resident's response as Staff C began to lift his foot to provide the treatment. The resident continued to scream, call out, and vocalize. The family member confirmed the resident was screaming of pain and the resident was trying to communicate severe pain. The family member requested that Staff C stop the procedure, and told Staff C that the resident was not able to tolerate the pain. The family member reported it was hard to hear the resident expressing severe pain during the dressing change. Staff C stated that she would contact the doctor, get an order for [REDACTED]. Observation on 04/10/19 at 1:45 PM, showed Staff C approach the resident to continue the dressing change. Staff C explained the physician had been contacted and an new order received to administer a narcotic pain medication prior to providing wound care and treatments. During the observation, Resident 46 tolerated the treatment without yelling or calling out in pain, but still displayed some non-verbal signs of pain, grimacing, and guarding. During a follow up interview on 04/10/19 at 2:00 PM, the resident's family member stated that the resident complained of pain when the wound specialist debrided the wound. (Debridement is a surgical treatment to remove dead tissue). She stated that this had occurred three to four times, and that the resident had complained of how painful the procedure was. The family member stated the only pain medication provided was Tylenol. The family member then said the Tylenol was intended for the resident's [MEDICAL CONDITION] pain, and was not intended for pain associated with treatments for the heel. The family member also stated that the pain the resident experienced today and during wound care debridement was severe to the point where the resident was screaming and was in agony. The family member stated, I had to hang-up the phone this morning because I cannot take it and it was crushing my heart. The family member stated the resident was raised to not to yell or scream, but today, she was screaming out in pain. Further review of Resident 46's clinical records, showed the care plan addressing pain was last updated on 11/22/18, prior to the development of the pressure ulcer. The directives included for staff to anticipate the need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain management, observe and report any signs and symptoms of nonverbal pain, which included groaning, yelling out, and facial expressions such as grimacing. A summary of the wound consultant's visit showed the consultant had provided treatment to the wound weekly since 01/08/19. A summary of the visits showed the wound was debrided every time the consultant provided treatment. The last quarterly MDS assessment, dated 02/06/19, identified the resident experienced pain, was administered pain medication(Tylenol) three times a day routinely, did use any PRN pain medication (which was available), and documented the resident reported no problems with pain. In addition, it noted the resident had developed a Stage 3 pressure ulcer ( Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible undermining and tunneling may occur.) The facility pain assessments completed between 11/24/18, 11/27/18 and 02/27/19. A quarterly assessment, dated 11/24/18, showed a pain level of zero and documented pain did not impact the resident's quality of life. The most recent pain assessment, dated 02/27/19, was a quarterly assessment. It documented the resident's pain level as zero, identified that pain affected the resident's quality of life, was managed with Tylenol, and noted position change was an effective intervention to relieve pain (non-pharmacological intervention). The Medication and Treatment Administration Record (MAR/TAR) for (MONTH) 2019 showed the resident was administered Tylenol routinely three times a day at 8:00 AM, 1:00 PM and 5:00 PM, and had an additional dose available which could be administered as needed. The MAR indicated [REDACTED]. The record did show the resident complained of pain at level 4 on 04/07/19, however the additional dose of Tylenol available was not administered. On 04/11/19 at 9:10 AM, Staff A, a Registered Nurse and the Resident Care Manager, was asked how the resident was assessed for pain. She explained if the resident displayed symptoms of pain the staff should respond. When asked if there were any communication tools to assist Resident 46, who primary language was Chinese, Staff A explained a sheet of translations had been placed at the bed side by the family members. By not ensuring the staff assessed the resident pain, identified the location, precipitating factors, and anticipated the needed for additional pain interventions to manage the resident's pain associated with the wound treatments and care contributed to Resident 46 experiencing severe, unrelieved pain. RESIDENT 51 Resident 51 was re-admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. The resident was admitted with a gastrostomy tube (a feeding tube inserted though the abdomen). A review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition and required one person assistance with activities of daily living. The MDS also showed the resident had reported moderate level of pain frequently and the pain had limited the resident's day to day activities including the resident's ability to get sleep. Review of the resident's pain care plan, dated 01/28/19, showed the resident expresses discomfort r/t (related to) cancer and impaired mobility. The care plan directed the facility staff to: Evaluate the effectiveness of pain interventions and Observe for pain characteristic every shift and as needed. During an observation and interview on 03/27/19 at 10:21 AM, the resident reported and verbalized pain to the surveyor. The resident was grimacing and was turning side to side in bed. The resident's tube feeding site was visible and was observed with yellowish discharge from the site. The resident showed his abdomen to the surveyor and started saying pain, very bad pain and the stoma site (insertion site of the tube feeding) was red with partial skin loss and macerated skin. During multiple observations and interviews on 03/27/19 at 11:00 AM, 03/27/19 at 1:15 PM, 03/27/19 at 2:01 PM, and 03/27/19 at 2:32 PM, the resident continued to verbalize and report severe abdominal pain to the surveyor. The resident was grimacing and was observed rubbing and massaging his abdominal area. During a phone interview on 03/27/19 at 2:03 PM with the resident's family member, the family member stated that the pain that the resident reported today was not new. The family member stated that the resident would constantly complain of pain and it was mostly related to his abdominal area. During an observation and interview on 03/28/19 at 8:35 AM, the resident reported and verbalized severe abdominal pain to the surveyor. Pain, very bad pain while grimacing and massaging his abdominal area. In an interview on 03/29/19 at 1:24 PM, Staff L, Nursing Assistant (NA), stated the resident would verbalize pain constantly during her shift. In an interview on 03/29/19 at 1:25 PM, Staff N, Licensed Practical Nurse (LPN), stated that the resident had constant pain related to [MEDICAL CONDITION]. Staff N also stated that the resident was on [MEDICATION NAME] (narcotic pain medication) and she had given it to the resident twice today during her shift. Review of the resident's most recent pain assessment dated [DATE] showed the resident had pain to his left hip area description: Resident unable to provide details, related to Russian speaking . Pain rating was 5 The assessment also documented the resident's quality of life (sleep and rest) were affected because of pain. The assessment was missing information related to the resident'[MEDICAL CONDITION] pain and abdominal pain, including the increase risk of pain and discomfort and intolerance related to the new gastrostomy tube. The only other pain assessment on the resident's clinical record was dated 02/01/19, and was also missing information related to the resident's pain and risk factors for pain. Review of the resident's Physician order sheet and Medication Administration Record [REDACTED] A. [MEDICATION NAME] (Tylenol) 500 milligram (mg) every 8 hours as needed for pain. Initiated on 02/05/19. B. [MEDICATION NAME] 500mg (give 2 tablets = 1000mg) three times a day for chronic pain. Initiated on 02/05/19. C. [MEDICATION NAME] 10mg at bedtime for SOB (shortness of breath). Initiated on 03/11/19. D. [MEDICATION NAME] 10mg every 2 hours as needed for pain/SOB. Initiated 03/11/19. (was every 4 hours prior to 03/11/19) The resident was receiving the scheduled pain medications as ordered. However, the record did not reflect evidence of documentations that the facility had consistently evaluated the effectiveness of the regularly scheduled pain medication (routine [MEDICATION NAME] and [MEDICATION NAME]) on a routine basis. The pain medication orders were not clear and specific on when the staff should be giving the as needed [MEDICATION NAME] tablets, rather than the narcotic pain medication [MEDICATION NAME]. The resident's pain monitoring sheet also showed the resident reported/observed at least 37 times (21 days) with moderate to severe pain from 03/01/19 to 03/29/19 and received as needed pain medication as ordered. However, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During a record review and interview on 03/29/19 at 2:06 PM, Staff A, Registered Nurse/Resident Care Manager (RN/RCM) stated the resident should have specific and comprehensive pain assessment done recently related to the new onset of uncontrolled abdominal pain and initiation of [MEDICATION NAME]. Staff A also stated, the comment Unable to provide details related to Russian speaking documented on the pain assessment was not acceptable and should have a follow-up and/or should have been re-assessed to ensure a comprehensive pain assessment was completed. Review of the resident's clinical records showed the resident was hosptalized on [DATE]. The hospital record dated 03/30/19 Emergency Department Course showed the patient began to complain of abdominal pain. His son is here at this time and states that he does have chronic abdominal pain although the patient states it feels worse at this time and would like to have this looked into and treated . He does have chronic pain in the abdomen. He has been on chronic narcotics for this. In addition he has had a recent pain around the gastrostomy site and was started on Keflex for potential [MEDICAL CONDITION] (a bacterial infection involving the inner layers of the skin.) See also F693 - Tube Feeding Management/Restore Eating skills for more information. Reference WAC: 388-97-1060 (1)

Based on interview and record review, the facility staff failed to assure the services provided for 1 of 3 residents (Resident #1) with an extremity device, met professional standards of quality to prevent pressure ulcers. Licensed staff performed skin assessments and did not thoroughly assess the right foot which had an immobilizer device. This practice was not conducive to professional standards of quality, and the non-action prevented an evaluation of the extremity at risk for pressure sores, resulting in the resident developing a 6x5cm, 5cm deep tissue injury with an infection of the bone, 100% eschar, and a delay in treatment, constituting harm. Findings include: Resident #1 was admitted to the facility on [DATE]. According to her medical record, the resident had multiple complex [DIAGNOSES REDACTED]. The resident was unavailable for interview or observation during the investigation, she had discharged from the facility. According to physical therapy progress notes dated 9/3/17, the resident received therapy and performed toe touch weight bearing to the right leg, with the immobilizer device in place. The facility's initial skin assessment documented: an immobilizer present on Resident #1's right lower leg. According to the treatment sheet, the resident was to have a weekly skin assessment. Upon review of the weekly skin integrity data collection document; staff indicated that skin assessments were done on 9/5, 9/12, 9/19 and 9/26/2017. Upon review of the skin assessments, progress notes and staff interviews, staff did not document removal of the immobilizer or stockinet to assess the entire right foot. According to professional quality standards, without a complete assessment of the at risk extremity, staff could not determine the condition of Resident #1's foot or evaluate for factors, such as a purple or very dark area that is surrounded by profound redness, [MEDICAL CONDITION] or induration. (SOM 2016 F314). The assessment should have identified overall risk factors that could be removed and/or modified. According to the care plan dated 9/2/2017, Resident #1 had a focus area related to impairment skin integrity. The care plan did not mention Resident #1 had an immobilizer device on her right leg or include interventions that addressed prevention of skin breakdown related to that device. The weekly skin assessment documentation did not include evidence that the entire right leg had been appropriately assessed according to professional standards. A thorough assessment of the skin is necessary to determine prevention strategies. Recommended professional standards are outlined in the literature by the National Pressure Ulcer Advisory Panel (2015), www.npuap.org. The information states: Include the following factors in every skin assessment: o skin temperature o [MEDICAL CONDITION] o change in tissue consistency in relation to surrounding tissue o localized pain Localized heat, [MEDICAL CONDITION] and change in tissue consistency in relation to surrounding tissue have all been identified as warning signs for pressure ulcer development. Additionally; the information states: Inspect the skin under and around medical devices at least twice daily for the signs of pressure-related injury on the surrounding tissue. Conduct more frequent (greater than twice daily) skin assessments at the skin-device interface in individuals vulnerable to fluid shifts and/or exhibiting signs of localized/generalized [MEDICAL CONDITION]. According to progress notes dated 10/3/2017, when the boot was finally removed at the request of an outside X-Ray technician; a 6x5, 5cm deep tissue injury was found on the plantar aspect of right foot, edges intact, 100% eschar. According to X-ray findings result of the date of service 10/3/17, indicated bony destruction consistent with osteo[DIAGNOSES REDACTED], indicating an infection into the bone. In interview with Staff A, an Occupational Therapist, on 10/16/17 at 1:46 p.m. regarding the immobilizer brace, Staff A stated she removed the immobilizer on 10/3/17 at the request of the X-Ray technician. Staff A noted a beige colored sock on the leg that exposed the resident's toes. Staff A stated the immobilizer had Velcro fasteners and was removed without incident and the resident did not have pain. When she removed the immobilizer, Staff A immediately noticed dried blood on the bottom of Resident #1's foot which was covered by the stocking. Staff nurse B was interviewed on 10/16/17 at 12:00 p.m. regarding the appearance of the foot after the brace was removed. Staff B stated the leg had a beige sock which exposed only her toes, the tube sock is called tubagrip. A sample piece of the tubagrib was observed; it was beige in color, cotton and opaque. Staff nurse C, a Registered Nurse, was interviewed on 10/16/17 at 1:50 p.m. regarding the appearance of the foot after the brace was removed. Staff C stated, initially she only saw the toes exposed, she had to cut the sock off because the sock adhered to the bottom of the resident's foot because there was dried blood present. I had to cut around the area of the dried blood and moisten the area with normal saline to remove the sock from the tissue injury. INTERVIEWS OF STAFF WHO PERFORMED ASSESSMENTS Staff Nurse D who had performed the skin assessment was interviewed on 10/16/17 at 3:33 p.m. The nurse stated I worked on that floor on 9/12, she (the resident) had an ace wrap on, I did not take it off and I could not see the bottom of her foot. Staff Nurse E who had performed the skin assessment was interviewed on 10/16/17 at 4:40 p.m. The nurse stated, No I did not remove the brace, there was no order to remove it. According to the facility's investigative report Staff F stated, I undid the strap of the boot, I did not remove the immobilizer, and I did not see any redness or smell anything. Staff H, the Physician Assistant, was interviewed on 10/18/17 at 9:00 a.m. Staff H stated that when she checked the resident, I saw the toes and the patient was able to move her toes, she assumed that nurses were .looking at her foot. The Director of Nursing (DON) was interviewed on 10/16/2017 at 11:00 a.m. regarding the lack of Resident #1's skin assessments of the covered extremity. The DON stated the nurses did weekly checks and checked the CMS (circulation, movement, sensation). The DON added that the last skin check was done on 9/29, and there were no issues. According to the Licensed Nurses In-Service Record dated 10/4/17, (after the deep tissue injury was identified) the DON presented training to staff and directed them to, remove immobilizer for skin check unless ordered not to remove boot. There was no evidence for the month of September 2017 that staff had removed the immobilizer device and completed a full assessment of Resident #1's right leg and foot in accordance with professional standards of quality. Finally, when the immobilizer and stockinet were removed on October 3, 2017 and the resident's foot was observed by staff; a 6x5, 5cm deep tissue injury was found on the plantar aspect of the right foot, edges intact with 100% eschar, with imaging diagnostics showing bone infection, and this constituted harm. Refer to WAC 388-97-1080(4) (5) (c) and WAC 388-97-1060(3)(b)